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Principles of Patient Management > Developing core communication skills > Flashcards

Developing core communication skills Flashcards

1
Q

Why are communication skills important?

A

GDC have identified dental team-patient communication as one of the core competencies required for good dental practice

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2
Q

Four domains of preparing for practice: dental team learning outcomes for registration (GDC)

A

Clinical
Management and Leadership
Professionalism
Communication

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3
Q

Are there problems in communication between health care practicioners and patients?

A 
Discovering reasons for px’s attendance
Gathering info
Explanation and planning
Px adherence
Medico-legal issues
Lack of empathy and understanding
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4
Q

Discovering reasons for px’s attendance

A

54% of pxs’ complaints & 45% of their concerns not elicited
In 50% of visits, px and doctor do not agree on nature of main presented problem
Only minority of health professionals identify more than 60% of pxs’ main concerns
Doctors frequently interrupt patients during opening statement which causes pxs fail to disclose significant concerns
Doctors often interrupt pxs after initial concern, apparently assuming that 1st complaint is chief one, yet order in which patients present their problems not related to clinical importance

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5
Q

Gathering information

A

Doctors often pursue “doctor-centred”, closed approach to info gathering that discourages patients from telling their story or voicing their concerns
Both a “high control style” and premature focus on medical problems can lead to over-narrow approach to hypothesis generation and inaccurate consultations
Doctors rarely ask pxs to volunteer their ideas and in fact, doctors often evade their pxs’ ideas and inhibit their expression. Yet if discordance between doctors’ and pxs’ ideas and beliefs about the illness remains unrecognised, poor understanding, adherence, satisfaction and outcome are likely to ensue

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6
Q

Explanation and planning

A

Doctors give sparse info to pxs, with most pxs wanting doctors to provide more info than they do
Doctors overestimate time they devote to explanation and planning in the consultation by up to 900%
Pxs and doctors disagree over relative importance of different types of medical info; pxs place highest value on info about prognosis, diagnosis and causation of condition while doctors overestimate px’s desire for info concerning treatment and drug therapy
Doctors consistently use jargon that pxs do not understand
There are significant problems with pxs’ recall and understanding of the info that doctors impart

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7
Q

Medico-legal issues

A

Breakdown in communication between pxs and doctors is critical factor leading to litigation]
Communication and attitudes primary reason for patients pursuing a legal case in 70% of cases.
4 communication problems were present in >70% of cases: deserting px, devaluing pxs’ views, delivering info poorly and failing to understand pxs’ perspectives
In USA, malpractice insurance companies award premium discounts of 3 to 10% annually to doctors who attend a communication skills workshop

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8
Q

Effective communication significantly improves

A 
Quality and amount of info obtained from px        
> accuracy and efficiency of diagnosis
Likelihood of px adherence to recommendations and treatment
Health outcomes for pxs
Px's anxiety levels
Satisfaction for both px and dentist
Levels of px complaints and litigation 
Patient referrals
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9
Q

Calgary-Cambridge framework

A 
Px-centred clinical approach
Content: what dentists communicate
Process: how dentists communicate
-combining content and process
Initiating session --> gathering info --> physical exam --> explanation and planning --> closing session (during these you provide structure to px and build relationship)
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10
Q

Patient-centred approach

A

Dentist tries to enter the patient’s world to see the [illness/symptoms/condition] through the patient’s eyes
You are expert on clinical dentistry, but pxs are experts on their own decisions and how they impact on them

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11
Q

Initiating session

A

Preparation
Establishing initial rapport
Identifying reason(s) for consultation

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12
Q

Gathering info

A

Exporation of px’s problems to discover

  • biomedical perspective
  • px’s perspective
  • background info - context
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13
Q

Explanation and planning

A

Providing correct amount and type of info
Aiding accurate recall and understanding
Achieving shared understanding: incorporating px’s illness framework
Planning: shared decision making

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14
Q

Closing session

A

Ensuring appropriate point of closure

Forward planning

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15
Q

Initiating consultation problems

A

Dentists tend to underestimate the potential difficulties and opportunities of these first few minutes
Root cause of difficulties later in consultation

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16
Q

Initiating communication skills

A

Establishing initial rapport
1. Greet patient and obtain name
2. Introduce yourself and clarify role
3. Demonstrates respect and interest
Identifying reasons for appointment
4. Identifies the patient’s problem/issue with appropriate opening question
5. Listens attentively to opening statement without interrupting or directing conversation
6. Confirms list and screens for further problems
7. Negotiates agenda taking patient’s needs into account

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17
Q

Identifying reason(s) for visit

A 
(“Why are you here, today?”)
Begin with an open-ended question 
Listen attentively, without interruption, to the patient’s opening statement 
Confirm and screen for more problems 
Negotiate an agenda for the visit
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18
Q

Attentive listening

A

… the process by which an individual listens to and,
at the same time, attempts to interpret and summarise
what the speaker is saying
25% of the time
-Wait time
-Facilitative response
–>‘Occasional smile, nod, praise, eye-contact
–>‘uh-huh’, ‘go on’, ‘I see’
-Non-verbal skills
-Picking up patient’s verbal and non-verbal cues

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19
Q

Establishing all the reasons

A

“Is there anything else ….we need to take care of today?….that concerns you today?”
Patients have an average of 3.6 problems
In 34/51 visits the doctor interrupted after the first complaint
In 94% of interviews, after an interruption the patient stopped volunteering information

20
Q

Negotiating the agenda

A

Establish an agenda that respects your and the patient’s priorities for the session:
“It sounds as though you have several problems but it seems the most important one to you is the pain in your LL6…shall we focus on that first and the move on to the sensitivity you have been having in your front tooth?”

21
Q

The ‘traditional’ dental history steps

A 
Chief complaint
History of present complaint
Past medical history
Personal and social history
Drug and allergy history
Functional enquiry/ systems review
22
Q

The traditional dental history

A

Disease framework or biomedical perspective
Symptoms, signs, investigations, underlying pathology
Diagnosis and classification –> only one agenda (the dentist’s agenda)
!Disease- or dentist-centred approach!

23
Q

Patient-centred consultation

A 
Patient presents with problem
Gathering information
Parallel search of two frameworks
-the biomedical perspective
-the patient's perspective
*Integration of two frameworks, collaborative explanation and planning: shared understanding and decision making*
24
Q

The biomedical perspective

A 
Symptoms
Signs
Investigations
Underlying pathology
Differential diagnosis
25
Q

The patient’s perspective

A 
Ideas
Concerns
Expectations
Feelings
Effects on life
Understand the patient's unique experience of illness
26
Q

Why is the patient’s perspective important?

A

Px-centred approach associated with:
-better recovery and emotional health, fewer diagnostic tests and referrals
-higher levels of compliance and satisfaction
Px’s beliefs (treatment, aetiology, prognosis) influences how they cope with symptoms/ illness
Many communication misunderstandings due to lack of patient participation
ONLY TAKES 1 MIN LONGER

27
Q

Advantages to paying attention to both agendas

A
  1. Supporting, understanding and building a relationship
  2. Traditional disease model does not explain everything about a patient’s problems
  3. The px’s perspective can aid diagnosis and lead to more effective, accurate and efficient consultations
  4. Groundwork for explanation and planning stage
28
Q

Gathering information skills

A

Exploration of patient’s problems

Additional skills for understanding patient’s perspective

29
Q

Exploration of patient’s problems

A
  1. Encourages patient to tell story of problem in own words
  2. Uses open and closed questioning appropriately
  3. Listens attentively without interruption and leaving space for patient to answer
  4. Facilitates patient’s responses verbally and non-verbally
  5. Picks up verbal and non-verbal cues
  6. Clarifies patient’s statements that are unclear or need expanding
  7. Periodically summarises to verify own understanding
  8. Uses concise, easily understood questions / comments
  9. Establishes dates and sequence of events
30
Q

Additional skills for understanding patient’s perspective

A
  1. Actively determines and appropriately explores:
    - patient’s ideas (i.e. beliefs about cause)
    - patient’s concerns (i.e. worries) about problem
    - patient’s expectations (i.e. goals)
    - effects – on patient’s life
  2. Encourages patient to express feelings
31
Q

Open and closed questions

A

Open questions/ statements to initiate the session and explore patient’s agenda
Closed questions to focus down on points needing further elaboration
-avoid leading questions and the multiple question

32
Q

The questioning funnel

A 
Open
-probe
-probe
Closed - to clarify or commit
Check - you've understood
!listen throughout!
33
Q

Advantages of open questioning techniques

A
  1. Encourages px to tell their story in more complete fashion
  2. Prevents stab-in-the-dark approach of closed questioning
  3. Allows dentist time and space to listen and think and not just ask next qu
  4. Contributes to more effective diagnostic reasoning
  5. Helps in exploration of both disease and illness frameworks
  6. Sets pattern of px participation rather than dentist dominance
34
Q

Traffic light analogy of active listening

A 
Stop all other activities
Look directly at the speaker
Listen and reflect
React
1. Identify important points
2. Make mental pictures
3. Record in point form
4. Make sketches
5. Make connections
35
Q

Non-verbal communication

A

A system of symbolic behaviours that includes all forms of communication except words e.g. body language
“The most important thing in communication is to hear what isn’t being said”

36
Q

Non-verbal communication includes

A 
Ways of talking (e.g. pauses, stress on words)
Sounds (e.g. laughing)
Closeness (e.g. invading someone's space)
Body contact
Facial expression
Eye movements
Hand movements
Head movements
Appearance
Posture
37
Q

Non-verbal cues

A

Maintain eye-contact when asking questions and listening
Maintain face-to-face contact at same level when asking/ answering qus or providing explanation
Be aware of posture and paralinguistics
Be aware of patient’s non-verbal signals = anxiety, pain

38
Q

Advantages of summarising

A

Demonstrates that you are interested and have listened
Offers collaborative approach to problem solving
Allows px to check your understanding and thoughts
Invites px to go further in explaining of their probelms
Demonstrates interest in disease and illness aspects
-maximises accurate info gathering
-provides space for review
-allows you to order thoughts
-helps you recall info later

39
Q

Understanding px’s perspective

A

Identification
-discovering and listening to px’s ideas, concerns, expectations
Acceptance
-acknowledge px’s views, without necessarily agreeing
Explanation
-explaining problem relative to px’s understanding and reaching mutually understood common ground

40
Q

Emapthy

A

Experience of understanding another person’s condition from their perspective
You place yourself in their position
-how would I feel in this situation?

41
Q

4 key aspects of explanation and planning

A
  1. Providing correct amount and type of info
  2. Aiding accurate recall and understanding
  3. Achieving shared understanding: incorporating px’s perspective
  4. Planning: shared decision making
42
Q

Providing correct amount and type of info

A
  1. Chunks and check; check for understanding
  2. Assess px’s starting point: ask for px’s prior knowledge; discover how much info wanted
  3. Ask px what info would be helpful e.g. aetiology, prognosis
  4. Give explanation at appropriate times; avoid premature reassurance
43
Q

Aiding accurate recall and understanding

A
  1. Organises explanation: divides into discrete sections
  2. Uses explicit categorisation or signposting
  3. Uses repetition and summarising
  4. Uses concise, easily understood language
  5. Uses visual methods of conveying info
  6. Check px’s understanding of info given or plans made
44
Q

Achieving a shared understanding: incorporating the px’s perspective

A
  1. Relate explanations to px’s perspective; to previously elicited ideas, expectations etc.
  2. Provide opportunities and encourages px to contribute: to ask qus, seek clarification, express doubts
  3. Pick up and respond to verbal and non-verbal cues e.g. distress, anxiety
  4. Elicit px’s beliefs, reactions and feelings re. info given
45
Q

Planning: shared decision making

A
  1. Share own thinking as appropriate: ideas, dilemmas
  2. Involve px; offers suggestions and choices rather than directives
  3. Explore management options
  4. Ascertain level of involvement patient wishes in making decision(s)
  5. Negotiate a mutually acceptable plan; signposts own preference on available options, determines patient’s preferences
  6. Check with px: if accepts plan and concerns have been addressed
46
Q

Closing the session

A

Forward planning
1. Contract with px next steps
2. Safety net; explains possible unexpected outcomes, when and how to seek help
Ensuring appropriate point of closure
3. Summarise session and clarifies next steps
4. Final check that px agrees and asks if any questions, issues

Principles of Patient Management (15 decks)

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