L23 Clinician Patient family communication Flashcards
Coaching patients to ask questions (ASK)
Study, GP setting: (actors) presenting at different GP clinics, blind to who was an actor or who was a patient.
•(actors) coached to ask 3 questions:
1. What are my options?
2. What are the possible benefits and harms of those options?
3. How likely are the benefits and harms of each option to occur?
• Designed to prompt physicians to provide minimum information that patients need to make an informed decision
• It worked!
- doctors gave more information
- patients were more likely to share in decision-making (Shepherd et al., PEC, 2011)
What about real patients?
4-min ASK video clip viewed by 121 participants: Online modelling, they can see how these questions are implemented in the consultation.
- the majority (87%) asked at least 1 out of the 3 questions
- almost half (43%) asked all 3 questions
- a half (49%) recalled all 3 questions two weeks post-consultation
Question Prompt Lists (QPLs)
Provide a list of common questions patients/family may want to ask
• Questions may relate to: ‘My illness’ – what is it (diagnosis)
- ‘How serious is my illness’ (prognosis)
- ‘Treatment’ options
- ‘Benefits vs. costs’ of treatment options
- ‘Support’ for me and my family
• Patient/family tick relevant questions & write their own questions (pass it to the doctor)
• QPLs taken into consultation as a prompt
Both patients and doctors find QPLs useful and helpful
• Increases likelihood ‘difficult’ questions
• More effective with clinician’s endorsement
• QPLs in isolation, are not a substitute for effective communication, cannot ‘fix’ poor communication
• Can be used in subsequent consultations QPLs for people with cancer (translated into 20 languages)
Decision Aids (DAs)
- Inform , ALL options (benefits vs. harms) (even no treatment as an option)
- Communicate probabilities in a clear graphical form - Clarify values - Ask which benefits and harms ‘matters most’
- Support process
- Guide re steps in deliberation
• the optimal format will depend on the clinical situation
detailed DAs more effective than simple
• the International Patient Decision Aid Standards (IPDAS; 2006) DA inventory
DA’s are effective 7
• Improve knowledge of screening/treatment options
• Facilitate more realistic and accurate expectations of possible benefits and harms
• Facilitate choices that are more consistent with patients’ values
• More accurate risk perceptions
• Increase active participation in decision-making
• Improve doctor-patient communication
• Reduce overuse of major elective surgeries, PSA (prostate cancer) screening, and the choice to use HTR (menopausal hormones)
(Stacey et al. 2017; Cochrane review of 115 studies, n = 34,444 patients)
Patients expect more from their doctors than 30 years ago
- Technical expertise
- Accurate information
- Empathy / emotional support
- Access to services
- Continuity and coordination of care
Communication differences between SUED vs. NOT-SUED clinicians
Levison et al (1997): 10 audiotaped routine consultations, each with 59 GPs and 65 surgeons (general/orthopedic) => 1,265 consultations
Clinicians who were NOT SUED: - longer consultations (only by 3 mins)
- explicit agenda for patient (really asked about what the problems were)
- facilitating behaviours
- used humour & active listening
Surgeons’ tone of voice: a clue to malpractice history. N = 112 (1/2 sued) 2 x 1-=second voice clips
Tamblyn et al (2007): n= 3,424 Canadian physicians, There was a 10 year follow-up!
•In follow up, Dr-patient communication decision-making score in the clinical skills exam predicted future patient complaints, future of whether the Dr would be sued or not.
DOCTOR barriers
Insufficient training - I don’t know how Lack of evidence - Why should I? Difficulty - It’s hard! Vulnerability - I can’t cope Attitudes - It’s not my job Patient reticence - I can’t read minds System constraints - I don’t have time
ways of communicating risk
• Words • Absolute risk • Relative risk • Pie charts • Horizontal bars • 100 person diagram • Survival graph
RISK COMMUNICATION: Absolute vs. relative risk
Absolute risk
- your risk of developing the disease over a time period
• Relative risk
- compares the risk in two different groups of people e.g. smokers vs. non-smokers
- tells you nothing about the actual risk
- the benefit really depends on how common or rare the disease is (i.e. baseline rate)
Active treatment options (e.g. surgery, medication) are chosen more often when outcomes described in terms of what kind of risk??
of RELATIVE (rather than ABSOLUTE) risk reductions. (Moxey et al, 2003; Wills & Holmes-Rovner, 2003)
how do you simplify risk
analogies are helpful
Risk communication: KEY POINTS
Use consistent framing when discussing pros/gains & cons/losses
• Provide base rates of outcomes
• Use absolute risk comparisons
• Provide information about the consequences of the risk
• Preferred formats are not always the best understood
• 100 dot/person diagrams: the greatest accuracy/understanding (can cause distress)
• Check and re-check understanding of risk
• Best graphical format will depend on its intended purpose
How can we help patients/family better negotiate medical consultations and decision-making
Interventions for CLINICIANS
Communication skills
Generally, clinician communication skills do NOT:
reflect personality
• reflect natural talent
• improve with age
• improve with professional experience
• Effective communication skills can be taught, maintained, and improved
• Only few health professionals receive formal training in communication skills
Effectiveness of Communication Skills Training (CSTs)
Cochrane systematic review • 14 RCTs: 11 comparing CST vs. no CST intervention N=1147 clinicians
• Significantly group differences - CST group more likely to: - use open ended questions - show empathy towards patients
- No group differences: patient satisfaction and perception of clinicians’ communication skills, and clinician burnout.
- CST courses appear effective in improving information-gathering skills + supportive skills BUT unclear which CST programs work
