Patient Centered CommunicationMobeen H. Rathore, MD, CPEProfessor and Associate Chairman

Department of PediatricUniversity of Florida

Chief Pediatric Infectious Diseases and

ImmunologyWolfson Children’s Hospital

Jacksonville, Florida

Disclosure• I have the following financial relationships with the

manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity– Research Support from: Gilead– Speakers’ Bureau for: GSK/Sanofi– Consultant for: GSK/Cerexa

• It is my obligation to disclose to you (the audience) that I am on the Speakers Bureau for GSK and Sanofi. However, I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation using the best available evidence to support my conclusions and recommendations.

• I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Evidence for Benefits of Better Communication Skills

Better Patient Outcomes-Improved qualityIncreased patient and physician satisfactionIncreased adherence; less tests and referralsMore appropriate medical decisionsBetter management of chronic

conditionsFewer medical errors-Dec malpractice claims

Hughes CM. Drugs & Aging. 21(12):793-811, 2004.

Suarez-Almazor ME.. Current Opinion in Rheumatology. 16(2):91-5, 2004 Mar.

Lussier MT. Richard C.. Canadian Family Physician. 51:37-9, 2005 Jan.

Evidence for Benefits of Better Communication Skills

Arch Intern Med. 1994:154;1365

• Decreasing chance of law suits by avoiding– Perceived problems in patient-physician

relationship– Poor delivery of information – even bad news– Ineffective or absent apology– Feeling of desertion– Devaluing patient view/concern– Failing to understand patient/family

perspective

Communication Challenges

What are your hot buttons?

Need to know them!

Hot Button: Patients who…..

• Want everything done now

• Come with a diagnosis in mind and want you to confirm

• Graduated from University of Google

• Set you up

• Manupalative• Rude• Unreasonable

expectations• On cell phone

when you are trying to see them

• Non-Adherent

IMPRESSIONS ABOUT PHYSICIANS

• Too busy to listen and too distant to care• Technologies taking precedence over the art of

medicine (read: listening)• Using sophisticated science without

sophisticated communication skills• Deep scientific knowledge important &

abundant; effective communication skills critical & lacking

• Educators not trained in communication skills• ACGME recognizes and requires trainees to

demonstrate competence in communication• IOM desirable physician attribute

Patient Centered Communication not new

• “The secret of the care of the patient is in caring for the patient”

(Peabody FW. JAMA 1927;88:877-882)

• Focus on the person with the disease rather than disease itself

(Kleinman A, et al. Ann Inter Med. 1978; 88: 251:258)

• Patient Centered Care: Focusing on understanding the needs of the individual patient and tailoring specific treatment to them (IOM)

Why Improve Communication

• Half of what we know in medicine today is wrong, the challenge is we don’t know which half

• Medicine is the science of uncertainty and the art of probability – Osler

• Medicine is science of certainty to the degree of current available evidence ……until evidence to the contrary becomes available.

• Uncertainty isn’t going away, learn to manage it

• In every era of medicine those who focused on treating the patient and not just the disease were successful

Physician Perspective on Communication

250,000 patient encounters during career25% encounters described as frustrating 50% of these described as dysfunctionalPoorly equipped to deal with the many

demands placed on themThe behaviour/personalities of certain patients

often strain inadequate skillsPersonal, social, and cultural “baggage” often

interfere with communication

Patient Perspective on Communication

80% feel their doctors are too busy to listen to their complaints

27% state their primary care physician failed to address their main concern

32% state that their sub-specialist failed to address their main concern

“That doctor is probably a pretty good doctor, but you can’t talk to him. He didn’t seem to want to know what I was worried about.”

“Tell me About Yourself”; The Patient Centered Interview. Annals of Internal Medicine. Vol. 134. No. 11.

June 2001. pp. 1079-1081.

Physician Patient CommunicationSchwartz Center for Compassionate Healthcare, Mass Gen Hospital

• Survey of 800 patients and 500 doctors• 48% patients felt they played no role in

decision making for their care• 29% patients did not know which

Doctor was in charge of there care• 81% of patients and 71% of doctors

reported that outcomes were better with better communication

Communicating Effectively

Communication skills are essential to: – Physician-pt relationship, Daily interpersonal contact

“Art of medicine” Hard science demonstrating clinical outcome benefits

Centered on the patient’s needs NOT DISEASE-CENTERED and NOT DOCTOR-CENTERED

It is a skill that can be mastered Engage the patient to play a larger role Help the physician to manage time and improve

efficiency and effectiveness”“Tell me About Yourself”; The Patient Centered Interview. Annals of Internal Medicine. Vol. 134.

No. 11. June 2001. pp. 1079-1081.

The Skill of Reflective Listening

Excellent starting point for beginning a dialogue with a complex patient.

- Attitude: curious, non-judgmental, seek to understand the patient’s perspective

- Skill: Ask open ended questions and actively listen.

This attitude will often take the patient by surprise.

Patient Education

The Patient-Centered Interview

Relationship Building

Information Gathering

The Physician-Centered InterviewTraditional history-taking and interview

- A manual of laundry lists

- Hundreds of items pertaining to organ systems

• Clinician expert on disease • Patient expert of her/himself• On the average, physicians interrupt the

patient 18 seconds after the patient begins to speak1.

1.Lipkin M, Putnam S, Lazare A. eds. The Medical Interview. Clinical Care, Education and Research. NY. Springer-Verlag.1995.p.531.

Patient Centered Interview

• Consider each Pt encounter like a discussion with a specialist, an expert or a colleague you have invited to take care of a patient

• You and your team are the expert/specialist in the disease

• Patient/Family is the expert on the patient.• Think of the patients’ specialty as

“Patientist”• Seek patient’s input and perspective

The Patient-Centered InterviewPatients who were not interrupted

rarely took more than to complete their list.

Patients who were not interrupted never took more than to complete their list.

one minute

three minutes

Why not interrupt? We lose potentially relevant information:

- We change the course of the story We jump to conclusions: Premature

hypothesis testing (Diff Diagnosis)Patients need a period of uninhibited

talk at the beginning of the interview to express their concerns

IT DOESN’T TAKE LONGER!

Patient Education

The Patient Centered Interview

Relationship Building

Information Gathering

OARS (Information Gathering)

•Open ended questions

•Affirmations

•Reflective Listening

•Summaries

Information Gathering: Eliciting Data Efficiently and Accurately

– Patients want to give information abouttheir concerns.

– Begin with a comprehensive inquiry about the patient’s entire list of concerns before collecting details on any one complaint

– This ultimately saves time and assures focus on key issues.

Information Gathering:Seek the Patient’s Concerns

When? At the beginning of the visitHow? Comprehensive “What Else?” examples…

“What else has concerned you?”,“Are you worried about anything else?”,“Tell me more”;

Why? Minimize “Oh by the way” at end of visitClarify: “Help me understand what you mean

by..”,“Let me review what I think I heard”,“Let’s summarize so we can both be sure I have the story straight”

Facilitate: “Tell me more”, Attentive listening, Echo the patient’s last few words

Information Gathering: Negotiating Priorities & Joint Agenda Setting

Example: I’m not certain we can cover all our concerns. “We agree that A is important. I also want to address B, and you expressed concern about C. Where should we start?”

Patient and Physician: Negotiate priorities together; share control; establish concept of limits

When patients believe their concerns have been heard, they are more willing to accept the clinician’s recommendations otherwise dissatisfaction and poor compliance result.

Four Habits ModelAlderson P, Montgomery J: Health Care Choices:Making Decisions with Children. 1996

• Opening Ceremony (Invest in the beginning): plan visit, develop rapport, elicit concerns

• Main Event: Elicit patient’s perspective, ask for specific requests, patient’s thoughts

• Closer: Demonstrate empathy, understand patient’s emotions, convey verbally and non-verbally

• Grand finale (Invest in the end): shared decision making, follow-up plan, education

Kalamazoo Consensus StatementPediatrics. 1982; 70:396

• Build relationship (Reflective listening, Partnership, Empathy, Respect, Support)

• Open the discussion (Reflective listening, agenda setting)

• Gather information (patient centered interview)

• Understand patient’s perspective (empathy)

• Share information (partnership, respect)

• Reach agreement (Agenda setting, priortizing)

• Provide closure (Partnership, Support)

CONNECTING

The Patient-Centered Interview

Success of Patient Encounter

• Physicians: Correct diagnosis and treatment plan is key

• Patient: Connecting with physician is key

• To make an alliance with patient connecting is key: listen, recognize and respond

CONNECTINGRelationship Building

Recognize Recognize Patient’s feelings and emotions: – Anger, – fear ,– sadness,– anxiety, – uncertainty

RespondRespond with a supportive statement using “PEARLS”

CONNECTINGRelationship Building

P = PARTNERSHIP

E = EMPATHY

A = APOLOGY

R = RESPECT

L = LEGITIMIZATION

S = SUPPORT

PARTNERSHIPPatient and physician working

together to correctly define the issues and solve problems jointly…

– “Let’s tackle this together.”

– “We can do this.”

P

E

A

R

L

S

EMPATHY Understand the patient’s feelings and

communicate that understanding to the patient. Requires:

– Listening

– Wanting to understand: walk in his/her shoes– Communicating…

• “That sounds hard.”• “You look upset.”

– Express understanding of how patient feels…• “Let me see if I have this right . . .”

P

E

A

R

L

S

How to elicit empathy?• How is everything going today?

– You must be exhausted staying up with Johnny all night

• How are you feeling today?– Are you scared (anxious, upset…)?

• It is OK to be scared.– I would be scared too if I did not know

what will happen today?

• No one likes shots, it is OK to cry.

APOLOGY/ACKNOWLEDGE

Acknowledge patient’s frustrations/anxietyApologize for the situationTake personal responsibility and apologize

when appropriate…– I am sorry we can’t get everything done today

and tomorrow. Let’s try to do the best we can– I’m sorry I was late– I am sorry your call was not returned

P

E

A

R

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RESPECT

Demonstrate appreciation/value for Pt’s choices, behaviors, special qualities: You have obviously worked hard on this; That was tough; You handled it well, You have obviously researched this problem. Let’s see if I can add to your knowledge

Shared decision makingEmpowering the patient/familyListening to their concerns:non-judgmentalNot “blowing off concerns”Respectful of everyone’s time

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PATIENT CENTERED COMMUNICATION

• Consider each pt encounter a discussion with a specialist/expert/colleague you have invited to take care of a patient

• You are the expert in the disease• Patient/Family is expert on the patient.• Patients’ specialty as “Patientist”• Seek patient’s input and perspective

LEGITIMIZATION

Concur that patient’s feelings and choices are appropriate…– “Anyone would be (confused, sad,

irritated) by this situation.”

– “No one likes shots I would be scared/crying too”

P

E

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R

L

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SUPPORT

Offer ongoing personal support…

– “I’ll stick with you as long as necessary.”

– “I’ll be here when/if you need me.”

– “Call me if Johnny is not feeling well at night or on weelend”

P

E

A

R

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SUCCESSFUL CONNECTION

Patient feels alliance, safety and trust

Stronger relationship to cope with stresses of illness

Successful Connection = Satisfied Patient and Physician

P

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L

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Communication Tool Box

Reflective Listening

Patient Centered Interview

Agenda Setting

Exhaustive “what else”

PEARLSConnecting