1.Models of Doctor Patient Interaction

2.Miscommunication in Health care settings

1. Doctor – Patient communication
2. 2. Session outline • Understanding how doctor-patient relationship / communication has evolved • Importance and benefits of good doctor-patient communication • Effects of bad doctor- patient relationship / communication • Improvements in communication • Communication styles in Health context • Importance and role of patient satisfaction • Consultation styles • Role of consultation in diabetes care
3. 3. Evolution of doctor patient relation* Model Physician’s role Patient's role Clinical application of the model Prototype model Time period Activity - Passivity Does something to the patient Recipient (unable to respond to inert) Anaesthesia, acute trauma, coma, delirium, etc. Parent- infant Ancient Egypt Greek Enlightenment Medieval Europe Guidance- co- operation Tells patient what to do Co-operator (obeys) Acute infectious processes, etc. Parent- Child / adolescent French Revolution Mutual participati on Helps patient to help himself Participant in “partnership” uses expert help Most chronic illness, psychoanalysis Adult - Adult 1700s - today
4. 4. Forms of doctor – patient relationship Described four basic forms of patterns of control and communication in doctor-patient relationships (think of the table at the beginning): 1. Default: characterised by a lack of control on either side, not ideal 2. Paternalism: characterised by dominant doctors and passive patients 3. Consumerism: associated with the reverse, with it focusing on patients rights and doctors obligations 4. Mutuality: characterised by shared decision making and is often advocated as the best type of relationship (Hall & Rotter, 1991)
5. 5. Think about your experiences for a moment! How was it for you?
6. 6. Why is doctor-patient communication important? • “Medicine is an art whose magic and creative ability have long been recognized as residing in the interpersonal aspects of patient-physician relationship.” (Hall et al, 1981) • A doctor's communication and interpersonal skills encompass the ability to gather information in order to facilitate accurate diagnosis, counsel appropriately, give therapeutic instructions, and establish caring relationships with patients (Duffy et al, 2004) • The 3 main goals of current doctor-patient communication are creating a good interpersonal relationship, facilitating exchange of information, and including patients in decision making. Effective doctor-patient communication is determined by the doctors' “bedside manner,” which patients judge as a major indicator of their doctors' general competence (Platt & Keating, 2007)
7. 7. Fallowfield (2002) Effective communication is an important determinant of: -Accuracy and completeness of data collection about symptoms and side effects -Dictates the problems elicited -Adherence to treatment -Emotional and physical well-being -Doctor and patient satisfaction
8. 8. Benefits of doctor- patient communication Patient Satisfaction, adherence, Health outcomes • Good doctor-patient communication has the potential to help regulate patients' emotions, facilitate comprehension of medical information, and allow for better identification of patients' needs, perceptions, and expectations (Platt & Keating, 2007) • Patients reporting good communication with their doctor are more likely to be satisfied with their care, and especially to share pertinent information for accurate diagnosis of their problems, follow advice, and adhere to the prescribed treatment (Chen et al, 2007, Zolnierek & Dimatteo, 2009) • Patients' agreement with the doctor about the nature of the treatment and need for follow-up is strongly associated with their recovery (Stewart et al, 2000) • Studies have shown correlations between a sense of control and the ability to tolerate pain, recovery from illness, decreased tumour growth, and daily functioning. Enhanced psychological adjustments and better mental health have also been reported. Some studies have observed a decrease in length of hospital stay and therefore the cost of individual medical visits and fewer referrals • A more patient-centered encounter results in better patient as well as doctor satisfaction. Satisfied patients are less likely to lodge formal complaints or initiate malpractice complaints. Satisfied patients are advantageous for doctors in terms of greater job satisfaction, less work-related stress, and reduced burnout. (Stewart et al, 2000, Little et al,2001, Hemdon & Pollick, 2002,Roter et al, 2002, Maguire & Picheatly, 2002)
9. 9. Factors that influence this relationship 1. The characteristics of the doctor (gender, level of experience, personality) 2. The characteristics of the patient (gender, social class, age, education, desire for information) 3. Differences between the two – in terms of social class and education, attitudes, beliefs and expectations 4. Situational factors – such as patient load, level of aquaintance and the nature of the problem (Endelman, 2000)
10. 10. Problems with Doctor – patient communication • Deterioration of Doctors’ communication skills • Nondisclosure of information • Doctors’ avoidance behaviour • Discouragement of collaboration • Resistance by patients (Ha, Anat & Longnecker, 2010)
11. 11. Recent shift in agenda • After 1991 there was a shift in model of healthcare, the Department of Health recognised that the patient deserves information on their treatment • Governments commitment to provide not only an NHS offering high quality patient-centred care, but also to ensure the patients voice was heard • This included having any proposed treatment, including any risks involved, clearly explained before decision – taking into account the importance of communication
12. 12. Possible improvements Communication skills training • Doctors should encourage patients to discuss their main concerns without interruption or premature closure • The appropriate use of open-ended questions, frequent summaries, clarification and negotiation which are key factors which influence the quality and quantity of information gathered • Institutions should consider requiring and facilitating such skills training with medical schools, hospitals and practices • Encouraging Collaborative communication • Conflict management (Feudtner, 2007, Lee et al, 2002) • Health beliefs (Platt & Keating, 2007, Tongue et al, 2005)
13. 13. What makes a good doctor? • What do you think? Doctors and patients have different perspectives on what factors they see as being most important in doctor – patient communication Paling (2004) • Asked doctors and patients to describe what makes a good doctor • The doctors stated that ‘diagnostic ability’ was the most important quality of a good doctor whereas the patient said that ‘listening’ was the most important aspect – which doctors rated as being the least important
14. 14. What makes a good doctor (cont’d) • How well the doctor communicates with the patients and shows a caring attitude • Exploring medical or technical procedures in an easy to understand way • Listening and taking time to ask questions • In contrast, the aspects most highly rated by doctors were number of years in practice and whether they had attended a well known medical school (Delamothe, 1998)
15. 15. Specifically considers communication in the context of health. The model emphasises the way in which a series of factors can impact on the interactions in healthcare settings based on three elements: 1. RELATIONSHIPS: The model illustrates the four major types of relationships that exist in healthcare settings; a) Professional – Professional b) Professional – Client c) Professional – Clients significant others d) Client – Significant others 2. TRANSACTIONS: health transactions include both verbal and non verbal health communications as well as the content and relationship dimensions of messages 3. HEALTHCARE CONTEXTS: the settings in which health communication occurs Both health professionals and clients bring unique characteristics, beliefs, values and perceptions to the healthcare setting which effect how they interact (Northouse & Northouse,1998) Model of health communication
16. 16. • Looked at key communication skills and how to acquire them discussing the importance of good communication skills in medical care and the maxamising impact it can have on treatment adherence • They conducted a clinical review using original research studies into doctor-patient communication They noted the key tasks in communication that good doctors should be able to: • Elicit the main problem and the patients perception of the main problem • Understand the physical, emotional and social impact of the patients problem and its impact on the patient and their family • Tailor information to what the patient wants to know, checking their understanding • Determine how much the patient wants to participate in decision making (when treatment options are available) and discuss treatment options so that the patient understands the implications Maguire and Pitceathly (2002)
17. 17. Results in • Patients not disclosing problems as belief nothing can be done, do not want to appear a burden to doctor, desire not to seem pathetic or ungreatful, concern that problem is not legitimate enough to mention, worry that fear will be confirmed Effective teaching methods • The opportunity to practice key skills and receive constructive feedback of performance is essential • Provide evidence of current deficiencies in communication, reasons for them and the consequences for doctors and patients • Offer an evidence base for the skills needed to overcome these deficiences • Demonstrate the skills to be learned and elicit reactions to these • Provide an opportunity to practice the skills under controlled and safe conditions • Give constructive feedback on performance and reflect on the reasons for any blocking behaviour
18. 18. What are the common mistakes? • Not introducing themselves • Not asking for clarification from patient • Not allowing or encouraging patients to ask questions • Not asking questions about patients feelings • Not providing information in a form that patients can use Use of medical Jargon (language)  Although healthcare providers can potentially switch from medical to everyday language, they tend to over-rely on medical jargon which often patients have difficulty understanding  They found that patients only understood 36% of the terms that were commonly used by health professionals  The use of technical language is particularly problematic as studies have shown that the use of more technical messages is associated with less cognitive satisfaction, comprehension and recall  Leading to patient dissatisfaction (Hadlow & Pitts, 1991, Jackson, 1992, Davis and Fallowfield, 1994)
19. 19. Bad communication Bad communication and consequent patient dissatisfaction can result in:  Patient lack of engagement  Patient refusal to follow recommended health behaviours  Failure to adhere  Psychological damage  Physical harm (Korsek et al.,1968)
20. 20. Predictors of patient satisfaction • The amount of information given, technical and interpersonal competence, partnership building, immediate and positive non verbal behaviour, social conversation, positive talk, less negative talk (Hall, Roter & Katz, 1988) • Patients are more likely to be satisfied if their treatment choice is accepted and dissatisfied when their choice is rejected (Amyx et al., 2000) • Meeting idealised expectations of care is important determinant of patient satisfaction (McKinley, 2002) • Expectations are important determinants of satisfaction The three main types of expectations (Zeithaml & Bitner, 1999) 1. Expectations about desired service 2. Expectations about adequate service 3. Predicted services Fulfillment theory • Expectancy is determined by relationship between the importance of an outcome and the perceived possibilities of achieving the outcome, this expectancy is the most important determinant of patient satisfaction (Linder-Pelz, 1982)
21. 21. Measuring patient satisfaction The consultation satisfaction questionnaire (Baker, 1997) • developed a questionnaire with a model to measure patient satisfaction within practices and consultations • The model used indicates how satisfaction should be measured, satisfaction was regarded as an attitude • Note that qualitative research is needed alongside questionnaires as self reports do not always provide accurate picture Dougall et al. (2000) • Emphasised the importance of qualitative research • Conducted a pilot patient satisfaction study of cancer service using a combination of participant observation, in dept interviews and questionnaire methods • difficult to define what satisfaction is therefore difficult to measure, when patients fill out satisfaction questionnaires responses show high level of satisfaction - failing to elicit patients true satisfaction levels • In depth qualitative interviews reveal a different picture than that conveyed through questionnaire methods
22. 22. The consultation The key goals of the consultation are to exchange relevant information and make decisions alongside relationship building The 6 key dimensions for a good consultation; 1. Having a good knowledge of research or medical information and being able to communicate this to the patient 2. Achieving a good relationship with the patient 3. Establishing the nature of patients medical problem 4. Gaining an understanding of patients understanding 5. Engaging the patient in decision making process 6. Managing time (Ford, Schofield & Hope, 2003)
23. 23. Consultation styles • Professional-centred approach The doctor keeps control of the consulation, ask direct, closed questions in order to gain information and refer to medical facts, makes decision and patient passively accepts • Patient-centred consultation The doctor identifies and works with the patients agenda as well as their own, doctor actively listens, professional and encouraging communication, listening to patients views and understanding of health, patient is an active participant in the process • Shared decision making clinicians and patients share best available evidence for decision making and both must agree, all about involving the patient and checking their understanding and ideas as well as taking into account affective components - gaining increasing prominence in health care policy (Coulter, 1999, 2001) • Evidence based patient choice (EBPC) newly emerging templates for medical encounters that advocate evidence-informed choice and shared decision making
24. 24. What consultation style leads to satisfaction for patients? Lee et al (2002) looked at decision making preferences of 999 women with early stage breast cancer and 141 stem cell transplant patients, they found shared decision making to the most preferred style at 44% and 40% Little et al (2001) conducted a questionnaire study of 865 participants looking at their preference for a patient-centred approach, found before entering the room patients had a strong preference for a patient-centred approach and this preference was most prevelant in vulnerable groups (low SES or bad health) • Although patients should be offered the chance to and be encouraged to take part in shared decision making there is suggestion that active participation is not uniformly desired and this preference should be respected
25. 25. Diabetes care 10 ‘commandments’ of effective communication in the diabetes clinic (Alzaid, 2014) 1. Recognize the importance of patient empowerment as being fundamental to diabetes management. 2. Use appropriate words and language when talking to patients with diabetes 3. Allow collaborative care and shared decision making and “strike a deal” with the patient at each therapeutic juncture encountered. 4. Be practical and seek realistic goals. Focus on the achievable. 5. Be non-judgmental 6. Consider cultural issues, religious beliefs, and personal values of the patient. 7. Reward effort, not just outcome. 8. Stay tuned to the patient's feelings and pick up the clues early. 9.Use visual tools as much as possible: make a simple drawing or show the patient a relevant graph or picture to facilitate understanding and enhance motivation. 10. Does your patient comprehend and remember the instructions given at the clinic?
26. 26. Summary • For an ideal consultation, doctors realistically need to figure out and tailor their approach with each different patient depending on their preference • Successful and unsuccessful communication has a major impact on adherence to treatment and patient satisfaction • For effective doctor patient communication there must be mutual respect and an exchanging of ideas - not just one sided • Doctors and patients perhaps value different aspects which can lead to confusion about what is an ideal doctor and consultation • Patient satisfaction and consultation preference can be influenced by demographic variables