Communication Skills

1
Communication Skills

• October 23, 2003
• Moritz Haager
• Dr. S. Pandya

2
Objectives

• Conflict resolution negotiation
• What are the barriers to communication in the ED?
• What strategies models exist for effectively
  dealing with conflict?
• Dealing with consultants
• Giving bad news
• Telephone advice

3
Why are we talking about this?

• teaching physician-physician communication
  skills in EM training programs is in its infancy
• OMara. Communication and conflict resolution in
  emergency medicine. Emerg Med Clin NA 17. 1999
• Although the Core Content for Emergency
  Medicine includes the topic of interpersonal
  skills, there remain no published guidelines for
  teaching these skills within an ED residency..
• Williams et al. Emergency department senior house
  officers consultation difficulties Implications
  for training. Ann Emerg Med. 31. 1998

4
The Importance of Communication

• Communication skills are the most important
  determinant of patient satisfaction with care..
• Brown et al. Effect of clinical communication
  skills training on patient satisfaction. Ann
  Intern Med. 131 822-29. 1999

5
The Importance of Communication

• absent appropriate communication skills,
  doctors cannot meet their responsibilities as
  medical professionals
• ..I do not ever remember having a faculty member
  sitting with me to talk about my feelings about
  death and suffering, or attempt to help me reach
  an understanding about what my patients go
  through.
• Whitcomb. Communication and professionalism.
  Patient education and Counseling 41 137-44. 2000

6
Historical Perspective

• In my fathers time, talking with the patient was
  the biggest part of medicine, for it was almost
  all there was to do.
• Lewis Thomas
• The focus has shifted away from the pt to
  focusing on disease with our increased ability to
  accurately Dx Tx

7
Barriers to Communication

• ED probably the worst place
• Divergent pt physician expectations of role of
  ED goal of visit
• Lack of understanding of triage system
• Patient-doctor relationship arises out of
  necessity rather than choice
• Loud hectic environment
• Frequent interruptions lack of privacy
• Balancing department flow addressing pt needs

8
Barriers to Communication

• Telephone consultations
• Appearance pt perceptions
• Youthful appearance
• Female gender
• Lack of formal dress
• Social, cultural, language
• Pt impairment
• EtOH, drugs, disease states

9
Language Culture

• Huge issue in Canada
• Virtually all communications research models
  based on western principles values
• Unknown as to how these apply to different
  cultures but easy to accept that the same
  question put to persons of different backgrounds
  can have tremendously different meaning

10
Is there any proof this is a problem?

• Taylor et al. Complaints from emergency
  department patients largely result from treatment
  and communication problems. Emerg Med 14 43-49.
  2002
• Retrospective review of ED complaints
• Found that most likely to complaints were from
  very old, very young, females, and non-english
  speaking
• 33.4 related to Dx and Tx
• 31.6 related to communication
• 11.9 related to delay in Tx
• 71.5 resolved through communication alone!!

11
Is there any proof this is a problem?

• Williams et al. Emergency department senior house
  officers consultation difficulties Implications
  for training. Ann Emerg Med. 31. 1998
• Conducted survey of SHOs working in ED in
  England regarding most difficult cases
  encountered cause of difficulty
• Found that communication problems were a factor
  in 76 of cases compared to lack of knowledge in
  52
• This did not change significantly over 4 months
  implying no significant improvement with
  experiences
• Authors conclude that formal communication
  training may be of benefit

12
Communication Problems

• Views conflicting with pts 40
• Pts w/ mental or behavioural problems 24
• Intoxicated or aggressive pts 12
• Distressed / anxious pts 7
• Difficult to obtain Hx 10
• Uncooperative / manipulative pt 5
• Language barrier 3
• Pt unable to speak or hear 3
• Children 2
• Conflict of opinion w/ other staff 2
• Williams et al. Emergency department senior house
  officers consultation difficulties Implications
  for training. Ann Emerg Med. 31. 1998

13
Elements of Effective Communication

• Listening
• Speaking
• Receiving feedback effectively
• Marco and Smith. Conflict resolution in Emergency
  Medicine. Ann Emerg Med. 40 347-9. 2002

14
Model of Prinicipled Negotiation

• Separate the people from the problem
• Focus on interests rather than positions
• Invent options for mutual gain
• Insist on objective criteria in judging an
  agreement
• Fisher Ury. Getting to yes. 2nd ed. 1991.
  Penguin Book, NYC, New York

15
The Challenge

• It seems apparent that communication skills are
• Central to practicing medicine
• A common problem area in the ED
• A potential area for improving pt physician
  satisfaction
• How do we teach communication?
• How do we evaluate whether the curriculum works?

16
Does Specific Training Make a Difference?

• Langewitz et al. Improving communication skills
  A randomized controlled behaviorally oriented
  intervention study for residents in internal
  medicine. Psychosom Med 60 268-76. 1998.
• Randomized 42 residents to intervention (22.5 hrs
  of communications training) control groups
• Assessment of pt-oriented interview skills in
  videotaped simulated clinical encounters using
  Revised Maastricht History and Advice Checklist
  by blinded observers at 0 10 months
• Simulated pts also were surveyed for their
  satisfaction with the clinical encounter using
  the American Board of Internal Medicine Patient
  Satisfaction Questionnaire
• Found that both groups improved over time, but
  the intervention group significantly more than
  the controls
• Actors were more likely to recommend physicians
  from the intervention group to friends or family

17
Assessing Communication Skills

• Rosenzweig et al. Assessing emergency medicine
  resident communication skills using videotaped
  patient encounters Gaps in inter-reliability. J
  Emerg Med 17 355-61. 1999
• Videotaped 50 pt-resident encounters
• Analysis of only 11 using a checklist of 23
  desirable 9 undesirable behaviours by 3 EPs
  and 2 medical educators
• Only able to achieve moderate-excellent
  inter-observer reliability on 10 of the 32 items

18
Key Communication Skills

• Introductions
• Introduce self by name
• Ask or state pts name
• Greet family or friends present
• Social overture prior to data gathering
• Rapport
• Gives comfort
• Investigates or acknowledges emotional response
  to illness or ED experience
• Gives reassurance
• Talks Pt through physical exam
• Conflict Management
• Clearly acknowledges Pts viewpoint
• Attempts to negotiate w/ Pt

• Information Gathering
• Allows Pt to tell story
• Uses open-ended questions
• Active listening indicators
• Checks understanding by summarizing information
• Contracting / Informing
• Explains immediate plan for further evaluation
  Tx
• Discusses expected time frame
• Guides expectations of possible outcomes
• Checks Pt understanding of info given
• Non-Verbal Communication
• Position closer to head than feet
• Emphatic appropriate physical touch
• Appropriate eye contact
• Posture oriented toward pt

Rosenzweig et al. Assessing emergency medicine
resident Communication skills using videotaped
patient encounters Gaps In inter-reliability. J
Emerg Med 17 355-61. 1999
19
Communication Skills Improve w/ Training

• Klamen Williams. The effect of medical
  education on students patients satisfaction
  ratings. Acad Med 72 57-61. 1997
• Cohort study of 133 medical students
• Compared scores on standardized patient
  interviews using the American Board of Internal
  Medicine Patient Satisfaction Questionnaire in
  2nd yr with repeat exams in 4th yr
• Used medical residents doing same exams as
  controls
• Found that mean scores improved over time
• Did not perform calculations to determine
  statistical significance making it difficult to
  draw any conclusions

20
Consultation Requests

• Go et al. Enhancing medical student consultation
  request skills in an academic emergency
  department. J Emerg Med 16 659-62. 1998
• Simple comparison of taped telephone consultation
  requests made by medical students briefly trained
  with sheet outlining structure of request with
  untrained EM residents
• Medical students found to use significantly more
  likely to use previously identified important
  criteria of effective consultation

21
Consultation Requests

• Medical Student Telephone Consultation Sheet
• Hello Dr.______, this is _______ in the ED. I
  have a pt I would like to present to you
• Pause for acknowledgement
• Mr_______ is a ___ yo _______ who comes in today
  complaining of ______
• Gives relevant Hx and data
• I think the most likely diagnosis is _____
• This is what I have done for him already _____
• Id like you to evaluate him for ________
• His condition right now is __________
• Thank you
• Total time should be less than one minute
• Go et al. Enhancing medical student consultation
  request skills in an academic emergency
  department. J Emerg Med 16 659-62. 1998

22
Do Communication Skills Seminars Improve Pt
Satisfaction?

• Brown et al. Effect of clinician communication
  skills training on patient satisfaction. Ann
  Intern Med 131 822-29. 1999
• Randomized physicians to taking a 10 hr
  communication skills seminar at different time
  points
• Assessed pt satisfaction using Art of Medicine
  Survey scores before and after taking seminar
• Found that physicians self-assessment of
  communication skills was improved, but no
  statistically significant change in pt
  satisfaction scores was noted

23
Criticisms

• Simulated situations difficult to know how this
  impacts upon pt satisfaction in real life
• Perhaps the amount of training was not enough, or
  the time for the training to manifest to short to
  be detectable

24
Conclusions

• Difficult to get a sense from the literature that
  specific courses aimed at improving communication
  skills produce tangible benefit
• However this may be as much a function of the
  study designs as well as the limitations of
  objectifying something that is inherently
  subjective in nature

25
Bad News

• Definition
• situations where there is either a feeling of no
  hope, a threat to a persons mental or physical
  well being, a risk of upsetting an established
  lifestyle, or where a message is given which
  conveys to an individual fewer choices in his or
  her life
• Dosanjh et al. Barriers to breaking bad news
  among medical surgical residents. Med Ed 35
  197-205. 2001

26
Advance Directives

• A study of audiotaped discussions about advance
  directives found
• Physicians tended to focus on more clear cut
  scenarios
• E.g. irreversible brain damage vs. severe
  infection
• Pretty clear that most pts do not desire
  intervention when there is no hope of recovery
• More common, uncertain scenarios were
  inadequately explored
• Pts reasons values underlying their responses
  were also rarely elicited
• Concluded that such advance directive discussions
  are inadequate to properly guide the physician
  and family in times of crisis
• Tulsky et al. Opening the black box How do
  physicians communicate about advance directive.
  Ann Intern Med 129 441-9. 1998

27
Death Notification

• Unexpected ED deaths are not uncommon (0.3 of
  visits)
• Represent a major source of stress for EPs
  particularily if the deceased was a child
• Little effort focused on teaching how to inform
  relatives of death of a loved one in medical
  school or residency

28
Death Notification

• Buss et al. The preparedness of students to
  discuss end-of-life issues with patients. Acad
  Med 73 418-22. 1998.
• Surveyed 226 4th yr medical students about
  conveying end-of-life issues
• 41 felt they were adequately prepared to do
  discuss this with their pts
• 27 had actually had such a discussion with a pt

29
Death Notification in the ED

• Tends to be more difficult
• Death usually unexpected
• No prior relationship w/ pt or family
• Previously noted barriers to communication in the
  ED
• Time demands

30
Death Notification Guidelines

• Make sure you are speaking to the right family
• Take them to a quiet room
• Give them a sense that you are not rushing off to
  see the next pt
• Sit down with them
• Identify yourself your role
• Communicate with emotion
• Convey warmth, caring, empathy
• Appropriate physical touch
• Allow them to dictate the pace
• Briefly summarize what happened before the pt
  arrived and while in the ED
• Get a sense from them of how they saw the pts
  health
• Provide warning of what is to come
• Olsen et al. Death in the emergency department.
  Ann Emerg Med 31 758-65. 1998
• Ptacek Eberhardt. Breaking bad news. JAMA. 276
  496-502. 1996

31
Death Notification Guidelines

• Avoid medicalese Use simple clear language
  tell them the pt died rather than euphemisms
• Reassure them everything possible was done
• This includes reassuring them that they did the
  right things
• Expect allow for grief response
• Expect a range from pathologic grief to anger
  resentment
• Let them see the body
• Body resus room should be cleaned as much as
  possible
• Prepare family for what they will see
• If body terribly disfigured may want to
  discourage viewing
• Ask about tissue donation autopsy
• Encourage them to ask questions
• Provide them with follow-up support
• Offer clergy or social worker support
• Olsen et al. Death in the emergency department.
  Ann Emerg Med 31 758-65. 1998
• Ptacek Eberhardt. Breaking bad news. JAMA. 276
  496-502. 1996

32
Autopsy Request

• Why do them?
• Explanation of unexpected deaths
• Can help improve care in 50 of cases by
  clarifying Dx or guiding research
• Can help grieving process (i.e. everything was
  done that could be done)
• Discovery of new diseases
• Quality assurance
• Vital statistics
• Validation of diagnostic tests
• Dx of genetic or infectious Dz and subsequent Tx
  of affected contacts
• Olsen et al. Death in the emergency department.
  Ann Emerg Med 31 758-65. 1998

33
Organ Donation

• ED deaths will be limited to ischemia-resistant
  tissues
• Liver, kidney (if ongoing CPR)
• Cornea
• Bone
• Skin
• Tendon fascia
• Cartilage
• Veins
• Heart valves
• Olsen et al. Death in the emergency department.
  Ann Emerg Med 31 758-65. 1998

34
Organ Donation

• Contra-indications to organ donation
• Infectious disease
• Cancer (can donate corneas)
• Toxic exposures (some exceptions)
• Olsen et al. Death in the emergency department.
  Ann Emerg Med 31 758-65. 1998

35
Organ Donation

• How to ask
• Wait until after family has viewed body
• Put in terms of letting pt have one final act of
  goodwill
• E.g. Do you think _____ would have wanted to help
  someone else as his/her final act here by
  becoming an organ donor?