Audience Experiences and Examples

Transcription

1 Susan Hingle: Southern Illinois University David Shaw: Scripps Mercy Hospital Jim Hopkins: Abington Memorial Hospital Background Institutional Examples Audience Experiences and Examples Questions and Answers

2 Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice Improved po edpate patient tsatsacto satisfaction 1 Improved adherence to treatment plans 2 Better health outcomes 2 Improved physician satisfaction Fewer malpractice claims 3,4 Fewer complaints to regulatory agencies 5, 6

3 How Are Residency Programs Preparing Our 21 st Century Internists? Skill Communication Skills with healthcare Providers Communicating Clearly with Patients about Diagnosis and Treatment Plans Percentage of Programs 58% 85% Engaging Patients in Shared 50% Decision Making Patient Education 30% Counseling in Adherence/Behavior 38% Change Cultural Competency 92% Using Interpreters 27% Health Literacy 50% End-of-Life Communication 85% Family Meetings 27%

4 Lectures Videos Web-based instruction Role playing Standardized patients Teaching and assessment should be broadly eac g a d assess e t s ou d be b oad y based Communication skills teaching and clinical teaching should be consistent and complementary Teaching should define and help students achieve patient-centered communication tasks

5 Communication teaching should foster personal and professional growth There should be a planned and coherent framework for communication skills teaching Students abilities should be directly assessed Programs should be evaluated Faculty development should be supported and adequately resourced Assessment Instrument Psychometric Properties Usability by Instrument s Purpose Usability by Trained Raters Overall Value Kalamazoo 2.3 (1.02) 2.2 (0.418) 2.7 (1.2) 2.5 (0.775) Macy 3.3 (1.47) 1.5 (0.548) 1.7 (1.21) 2.0 (0.316) MISCE 4.0 (0.837) 1.5 (0.548) 2.0 (0.894) 2.08(0.880) Calgary- 2.8 (1.12) 2.5 (1.22) 1.83 (0.753) 2.03 (1.03) Cambridge Common 1.9 (0.604) 2.4 (1.05) 1.5 (0.954) 1.9 (0.483) Ground SEGUE 2.7 (1.45) 1.8 (0.612) 1.8 (1.17) 2.6 (0.584) 4 Habits 3.1 (1.49) 2.2 (1.42) 2.1 (1.50) 2.0 (0.632) MAAS 1.2 (0.418) 2.0 (1.10) 1.5 ( 0.547) 2.0 (0.0) ACIR 1.8 (0.758) 1.8 (1.17) 1.7 (0.410) 3.0 (0.945) Rochester 2.22 (0.779) 1.3 (0.619) 3.1 (1.50) 1.8 (0.702) ECFMG 1.7 (0.416) 1.9 (0.763) 1.8 (0.753) 3.1 (0.801) BIC 3.3 (1.2) 1.9 (0.801) 2.8 (0.753) 3.2 (0.753) ICSC 2.2 (0.983) 2.2 (1.17) 3.7 (1.51) 3.5 (0.548) ABIM 2.1 (0.687) 2 (0.894) 3.2 (1.73) 2.8 (0.987) PPPC 2.2 (0.418) 1.5 (0.548) 2.8 (1.73) 2.2 (0.880)

6 Build doctor-patient relationship Open the discussion Gathers information Understand the patient s perspective Shares information Reaches agreement on problems and plans Provides closure 1. Greeted me in a way that made me feel comfortable 2. Treated me with respect 3. Showed interest in my ideas about my health 4. Understood my main health concerns 5. Paid attention to me 6. Let me talk without interruptions 7. Gave me as much information as I wanted 8. Talked to me in terms I could understand 9. Checked to make sure I understood everything 10. Encouraged me to ask questions 11. Involved me in decisions as much as I wanted 12. Discussed next steps 13. Showed care and concern 14. Spent the right amount of time with me 15. Staff treated me with respect

7 Springfield, IL

8 The great end of life is not The knowledge great end but of action. life is not knowledge, but action. Henry Huxley Basic Communication Skills Basic Interviewing Skills Basic Counseling Skills Cultural Integration

9 Adolescent Patients Advanced Counseling Skills Challenging Patient Encounters End of Life Issues Ethics Geriatric Patients Health Literacy Intimate Partner Violence Patients with Physical and Mental Challenges Scenario Skill Setting Description Cost Effective Cost Clinic Exam Patient comes to the clinic with c/o back Diagnostics awareness Room pain. The resident must decide on costeffective diagnostics. Patient also has many and risk/benefit health maintenance questions and has analysis obtained some incorrect health information from the internet. End of Life Advocate for Conference The residents will lead a family meeting with Care quality care Room ethics committee where decisions must be and optimal made whether to continue treatment to patient care extend life. Ethicist, nurse, wife, and systems daughter are present. Patient Hand Coordinate Hospital Resident will assess newly admitted patient, Offs patient care Room will need to recognize a potential within health misdiagnosis, and will sign out the patient to care delivery & Resident another resident who will be assuming care setting Lounge of this patient. Resources to Knowledge of Office Resident will receive a call from radiologist Assist practice and to tell him that an x-ray was misread in E.D. Caregiver delivery A fracture has been detected. Resident must systems call patient and daughter and decide with them how to manage care of the patient. Evidence Cost Clinic Exam Resident will interview a (new patient) with Based Health awareness Room no insurance and then will be asked to Promotion and select most appropriate screenings and risk/benefit health promotion interventions. analysis Informed Consent Coordinating Care through Consultation Patient Discharge from Hospital Chronic Disease Management Advocate for Clinic Exam quality care Room & optimal systems Coordinate Hospital patient care Nurses within Station health care delivery setting Coordinate Nurses care across Station in settings Hospital Knowledge Clinic Exam of practice Room and delivery systems Patient in the clinic is in need of a procedure. Resident must obtain informed consent from a patient where there are complicating issues such as foreign language, health literacy or cognitive problems. Resident will be called to see an unstable patient and will need to get a consultation with a cardiologist. He will need to talk with the cardiologist s nurse and then page the cardiologist. Resident will complete appropriate discharge documents, write prescriptions, request educational materials, phone the anticoagulant clinic and flag the PCP using the electronic record. The resident will interview a patient with drug-seeking behavior. The resident will need to recognize and explore the problem and coordinate appropriate resources. Need for Medication Code Blue Situation Advocate for quality care & optimal systems Advocate for quality care & optimal systems Office Hospital Room The drug the physician has prescribed is not covered by Medicaid. Resident will need to complete papers and communicate with pharmacist. Resident is in charge of a Code Blue on an elderly patient with multiple medical problems. All are in agreement that code should be ended except for one physician. The resident must work through the conflict with the team. Utilizing the Electronic Health Record (E.H.R.) for Outpatient Services Knowledge of practice and delivery systems Office The resident saw a stroke patient in clinic who is having problems with ADL function after hospitalization but had to make hospital rounds before he could complete the E.H.R. The resident now has time to complete the E.H.R. on the computer and make referrals to speech therapy, occupational therapy, or VNA.

10 GOALS: To give residents feedback on communication skills from real patient encounters To assess residents serially over the three years of their postgraduate training to assess progress in their communication skills To compare residents self-assessments to group assessments To incorporate feedback from clinicians as well as lay people Resident audiotapes patient encounters in continuity clinic Encounter is transcribed Resident self-assesses encounter Evaluation panel (2 clinicians, 2 lay persons) meets, reviews audiotape and transcript, completes formal assessment tool Clinician meets with resident individually to review panel feedback, self-assessment, etc

11 All levels of residents participate Articles focusing on communication cat o topics presented and discussed EXAMPLES: Use of medical jargon Self-management skills for patients with diabetes Patient preferences regarding sharing of medical information

12 1. Korsch BM, Gozzi EK, Francis V, Gaps in doctor-patient communication, Pediatrics. 1968; 42(5): Stewart MA, Effective physicianpatient communication and health outcomes: a review, CMAJ. 1995;152(9): Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM, Physicianpatient communication: the relationship with malpractice claims among primary care physicians and surgeons, JAMA. 1997;277(7): Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M, Evidence on patient-doctor communication, Cancer Prev Control. 1999;3(1): Tamblyn R, Abragamowicz M, Dauphinee D, et al, Physicians scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities, JAMA. 2007; 298(9): Papadakis MA, Teherani A, Banach MA et al, Disciplinary action by medical boards and prior behaviors in medical school, NEJM.2005;353(25): Makoul G, Essential elements of communication in medical encounters: the Kalamazoo consensus statement, Academic Medicine April; 76(4): Duffy FD, Gordon GH, Whelan G, Cole- Kelly K, Frankel R, Buffone N, Lofton S, Wallace M, Goode L, Langdon L, Assessing competence in communication and interpersonal skills: the Kalamazoo II report, Academic Medicine. i 2004 June; 79(6): Makoul G, Schofield T, Communication teaching and assessment in medical education: an international consensus statement, Patient Education Counseling June; 37(2): Scripps Mercy Hospital David Shaw

13 Resident to other healthcare professionals: Handoff project with Henry Ford Improvement in discharge summary project Team training in ICU for family conferences with Critical Care Nurses, Intensivists & Chaplains Residents with their patients Residents with their patients Direct feedback on quality of communication during CEX (done 4 x/year on each Resident and prn for under-performing Residents) Measuring interruption times during CEX Empathy Project (to be discussed today)

14 It has been shown that physician empathy and effective communication 1 : Increase patient satisfaction Improve patient compliance Enhance a physician s ability to diagnose and treat patients Conveying Empathy to patients can be broken down into 3 useful concepts when approaching apatient: 2 Attitudes Skills Behaviors Empathy is both a skill and an attitude of personal relatedness Empathy must have an implementation component ( empathy in action ): a willingness to bring a more meaningful assistance to a patient by truly understanding the patient and helping in specific, concrete ways besides just listening

15 Empathy skills can be broken down into 3 components: Verbal Nonverbal Reflective Listening Steps in creating an empathic relationship: Preparation Beginning the Encounter Patient Encounter Concluding the Encounter Debriefing

16 Set goals to achieve certain empathic behaviors or attitudes in your interaction with a patient Pay attention to patient feelings: ask yourself how the patient is feeling or how the patient will take certain news Pull curtain and turn down TV Wash hands at bedside Greet patient by name and shake patient s hand Introduce Resident team Make eye contact and don t write while talking with patient Sit on edge of bed to inspire confidence when appropriate

17 Interacting with the patient: Ask patient how he/she feels Ask patient what their goals of care are for the hospitalization Ask open-ended questions/do not interrupt patient Allow patient to complete sentences without interrupting Use appropriate lay language, tone of voice, facial expression Acknowledge patient concerns and feelings Clarify/paraphrase the patient s concerns (actively listen) Make suggestions to help patient Restore bed, call button, and side rails to appropriate locations Before leaving room, ask, Is there anything else we can do for you?

18 Reflect on your interaction with the patient and the empathic behaviors and attitudes you used in your encounter What did you do well? What would you have changed about your interaction with the patient How will you apply what you learned in this interaction to caring for other patients Direct Lecture to Residents OSCE with Residents using standardized scenarios Direct Lecture to Faculty Faculty then role model empathic behavior at the bedside with Residents during bedside rounds

19 Inpatient t satisfaction with Resident care before and after intervention Jefferson empathy scores before and after intervention Rate hospital Pre Post Recommend this hospital Pre Post Definitely yes Probably yes Probably no 3 4 Definitely no 1 6 COMM W/ Pre Post DOCTORS Always Usually Sometimes 5 6 Never 2 3

20 Doctors treat with Pre Post Doctors explain Pre Post courtesy/respect in way you Always 85 understand 82 Usually Always Sometimes 2 4 Usually Never 2 2 Sometimes 6 9 Doctors listen Pre Post Never 2 4 carefully to you Always Usually Sometimes 6 5 Never 2 3 Jefferson Question Pre-Mean Post-Mean Difference % Change My understanding of how my patients and their families feel does not influence my medical or surgical % treatment My patients feel better when I understand their feelings % It is difficult for me to view things from my patients perspectives % I consider understanding my patients body language as important as verbal communication in caregiver % 3.7% patient relationships I have a good sense of humor that I think contributes to a better clinical outcome % Because people are different, it is difficult for me to see things from my patients perspectives % I try not to pay attention to my patients emotions in history taking % Attentiveness to my patients personal experiences does not influence treatment outcomes % I try to imagine myself in my patients shoes when providing care to them % My patients value my understanding of their feelings which is therapeutic in its own right % Patients illnesses can be cured only by medical or surgical treatment; therefore, emotional ties to my patients % do not have a significant influence on medical or surgical outcomes. Asking patients about what is happening in their personal lives is not helpful in understanding their physical % complaints. I try to understand what is going on in my patients minds by paying attention to their non-verbal cues and % body language. I believe that emotion has no place in the treatment of medical illness % Empathy is a therapeutic skill without which my success in treatment is limited % An important component of the relationship with my patients is my understanding of their emotional status, as % well as that of their families. I try to think like my patients in order to render better care % I do not allow myself to be influenced by strong personal bonds between my patients and their family % members I do not enjoy reading non-medical literature or the arts % I believe that empathy is an important therapeutic factor in medical or surgical treatment %

21 It is possible to teach empathy to residents It is possible to teach faculty to role model empathy at the bedside In the course of a short project, it is not possible to have a material impact on patient satisfaction scores or Jefferson Empathy Scores 1. Hojat et al. Physician Empathy: Definition, Components, Measurement, and relationship to Gender and Specialty. Am J Psychiatry 159:9, September 2002.Pg Neuwirth, Zeev. Physician empathy-should we care? The Lancet. Volume 350 (9078), 30 Aug 1997, pg Shaprio, et al. How Do Physicians Teach Empathy in the Primary Care Setting? Academic Medicine: Volume 77(4)April 2002p

22 Jim Hopkins, PhD, LCSW AMH communication training program is co u cat o t a g p og a s embedded within the context of the whole clinical teaching experience.

23 Experiential e emphasis s Change through experience Corrective emotional experience Increased awareness and focus Tape actual interactions between resident and ape actua te act o s bet ee es de t a d patient. Review tape with treatment team 2X a week. Learner receives feedback from attending and peers also teaches residents how to give appropriate feedback as well as learning communication skills. Encourages group process.

24 Basic elements of medical communication structure, e.g., BIC or the Kalamazoo Consensus Statement. Reflection, ability to see one s self interacting with patient; developing understanding of one s personality. (Physician know thyself.) Waking up, Mindfulness Transformative Learning opening to the process. True CBET requires direct observation and True CBET requires direct observation and assessment Patients are rich sources of feedback Calibration of observers required Inadequacy of the OSCE alone

25 Dennis Novack- Drexel- suggested Debra Roter and the RIAS system RIAS description Project description Comparison with OSCE- Opportunities for Improvement Comparison with Faculty-? Relationship with self; relationship with others Can you teach residents to have closer, more emotional relationship with patients without improved relationship with self?

26 People e may forget what you tell them. People never forget how you made them feel.

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28 I have never e enjoyed my role as an attending physician more than I do now, and I have never felt as accomplished in that role. Our 11:00 AM rounds is an important feature of our clinical program that I enjoy and that I have never experienced in decades of hospitalist attending work.

29 I believe e e I have improved much more in communication, empathizing with and being a better advocate for patients and their families. I have also improved my physical examination skills since we began the communication curriculum. I have ebeen sup surprised sedbyt the esee serendipity dptyof transformational experiences. They have come when I least expected them. In my mind, all Internal Medicine training programs should be set up as potentially transformational training grounds.

30 I have learned to listen to my patients more carefullyy and to get to the emotional aspects of their lives related to the diseases that they have. Definitely changed me in a positive way. We get time to learn more about the patients, and the video taping gives us a lot to reflect on. Although we were taught to be compassionate to our patients, I really had not understood the full meaning or understood the means to doing the same. The video taping sessions and the discussions on the same helped me see and learn this important aspect of medicine. Now I definitely feel that I am able to make better connection with patients I look at patients in a holistic way now.

31 I used to rush to see my next patient on my list. But, now I spend plenty of time with my loved ones. I learned that day that, when we observe a patient even for a brief period of time, we can actually know a lot about the patient. I am beginning i to get it being in the moment, being present and open-minded to all possibilities, and not rushing to conclusions. The communication experiences have taught me mot to go through the motions of taking care of patients mechanically, to be aware in the moment of every interaction, to listen to the patient. Listening to the patient and complying with her request, rather than my own biased judgment led to a startling discovery and saved the patient s life.

32 The great end of life is not The knowledge great end but of action. life is not knowledge, but action. Henry Huxley

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