Patient Provider Interaction HCOM 510 Libby Bradshaw DO

Patient - Provider Interaction HCOM 510 Libby Bradshaw, DO, MS Department of Public Health and Family Medicine Tufts University School of Medicine

Memorial Hospital Rhode Island mhriweb. org/. . . / doctor_patient_full. jpg

Session I Outline Introductions Syllabus – It’s not as bad as it looks… Goal setting Purpose – Why Bother? Exploring an Example Course Overview Discussion of readings/topic Communication models

Patient-Provider Interaction Introductions What’s the purpose here? Why have this course? Why take this course? Why teach this course?

Patient-Provider Interaction Why take the course? Sounded easy, interesting, enjoyable Was told to take it Had a bad experience with a (doctor, nurse, X-ray tech, etc) I am/ I want to be a (provider, researcher, consultant, regulator. . ) Why teach the course?

Patient-Provider Interaction Why have this course? What’s the purpose here? Health Communications Public Health Pain Research-Education- Policy www. dtaresources. com

Patient When is a person a patient? How does a person become a patient? Who is a patient? How does a healthcare consumer differ from a patient? Must a person be a patient OR a consumer?

Provider Who is a “provider”? What personal qualities characterize healthcare providers? What are the motivations to become a provider? What makes a person a provider? What are the characteristics in common across the spectrum of health care providers? What are major differences between provider categories?

What’s In a Word? Patient-Provider Interaction Patient Provider Interaction (Healthcare)

Is there a difference? Interaction Communication Relationship Health care Medical care

Communication is a range of purposeful behavior which is used with intent within the structure of social exchanges to transmit information, observations, or internal states, or to bring about changes in the immediate environment. Verbal as well as nonverbal behaviors are included, as long as some intent, evidenced by anticipation of outcome, can be inferred……not all vocalization or even speech can qualify as intentional communicative behavior. Written by Susan Stokes under a contract with CESA 7 and funded by a discretionary grant from the Wisconsin Department of Public Instruction.

Communication: "Any act by which one person gives to or receives from another person information about that person's needs, desires, perceptions, knowledge, or affective states. Communication may be intentional or unintentional, may involve conventional or unconventional signals, may take linguistic or nonlinguistic forms, and may occur through spoken or other modes. “ (National Joint Committee for the Communicative Needs of Persons with Severe Disabilities, 1992, p. 2 Julia Scherba de Valenzuela, Ph. D.

Definitions Communication a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior Interaction mutual or reciprocal action or influence Relationship the state of being related or interrelated a state of affairs existing between those having relations or dealings » Merriam-Webster Online 2005 » http: //www. m-w. com/cgi-bin/dictionary

Definitions Relationship the way in which two or more people feel and behave towards each other Interaction when two or more people or things interact (communicate or react) Communication the act of communicating with people Communicate to share information with others by speaking, writing, moving your body or using other signals to talk about your thoughts and feelings, and help other people to understand them » Cambridge Advanced Learner’s Dictionary Online » http: //dictionary. cambridge. org/

Communication putting thoughts into words – expressing thoughts clearly understanding others’ perceptions “Communication is the process of understanding and sharing meaning. ” » JC Pearson & PE Nelson 1991

Understanding and Sharing Process On-going effort to understand Time frame – before encounter, continues after Expectations – past, present, future Personal goals - maintain, restore health Providers – other possible – time, burnout, knowledge, finances, personal Patients – healing, information – emotions (fear, anger), desires (forgiveness, reassurance) Interdependence No one communicates alone – Process of acting, reacting, negotiating Sensitivity Communication success related to sensitivity to other people’s feelings & expectations – Public health campaigns most effective when designed w/ audience’s resources & concepts – patient satisfaction w/ physicians who seem to understand patient feelings Shared meaning – how to know? Pre’ 2000

An Example Interaction Communication Physician socialization Relationships – – – Dr-Pt Dr-Dr Dr-Nr Pt-Pt Pt-Family Expectations Attitudes Life world views

Course Overview Road Maps

Course Overview – Rules of the Road Description - in the eye of the beholder health communications, pain, public health students Learning Objectives Evaluation, Assignments Syllabus, Readings Expectations – student, faculty, program, institution Contact information – student, faculty Calendar – presence / absences ? adjustments

Charting the Dyad Territory Clinical perspective Professional practice Goals, objectives Educational process Patient perspective Health status, Age Encounter structure, function Goals, objectives www. bridgeporthospital. org/. . . / HNF 006 H. gif www. louisville. edu/. . . / ss 01/images/patient 1. gif

Beyond the Dyad Who checks up? Professional oversight Rationale Professional “discipline” “Disciplinary” standards Hospital & health facility oversight accreditation Public Oversight State licensing boards Stae & Federal Payor Medicare Medicaid Third Party Payors Public – M’caid, M’care Health plans – MC Insurers – BC/BS Malpractice insurers Employers Consumer Oversight

Beyond the Dyad Setting the rules Ethical precepts Professional, discipline Legislative Regulatory Scientific Technological Cultural precepts, expectations

Exploring the Dyad Literature Poetic – – mystery, pain, magic, devotion Storytelling – – insights, humanness, frailty Journalism – – print, photo, media Themes Celebrating the dyad Exposing dyad weaknesses – Cynicism of / towards Dr – Fallibility of pt

Researching the Dyad Examining structure, function & outcomes Social sciences Sociology Psychology Anthropology Historical Health services Health status Health outcomes

Course Topics Big Picture & Tools I. III. Communication Models Interaction in a Changing Health Care System Analytic Methods & Tools - Satisfaction, Quality Encounters IV. V. VIII. IX. Types of Encounters – Health Promotion to Bad News Participatory and Shared Decision-Making Ethical Issues – Lifespan, Mental Illness, Disability Race, Ethnicity, Health Disparities Mental Health and Social Illness – Stigma/State of Mind Difficult Patients, Difficult Providers What’s the Problem? How to Improve? X. XII. Miscommunication – Quality, Outcomes, Malpractice Improving Communication – System Level Improving Interaction & Communication - Individual

Course Learning Objectives For patient-provider interactions Understand structural dynamics Recognize adverse effects & their causes Describe current, proposed interventions to improve Become familiar with measuring and analyzing methods Identify major effects of race & ethnicity Appreciate responsibilities and accountabilities Enjoy some self-directed learning

Course Requirements Analyze, deconstruct provider-patient interactions Role-play in-class interaction scenarios Observe standardized patient interactions Explore further resources; contribute to annotated bibliography Critically analyze an example from literature, film or personal experience in a written format from both patient and provider perspectives Examine policy options in topical arena of patient-provider interactions Independently develop a 7– 10 page paper and final presentation Evaluate, provide course feedback at mid-point and final sessions

Organization, Confidentiality, Respect Graduate level seminar with class discussions and minimal lecture presentations Individual opinions and experiences important Broad arena of topics and issues Respect and confidentiality expected Bring up communication and interaction issues individually or in class. Questions or suggestions welcome

Readings Syllabus has wide breadth of readings Additional suggestions are welcome Session readings may be divided and chosen by individual students in the preceding class Optional Texts Doctors Talking with Patients/ Patients Talking with Doctors: Improving Communication in Medical Visits. Debra L. Roter and Judith A. Hall. 1992. Auburn House, Westport, CT, pp 175. Talking with Patients, Volume 1: Theory of Doctor. Patient Communication. Eric J. Cassell. 1985. MIT Press, Cambridge, MA, pp 223.

Evaluation Activities 15% Classroom participation/preparation 5% Discussion forums 10% Communication exercises & role-plays 10% Critical analysis interaction - Experiential » Due June 1 5% IRB Training CITI online module – June 7 10 % Analysis of provider-patient interaction – June 10 15% Communication prescription write-up » Due June 24 30% Final project – Written (20%) – Due July 1 – Class presentation (10%) » Due July 3/5

Course Assignments Due June 1 Provider-patient interaction from literature, film or personal experience. Apply perspectives from readings, classroom discussions and personal insights, critically analyze the interaction in a 2 – 3 page paper. Particularly focus on the patient’s perspective, but examine the interactional frame or model used by both the patient and the provider. Questions to consider: What happened in the interaction? Why did it go the way it did? How was it successful? Unsuccessful? What did the patient want? Did they achieve their goals? Why, or why not? Who had a stake in the interaction besides the patient and provider? What communication model was used? Was the provider satisfied? Why or why not? How would the interaction be improved?

Course Assignments Communication Prescription Due June 24 - 3 page written paper Define patient health care problem or type of encounter. Examine challenges facing patients and providers. Describe how you would define quality in this interaction. Describe your prescription for optimizing quality in this interaction. Final Project Due July 1 / July 3/5 Paper 7 – 8 pages, plus references. Presentations can be discussions to power point presentations; 10 -15 minutes Include analysis of a problem and related issues; articulate clear objectives around this issue (stake out a stand!), Specify your recommendations and support your suggested strategies with appropriate references (5 -10 references)

Faculty Information – Please contact me with questions or suggestions at any time Ylisabyth (Libby) Bradshaw, DO, MS Arnold 106 Phone – 617 -636 -6946 Fax - 617 -636 -4017 Email – libby. bradshaw@tufts. edu Office Availability – M – T / Th – F appointment 1 – 5 pm or by Plus before class about 5 pm; after class

Calendar Absences? Adjustments?

Initial Conceptual Models Physician - Patient Relationship Parsons Physician dominant, controlling Patient’s sick role » Relieved of everyday responsibilities » Responsibility to get well Szasz & Hollender Activity-Passivity Model » Asymmetrical power; analogous Parsons’ Guidance-Cooperation » Most common, Dr dominant, Pt’s cooperation sought Mutual Participation

Mutual Participation Model Pt full participant Pre-conditions Both participants need equal power Mutual interdependence Interactions must be satisfying for both

Physician-Patient Relationships Models Multiple models Emmanuel & Emmanuel Paternalistic – Authoritarian Priestly Informative - Consumer Scientific, engineering Interpretive Deliberative

Emanuel & Emanuel 1992 Four Models Physician - Patient Informative Interpretive Deliberative Paternalistic Pt Values Fixed, pt known Unknown, requires help Development, Objective, revision thru shared by Dr moral discussion & Pt Dr Provide responsib relevant facts ilities Implement pt choices Elucidate, interpret pt values; inform, implement pt Articulate, persuade pt of best values; inform, implement pt Promote pt well-being, independent of pt current preferences Pt autonmy Choice, control over health care Selfunderstand’g re health care Moral selfdevelopment re health care Assent to objective values Dr role Competent technical expert Counselor, adviser Friend, teacher Guardian

Physician-Patient Relationships Physician Control Patient Control Default Consumerism Paternalism Mutuality Roter & Hall 1991

Expectations for Interactions Patient expectations – multiple forces Societal beliefs Cultural beliefs Personal beliefs Family Situational Physician expectations Personal beliefs Professional socialization Organizational Situational Interactional Models – prototypes – not proscriptive

Models of Health Biomedical model Physical phenomenon; Mechanistic; Like fixing a machine Strengths: Efficient, definitive Weaknesses: Marginalizes pt feelings, social experience Impersonal; patient = parts & symptoms Communication = Dr control, closed ? ’s Patients dissatisfied, mistrustful Cartesian dualism (Descartes) Mind-body dualism; bodies & souls (brain) Dx = physical condition; Illness = experienced condition Biopsychosocial model

Models of Health Biopsychosocial model Includes physical, psychological, social person’s biology, feelings, ideas, life events Engels 1977 Thoughts & emotions influence health Stress reduces body’s resistance to dx Stress results in depression, mood changes Humor improves immune functioning, outlook Support improves health status Weakness – difficult to implement time, effort, skills; limited by setting, pt expectation

Therapeutic Communication Patient presentation, concern, issue Physician response assessing, defining issue Rapport / Resolution information exchange cognitive, emotional meaning dyadic (team) interaction Barriers – setting, time, illness Mismatched expectations Physician communication styles – Control – spatial & social distance, – Affiliation – empathy, genuineness, nonjudgmental attitude

Silo Philosophy

Macy Initiative on Health Communication nyumacy. med. nyu. edu/ curriculum/model/m 00 a. html

Ithaca. Med Patient-Provider Interaction: A Human Scale We place a premium on humane interactions with our patients. All providers greet patients themselves from the waiting room. The initial discussion of a medical problem(s) takes place in a consulting room before the patient changes for the physical examination. We feel this allows the patient to feel fully comfortable discussing their health as a whole person on equal standing, face to face, rather than trying to present one’s medical concerns while perched on an examining table, half naked or draped in a flimsy, backless medical gown! After changing for the purpose of physical examination (into one of those flimsy, backless medical gowns!), the patient is then given a full physical or a problem-focused examination. Following the examination, the patient dresses and meets again with the doctor or nurse practitioner to discuss the results of investigations, diagnosis, and the proposed management plan. Health education and preventative medicine are an integral part of this part of the consultation. Patients are encouraged to take an active part in this process as we recognize that such collaboration leads to the best outcome. http: //www. ithacamed. com/the_practice/specialities. php 4

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