RCSI Royal College of Surgeons in Ireland Coliste

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Talking to Patients and Relatives Angela O`Dea, Marie Morris, Peter Gillen

Objectives for today: • Identify the communication techniques which can be used with emphasis for challenging consultations with patients and their relatives • Discuss the relevant research evidence regarding communication issues with patients and relatives • Practice using the skills of Breaking Bad News

• What are the difficult conversations that you face? • What kinds of conversations or situations require expert communication skills? • What makes them challenging?

What difference do communication skills make?

Evidence • blood sugars (Hb. A 1 c) • metabolic complications (hyperosmolar state, diabetic ketoacidosis, coma) • systolic blood pressure • Asthma control • Quality of Life and self efficacy

post-op pain headache return visits length of stay

§ Patient…… Engagement Adherence Satisfaction 20%

reductions in legal action reductions in complaints patient satisfaction

Problem/Diagnosis Outcome Fibromyalgia Pain, dep. , functioning Smoking cessation Osteoarthritis Pain Diabetes BP, serum levels Diabetes BP, serum, Psychosocial Hypertension BP Cancer Anxiety, Depression Asthma Qo. L Osteoarthritis Pain Diabetes Weight loss Lower resp. infection Return Consultations Somatic complaints Quality of Life Obesity Weight loss

Burnout

Empathy and job satisfaction/burnout Doctors with high empathy scores have higher job satisfaction and lower burnout.

Communication skills training works and…… leads to improved patient outcomes

q …. Up to 50% of patients complaints/concerns are not elicited In 50% of doctor patient interactions, doctors and patients do not agree afterwards what the plan is Doctors and patients agree on the chief complaint in 76% of somatic problems and in only 6% of psychosocial problems Doctors interrupt patients at the beginning of the consultation after 11/12 seconds. 50 % of medications are wasted Between 10% - 90 % patients are non adherent to medical recommendations

One way of breaking bad news

Spot the skills • https: //vimeo. com/141213476

Patient presents problem: gathering information - parallel search of two frameworks The bio-medical perspective (Disease framework) Sequence of events Symptoms & signs Investigations Underlying pathology Differential diagnosis The patient’s perspective (Illness framework) Ideas & beliefs Concerns & feelings Expectations Effects on life Understanding the patient’s unique experience of illness Integration of the two frameworks Collaborative explanation and planning: shared understanding and decision making

Initiating the session Providing structure Gathering information Physical examination Explanation and planning Closing the session Building the relationship

Kaiser Permanente • The Four Habits are: 1. Invest in the Beginning 2. Elicit the Patient’s Perspective 3. Demonstrate Empathy 4. Invest in the End

Breaking Bad News: SPIKE • • • Setting up Perception Invite the patient Knowledge Emotions

Gathering information exercise • • • Instructions: Divide up into teams of three: Player A Player B Referee • Player A : Think of a car. • Player B : Find out what kind of car player A is thinking of. • RULE: Player B is not allowed to ask direct questions about the make and model. Player A is not allowed to tell player B what the make and model is until correctly guessed. • Referee: Ensures rule is not broken. • The winning team is the team who gets the right answer first.

Getting things off to a good start… » Introduction and agenda » Use of open and closed questioning » Identify patient’s/relative’s starting point » Try not to interrupt !

Effective communication skills » Attentive listening » Attend to verbal and non-verbal cues » Avoidance of medical terminology- Jargon

Jargon !

Making the conversations easier… » Use of “signposting” » The `warning shot’ for BBN » Periodic summarising » Chunk and check information » Checks patients understanding » Summarises briefly and clarifies plan of action

Empathy • The art of demonstrating that you ‘get’ the emotion behind what is being expressed

Empathy versus sympathy and compassion • Empathy is a skilled response • Sympathy and compassion are reactive responses. • Developing the skill of empathy is a more realistic goal for medical education. • Emotional insights should inform clinical decision making

Empathy • https: //www. youtube. com/watch? v=-4 EDhd. AHr. Og

Name it!

Empathy saves time Physicians interrupt after 18 seconds It takes patients 2. 5 minutes on average to tell their story – uninterrupted. • Empathy saves time overall

Power of empathy

How we assess communication skills

Online review of skills

Practice Cancelled Op video – Communication with the patient • Good and bad versions

Practice RTA - communication with relative Videos • RTA 2 first 4 mins 25 seconds • RTA 1 Second 5 mins 18 seconds

Afternoon Practice 6 cases 20 minutes per case Facilitated by Faculty One trainee interacts with each patient – others observe and give feedback 1. SHO – Surgery on call/ SHO ED on call