NGu School of Medicine Introduction to Clinical Communication PDF

1.5.2 Introduction to Clinical Communication & IM [VM 2.6] The Patient-Centred Consultation & care prepared by: presented by: Dr. Maie Hilmy Dr. Salwa Ismail Consultant of Psychiatry Consultant of Dermatology Mental Health Team Lead Clinical Communication Team Lead...

1.5.2 Introduction to Clinical Communication & IM [VM 2.6] The Patient-Centred Consultation & care prepared by: presented by: Dr. Maie Hilmy Dr. Salwa Ismail Consultant of Psychiatry Consultant of Dermatology Mental Health Team Lead Clinical Communication Team Lead Intended learning Outcomes By the end of this session you should be able to: ▪Define what is meant by ‘clinical communication skills’, ‘the consultation’ in a medical context, person-centred care, patient-centred care and holistic care ▪Describe the features of a patient-centred consultation, person-centred care, patient-centred care and holistic care ▪Know the patient perspectives ▪Know why person-centred care is important, its impact on the quality of care ▪List key communication skills which facilitate an effective, patient-centred consultation Communication (com|mu¦ni|ca¦tion) the imparting or exchanging of information by speaking, writing, or using some other medium the successful conveying or sharing of ideas and feelings Consultation (con¦sul|ta¦tion) the act of discussing something with someone before making a decision about it meeting with an expert, especially a doctor, to get advice (or treatment) Who is the expert? Doctor: expertise in history- taking, clinical reasoning, management i.e. identifying and treating problems Patient: expertise in their own health, their needs, their capabilities The patient’s perspective Pre-formed thoughts/beliefs/worries Reason for seeking help now Expectations and preferences Influence of physical and psychological state The patient’s perspective Pre-formed thoughts/beliefs/worries Explanatory models of illness based on beliefs about: Cause Disease process Course Symptoms Effects of illness Patient desires, values (Kleinman, Eisenberg, Good 1978 Culture, illness, and care: clinical lessons Socioeconomic condition, from anthropologic and cross-cultural research. Ann Intern Med, 88:251-58) Family situation and lifestyle  The doctor’s perspective Information about the causes of problems (disease model) The structure of health care systems Professional regulation The doctor-patient partnership Listen to patients Ask for, and respect, their views about health Respond to their concerns and preferences Be honest and merciful with your patient Tasks in the consultation Define reasons for the patient’s attendance Consider other problems Choose appropriate action for each problem with the patient Achieve shared understanding of problem with the patient Involve the patient in management and encourage them to accept appropriate responsibility Use time and resources appropriately Establish or maintain rapport (Pendleton, Schofield, Tate et al. 1984; See also: Three Function Model, Four Habits, Essential Elements) What do patients want? What do patients want? What patients want from their doctor Greeted me in a way that makes me feel comfortable Treated me with respect Showed interest in my ideas about my health Understood my main health concerns Paid attention to me (looked at me, listened carefully) Let me talk without interruptions Gave me as much information as I want  Talked in terms I could understand Checked to be sure I understood everything Encouraged me to ask questions Involved me in decisions as much as I want Discussed next steps, including any follow-up plans Showed care and concern Spent the right amount of time with me (Makoul, Krupat & Chang 2007) What is ‘clinical communication’?  take account of views and taking account of symptoms values also psychological, spiritual, respond honestly to questions social and cultural factors be open and honest if things go wrong Listen to Assess the patients patient’s conditions Work in Support partnership in caring for themselves patients with share information they will to empower them to improve patients need to make decisions and maintain their health about their care work collaboratively with give patients information colleagues; share information they want /need to know in a including when you hand over way they understand care Communication process Listen Collect data Interpret Focus  Content 7% Body Language Tone of Voice 55% 38% Poor communication between healthcare & patient Inaccurate patient medication history taking Inappropriate therapeutic decisions Contribution to patient confusion Disinterest Non-compliance Harming the patient if information isn’t exchanged in appropriate manner Consequently… Patients: don’t ask questions (that we know they had in mind before the consultation started) will accept a statement about plans for treatment or referral without discussion realise later on that they don’t understand the plan, or don’t agree with it, or can’t follow it through Patient-centred care A philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of health problems with the patient and/or (b) a focus in the consultation of the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease) (Lewin et al., 2009. The Cochrane Library, Issue 1) Patient-centred communication The goal of patient-centred communication is to help practitioners provide care that: is concordant with the patient’s values, needs and preferences, and allows patients to provide input and participate actively in decisions regarding their health and health care (Epstein, Franks, Fiscella et al. 2005 Social Science and Medicine) Person-centred care Is thinking about people using health services as partner in planning, developing and monitoring care which suits their needs Putting people at the centre of decision Is doing things with people, rather than to them Aspects of Person-Centred Care Respecting values Making sure of continuity between and within services Coordinating and integrating care Emotional support Involving family and friends Person- Centred Care is a high priority Help people to get their needs when they need Help people be more active in looking after themselves Help reducing the burden on health services Practising with patients We don’t expect you to ‘take a history’ at this point It is much more important to listen to the patient’s narrative Try and understand the patient’s experience What are their priorities? How does health and healthcare feature in this? What does the patient want? What affects the person’s choices? What to practise ‘Invest in the beginning’ Encourage the patient to feel welcome and comfortable Warm room, sense of privacy, minimise distractions Introduction Good eye contact Sitting at similar level Arrangement of furniture Chaperone if patient needs to undress What to practise Gathering information Explore the person’s perspective Use what you say and your body language to create a warm, supportive atmosphere LISTEN Don’t be afraid of silence – it gives people time to collect their thoughts ‘Open to closed question cone’ Reflect back and acknowledge what the patient has said when exploring a topic Working towards… Conduct professional and sensitive discussions with patients, relatives and colleagues as a clinical student Establish and maintain good working relationships Conduct an effective consultation to gather information from patients e.g.‘taking a medical history’ Adapt your communicative style to meet the needs of the patient and the aims of the consultation Demonstrate (in a simulated consultation) how to share information with patients and relatives and how to respond to difficult situations (e.g. breaking bad news) in the role of a junior doctor Reflect on consultations and critically appraise your own communication (in terms of strengths and areas to improve on) Your structured guide to interviewing patients The Calgary-Cambridge Guide to the Medical Interview Initiating the consultation preparation establishing initial rapport Building the Providing identifying the reasons for the consultation relationship structure Gathering information exploration of the patient’s problems to discover the: using making organisation biomedical perspective appropriate overt patient’s perspective non-verbal behaviour background information - context attending to flow Physical examination Developing rapport Explanation and planning Involving the achieving a shared understanding: incorporating patient the patient’s illness framework Closing the consultation ensuring appropriate point of closure forward planning Holistic care Person should be treated as a whole ”wholistic” Consider the complete person, physically, psychologically, socially, and spiritually during management of health problem (comprehensive care)  Clinical holistic care dates as back as Hippocrates, also suggested by Percival in the first book of medical ethics(1803) The feeling and emotions of the patients require to be known and to be attended to, no less than the symptoms of their diseases(Percival T.,1803)  Consultation can be used as a tool in holistic healthcare to help find “the story behind the story” Patients tend to be more satisfied if a doctor take a holistic approach Communication Skills Communication Skills The ability to communicate clearly & effectively with patients, families, physicians, nurses, pharmacists & other healthcare professionals Communication Skills Communication Skills Active Listening Use face to face communication Focus on the patient (centre of attention) Conduct open relaxed & unhurried conversation Set aside all the distractions Prevent/minimize interruptions Communication Skills Observation & Assessment Use effective two-way communication Use body language & gestures. Sit or stand at eye level Maintain eye contact Use focused body posture to show interest & attentiveness. Be physically close to provide clear & comprehensive communication Don’t be too close in order not to be intruder (discomfort) Communication Skills Physical barriers Large countertops Windows with security display area bars & protective glass Elevated work area Pts in beds are intimidated by people standing over them Communication Skills Lack of Privacy Don’t discuss patient data or healthcare issues in public areas (hallway, walkways, elevators, Library). Don’t discuss patient information with family/friends. Converse with patients & discuss patient-specific information with other healthcare professionals in private areas (counselling room in the hospital & corner in community pharmacy). Close the room doors or curtains around the bed Phone Calls When making calls Identify yourself by name & the purpose of the call Be prepared to repeat the request several times before being connected to the right person Be patient & expect to spend some time waiting Speak clearly Listen carefully Be organized State facts clearly & calmly Phone Calls When answering the call Identify yourself & ask for caller’s identity Deal with the call as fast as possible Avoid holding the caller If too busy to talk arrange call back at convenient time When receiving calls from angry & upset person, stay calm, listen, clarify the issue & handle the problem as calmly as possible Written Communication j0215894 Patient Medical Record (PMR): 1ry written communication tool for all healthcare members Healthcare professionals must be able to accurately & effectively document patient information in PMRs & other records Adhere to legal, ethical & professional standards Black ink is more recommended than any other colours Written Communication Clear & legible handwriting is important Cross out any error with a line & initialize the error (Misteak NS) Document factual information & avoid assessments or judgments Notes should have : heading date time patient data & signature title of healthcare professional Communication Skills Communication with patients Patient Title Patient Respect Questioning technique Patient Instructions Avoid Jargon Communication Skills Patient title Use the correct title & never assume that all the adults are married or single Ask each patient how he/she wants to be addressed to convey a sense of respect for the patient Respect for the patient Avoid Respond to Arrange Introduce exchange patient as a adequate time yourself & personal person not a for interaction explain the information & Rx/case/room & minimize purpose of confidences /bed No. interruptions interaction with patient Respect for the patient Explain who Note taking Clean, neat & will see or use acceptable but organized obtained shouldn’t control environment information interaction Communication Skills Questioning Technique The clinician is the one controlling the interaction by controlling the types of questions asked & time allowed for response. Don’t fire off a rapid sequence of YES/NO questions Communication Skills 1017860598_80273496d4 Questioning Technique At the beginning, ask open ended questions to allow patients to talk freely about their medications & concerns Use minimal facilitators Provide non-verbal encouragement by smiling & nodding when appropriate Communication Skills Questioning Technique Give the patient time to answer Use directed & structured questions Narrow the focus of the question along the conversation Discuss one topic at a time & avoid leading questions Take some time to summarize information provided by the patient Close the interaction by providing final summary Avoid Medical Jargon Avoid medical jargon Speak in plain Give the patient with patients & language the chance to translate commonly ask questions used medial terms into commonly used terms (e.g., diuretics= urine frequency medication or diet) Special Situations 1. Embarrassing situations Most patients find it embarrassing to discuss certain topics (sex related topics, Haemorrhoids, Birth controls, Enemas, Douches, Drug or alcohol abuse, Obesity, Illiteracy, Constipation or diarrhoea, Incontinence, & Non-compliance) Special Situations Embarrassing Situations Clues showing Actions in Embarrassing embarrassment Situations Avoidance of eye contact Be aware of what may be Blushing embarrassing & try to bring up the subject Stammering Converse in a private Closed body language environment Excessive nervous small Discuss the issue in a talk about unrelated straightforward scientifically matters (weather, sports) appropriate manner. Avoid humour Special Situations 2. Mute patients Use written communication Allow sufficient time for adequate communication Special Situations 3. Paediatric patients Communicate directly with the paediatric patient as well with the parents Information must be age appropriate Take child’s ascent if over 8 years old Special Situations 4. Elderly patients Elderly patients have hearing impairment, loss of ability to distinguish between different sounds & tones & visual impairment (cataracts, reduced vision, problems distinguishing colours) Take time to engage elderly in unhurried conversation Speak slowly, distinctly & avoid slang language Treat elderly with respect Special Situations 4. Elderly patients Don’t assume that every elderly has impaired hearing Speak directly to the patient Use large-print written information Re-enforce written information with verbal communication Touching the patient lightly on the arm or shoulder may reassure the patient Special Situations 5. Physically challenged 6. Mentally impaired patients patients Don’t assume that physically disable patient is mentally disable Don’t assume that the patient Engage patient in unhurried is incapable of participation in conversation & give enough time their health care Speak directly to patient & don’t Communicate clearly & assume that the patient is directly with the patient & incompetent with the caregiver Don’t stare at patient or avoid eye contact Don’t physically assist or help patient without being invited????? Special Situations 7. Hearing Impaired patients 8. Chronically ill patients Don’t assume that they can read lips or understand the sign language They may be sophisticated Don’t yell and/or a demanding Speak on side of good ear category Don’t assume that hearing aid Assess the needs of each returns the patient’s hearing to patient normal Don’t assume that they suffer from Be flexible to communicate intellectual impairments on appropriate level Communicate clearly, slowly & distinctly with the most minimal background noise Face patients who can read lips Use written communication Special Situations 9. Hard to reach patients 10. Antagonistic patients This includes those of low This category includes those socioeconomic status, minorities who don’t want to be bothered & illiterate persons with medication histories, interviews & interactions Communicate directly with each patient as an individual Try to be as professional & direct as possible Provide as much respect, time & information as possible Limit the length of the interaction to the shortest Be sensitive to their needs possible period Help illiterates organize complex Define the need for the regimens by using different sized interaction containers or colour coding Treat them with respect technique Be sensitive to cost of medication Tips to enhance effective communication skills in the dental office 1. The confirmation: Make it clear what the patient's appointment is for, how long the patient will be here, and that he or she will be getting their mouth healthy, out of pain, or even pretty. 2. The greeting: The patient is greeted by name; you must give eye contact, be personal, shake the patient's hand, and clarify what they are present for. 3. The escort to clinical: When walking patients back to clinical, step out to the reception area and greet them by name. Shake their hand. 4. Seating the patient in clinical: Explain the treatment that the patient is having , use photos on the screen (or take photos), review the medical history, and address any objections the patient may have (time, cost, fear, trust, lack of urgency, etc.) Thank you