Communication SkillsCommunication Skills

October 23, 2003October 23, 2003

Moritz HaagerMoritz Haager

Dr. S. PandyaDr. S. Pandya

ObjectivesObjectives

Conflict resolution & negotiationConflict resolution & negotiation• What are the barriers to communication What are the barriers to communication

in the ED?in the ED?• What strategies & models exist for What strategies & models exist for

effectively dealing with conflict?effectively dealing with conflict? Dealing with consultantsDealing with consultants Giving bad newsGiving bad news Telephone adviceTelephone advice

Why are we talking about this?Why are we talking about this? ““teaching physician-physician teaching physician-physician

communication skills in EM training communication skills in EM training programs is in its infancy”programs is in its infancy”

O’Mara. Communication and conflict resolution in O’Mara. Communication and conflict resolution in emergency medicine. Emerg Med Clin NA 17. 1999emergency medicine. Emerg Med Clin NA 17. 1999

““Although the ‘Core Content for Although the ‘Core Content for Emergency Medicine’ includes the topic of Emergency Medicine’ includes the topic of interpersonal skills, there remain no interpersonal skills, there remain no published guidelines for teaching these published guidelines for teaching these skills within an ED residency..”skills within an ED residency..”

Williams et al. Emergency department senior house Williams et al. Emergency department senior house officers’ consultation difficulties: Implications for officers’ consultation difficulties: Implications for training. Ann Emerg Med. 31. 1998training. Ann Emerg Med. 31. 1998

The Importance of CommunicationThe Importance of Communication

““Communication skills are the most Communication skills are the most important determinant of patient important determinant of patient satisfaction with care..”satisfaction with care..”

Brown et al. Effect of clinical communication Brown et al. Effect of clinical communication skills training on patient satisfaction. Ann skills training on patient satisfaction. Ann Intern Med. 131: 822-29. 1999Intern Med. 131: 822-29. 1999

The Importance of CommunicationThe Importance of Communication

“…“…absent appropriate communication absent appropriate communication skills, doctors cannot meet their skills, doctors cannot meet their responsibilities as medical professionals”responsibilities as medical professionals”

““..I do not ever remember having a faculty ..I do not ever remember having a faculty member sitting with me to talk about my member sitting with me to talk about my feelings about death and suffering, or feelings about death and suffering, or attempt to help me reach an attempt to help me reach an understanding about what my patients go understanding about what my patients go through.”through.”

Whitcomb. Communication and professionalism. Whitcomb. Communication and professionalism. Patient education and Counseling 41: 137-44. 2000Patient education and Counseling 41: 137-44. 2000

Historical PerspectiveHistorical Perspective

In my father’s time, talking with the In my father’s time, talking with the patient was the biggest part of patient was the biggest part of medicine, for it was almost all there medicine, for it was almost all there was to do.”was to do.”

Lewis ThomasLewis Thomas

The focus has shifted away from the The focus has shifted away from the pt to focusing on disease with our pt to focusing on disease with our increased ability to accurately Dx & increased ability to accurately Dx & Tx Tx

Barriers to CommunicationBarriers to Communication

ED probably the worst placeED probably the worst place• Divergent pt & physician expectations of Divergent pt & physician expectations of

role of ED & goal of visitrole of ED & goal of visit• Lack of understanding of triage systemLack of understanding of triage system• Patient-doctor relationship arises out of Patient-doctor relationship arises out of

necessity rather than choicenecessity rather than choice• Loud & hectic environmentLoud & hectic environment• Frequent interruptions & lack of privacyFrequent interruptions & lack of privacy• Balancing department flow & addressing Balancing department flow & addressing

pt needspt needs

Barriers to CommunicationBarriers to Communication

Telephone consultationsTelephone consultations Appearance & pt perceptionsAppearance & pt perceptions

• Youthful appearanceYouthful appearance• Female genderFemale gender• Lack of formal dressLack of formal dress

Social, cultural, languageSocial, cultural, language Pt impairmentPt impairment

• EtOH, drugs, disease statesEtOH, drugs, disease states

Language & CultureLanguage & Culture

Huge issue in CanadaHuge issue in Canada Virtually all communications research Virtually all communications research

& models based on western & models based on western principles & values principles & values

Unknown as to how these apply to Unknown as to how these apply to different cultures but easy to accept different cultures but easy to accept that the same question put to that the same question put to persons of different backgrounds can persons of different backgrounds can have tremendously different have tremendously different meaningmeaning

Is there any proof this is a problem?Is there any proof this is a problem?

Taylor et al. Complaints from emergency Taylor et al. Complaints from emergency department patients largely result from department patients largely result from treatment and communication problems. treatment and communication problems. Emerg Med 14: 43-49. 2002Emerg Med 14: 43-49. 2002• Retrospective review of ED complaintsRetrospective review of ED complaints• Found that most likely to complaints were from Found that most likely to complaints were from

very old, very young, females, and non-english very old, very young, females, and non-english speakingspeaking

• 33.4 % related to Dx and Tx33.4 % related to Dx and Tx• 31.6% related to communication31.6% related to communication• 11.9% related to delay in Tx11.9% related to delay in Tx• 71.5 % resolved through communication 71.5 % resolved through communication

alone!!alone!!

Is there any proof this is a problem?Is there any proof this is a problem?

Williams et al. Emergency department senior Williams et al. Emergency department senior house officers’ consultation difficulties: house officers’ consultation difficulties: Implications for training. Ann Emerg Med. 31. Implications for training. Ann Emerg Med. 31. 19981998• Conducted survey of SHO’s working in ED in England Conducted survey of SHO’s working in ED in England

regarding most difficult cases encountered & cause of regarding most difficult cases encountered & cause of difficultydifficulty

• Found that Found that communication problems were a factor in communication problems were a factor in 76% of cases76% of cases compared to lack of knowledge in 52% compared to lack of knowledge in 52%

• This did not change significantly over 4 months implying This did not change significantly over 4 months implying no significant improvement with experiencesno significant improvement with experiences

• Authors conclude that formal communication training Authors conclude that formal communication training may be of benefitmay be of benefit

Communication ProblemsCommunication Problems Views conflicting with pts 40%Views conflicting with pts 40% Pts w/ mental or behavioural problems 24%Pts w/ mental or behavioural problems 24% Intoxicated or aggressive pts 12%Intoxicated or aggressive pts 12% Distressed / anxious pts 7%Distressed / anxious pts 7% Difficult to obtain Hx 10%Difficult to obtain Hx 10% Uncooperative / manipulative pt 5%Uncooperative / manipulative pt 5% Language barrier 3%Language barrier 3% Pt unable to speak or hear 3%Pt unable to speak or hear 3% Children 2%Children 2% Conflict of opinion w/ other staff 2%Conflict of opinion w/ other staff 2%

Williams et al. Emergency department senior house Williams et al. Emergency department senior house officers’ consultation difficulties: Implications for training. officers’ consultation difficulties: Implications for training. Ann Emerg Med. 31. 1998Ann Emerg Med. 31. 1998

Elements of Effective CommunicationElements of Effective Communication

ListeningListening SpeakingSpeaking Receiving feedback effectivelyReceiving feedback effectively

Marco and Smith. Conflict resolution in Marco and Smith. Conflict resolution in Emergency Medicine. Ann Emerg Med. 40: Emergency Medicine. Ann Emerg Med. 40: 347-9. 2002347-9. 2002

Model of Prinicipled NegotiationModel of Prinicipled Negotiation

Separate the people from the Separate the people from the problemproblem

Focus on interests rather than Focus on interests rather than positionspositions

Invent options for mutual gainInvent options for mutual gain Insist on objective criteria in judging Insist on objective criteria in judging

an agreementan agreement Fisher & Ury. Getting to yes. 2Fisher & Ury. Getting to yes. 2ndnd ed. 1991. ed. 1991.

Penguin Book, NYC, New YorkPenguin Book, NYC, New York

The ChallengeThe Challenge

It seems apparent that It seems apparent that communication skills are:communication skills are:• Central to practicing medicineCentral to practicing medicine• A common problem area in the EDA common problem area in the ED• A potential area for improving pt & A potential area for improving pt &

physician satisfactionphysician satisfaction How do we teach communication?How do we teach communication? How do we evaluate whether the How do we evaluate whether the

curriculum works?curriculum works?

Does Specific Training Make a Does Specific Training Make a Difference?Difference?

Langewitz et al. Improving communication skills – A randomized Langewitz et al. Improving communication skills – A randomized controlled behaviorally oriented intervention study for residents in controlled behaviorally oriented intervention study for residents in internal medicine. Psychosom Med 60: 268-76. 1998.internal medicine. Psychosom Med 60: 268-76. 1998.• Randomized 42 residents to intervention (22.5 hrs of Randomized 42 residents to intervention (22.5 hrs of

communications training) & control groupscommunications training) & control groups• Assessment of pt-oriented interview skills in videotaped Assessment of pt-oriented interview skills in videotaped

simulated clinical encounters using Revised Maastricht simulated clinical encounters using Revised Maastricht History and Advice Checklist by blinded observers at 0 & History and Advice Checklist by blinded observers at 0 & 10 months10 months

• Simulated pts also were surveyed for their satisfaction Simulated pts also were surveyed for their satisfaction with the clinical encounter using the American Board of with the clinical encounter using the American Board of Internal Medicine Patient Satisfaction QuestionnaireInternal Medicine Patient Satisfaction Questionnaire

• Found that both groups improved over time, but the Found that both groups improved over time, but the intervention group significantly more than the controlsintervention group significantly more than the controls

• Actors were more likely to recommend physicians from Actors were more likely to recommend physicians from the intervention group to friends or familythe intervention group to friends or family

Assessing Communication SkillsAssessing 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 EP’s and 2 medical educators

• Only able to achieve moderate-excellent inter-observer reliability on 10 of the 32 items

Key Communication SkillsKey Communication Skills IntroductionsIntroductions

• Introduce self by nameIntroduce self by name• Ask or state pt’s nameAsk or state pt’s name• Greet family or friends presentGreet family or friends present• Social overture prior to data Social overture prior to data

gatheringgathering RapportRapport

• Gives comfortGives comfort• Investigates or acknowledges Investigates or acknowledges

emotional response to illness or emotional response to illness or ED experienceED experience

• Gives reassuranceGives reassurance• Talks Pt through physical examTalks Pt through physical exam

Conflict ManagementConflict Management• Clearly acknowledges Pt’s Clearly acknowledges Pt’s

viewpointviewpoint• Attempts to negotiate w/ PtAttempts to negotiate w/ Pt

Information GatheringInformation Gathering• Allows Pt to tell storyAllows Pt to tell story• Uses open-ended questionsUses open-ended questions• Active listening indicatorsActive listening indicators• Checks understanding by Checks understanding by

summarizing informationsummarizing information Contracting / InformingContracting / Informing

• Explains immediate plan for Explains immediate plan for further evaluation & Txfurther evaluation & Tx

• Discusses expected time frameDiscusses expected time frame• Guides expectations of possible Guides expectations of possible

outcomesoutcomes• Checks Pt understanding of info Checks Pt understanding of info

givengiven Non-Verbal CommunicationNon-Verbal Communication

• Position closer to head than feetPosition closer to head than feet• Emphatic & appropriate physical Emphatic & appropriate physical

touchtouch• Appropriate eye contactAppropriate eye contact• Posture oriented toward ptPosture 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

Communication Skills Improve w/ TrainingCommunication Skills Improve w/ Training

Klamen & Williams. The effect of medical education on Klamen & Williams. The effect of medical education on students’ patients satisfaction ratings. Acad Med 72: 57-61. students’ patients satisfaction ratings. Acad Med 72: 57-61. 19971997• Cohort study of 133 medical studentsCohort study of 133 medical students• Compared scores on standardized patient Compared scores on standardized patient

interviews using the American Board of interviews using the American Board of Internal Medicine Patient Satisfaction Internal Medicine Patient Satisfaction Questionnaire in 2Questionnaire in 2ndnd yr with repeat exams in 4 yr with repeat exams in 4thth yryr

• Used medical residents doing same exams as Used medical residents doing same exams as controlscontrols

• Found that mean scores improved over timeFound that mean scores improved over time• Did not perform calculations to determine Did not perform calculations to determine

statistical significance making it difficult to statistical significance making it difficult to draw any conclusionsdraw any conclusions

Consultation RequestsConsultation Requests

Go et al. Enhancing medical student Go et al. Enhancing medical student consultation request skills in an academic consultation request skills in an academic emergency department. J Emerg Med 16: emergency department. J Emerg Med 16: 659-62. 1998659-62. 1998• Simple comparison of taped telephone Simple comparison of taped telephone

consultation requests made by medical consultation requests made by medical students briefly trained with sheet outlining students briefly trained with sheet outlining structure of request with untrained EM structure of request with untrained EM residentsresidents

• Medical students found to use significantly Medical students found to use significantly more likely to use previously identified more likely to use previously identified important criteria of effective consultationimportant criteria of effective consultation

Consultation RequestsConsultation Requests Medical Student Telephone Consultation SheetMedical Student Telephone Consultation Sheet

• Hello Dr.______, this is _______ in the ED. I have a pt I Hello Dr.______, this is _______ in the ED. I have a pt I would like to present to youwould like to present to you

• Pause for acknowledgementPause for acknowledgement• Mr_______ is a ___ yo _______ who comes in today Mr_______ is a ___ yo _______ who comes in today

complaining of ______complaining of ______• Gives relevant Hx and dataGives relevant Hx and data• I think the most likely diagnosis is _____I think the most likely diagnosis is _____• This is what I have done for him already _____This is what I have done for him already _____• I’d like you to evaluate him for ________I’d like you to evaluate him for ________• His condition right now is __________His condition right now is __________• Thank youThank you• Total time should be less than one minuteTotal time should be less than one minute

Go et al. Enhancing medical student consultation request Go et al. Enhancing medical student consultation request skills in an academic emergency department. J Emerg Med skills in an academic emergency department. J Emerg Med 16: 659-62. 199816: 659-62. 1998

Do Communication Skills Seminars Do Communication Skills Seminars Improve Pt Satisfaction?Improve Pt Satisfaction?

Brown et al. Effect of clinician Brown et al. Effect of clinician communication skills training on patient communication skills training on patient satisfaction. Ann Intern Med 131: 822-29. satisfaction. Ann Intern Med 131: 822-29. 19991999• Randomized physicians to taking a 10 hr Randomized physicians to taking a 10 hr

communication skills seminar at different time communication skills seminar at different time pointspoints

• Assessed pt satisfaction using Art of Medicine Assessed pt satisfaction using Art of Medicine Survey scores before and after taking seminarSurvey scores before and after taking seminar

• Found that physicians self-assessment of Found that physicians self-assessment of communication skills was improved, but no communication skills was improved, but no statistically significant change in pt satisfaction statistically significant change in pt satisfaction scores was notedscores was noted

CriticismsCriticisms

Simulated situations – difficult to Simulated situations – difficult to know how this impacts upon pt know how this impacts upon pt satisfaction in real lifesatisfaction in real life

Perhaps the amount of training was Perhaps the amount of training was not enough, or the time for the not enough, or the time for the training to manifest to short to be training to manifest to short to be detectabledetectable

ConclusionsConclusions

Difficult to get a sense from the Difficult to get a sense from the literature that specific courses aimed literature that specific courses aimed at improving communication skills at improving communication skills produce tangible benefitproduce tangible benefit

However this may be as much a However this may be as much a function of the study designs as well function of the study designs as well as the limitations of objectifying as the limitations of objectifying something that is inherently something that is inherently subjective in naturesubjective in nature

Bad NewsBad News

DefinitionDefinition• ““situations where there is either a situations where there is either a

feeling of no hope, a threat to a person’s feeling of no hope, a threat to a person’s mental or physical well being, a risk of mental or physical well being, a risk of upsetting an established lifestyle, or upsetting an established lifestyle, or where a message is given which where a message is given which conveys to an individual fewer choices conveys to an individual fewer choices in his or her life”in his or her life”

Dosanjh et al. Barriers to breaking bad news Dosanjh et al. Barriers to breaking bad news among medical & surgical residents. Med Ed among medical & surgical residents. Med Ed 35: 197-205. 200135: 197-205. 2001

Advance DirectivesAdvance Directives A study of audiotaped discussions about advance A study of audiotaped discussions about advance

directives found:directives found:• Physicians tended to focus on more clear cut scenariosPhysicians tended to focus on more clear cut scenarios

E.g. irreversible brain damage vs. severe infectionE.g. irreversible brain damage vs. severe infection Pretty clear that most pts do not desire intervention when Pretty clear that most pts do not desire intervention when

there is no hope of recoverythere is no hope of recovery• More common, uncertain scenarios were inadequately More common, uncertain scenarios were inadequately

exploredexplored• Pts reasons & values underlying their responses were Pts reasons & values underlying their responses were

also rarely elicitedalso rarely elicited• Concluded that such advance directive discussions are Concluded that such advance directive discussions are

inadequate to properly guide the physician and family in inadequate to properly guide the physician and family in times of crisistimes of crisis

Tulsky et al. Opening the black box: How do physicians Tulsky et al. Opening the black box: How do physicians communicate about advance directive. Ann Intern Med communicate about advance directive. Ann Intern Med 129: 441-9. 1998129: 441-9. 1998

Death NotificationDeath Notification

Unexpected ED deaths are not Unexpected ED deaths are not uncommon (~0.3% of visits)uncommon (~0.3% of visits)

Represent a major source of stress Represent a major source of stress for EP’s particularily if the deceased for EP’s particularily if the deceased was a childwas a child

Little effort focused on teaching how Little effort focused on teaching how to inform relatives of death of a to inform relatives of death of a loved one in medical school or loved one in medical school or residencyresidency

Death NotificationDeath Notification

Buss et al. The preparedness of Buss et al. The preparedness of students to discuss end-of-life issues students to discuss end-of-life issues with patients. Acad Med 73: 418-22. with patients. Acad Med 73: 418-22. 1998.1998.• Surveyed 226 4Surveyed 226 4thth yr medical students yr medical students

about conveying end-of-life issuesabout conveying end-of-life issues• 41% felt they were adequately prepared 41% felt they were adequately prepared

to do discuss this with their ptsto do discuss this with their pts• 27% had actually had such a discussion 27% had actually had such a discussion

with a ptwith a pt

Death Notification in the EDDeath Notification in the ED

Tends to be more difficultTends to be more difficult• Death usually unexpectedDeath usually unexpected• No prior relationship w/ pt or familyNo prior relationship w/ pt or family• Previously noted barriers to Previously noted barriers to

communication in the EDcommunication in the ED• Time demandsTime demands

Death Notification GuidelinesDeath Notification Guidelines Make sure you are speaking to the right familyMake sure you are speaking to the right family Take them to a quiet roomTake them to a quiet room

• Give them a sense that you are not rushing off to see the next Give them a sense that you are not rushing off to see the next ptpt

Sit down with themSit down with them Identify yourself & your roleIdentify yourself & your role Communicate with emotionCommunicate with emotion

• Convey warmth, caring, & empathyConvey warmth, caring, & empathy• Appropriate physical touchAppropriate physical touch• Allow them to dictate the paceAllow them to dictate the pace

Briefly summarize what happened before the pt arrived and Briefly summarize what happened before the pt arrived and while in the EDwhile in the ED• Get a sense from them of how they saw the pt’s healthGet a sense from them of how they saw the pt’s health• Provide warning of what is to comeProvide warning of what is to come

Olsen et al. Death in the emergencyOlsen et al. Death in the emergency department. Ann Emerg department. Ann Emerg Med 31: 758-65. 1998Med 31: 758-65. 1998

Ptacek & Eberhardt. Breaking bad news. JAMA. 276: 496-502. 1996Ptacek & Eberhardt. Breaking bad news. JAMA. 276: 496-502. 1996

Death Notification GuidelinesDeath Notification Guidelines Avoid “medicalese” : Use simple clear language – tell them Avoid “medicalese” : Use simple clear language – tell them

the pt “died” rather than euphemismsthe pt “died” rather than euphemisms Reassure them everything possible was doneReassure them everything possible was done

• This includes reassuring them that they did the right thingsThis includes reassuring them that they did the right things Expect & allow for grief responseExpect & allow for grief response

• Expect a range from pathologic grief to anger & resentmentExpect a range from pathologic grief to anger & resentment Let them see the bodyLet them see the body

• Body & resus room should be cleaned as much as possibleBody & resus room should be cleaned as much as possible• Prepare family for what they will seePrepare family for what they will see• If body terribly disfigured may want to discourage viewingIf body terribly disfigured may want to discourage viewing

Ask about tissue donation & autopsyAsk about tissue donation & autopsy Encourage them to ask questionsEncourage them to ask questions Provide them with follow-up supportProvide them with follow-up support

• Offer clergy or social worker supportOffer clergy or social worker support Olsen et al. Death in the emergency department. Ann Emerg Med Olsen et al. Death in the emergency department. Ann Emerg Med

31: 758-65. 199831: 758-65. 1998 Ptacek & Eberhardt. Breaking bad news. JAMA. 276: 496-502. 1996Ptacek & Eberhardt. Breaking bad news. JAMA. 276: 496-502. 1996

Autopsy RequestAutopsy Request Why do them?Why do them?

• Explanation of unexpected deathsExplanation of unexpected deaths Can help improve care in ~50% of cases by clarifying Can help improve care in ~50% of cases by clarifying

Dx or guiding researchDx or guiding research Can help grieving process (i.e. everything was done Can help grieving process (i.e. everything was done

that could be done)that could be done)• Discovery of new diseasesDiscovery of new diseases• Quality assuranceQuality assurance• Vital statisticsVital statistics• Validation of diagnostic testsValidation of diagnostic tests• Dx of genetic or infectious Dz and subsequent Dx of genetic or infectious Dz and subsequent

Tx of affected contactsTx of affected contacts Olsen et al. Death in the emergency department. Olsen et al. Death in the emergency department.

Ann Emerg Med 31: 758-65. 1998Ann Emerg Med 31: 758-65. 1998

Organ DonationOrgan Donation ED deaths will be limited to ischemia-ED deaths will be limited to ischemia-

resistant tissues:resistant tissues:• Liver, kidney (if ongoing CPR)Liver, kidney (if ongoing CPR)• CorneaCornea• BoneBone• SkinSkin• Tendon & fasciaTendon & fascia• CartilageCartilage• VeinsVeins• Heart valvesHeart valves

Olsen et al. Death in the emergency department. Olsen et al. Death in the emergency department. Ann Emerg Med 31: 758-65. 1998Ann Emerg Med 31: 758-65. 1998

Organ DonationOrgan Donation

Contra-indications to organ donationContra-indications to organ donation• Infectious diseaseInfectious disease• Cancer (can donate corneas)Cancer (can donate corneas)• Toxic exposures (some exceptions)Toxic exposures (some exceptions)

Olsen et al. Death in the emergency Olsen et al. Death in the emergency department. Ann Emerg Med 31: 758-65. 1998department. Ann Emerg Med 31: 758-65. 1998

Organ DonationOrgan Donation

How to askHow to ask• Wait until after family has viewed bodyWait until after family has viewed body• Put in terms of letting pt have one final Put in terms of letting pt have one final

act of goodwillact of goodwill E.g. Do you think _____ would have wanted E.g. Do you think _____ would have wanted

to help someone else as his/her final act to help someone else as his/her final act here by becoming an organ donor?here by becoming an organ donor?