1 Doctor Patient Communication dr. Rima Viliūnienė Clinic of Psychiatry
2 The interview The task in medicine a practitioner will do the most often and spend the most time on from now until he or she retires. An average primary care practitioner may do between as many as 250,000 interviews in a professional lifetime of 40 years; Therefore it is worth doing expertly, cogently, and efficiently.
3 A famous heart surgeon is reported to have admitted that "most doctors don't want their patients to understand them because they prefer to keep their work a mystery. If patients don't understand what a doctor is talking about, they won't ask him questions. Then the doctor won't have to be bothered answering them" (Robinson, 1973). Such a physician-centered interviewing style has been said to dominate the delivery of most medical care in the United States today.
4 In the 1970s, the interview was the subject of charisma and speculation. Teaching was based on the precept that students should do as the teachers do. Some deans and program directors believe skill in the interview just requires talent. It is true that each trainee has a unique complex of interactive strengths and weaknesses, some beginning stronger than others.
5 A variety of authors, in the United States, the Netherlands, and the United Kingdom have shown that simple efforts to improve interviewing skills will succeed in changing behavior and improving clinical care.
6 Undergraduate or graduate medical training that does not explicitly address the recognition and management of the emotional aspects of general medical illness may, therefore, not prepare trainees adequately for their future practice of medicine. Training in communication skills has been shown to be effective in improving detection and management of psychiatric illness in primary care as well as overall clinician -patient rapport. Roter, DL, et al. Improving physicians interviewing skills and reducing patients emotional distress. A randomized clinical trial. Arch Intern Med. 1995; 155( 17): Jenkins, V, Fallowfield, L. Can communication skills training alter physicians beliefs and behavior in clinics? J Clin Oncol. 2002; 20( 3):
7 The opposite is equally true. Those interviewing without adequate training and supervision are likely to make one or more serious errors regularly. This will damage diagnostic ability, practitioner satisfaction, and patient satisfaction and adherence.
8 Communication should facilitate recognition of the link between a patient s mental state and the physical experience of illness. Communication should go beyond biomedicine to reflect and respect the patient s experience of life.
9 The evidence Mumford and associates, reviewed 34 controlled studies of emotionally supportive or educational interventions after surgery or myocardial infarctions. Patients in the experimental groups suffered fewer physical and emotional complications of illness and they were discharged from hospitals an average of 2 days earlier than were patients in the control groups. Mumford, E, Schlesinger, HJ, Glass, GV. The effect of psychological intervention on recover from surgery and heart attacks: an analysis of the literature. Am J Public Health. 1982; 72( 2):
10 Evidence Other studies indicate that patients who are more satisfied with their physicians are more likely to adhere to treatment recommendations and that physicians who are more skilled in the emotional domain of patient interaction are likely to have more satisfied patients. Suchman, AL, et al. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Med Care. 1993; 31( 12): Roter, DL, Hall, JA. Communication and adherence: moving from prediction to understanding. Med Care. 2009; 47( 8):
11 Evidence Health care providers who have been trained in interviewing skills have been shown to be better able to detect and manage emotional distress in their patients who in turn report better emotional outcomes. Roter, DL, et al. Improving physicians interviewing skills and reducing patients emotional distress. A randomized clinical trial. Arch Intern Med. 1995; 155( 17):
12 Similarly, patient centeredness on the part of the physician, partnership, and participatory decision making between the physician and the patient have been shown to lead to improved physical outcome in hypertension, diabetes, and arthritis. Stewart, MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995; 152( 9):
13 A basic tenet of the biopsychosocial model of illness is that physicians who are both aware of the psychosocial dimensions of illness and skilled in the assessment and management of these variables will deliver optimal patient care.
14 Research indicates that physicians who are better able to respond to patients' emotional distress report higher satisfaction of their own. Suchman, AL, et al. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Med Care. 1993; 31( 12):
15 Although approximately 20% of medical patients suffer from significant psychiatric disorders (primarily anxiety, depression, and substance abuse), studies indicate that, in general, their primary care physicians do not recognize half of these disorders. Mant, A. Is it depression? Missed diagnosis: the most frequent issue. Aust Fam Physician. 1999; 28( 8): 820.
16 Patients who were asked to discuss their illness and its treatment (even immediately after leaving their physicians' offices) could correctly identify only about 50% of critical information. (1) Additional research demonstrates that about 50% of patients do not know the medications they are supposed to take. (2) (1) Stewart, M. Patient recall and comprehension after the medical visit. In: Lipkin M, Jr., eds. The medical interview: clinical care, education, and research. NY. P: Springer; 1995: (2) Kravitz, RL, et al. Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med. 1993; 153( 16):
17 Patient nonadherence Hundreds of studies indicate that between 22% and 72% of patients do not follow their doctors' recommendations. The percentage of nonadherent patients varies according to illness category (e.g., 23% nonadherence in medications for acute illness vs. 45% for illness prevention) and outcome measured (e.g., 54% nonadherence to appointments for prevention and 72% nonadherence to diets). It is worth noting, however, that these numbers, in general, do not vary according to the educational level or socioeconomic status of the patient.
18 Noncompliance with prescribed medication regimens has been shown to be a significant cause of hospital admissions (Ley, 1988). Additional studies have revealed that patient compliance with prescribed medication falls to around 50% by the second visit to the physician and continues to fall to about 30% by the fifth visit (Phillips, 1988). It has been reported that as many as 50% of patients leave a physician's office or clinic with little or no idea of what to do to care for themselves. They don't have even a rudimentary understanding of their medical problem, and they can't describe the treatment that is prescribed for them (Svarstad, 1976).
19 Build the Relationship Clinicians with good relationship skills will have patients who are more satisfied and who will be more likely to adhere to treatment recommendations. Roter, DL, Hall, JA. Communication and adherence: moving from prediction to understanding. Med Care. 2009; 47( 8):
20 Clinicians with good relationship skills will have patients who are much less likely to sue them when unexpected bad outcomes occur or even when mistakes are made. Cole, S. Reducing malpractice risk through more effective communication. Am J Manag Care. 1997; Frank, GW. Malpractice claims and physicians communication patterns. JAMA. 1997; 277( 21): Beckman, H. Communication and malpractice: why patients sue their physicians. Cleve Clin J Med. 1995; 62( 2):
21 The patient should be considered an expert in his or her own right and therefore to have unique perspectives and valuable insights into his or her physical state, functional status, and quality of life.
22 Communication should facilitate recognition of the link between a patient s mental state and the physical experience of illness. Communication should go beyond biomedicine to reflect and respect the patient s experience of life.
23 The practitioner with good relationship skills will cope with emotionally troubling situations more easily and will, in general, find the clinical practice of medicine more enjoyable. Such a physician will be able to give more to patients emotionally and will, in turn, get more satisfying responses from them. Suchman, AL, et al. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Med Care. 1993; 31( 12): Suchman AL, Hinton-Walker P, Botelho RJ, eds. Partnerships in healthcare: transforming relational process. Rochester: University of Rochester Press, 1998.
24 In general, research documenting the relevance of physician-patient relationships to the outcome of illness emanates from a theoretical perspective called the biopsychosocial model of illness. (1) This view of illness asserts that psychological and social variables play a key role in the development, course, and outcome of all illnesses. Persuasive scientific evidence supports this model: meta-analysis of 27 prospective studies demonstrates that psychosocial stress predicts the subsequent onset of upper respiratory infections; (2) metaanalysis of more than 300 studies indicates that acute and chronic stress is associated with significant impairments of multiple measures of immune functioning; (3) depression or depressive symptoms are associated with a twoto fivefold increase in post-mi and post-cabg complications or death; (4,5) depression predicts subsequent development of coronary artery disease, cerebrovascular disease, and diabetes; (4) low social support has been associated in prospective studies with subsequent death, even after controlling for other health-related variables such as previous health status, smoking, visits to the doctor, and social class; meta-analysis of 18 prospective studies shows that stress is associated with onset and course of inflammatory bowel disease. (6) Numerous other studies and reviews of similar data are available. 6, 7-12, 1 Engel, GL. The need for a new medical model: a challenge for biomedicine. Science. 1977; 196( 4286): Pedersen, A, Zachariae, R, Bovbjerg, D. Influence of psychological stress on upper respiratory infection A meta-analysis of prospective studies. Psychosom Med. 2010; 72: Segerstrom, SC, Miller, GE. Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychol Bull. 2004; 130( 4): Rozanski, A, et al. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol. 2005; 45( 5): Blumenthal, JA, Lett, HS. Depression and cardiac risk. J Cardiopulm Rehabil. 2005; 25( 2): Zanbelt, LC, et al. Medical Specialists patient-centered communication and patient-reported outcomes. Med Care. 2007; 44( 4): Camara, RJ, et al. The role of psychological stress in inflammatory bowel disease: quality assessment of methods of 18 prospective studies and suggestions for future research. Digestion. 2009; 80( 2): Grippo, AJ, Johnson, AK. Stress, depression and cardiovascular dysregulation: a review of neurobiological mechanisms and the integration of research from preclinical disease models. Stress. 2009; 12( 1): Zupancic, ML. Acute psychological stress as a precipitant of acute coronary syndromes in patients with undiagnosed ischemic heart disease: a case report and literature review. Prim Care Companion J Clin Psychiatry. 2009; 11( 1): Karasek, R. The stress-disequilibrium theory: chronic disease development, low social control, and physiological de-regulation. Med Lav. 2006; 97( 2): Takkouche, B, Regueira, C, Gestal-Otero, JJ. A cohort study of stress and the common cold. Epidemiology. 2001; 12( 3): Gwaltney, JM, Jr., Hayden, FG. Psychological stress and the common cold. N Engl J Med. 1992; 326( 9):
25 A study focusing on the first 90 seconds of the medical visit found that the patient s response to the physician s opening question was completed in only 23% of the visits studied. In 69% of the visits, the physician interrupted the patient s opening statement, after an average of only 15 seconds, to follow up on a stated problem. In only one of these visits was the patient given the opportunity to return to, and complete, the opening statement. For those 30% of patients who were allowed to continue, none of their statements took more than 2.5 minutes. Beckman, H. B., & Frankel, R. M. (1984). The effect of physician behavior on the collection of data. Annals of Internal Medicine, 101,
26 A replication of this study some 15 years later found little had changed in physicians attention to their patients agenda; patients initial statements of concern were completed in only 28% of interviews, and their opening statements were redirected after an average of 23 seconds. Marvel, M. K., Epstein, R. M., Flowers, K., & Beckman, H. B. (1999). Soliciting the patient s agenda: Have we improved? Journal of the American Medical Association, 281,
27 Physicians have the duty to share their medical expertise with patients in such a way that this information is clear, relevant, and useful to patients.
28 BENEFITS TO BE DERIVED FROM EFFECTIVE INTERPERSONAL SKILLS *Physicians gather more accurate data and make more correct diagnoses Nurses find out how patients are really feeling Patients have more trust in their caregiver Patient resistance to therapy and management will be reduced Patient catharsis and tension release are facilitated Negative nonverbal communication with patients is reduced Patient problem-solving promoted Health professionals are better equipped to counsel patients with problems in their lives Health professionals are more capable of helping patients cope in situations that exacerbate their disease Health professionals are more effective in dealing with specific groups of patients difficult; aged; dying patients, the bereaved, adolescents, retarded and very young children, the chronically ill *There is higher patient compliance with physicians' instructions There is greater patient satisfaction with visits to physicians There is higher assessment by patients of physicians' technical skills Patients are less likely to become helpless, dependent, and depressed when hospitalized Patients are discharged earlier from hospital Patients change physicians less often and are more likely to return to same practitioner Patients are less resistant to treatment Patients are less apt to bring malpractice suits Patients are less likely to seek out quacks and faith healers Patients are more likely to be optimistic and show a will to live.
29 DiMatteo describes three basic models of the physician-patient relationship: (1) the active-passive model, where the patient is unable to participate in his or her own care; (2) the guidance-cooperation model, where the physician takes the bulk of responsibility for diagnosis and treatment; (3) the mutual participation model, which involves physician and patient making joint decisions about every aspect of care, from the planning of diagnostic studies to the choice and implementation of treatment (DiMatteo, 1991).
30 Proposed by Harvard physicians (Emanuel and Emanuel, 1992 (1) the paternalistic model, where the physician decides what intervention is best and tries to encourage the patient to consent; (2) the informative model, where the physician as the technical expert provides the relevant information and the patient selects the intervention he or she wants; (3) the interpretive model, where the physician provides information on both the medical condition and the risks and benefits of possible interventions. The physician also is a counselor, helping the patient through the process of deciding which values and course of action best fit the personality of the patient; (4) the deliberative model, where the physician, acting as a teacher or friend, engages the patient in a dialogue to empower the patient to consider values and select a course of action that best fits his or her values.
31 Bioethicists suggest that power relations in medical visits are expressed through several key elements, including (1) who sets the agenda and goals of the visit (the physician, the physician and patient in negotiation, or the patient); (2) the role of the patient s values (assumed by the physician to be consistent with his or her own, jointly explored by the patient and the physician, or unexamined); and (3) the functional role assumed by the physician (guardian, advisor, or consultant). Emanuel, E. J., & Emanuel, L. L. (1992). Four models of the physician-patient relationship. Journal of the American Medical Association, 267,
32 TYPES OF DOCTOR-PATIENT RELATIONSHIPS Patient Control Low Physician Control High Low Default Paternalism High Consumerism Mutuality
33 BASIC ELEMENTS IN IDEAL RELATIONSHIPS WITH PATIENTS Patients as active participants Interdependence Joint decision making Empowerment of patients in their health Two-way communication.
34 OTHER TERMS FOR RELATIONSHIPS WITH PATIENTS Mutual problem-solving relationships Patient-centered vs. physician-centered relationships Open relationships Two-way relationships Mutually interdependent relationships.
35 THE RELATIONSHIP IDEALLY SHOULD BE * Person focus as opposed to problem focus Commitment to patients Humanistic professional as opposed to technological soldier Better bedside manner Style of the old family doctor Patient-centered as opposed to physician-centered More concern for patients Caring as well as curing More empathy with patients Treating patients with respect Fostering more patient involvement Compassion for patients Bonding with patients Unconditional, positive regard for patients Seeing patients as persons Listening more to patients Being a teacher to patients.
36 TERM COLLABORATIVE RELATIONSHIP In the collaborative approach the client is an active participant in the diagnosis. Collaborative practitioners view their patients more holistically and are more person-focused than problem-focused. They have a goal of empowering their patients in an ongoing process of self-diagnosis. As a result, patients are more likely to feel satisfied through developing more "fate control" and less likely to feel dependent on the expert.
37 THE THREE FUNCTIONS address three core objectives of the clinicianpatient communication process: (1) build the relationship; (2) assess and understand the patient's problems; and (3) collaborate for management of these problems.
38 The skilled clinician strives to accomplish the three broad objectives defined by the model: (1) to build an effective relationship; (2) to assess and understand the patient's problems; and (3) to collaboratively manage those problems.
39 To build an effective relationship Concerns the relationship and employs skills focused on the emotional domain of the interview, including engagement, rapport, mutual respect, trust, expression of empathy, and development of the affective connection for a working alliance.
40 To assess and understand the patient's problems Uses inductive and deductive informationgathering techniques to diagnose, assess, and understand patient problems as well as the patient as a person who is experiencing those problems;
41 Collaboratively manage problems Relies primarily on education, patient activation, shared decision making, selfmanagement support, and motivational skills to facilitate collaboration for management of patient problems.
42 A basic tenet of the biopsychosocial model of illness is that physicians who are both aware of the psychosocial dimensions of illness and skilled in the assessment and management of these variables will deliver optimal patient care.
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