Improving doctors' communication skills: teaching what is measured 1 2 3 4 L.H. Baker *, M.Greco, M.L.O'Brien, S.Squire Oregon Health and Sciences University, USA Exeter Peninsula Medical School, Universities of Exeter and Plymouth, UK: The Cognitive Institute, Australia: NHS Clinical Governance Support Team, UK bakerlh@teleport.com 1 2 3 4 I so enjoyed the workshop and have talked about it ever since. The skills which we learned about were really interesting and very useable. I think everyone would benefit by attending! (Staff Grade Gynaecologist) This course really works, not like other courses I've been on. (GP) I arrived determined to have a good day and was not disappointed. I like your cognitive-behavioural approach and believe that many of the concepts and skills are transferable to any difficult interpersonal problems. The practical exercises in the afternoon were superb learning exercises with excellent facilitation. It is some time since I came away from an educational day with an immediate grasp of such useful and applicable ideas and skills. (Consultant Anaesthetist)
Improving doctors' communication skills: teaching what is measured Summary 1 2 3 4 L.H. Baker *, M.Greco, M.L.O'Brien, S.Squire Oregon Health and Sciences University, USA Exeter Peninsula Medical School, Universities of Exeter and Plymouth, UK: The Cognitive Institute, Australia: NHS Clinical Governance Support Team, UK bakerlh@teleport.com 1 2 3 4 Doctors respond best to learning that is focused on a specific challenge they face The process of training included receiving specific feedback, identifying a personal goal related to that feedback, exploring specific techniques related to personal goal, practicing techniques with simulated patient/actor Prior to training, doctors were assessed on communication skills by their patients on the DISQ Training began with each participant receiving the results of patient feedback and identifying techniques related to the items they wanted to change on a Ready Reckoner The one-day workshops provided descriptions of skills, video exercises and skills exploration with actor-simulated patients After training, doctors were assessed again using the DISQ Comparisons of pre and post DISQ scores for 25 doctors showed significant improvement Purpose Communication between doctors and patients has been clearly demonstrated to affect many aspects of patient care, including health outcomes. As a growing number of health systems are measuring patient experience of the medical encounter, doctors are receiving feedback on how patients experience their communication. While there are numerous training programs to improve communication, few have demonstrated improvement from the patients' perspective. A training program was developed to assist doctors in focusing their learning on those communication techniques that tie directly to key feedback from their patients. Methodology Prior to training, doctors were assessed on communication skills by their patients on the DISQ, an internationally validated instrument for assessing patient perspective of doctors' interpersonal skills. Training began with each participant receiving a written report on their patients' ratings of their communication skills After individually reviewing feedback, each doctor identified a personal improvement goal related to the DISQ Using a Ready Reckoner, participants identified three specific communication techniques related to the DISQ item of their personal improvement goal Workshop began with presentations and video reviews of the communication techniques on the Ready Reckoner Doctors worked in small groups, rehearsing and exploring their target communication techniques with simulated patients/actors After training, doctors were assessed again using the DISQ
DISQ items and doctor behaviors that can improve patients' report of their experience DISQ Item Welcome the patient Setting the agenda Discover patient expectations Listen to the patient s story uninterrupted Maintain eye contact Make a personal connection Mirroringbodylanguage Matching voice and vocabulary Express empathy Touch and go Check patient understanding Questions Common Language Collaborate on a plan Listen Explain Warmth of Greeting Listening Skills Clarity of Explanation Reassurance Confidence in ability Allows expression of concerns/ fears Respect shown Time given Considers personal context Concern for patient as person
Communication Skills Descriptions Welcome the Patient: When greeting the patient, make eye contact, smile, shake hands, position height to align your eyes with same level as patient's, remove barriers, greet patient's companion and learn their name and role. Agenda Setting: Acknowledge the reason for visit given to staff, What were you hoping to accomplish at this visit today? And what else?, summarize patient's concerns, ask patient to prioritize, What is the one thing you want to make sure happens before you leave here, today?, Doctor explains his/her priorities,. Suggest a shared agenda Discover Patient Expectations: When discussing symptoms, invite the patient to tell you what s/he think might be causing it; Ask about other people in patient's life. When you go home tonight, who will ask you, 'What did the doctor say?' What are they concerned about? Ask patients what s/he thinks should be done to diagnose or treat the problem.. Listen to the Patient's Story uninterrupted: Allow patient to finish opening statement, after you've asked him/her to tell you what they hope to accomplish at the consultation. Maintain Eye Contact, etc.: As much as possible, keep eye contact with the patient. Make a Personal Connection: At each visit, invite the patient to tell you about something non-medical in his/her life. Do not ask about weather or parking. Make a note in your record of the visit. Review the previous visit note before seeing the patient. Mention that personal item at the next visit. I recall you were taking your grandchildren for a holiday at the shore. How did that go? Mirror Body Language: Adopt postures, gestures and expressions Matching Voice and Vocabulary: The patient's perception of understanding and concern can be enhanced by matching his/her: rate of speech, volume of speech, and vocabulary. Empathy: Identify feeling, label it, express concern. Expressing empathy is not necessarily agreeing. Touch and Go: When patient brings up concerns, especially non-medical, empathize with the concern, and then bridge back to the patient's priority items on the agenda you previously set. Check Patient Understanding: Check patient's current understanding and assess new understanding. Questions: Create opportunities for the patient to ask questions. Common Language: Avoid technical terms, use language most patients will understand, use drawings, write down instructions. Names: Use patient's name when greeting, and throughout the consultation, as appropriate. Start with formal name and ask patient, How would you prefer to be addressed? If patient's name is difficult pronounce, acknowledge that difficulty and invite the patient to teach you how to pronounce his/her name. Collaborate on a Plan: Share decision making Explain: Answer questions and provide additional information
Results Patient assessment involved over 2,000 patients completing the Doctors' Interpersonal Skills Questionnaire or DISQ. Results showed that there was a significant improvement in scores for the 25 doctors who completed both pre- and post-disq assessments (p=0.009). Initially, only 28.6% of patients gave their doctors full marks on the DISQ (i.e. 'Excellent' ratings on every question), but afterwards, this figure increased to 37.6%. All questions on the DISQ except for two ('Extent of feeling reassured' and 'My confidence in the doctor's ability') showed significant improvements in score after the workshops. The question with the largest change in 'Excellent' ratings was about the doctor's ability to really listen to the patient. The question with the lowest 'Excellent' rating (before the workshop, ('Amount of time given') rose from 46.15% to 55.58% simulated patients/actors Mean Patient Ratings 4.8 4.7 4.6 4.5 4.4 4.3 4.2 Pre and Post Workshop Mean Ratings Pre workshop mean Post workshop mean 4.1 4 Overall satisfaction Warmth of greeting Listen to me Explanations Feeling reassured Confidence in the doctor's ability Express concerns & fears DISQ Questions Respect Amount of time Personal consideration Concern for me as a person Recommend to my friends
Pre workshop mean Pre total Post workshop mean Post total q1 Overall satisfaction with this visit 4.46 889 4.58 918 0.007 q2 Warmth of greeting 4.46 891 4.60 921 0.001 q3 Ability to really listen to me 4.45 876 4.6 921 <0.001 q4 Explanations of things to me 4.39 879 4.54 922 0.009 q5 Extent of feeling reassured 4.36 881 4.46 921 0.057 NS q6 My confidence in the doctor's ability 4.47 884 4.57 915 0.036 NS q7 Opportunity to express my concerns & fears 4.33 883 4.54 917 <0.001 q8 The respect shown to me 4.54 889 4.68 923 0.001 q9 The amount of time given to me 4.24 884 4.41 916 0.001 q10 The doctor's consideration of my personal situation 4.39 877 4.50 908 0.002 q11 The doctor's concern for me as a person 4.35 886 4.50 910 0.006 q12 The recommendation I would give to my friends 4.47 888 4.58 910 0.009 p Conclusions Training doctors in specific communication techniques that affect patient experience resulted in significant improvement in patient ratings their interpersonal skills. Doctors who receive patient feedback can focus on learning skills relevant to their own learning goals in a communication workshop Tailor training to specifically address the skills that are measured produces significant results The greatest improvement is in the ability to listen The nemesis of the harried doctor, patient perception of amount of time spent, improves significantly with training