The Human Factor: The critical importance of communication and - - PDF document

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The Human Factor:

The critical importance of communication and effective teamwork in providing excellent care

Anna K. Meyer, MD,FAAP, FACS Associate Professor Coach‐UCSF School of Medicine Facilitator, UCSF Center for Enhancement of Communication in Healthcare Faculty in Training, Academy of Communication in Healthcare

It’s Not About the Nail

https://www.youtube.com/watch?v=-4EDhdAHrOg

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Objectives

• Understand the evidence that supports effective communication

approaches.

• Identify techniques for developing a relationship-centered

approach in both patient care and teamwork.

• Inspire you to seek opportunities to develop more skills in

communication.

• Commit to practicing one skill in the next week.

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“Melissa Ho has an uncanny and special communication ability with children, especially

• urs. Our daughter feels so confident and happy

after her visits.”

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Communication as a Precise Skill

• Communication is the most common “procedure” we perform
• Audiology career: 60,000 – 130,000 encounters
• Less training, observation, and feedback than technical training
• Can be learned, improved, and perfected with deliberate practice

+ feedback

“And” vs. “But"

• “I know you would like to not wear hearing aids, BUT they are

important to help you hear.”

• “I heard you wanted to see fewer patients in a day, BUT our financial

situation won’t allow us to cut your schedule back.”

• “I know you would like to not wear hearing aids AND I would like to

hear more about what is hard for you about wearing them.”

• “I heard you wanted to see fewer patients in a day AND I would like to

work with you on how to make your schedule more manageable.”

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Pairs Activity

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Exercise: Think of an activity or part of your life that you really enjoy. Person 1: I really enjoy X… Person 2: You really enjoy X, BUT… Person 1: I really enjoy X… Person 2: You really enjoy X, AND… Switch roles and repeat.

What do Patients Say?

She treated me with kindness and respect. She was very patient and ready to answer any concerns or questions. The provider was incredible!! He communicates compassion & professionalism. After meeting with her I felt assured that we were working together. She truly listens to my concerns…I feel like she is the first doctor I can really trust. He listens with great care.

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What Do Patients Say?

She was not patient. so much technical information and no time to ask questions didn’t even sit down I don't hear well and sometimes I could not really hear what they said, but it wasn't too important. rushing Curt, bordering on rude Dismissive of my questions

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Dickson R et al. J Palliat Med. 2012. Dickson R et al. J Palliat Med. 2012.

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Enhanced communication 

Better Patient Outcomes:

• Improved symptom management
• Adherence to recommendations and advice
• Patient experience

Matthias, et al. Communicating About Opioids for Chronic Pain. Eur J Pain, 2014; Levinson et al, Health Affairs 2010; Dwamena et al, Cochrane Database Syst Rev 2012; Hojat et al, Acad Med 2013; Kennedy et al, Pat Experience J 2014; Safran et al, J Fam Pract 1998; Stewart et al, J Fam Pract 2000; Swayden et al, Pt Ed and Counsel, 2012.

Enhanced communication  Better Outcomes for Clinicians & Teams

• Better meaning in work
• Decreased provider burnout
• Decreased medical malpractice
• Better work environment
• More effective teams
• Improved care across differences

Boissy et al, J Gen Intern Med, 2016; Levinson et al, Patient Educ Couns, 2013; Suchman, Med Care, 1993; Ambady, et al, Surgeon’s Tone of Voice, Surgery, 2002.

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Frustrations and Challenges

What are the things that patients or colleagues say

• r do that:



Create challenges?



Lead to “heart sink” moments?



Keep you up at night?

How Can We Improve?

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Relationship‐Centered Communication

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Sitting down inc r eases per c eption

• f time spent…

 80% of patients prefer for the provider to sit.  Sitting takes no more time than standing.  Patients perceive 40% longer time spent.

19

1.04 1.28 5.14 3.44

1 2 3 4 5 6 Physic ians Sitting Physic ians Standing T ime in minutes.sec onds

Ac tual and Per c eived T ime

• f Pr
• vider

Inter ac tion

Time in minutes.seconds Actual Time Time in minutes.seconds Perceived time

Swayden KJ et al. “Effect of sitting vs. standing on perception of provider time at bedside: A pilot study.” Patient Educ Couns 86(2) 2012:166‐171.

…and per c eption of c ommunic ation impr

• ves
• Patients report a more positive interaction (95% versus

61%).

20

95% 5% 61% 39%

0% 20% 40% 60% 80% 100% Positive Sit Comments (n=19/ 20) Negative Sit Comments (n=1/ 20) Positive Stand Comments (n=11/ 18) Negative Sit Comments (n=7/ 18)

T ype of Comments for Siting and Standing

− Better understanding

• f their condition.

− Provider viewed as more compassionate and caring. − Encouraged patient questions. − Answered all questions. − Took time to listen.

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Eliciting a List of the Person’s Agenda Items

• “Can you tell me what’s on your list to talk about today?”
• Then ask, “What else?”
• Keep asking until until all concerns exhausted – before

delving further

• Negotiate what can be discussed that visit

10/20/2018 21 Marvel et al, JAMA 1999; Heritage et al, JGIM 2007

Eliciting the Agenda

Getting the LIST up front is more efficient….why?

• Patients do not always state their “chief complaint” first.
• “oh, by the way, I’ve also been feeling dizzy….”
• reduces “doorknob” questions from 35% vs 15%

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Example of Negotiating a List

• Establish patient’s priorities:

“Of the things you listed, what is more important to you address today”

• State your perspective:

“I’m most concerned about your fluctuating hearing loss. Like you, I’d like to retest your hearing today and begin to discuss hearing aid options. We will have to schedule the full hearing aid evaluation for another visit.”

• How soon do providers interrupt

patients after asking a question?

• How long will a patient talk if

uninterrupted? 18-23 seconds 90 seconds

• Most important concerns won’t come out
• 75% never finish what they were saying
• Diagnosis difficulty
• What are the risks of not allowing

person to tell their story?

Listening: Aren’t We Opening Pandora’s Box?

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Open/Deepen the Conversation

• Begin with an open-ended request / question
• “Tell me all about your experience with hearing loss.”
• Listen attentively and silently
• Resist the urge to jump to questions
• Embrace the possibility of hearing more of their story
• What IDEAS do you have about what has caused your hearing

loss?

• What CONCERNS do you have about your clinic schedule?
• What EXPECTATIONS do you have for what the hearing aids

will do for you?

Before RCC

• No teenager wants to show that they have

hearing loss, BUT hearing aids will help you because…

• But it can connect directly to your phone!
• Here’s normal hearing, here’s your hearing...
• Hearing aids are important because…
• Excuses:
• Mom never reinforces at home…
• There’s only so much I can do…
• Young people…

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With RCC – Elicit perspectives using The Box (Ida Institute)

No Intervention Hearing Aids Surgery Pros Don't have to wear uncomfortable hearing aids. Hear better at

• school. Get

better grades. Hear better without using hearing devices. Cons Can't hear as well, academic performance poorer. Uncomfortable fit and sound, despite many attempts to make fit more comfortable. Potential complications from surgery.

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With RCC

• “These are all great points you bring up. Based on this list you

made, which option would you be most interested in learning more about?”

• Surgery
• “Wonderful! Let’s partner on that next. So that I have a better idea

what we can discuss next, could you answer on a scale of 1 to 10 (1=not considering surgery; 10=desiring surgery immediately), where would you rate yourself?”

• 6-7
• “May I ask what would make your rating a 8-9?”
• learning about more of the complications of surgery
• Discussed with Dr. Meyer  follow-up with patient during HCC

visit

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SLOW PROCESS

• Patient came back 6 months later and said she wanted to

consider surgery over winter break. (transcanal endoscopic ear surgery)

• In the meantime, for non-surgical ear, requested a hearing aid IF

we could make it more invisible (CIC vs previous BTEs)

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Developing Teams by Relationship-Building

• Work to know the people you work with as people
• Asking open ended questions of team members
• Arranging teambuilding time that focus on the work you do AND the

people you are.

• Tell us something about your name
• Tell us all about your journey to being here in this room.
• I’ve found that our work and our lives are influenced by our

backgrounds and experiences, tell us about a part of your background that you have pride in and also a challenge you have faced.

• Develop curiosity and use active listening when conflicts arise

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Skills Practice



Work in pairs



You will be in two different roles for a minute each

1.

Storyteller describes a recent challenge at work.

2.

Interviewer asks no questions and tells no stories.

1.

Nod or use small verbal agreements

2.

Consider adding reflections without fixing: “Sounds like you tried to help…” “Wow. That sounds really challenging.”

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Debrief

 For the storyteller roles:

What was it like to tell your story and experience reflective listening?

 For the interviewer roles:

How was it to listen without using questions?

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Hearing loss is often “bad news”

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What is Empathy?

https://vimeo.com/130824700

Brene Brown

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Empathy Enhances Efficiency

Made empathic statements Didn’t make empathic statements Internists 17.5 min visits 20 min visits Surgeons 12.5 min visits 14 min visits

Levinson et al, JAMA 2000; Hojat et al, Acad Med 2011 10/20/2018 36

Express empathy:

Make at least one empathic statement

PEARLS:

Partnership: Let’s work together to find a way to manage noisy situations. Empathy: I can imagine how frustrating the tinnitus is for you. Apology: I’m sorry that your hearing has continued to worsen. Respect: I give you a lot of credit for keeping the hearing aids on your child. Legitimization: Most people in your position would feel the same way. Support: I’m going to stick with you as you start this new role in your career.

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Have People Reflect Back

• ART Cycle
• Ask the person to summarize
• Respond/Reflect on what they say
• Teach or Tell more

Before RCC

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S S S S

Soundfield SDT =10 dB HL

Today hearing in the mild to moderate range for tones, but normal for speech… Soundfield responses are not ear specific… Possibly minimal response levels… Can’t rule out hearing loss…

“Downloading”

• n the patient/parent

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After RCC

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S S S S

Soundfield SDT =10 dB HL

I’m always curious to ask parents what they

• bserved during this

test session with the toys. (silence) Would you care to share your

• bservations?

With RCC - ART

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Parent: “Sam did not turn to some of the soft whistle sounds, but I thought he responded to you talking at soft volume.”

OR

Parent: “Sam seemed to hear pretty well.”

OR

Parent: “It was hard to tell because I couldn’t see his face.”

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With RCC - ART

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End with: “When you go home and tell Sam’s [other parent] about Sam’s hearing test today, how might you describe it?”

Hearing and Communication Clinic

• Combined Visit with
• audiology, SLP, social work, pediatric otolaryngology, genetics,

clinic coordinator.

• Before RCC:
• Morning meeting: list of what we want to do
• We decided who on the team the patient would see
• Patient missed opportunities
• Team administrative meetings focused on tasks for the clinic
• Flares of discord between team members

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Hearing and Communication Clinic

• After RCC:
• Gather the list of what want addressed and who the patient

wants to see

• Delineate tasks that would best serve patients needs
• Greater collaboration on patient care
• Better understanding of our patient’s lives
• Team administrative meetings foster connection
• More growth and understanding across differences

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Melissa: How RCC helped me

• More meaningful relationships with patients
• More energy in clinic (Reduced burnout)
• Appointments feel more organized (Eliciting the list)
• Precepting students
• Individualized approaches knowing their perspectives
• Improved interdisciplinary communication
• Less patient confusion; same message
• Improved workplace communication

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Communication Resources

• This presentation is not enough!
• You must practice
• First attempts at skills may not land

authentically…keep trying

• Consider courses in person or online

Commit to a Skill to Practice

• “And” vs. “But”
• Sitting down
• Eliciting a list and negotiating an agenda
• Asking the patient, “Tell me all about X…”
• ICE: Eliciting a patient’s Ideas, Concerns, or Expectations
• Expressing empathy: PEARLS statements
• ART cycle: Asking patient’s what they understand, Reflecting,

Teaching

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Overview of Relationship-Centered Communication Skills

Data gathering/Testing

Modified from Fortin AH 6th, et al. Smith’s Patient Centered Interviewing. 3rd ed. New York, McGraw Hill, 2012

Connect List Agenda Relationship- Centered Skills

Beginning Middle End

Educate Motivate Plan