AUSTRALIAN INSTITUTE OF HEALTH INNOVATION Faculty of Medicine and Health Sciences Tales of Give and Take Communication and the Diagnostic Odyssey Dr Mary Dahm , Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University. @DrMaryDahm AIHI Seminar Series, Macquarie University. 28 May 2019
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION Faculty of Medicine and Health Sciences Welcome to LING101 AN INTRODUCTION TO LINGUISTICS Linguistics Myths • Linguists speak many languages. They don’t (or not all).
Sing to me of the man, Muse, the man of twists and turns driven time and again off course... Homer. Odyssey Volume I: Books 1-12 (ca. 8 th century B. C., translation Robert Fagles, 1990). Ulysses Deriding Polyphemus, 1829 by JMW Turner (1775–1851), National Gallery London.
Failures in the Diagnostic Process 5 IOM. Improving diagnosis in healthcare (2015)
Failure to gather or interpret information? Premature closure Anchoring Diagnosis Framing Momentum effect Confirmation bias Unpacking principle Ulysses and the Sirens, 1891 by JW Waterhouse (1849–1917), National Gallery of Victoria, Melbourne. 6
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION Faculty of Medicine and Health Sciences Failure to gather information 7
Failure to gather information Bluey. Hospitals (2 OCT 2018). Joe Brumm, ABC, Ludo Studio 8
Patient – interrupted 33 35 28 30 23 25 23 20 Time in seconds 18 15 10 11 5 0 1984* 1999~ 2019# Study years Patient speaking time (in seconds) before 1st interuption % of patient who completed initial statement *Beckman & Frankel, Ann Int Med, 101 (1984):692 , ~Marvel et al., JAMA, 281 (1999):283. 9 #Ospina et al., J Gen Int Med, 34 (2019):36
Unpacking principle • The failure to elicit all relevant information (unpacking) in establishing a differential diagnosis may result in significant possibilities being missed • !!! if the gathering of history information is limited, potential alternative diagnosis may be discounted. Croskery. Acad Med 78.8 (2003):775-780 10
Patient – un-interrupted “In all cases doctors felt that the patients were giving • 331 patients important information and • Mean 92s speaking time • 78% patients speak < 2m should not be interrupted.” Langewitz, Wolf, et al. BMJ 325.7366 (2002): 682-683 11
What’s in a word? SEMANTICS Anamnesis – Receiving a Memory History taking – Taking a Record 12 Mosby's Dictionary of Medicine, Nursing & Health Professions, 10th Edition, 2016
Tales of Give and Take RECEIVING (NOT TAKING HISTORY) • “We weren’t trained to listen . We were trained to ask questions that steered people to a destination […] In turn we were given answers that fit neatly in checkboxes.” • “We didn’t receive a history from people. We didn’t sit and listen as it unfolded. […] If we can't be present to receive the story , we can't serve the patient. We can't be the physicians that we want to be.” ** Patient-centred communication skills as solution ** From an interview on Good Life Project Podcast 28 Feb 2018 13 “Choosing Not to Die, When Doctor Becomes Patient – Dr Rana Awdish”
Patient- centred communication skills The little things we do, often without noticing… • More approachable • Increased trust • Better patient participation • Better rapport 14 Dahm & Yates. TESL Canada 30.S7 (2013):21
The thing about time… 15
Oh, by the way… • Patients introduced new topics in 21% of closing phases • New problems associated with • less information exchanged previously by doctors and patients and • less orientation statement by doctors OFFICE | FACULTY | DEPARTMENT 16
It really is the little things…. 17
It really is the little things “what’s happened” vs “what happened” • shorter reports (9 s vs. 18 s, p < 0.001) • less time to dispatch (50 s vs. 58s, p = 0.002) 18
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION Faculty of Medicine and Health Sciences Failure to interpret information 19
Failure to interpret information 20 Bluey. Hospitals (2 OCT 2018). Joe Brumm, ABC, Ludo Studio
Premature closure & Diagnosis momentum • Premature closure : It is the tendency to accept diagnosis before it has been fully verified. • Diagnosis momentum : once diagnosis labels are attached to patients they tend to become stickier and stickier […] what might have started as a possibility gathers increasing momentum until it becomes definite, and all other possibilities are excluded. Croskery. Acad Med 78.8 (2003):775-780 21
Patient is a poor historian and denies, complains, fails, refuses… Fisher, Age & Aging 45 (2016):11-13 Coulehan, JAMA 252.2 (1984):221 22
Neutral Stigmatising still has 10/10 pain insisting that his pain is “still a 10” He spent yesterday afternoon with hanging out with friends outside friends McDonald’s he is not tolerating the oxygen mask he refuses his oxygen mask = significantly more negative attitudes towards the patient = less aggressive management of the patient’s pain 23
Challenging failures – just check it a bit closer NSW Clinical Excellence Commission • Red Team - Blue Team Challenges Second review of: • Samples, test results, film or • Generated or • Ungenerated hypothesis • Interpersonal skills 24
Diagnostic safety net 25
Communication as a Diagnostic Tool “Communication is a key responsibility throughout the diagnostic process .” IOM, 2015 “For all the sophisticated diagnostic tools of modern medicine the conversation between doctor and patient remain the primary diagnostic tool.” Danielle Ofri, 2017 26
Even the little things we say (or don’t say) and how we say them can have a big impact on the diagnostic process and patient safety. 27 The Return of Ulysses to Ithaca, ca. 1710s, by Gerard de Lairesse (1640- 1711), Kunstpalast Düsseldorf, Germany
AUSTRALIAN INSTITUTE OF HEALTH INNOVATION Faculty of Medicine and Health Sciences Thank you. ANY QUESTIONS? 28
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