Therapeutic relationships and the illusion of communication Lisa Roberts PhD MCSP Arthritis Research UK Senior Lecturer in Physiotherapy / Consultant Physiotherapist University Hospital Southampton

Plan The challenge of communication Issues of truth telling Current research Opening clinical encounters Implications for practice

‘The most important aspect that health professionals have to master’ Communication is ….. ‘The most important aspect that health professionals have to master’ Weatherall (1998)

Communication Importance of: Verbal communication Non-verbal (55-97%) Patient-therapist relationship

Poor communication 80% of patients’ complaints arise from a breakdown in communication Towles BMJ;1998:301-4

Non-specific treatment effect Touch Showing interest (Hawthorne effect) Professionalism Actively listening Environment Technical equipment Placebo effect ….

The most important thing in communication is to hear what isn't being said. Peter Drucker

Why do we tell lies? To reduce fear To tolerate stress To gain control over uncertainty Superstition To enhance well-being To protect privacy / confidentiality To help others To be malicious

Physiotherapists’ perceptions… …of the most important factors in successful treatment patient-therapist relationship patients’ resources More important to success than treatment techniques Stenmar & Nordholm. Physical Therapy 1994;74:1034-9.

Aim of the pilot study To measure the content and prevalence of the verbal and non-verbal communication that occur between physiotherapists and patients with low back pain in an outpatient setting. Roberts L & Bucksey SJ. Communicating with patients: what happens in practice? Phys Ther 2007; 87: 586–94

Patients (n = 21) Physiotherapists (n = 7) Video recording: Initial treatment session (n=21) Key findings Verbal & non-verbal communication can be measured with valid and reliable tools Affective behaviours were more prevalent among experienced physiotherapists Video camera was perceived to influence communication, planning and treatment Roberts & Bucksey Physical Therapy 2007;87(5):586-94

Communication and clinical decision making in low back pain consultations Funded by Arthritis Research UK 'What communication and clinical decision making takes place in consultations between physiotherapists and people with back pain?'

Observation of initial back pain consultation Patient interview Home visit Observation of initial back pain consultation Physio interview

Wessex Medical Research: Student Innovation Grant 2009 “Piloting an analysis of verbal communication using Synote in consultations between physiotherapists and people with back pain.” The aim of this study is to pilot an analysis of verbal communication using “Synote” in consultations between physiotherapists and people with back pain. The Wessex Medical Trust has awarded a Student Innovation Grant which aims to attract the interest of students in the second or subsequent years of an undergraduate course who may be considering applying for post-graduate courses. During the first study, Dr Lisa Roberts (School of Health Sciences) collected audio-data (and transcripts) from 25 initial consultations between physiotherapists and patients with back pain from a secondary care setting.  This work is to pilot data management using Synote.  This software package, developed by the University of Southampton, can be used to create bookmarks (or ‘Synmarks’) containing notes and synchronise them with the audio recordings and transcripts. Synote has a unique feature which enables the user to find and replay parts of the recordings: (while other software may allow researchers to bookmark and search a whole recording, only Synote will enable the data to be managed in this way).  This approach, using Synote, will enable further analysis of the data using a valid outcome measure of verbal communication: the Medical Communications Behaviour System (MCBS).  The MCBS has categories for informational (‘content’), relational (‘affective’) and negative behaviour for both clinicians and patients, with subdivisions of 13 clinician ‘behaviours’, 7 patient ‘behaviours’ and 3 miscellaneous categories.  Using Synote in conjunction with the MCBS has not been done previously. Christopher Whittle University of Southampton

Synote http://www.synote.org/synote/

Analysis Grounded theory approach Data managed through ‘Framework’ 27 home visits 25 initial consultations 25 interviews with physiotherapists 25 interviews with patients

Expectations data Knowledge: Technical Life Skills: Interpersonal Personal attributes: Appearance Manner

Opening questions ‘How can I help you today?’ ‘Do you want to tell me your story’ ‘I’ve had this referral through. Tell me what’s happened’ ‘What problem are you having at the moment?’ How long have you had back pain for? It’s your back pain that you’re here for is it?’ The referral says you’ve got back pain. Is this correct? ‘What we’ll do today is just have a bit of a chat about your back pain I believe it is. All right?

Clinical implications How do you open your clinical encounters? How often do you interrupt your patients? Do you tailor your communication to take account of gender and age? When was the last time you told a ‘little white lie’? Have you spent time evaluating your communication skills? How will you maximise your non-specific treatment effects?