Workshop Track One: Relationship-centered Communication to Improve Clinical Quality and Patients' Experience of Care Session One: Opening the Patient Encounter, Building Rapport, and Setting the Agenda AACH ENRICH 2011

Objectives for Session 1 Build rapport amongst workshop participants Define skills and attitudes needed for patient- centered interviewing Define the skills for opening a clinical encounter and creating an agenda Practice the skills for opening a clinical encounter and negotiating priorities to create an agenda Identify skills you commit to practicing to improve patient/family outcomes and experience of care

Agenda for Session 1 Build rapport Learning goals

ARTS - Attend to Relationships with the ARTS of Communication Ask first for the other’s perspective Cone in the box Ladder of Inference Respond with empathy Tell your perspective Seek solutions

THE CONE IN THE BOX

BE AWARE of the Ladder of Inference I take actions based on my beliefs I adopt beliefs I draw conclusions I make assumptions I select “data” Observable “data” (After Argyris, Schön)

Example John, the intern, arrives with his coat on John didn’t pre-round! John only cares about himself John is lazy and cannot be trusted These Prelim interns are dangerous I am spiteful to him during rounds Rounds are Beginning

Open-ended Questions  Are difficult to answer with brief replies or simple “yes” or “no” answers.  Contain an element of surprise; you don’t really know what the patient will say.  Are conversational door-openers that encourage the patient to talk.

Open and Closed Questions Quiz When was the last time you smoked? What would make going to the diabetes education program worthwhile? How is it going with the Prozac? Tell me about your headache. When did it start? Take me back to the beginning

Open Questions Activity Speaker: Something you feel two ways about Listener: Use only open-ended questions/statements.

Definitions Biopsychosocial Patient-Centered Interviewing Clinician-Centered Interviewing Integrated Clinician-Centered and Patient Centered Interviewing PROBLEM: Isolated Clinician- Centered Interviewing

Why Integrate Patient-Centered Skills into the Encounter? Numerous Studies Document Isolated Clinician-Centered Interviewing: –Premature interruption of patient fail to address patient’s concerns and agenda –Ignore personal information “(S)he didn’t listen to me…” –Little use of empathy “(S)he doesn’t seem to understand me or care…”

Integrating Patient-Centered Interviewing Results In... More Reliable and Valid Data –More “Scientific” Better “Intermediate” Health Outcomes –patient recall, understanding –medication adherence Better “Ultimate” Health Outcomes –faster symptom resolution (eg., PUD) –better control of BP, HgBA1C, pain –shorter post-operative and perinatal stays

Integrating Patient-Centered Interviewing Results In... Better “Social” Outcomes –less doctor-shopping –greater patient satisfaction –Fewer malpractice lawsuits –greater CLINICIAN satisfaction

How to improve competence with patient-centered interviewing? Consider the medical interview as a procedure –“reframe” as procedure Gain knowledge of the procedure, practice the skills of the procedure, cultivate an attitude of valuing competence in the procedure –Break it down into manageable steps –Even the “art” of interviewing is learnable and teachable

Integrated Patient-Centered and Clinician-Centered Interviewing Middle Physical Exam Pt Centered Beginning: Patient-Centered = Psychosocial and Symptom Data Middle: Clinician-Centered = Symptom and Psychosocial Data Clinician synthesizes… BIOPSYCHOSOCIAL STORY -- HPI, PMH, Meds, All., FH, SH, ROS] EducationEducation HPI ----[CC, Modified from Smith, RC. Patient Centered Interviewing. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, Greet 1 Set Agenda 2 Beginning 3,4,5 90% Pt Centered 10%

Step 1: Setting the Stage (1 min) Welcome the patient Use the patient’s name Introduce self and identify specific role Ensure patient readiness and privacy Remove barriers to communication Ensure comfort and put patient at ease

Step 2: Chief Concern and Agenda Setting (1-2 min) Indicate time available Indicate own needs Obtain list of all issues patient wants to discuss; e.g., specific symptoms, requests, refills, forms, expectations, understanding Summarize and finalize the agenda; negotiate specifics if too many agenda items

Demonstration

Skills Practice