BASIC DOCTOR SKILLS EM Conference 5/15/08 Joshua Rocker, MD Pediatric Emergency Medicine Schneider Children’s Hospital

Much of this talk is extracted from articles I read and a lecture I heard from Robert Strauss, MD (EM attending in Poughkeepsie, NY)

What makes a good ER doc?

Are you a good ER doc? ?

How can I become a better ER doc? ?

How do we measure our abilities? ?

What the ACGME expects of you- Core Curriculum! Patient Care Medical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice

Are your thoughts and the ACGME’s consistent?

Why not?

Because… Competitive med school/residency atmosphere (skills, knowledge based) Teaching communication/ compassion/professionalism is not easy It requires the educator to be a good communicator and that is not simple It requires confronting residents regarding personal issues

Another measure of our performance Press-Ganey Scores

5 Press-Ganey Scores (MD) Did the doctor spend enough time with you? Did the doctor keep you informed in a language you understand? Did the MD seem attentive to your questions and worries? Was the MD friendly and caring? Did you trust your MD?

Press-Ganey Scores… Did they ask about skills or knowledge? What are your mother’s or grandmother’s comments about their doctors?

What we notoriously do Interrupt patients early in the encounter Fail to identify and prioritize patient’s concerns Miss opportunities to understand and acknowledge patient’s ideas and feelings Fail to understand importance of culture and ethnicity

More things we do wrong Minimize patient’s role in their own care Underestimate pts health literacy Don’t negotiate differences well Don’t give bad news concisely and compassionately

Communication Skills When was the last time someone commented on your communication skills? Towards colleagues? Towards patients?

Communication Skills Was that feedback helpful? Was it constructive? Did it change your behaviors?

OKAY, IS THIS HOUR GOING TO BORE ME?

Why waste my time with this med school bullshit!

Localio, NEJM, 7/91 For every 7.6 negligent adverse event there is only 1 lawsuit

Levinson, JAMA, 2/97 Comparing MDs with no lawsuits and MDs with lawsuits Those with no cases Educated pt re: expectations Sense of Humor Solicited pt opinion Checked pt understanding Encourage pt to talk Spent more time on routine visits

Hickson, JAMA, 10/94 Comparing Ob/Gyns with little to no lawsuits vs those with many Quality of care, same Perception of care, different

Basic facts about proper communication skills Greater patient and clinician satisfaction Greater patient understanding and acceptance of treatment plan Reduce patient distress FEWER LAWSUITS

Marvel, JAMA, ‘99 25% of FM MDs in their offices did not solicit pts concern, ask why pt was there, or how they can help 28%- did all Time difference between their interactions:

Marvel, JAMA, ‘99 25% of FM MDs in their offices did not solicit pts concern, ask why pt was there, or how they can help 28%- did all Time difference between their interactions: 6 Seconds

I am what I am… “Meaning well and trying hard do not guarantee a good outcome.” “It takes 18 months to 2 years to change a behavior… and you’ve really got to want to.” Harles Cone

I can’t change! Interventions directed to improve clinician- patient communication demonstrated Better patient self-management of DM Reduction of post-op morbidity Better coping and quality of life with cancer

SKILLS 1. Identify and remove barriers to communication Physical Psych/Social Cultural

SKILLS 2. Survey patient’s concerns Ask Don’t just listen to the facts/details, sense their emotions

SKILLS 3. Care Listen with eyes and body Remain silent Be empathic

SKILLS 4. Negotiate a consensual agenda Work with patient Make sure they understand and agree with plan, otherwise… non-compliance (whose fault is that!)

Josh, wake up… that will take forever

Evidence shows that these skills and the skills of making explicit empathic and caring statements in the end saves time

Albert Mehrebian on Persuasion (%) Verbal content Vocal Expression Visual Cues

Albert Mehrebian on Persuasion (%) Verbal content 7% Vocal Expression38% Visual Cues55%

Mehrebian on Persuasion We tend to overemphasize the content, to convince them with words. If they are not getting it, perhaps… you’re not delivering it

Gorlin, NEJM, ‘83 MDs frequently react to difficult situations with avoidance Become hostile/angry Feel Loss of control

Gorlin, NEJM, ‘83 Recommendations- Acknowledge your response Accept response is justified, but ill advised (Raul May- “What makes us humans is the time between impulse and action.”)

Clip of interaction….