1. Foundation Doctor Teaching 18/11/09
COMMUNICATION SKILLS
Foundation Doctor Teaching
18/11/09

2. Objectives
To understand the difference between a patient-centred and a doctor-centred approach
To explore the advantages and disadvantages of both these approaches
To identify specific strategies to elicit the patient’s agenda
To apply this to breaking bad news

3. All talk
But no trousers?

4. Or the holy grail for the ultimate Doctor?

5. Models and theories
1957 : M Balint - The Doctor, His Patient and The Illness
1964 : E Berne - Games People Play
1975 : Becker & Maiman - Sociobehavioural Determinants of Compliance
1975 : J Heron - Six Category Intervention Analysis
1976 : Byrne & Long - Doctors Talking to Patients
1977 : RCGP definition - Physical, psychological & social
1979 : Stott & Davis - The Exceptional Potential in Each Primary Care Consultation
1981 : C Helman - Disease vs Illness in Gen Practice
1984 : Pendleton et al - The Consultation
1987 : R Neighbour - The Inner Consultation
1987 : R C Fraser - Clinical Method: A Gen Pract Approach
1996 : Kurtz & Silverman The Calgary-Cambridge Observation Guide to The Consultation

6. Evidence?
Papers regarding patient compliance with medication, qualitative studies re satisfaction etc.
No references to RCTS found personally.

7. But complaints.....
.....different story

8. Complaints Utah and Colorado study 15,000 claim reviews
3% filed negligence claims
77% of claims there was no negligence
55% of claims there was no adverse outcome
Studdert et al, 1999

9. What motivates patients to claim?
80% of complaints related to poor communication.
Health Service Report Victoria 1993
To correct deficient standards of care
To find out what happened and why
To enforce accountability
Compensation for accrued/future costs
Vincent et al LANCET 1994

10. Negative communication behaviour by Doctors increases likelihood of claim – even when there has been no adverse outcome.
Lester and Smith 1993, West J Med

11. Greater than 50% of 263 patients (who complained) claimed that they were so turned off by the Doctor that they wanted to claim against the Doctor before the alleged event occurred.
Mangels 1991, Med Econ

12. What do doctors not want? What do patients want?
What do doctors want?
What do doctors not want?
What do patients want?
What do patients not want?

13. We know what
we want!
What do patients
say they want?

15. Frequent complaints Patient felt rushed Received no explanations
Felt ignored or devalued
Felt deserted
Hickson et at 1994

16. No Complaints Asked patient opinions
Patient perceived that sufficient time was spent
Laughed
Explained the process of the consultation
Levinson and Roter 1997

17. Doctor centred: advantages
Taking a history is doctor centred
Medical thoroughness and good pattern recognition are a hallmark of this style
Is often appropriate
The doctor is in control
Patients often want powerful doctors who have reassuring authority

18. Doctor centred: disadvantages
Afraid of opening up a can of worms
Taking too much time
You only get the answers to the questions you ask
Will you find out what the patient thinks
Some patients don’t like this approach.

19. The patient’s story
Tell me what’s going on?

20. The patients beliefs, hopes and fears
A useful “aide-memoire” is: ICE
Ideas - what the patient believes about the problem, for instance what might be causing it.
Concerns - what worries the patient about it.
Expectations - what the patient is hoping for, or thinks is the best way to tackle the problem.

21. WHAT ARE THE QUESTIONS THE DOCTOR CAN ASK?

22. What are you thinking????
Did you have any thoughts of what might be causing this? --- if so what were they?
Do you have other concerns about the cause?
What where you hoping I could do to help?
What would be the most important things to address for you?
What do you understand about ....?
What would you feel about this treatment?

23. How’s this?

24. Observation Think about:
the processes that are taking place (rapport, questioning, listening)
the clinical information that is elicited – the content
the non verbal communication
Judge the extent to which the agenda, process and outcome are determined by the doctor or the patient

25. What are you thinking? ?