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Objectives

  • Convince why we’d bother teaching about communication
  • Demonstrate benefits for both PATIENT & DOCTOR
  • Show you how to do it - some tricks
  • Introduce you to difficult communications i.e. challenges of communicating with patients with depression &/or anxiety.

Why need to communicate

  • To do your job
  • Make job easier
  • To keep you out of trouble
  • Pass exams

Doing job properly

  • Finding out what the problem is (DIAGNOSIS) in everyday & more difficult situations
  • Telling patients what the problem is
  • Communication as a means of treatment

How to interrupt people

  • "Can I just interrupt you there?"
  • Use their words to move back to your interview agenda
  • Set the frame for the interview to start off, and let them know that you're sorry that I've only got 10 minutes today, need to get to the bottom of the problem, might need to interrupt them
  • Set their expectations so they don't get pissed off

Not being stupid

  • If they say "my uncle put his head in the oven" you can probably assume his uncle had depression or psychiatric disturbance
    • Or just stay that we don't know the aetiology of the problem, but we have the history of suicidal intentions in the past
      • Don't need formal
  • Going to bed for ages: neurodegenerative disorders, paranoid schizophrenia, depression, somatisation syndromes
  • Admit to your mistakes in your time with the examiner

Schizoaffective person

  • Depressed, feeling down
  • Poorly-formed sentences

Doing your job properly: routine situations

  • Information exchange & recall (history taking)
  • Techniques previously dealt with in earlier yrs (e.g. open questions, restating, checking for understanding)
  • Patient compliance
  • Doctor-doctor communication

Education by normalising the problem (e.g. say it is common for psychological disorders to occur).

  • Avoid premature closure (rapid pattern recognition as you get more experienced)
  • Give patient hope: "depression is common and fixable! So many things we can do for you"

Doing your job

  • Depression and anxiety are common
  • Nat Survey Mental Health
    • Depression 6.2% 12mo prevalence
    • Anxiety 14.4% 12 mo prevalence
  • 2 problems:
    • people don’t come to us
    • When they do come we miss it
  • 59% of those with mood disorder, 38% with anxiety disorder made use of mental health service

Who do we miss with depression and anxiety?

  • Men (internalise, stoic, drink, violence)
  • Old people (more subtle, believe it's a normal part of ageing, old people should be happy/at peace)
  • Somatisers (blame on physical symptoms)
  • Suicide (psychological autopsy over suicide; recent research has shown that people who commit suicide have had contact with HCWs 3-6 months before death but HCWs don't help)

Why don’t people tell us about their depression/anxiety?

  • Older people
    • “whatdyu expect” at that age,
    • stoicism,
    • depression doesn’t look like depression
  • General:
    • Shame /stigma/should be able to help myself"
    • Poor mental health literacy
    • don’t understand
    • “What’s the point it won’t help”; treatment actually helps

Why don't we ask

  • Fear of mental health patients

What are the consequence

  • Decreased cardiac health
  • Mortality
  • Suicidality
  • Family and work dysfunction

Importance of the interview

  • Your interview technique is important, to diagnose from their narrative
  • Barriers in mental illness for opening up:
    • Shame, stigma
    • Guilt
    • Consequences for profession
    • Withdrawal
    • Hopelessness
    • Lack of psychological mindedness (can't recognise it's a psychological problem)

Male patients

2003: 32(6) 'For men only': a mental health prompt list in primary care. Abstract: BACKGROUND: Barriers to detecting symptoms of depression in male patients in primary care include patients' reticence to self disclose and doctors' failing to ask questions that tap into their patient's emotional distress. Effective consultation is further hindered by time constraints, undifferentiated and nonspecific symptoms of depression, differing attribution of symptoms and expectations of the consultation, and low levels of mental health literacy. These issues, of particular relevance to men, informed the design of a screening instrument, the 'For Men Only' Prompt List (PL). OBJECTIVE: This article reports an evaluation by male patients and their general practitioners of the PL conducted in the context of primary care. The patients completed the PL in the waiting room and used it to raise issues during consultation. The instrument was evaluated using a short questionnaire completed by patients, a postal questionnaire by GPs, and field notes. DISCUSSION: The PL was useful for those patients who required prompting in raising issues surrounding depression. Those who already had a good relationship with their doctor, were at case discussing issues without prompting, or had a specific physical problem to be treated, did not find it as useful. All practitioners found the PL provided extra information about their patients. It also helped them build rapport with patients and made their job of assessment easier. Doctors depend on patients to self disclose and patients depend on doctors to provide an accurate diagnosis. The PL addresses some of the barriers to identifying depressive symptoms in men, particularly in assisting male patients to 'open up' to their doctors.

Warning signs

  • OBJECTIVES: To assess the characteristics of people with common

mental health problems who are recognised by their general practitioner, and those who are not.

  • DESIGN: Two different case-finding techniques (brief self-report and structured diagnostic interview) were compared with GPs' independent assessments of patients' presentations as psychological and/or medical.
  • SETTING AND PARTICIPANTS: 371 patients in general practices in metropolitan Sydney and rural NSW
  • RESULTS: Patients who presented with somatic symptoms alone were most likely to be overlooked by GPs: none of the 57 patients identified by SPHERE-12 with a somatic disorder were identified by GPs as psychological presentations.
  • CONCLUSION: Low rates of recognition of psychological problems

by GPs, and infrequent treatment for those presenting with somatic symptoms, indicate a need for building GPs skills in the assessment and management of somatisation. The SPHERE-12 may be a useful screening tool for primary care if followed by further questioning and other methods to assess diagnosis and severity to target appropriate treatment.

Female GPs better for mental health

  • OBJECTIVE: The aim of the present study was to determine whether anecdotal claims of gender differences in the treatment of depression by general practitioners (GPs) existed in practice.
  • METHOD: Referral letters from 100 GPs to a specialized psychiatric depression clinic were analysed by word count and gender of referrer. Second, a Web-based survey of 517 participants examined the impact of GP gender in terms of levels of management nuances. RESULTS: The first study established that female GPs wrote distinctly longer referral letters. The second study identified that female GPs were seen as distinctly more caring over a range of parameters and identified the impact of some GP-patient gender differences.
  • CONCLUSIONS: Reasons why female GPs are viewed as more caring - and any impact on the management of those with a depressive disorder - would benefit from refined investigation

Class exercise 1: Doctor observation competition (bad doctor)

  • Divide into groups
  • Tutors demonstrate bad communication in woman with depression/thyroid disease
  • Identify as many elements of bad communication

Assessment of suicidal risk

  • Feels life is not worth living
  • Wishes he/she were dead or any thoughts of possible death to self
  • Suicide ideas
  • Suicide plans/notes/affairs in order etc

Start with comfortable questions, then go to threatening questions.

If you find out they don't want to live any more, you ring their parents (if an adult), or admit them to the hospital. If they walk out, see the crisis team.

GPs identifying psychological distress

  • It is argued that a GP's ability to make accurate ratings of psychological

distress is partly determined by the rate at which patients emit cues that are indicative of such distress. This study addresses the behaviours of doctors which influence the rates at which patients emit such cues. Consultations were videotaped involving 6 GP Vocational Trainees (3 poor & 3 able identifiers of emotional illness). Consultations were selected so that each trainee was rated interviewing 4 patients with low GHQ scores, & 4 patients with high scores. Behaviours are described which lead to  cue emission & which are also practised more frequently by able identifiers, while other behaviours  cue emission & are practised less frequently by them. Another set of behaviours is no more frequent among the able identifiers, but when practised by able identifiers is associated with  cue emission by the patients, & when practised by poor identifiers with unaltered or  cue emission. Interviews that are 'patient- led' are associated with  rates of cue emission, while those that are 'doctor-led' are associated with  rates. Implications of these findings for training doctors working in general medical settings are discussed.

  • Basically, patient-led interviews have increased cue emission, but doctor-led interviews decrease cue emission. Don't appear rushed to the patient.

Making job easier

  • Efficiency
  • Learning to interrupt
  • Control the interview
  • Patient compliance and satisfaction

Class exercise 2: (good doctor)

  • Divide into groups of 3 (i.e. 2 with observer)
  • Demonstration of good communication taking over where we left off with depressed woman (broaching idea of depression & Rx)
  • Identify as many elements of good communication

Why might communicating with patients with depression/anxiety be challenging?

  • P may be less understanding of and resistant to dx & Rx
  • Less easily dx, no objective test, variable symptoms
  • Often involves long term Rx/partnership - can’t be treated in 7 days with antibiotics

Barriers to communication

  • Mental state e.g. anxiety, depression, cognitive impairment, fear embarrassment
  • Understanding
  • Information overload
  • State dependent learning
  • Language, culture

Class exercise 3

  • Demonstration bad communication- oncology/anxious patient
  • Tutors demonstrate

What do patients remember of what you tell them? Not much

  • P received blood transfusion at 30care centre over 3/12, the majority recalled the consent process, many did not recall the discussion of specific transfusion risks or alternatives to donor blood (88%). Although the majority felt the discussion was at least somewhat understandable (77%), only 35% felt better informed and more comfortable with accepting blood. Despite implementation of written informed consent for transfusion, patients' recollection and understanding of risks and alternatives remain poor.

Tools & Tricks

  • Rapport and tailoring information
  • Sufficient time for assimilation of information
  • Visual aids
  • Readability of materials

Tools & tricks: self report forms

  • Impt detection & screening
  • SPHERE- national mental health project
  • Instruments – PHQ, GAD-7,

Avoiding/minimising trouble

  • Informed consent
  • Relationship between communication skills/empathy & patient satisfaction
  • Relationship between communication skills/empathy malpractice

Communication & risk- KYR2

  • I empathise with my p re their health problems
  • I ask my p if they have understood the nature of their problem
  • I vary the way I deliver info to best suit the p
  • I summarise the impt issues discussed
  • I discuss management plan with my p
  • I feel hurried when communicating with p during consults
  • I encourage my p to talk about themselves
  • I encourage my p to express their feelings about their health problems
  • I take phone calls during consultations
  • I acknowledge p remarks about aspects of their personal lives relevant to their health problems

Surgeons and medical error disclosure

Acknowledge that you make a mistake

BACKGROUND: Calls are increasing for physicians to disclose harmful medical errors to patients, but little is known about how physicians perform this challenging task. For surgeons, communication about errors is particularly important since surgical errors can have devastating consequences. Our objective was to explore how surgeons disclose medical errors using st&ardized patients. METHODS: Thirty academic surgeons participated in the study. Each surgeon discussed 2 of 3 error scenarios (wrong-side lumpectomy, retained surgical sponge, & hyperkalemia- induced arrhythmia) with standardized patients, yielding a total of 60 encounters. Each encounter was scored by using a scale developed to rate 5 communication elements of effective error disclosure. Half of the encounters took place face-to-face; the remainder occurred by videoconference. RESULTS: Surgeons were rated highest on their ability to explain the medical facts about the error (mean scores for the 3 scenarios ranged from 3.93 to 4.20; maximum possible score, 5). Surgeons used the word error or mistake in only 57% of disclosure conversations, took responsibility for the error in 65% of encounters, & offered a verbal apology in 47%. Surgeons acknowledged or validated patients' emotions in 55% of scenarios. Eight percent discussed how similar errors would be prevented, & 20% offered a second opinion or transfer of care to another surgeon. CONCLUSIONS: The patient safety movement calls for disclosure of medical errors, but significant gaps exist between how surgeons disclose errors & patient preferences. Programs should be developed to teach surgeons how to communicate more effectively with patients about errors.

Class exercise 4

  • Divide into groups of 2 explain that you left a sponge in the patient’s abdomen
  • Consult MDO
  • Empathise
  • Assure that you'll improve it

Note: Physicians should encourage patients to become actively involved in their treatment

Summary of key points

  • Good communication has benefits for both patient and doctor
  • Enhances information exchange
  • Increases patient satisfaction, decreases litigation
  • Increases compliance
  • Therapeutic benefits
  • Saves time, increases efficiency by recording their symptoms, goals of therapy, side effects, changes in their condition and by voicing their concerns. (Savard, 2004)