Effective communication
MBBS 1
Friday 13th May 2005
Professor Graham Martin
“The greatest problem in
communication
is the illusion it has been
accomplished”
George Bernard Shaw
What we need to cover
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Evidence about Communication
The spoken word
Emotional voice tone
Body language
Receiving the message
Delivering Bad News
Neurolinguistic programming (NLP)
Other People’s Tragedy
Common descriptors of inappropriate
medical student behaviours & attitudes
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arrogant
power-seeking
inflexible
defensive
dishonest
patronising
brash
egocentric
isolated
insensitive
self-centred
uncaring
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indifferent
selfish
antisocial
amoral
devious
prejudiced
flippant
rude
aggressive
condescending
rigid attitudes
judgemental
Medical Consumerism
Doctor to Patient: Do you fully
appreciate the risks of this
procedure?
Patient to Doctor: Sure, you
screw up and I’ll sue!
9 February 2001
MEDICAL OBSERVER
“Patients’ complaints cause
years of hurt, study shows”
17 May 2002
MEDICAL OBSERVER
“GPs left undefended as
UMP walks away”
Friday 8 December 2000
AMAQ MEDIA RELEASE
Alternative models to the
adversarial system should be
identified.
 Aim to speed up resolution and
reduce high costs of litigation.
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The nature of complaints
UK Study
70 % of patient complaints
 Deserting the patient
 Devaluing the patients views
 Delivering information poorly
 Failing to understand the patients
perspective
Types of Issues
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Misdiagnosis
Treatment
Negligence
Medication
Conduct
Lack of Care
Cost
Assault
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Access to Records
Confidentiality
Discrimination
Delays
Refused Treatment
Public Health
Overservicing
Hygiene
Complaint Issues 2000/01 (2,520)
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Treatment
Communication
Access
Rights
Administration
Costs
1,366
405
263
286
130
70
54%
17%
10%
11%
5%
3%
Communication 2000/01 (405)
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Arrogance
Discourtesy
Failure to Consult
Lack of Care/Consideration
Misinformation
Undignified Service
Other
91
68
76
68
55
8
39
Who Can Make a Complaint?
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User of a health service.
Someone chosen by the user if it would be
difficult for them to complain themselves.
Legal Friend on behalf of an assisted citizen.
Minister for Health.
A person the Commissioner accepts in the
public interest. eg another health provider
The Health Rights Commission
…. provides an independent, impartial and
collaborative health complaints system
designed to improve health care services
and promote health rights and
responsibilities in Queensland.
Reasons People Complain
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Regulation
I want to ensure this event never
happens to anyone else.
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Information
I want to find out what really
happened.
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Accountability I want the person brought to
account or disciplined.
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Compensation I want the money.
Complaint Algorithm
Poor communication
+ Patient’s unmet / unrealistic expectation
+ Adverse event or bad outcome
= a writ or complaint
POOR RESPONSE
POOR RESPONSE
“After much consideration and as
an act of my good faith, I have
decided to allow copies of your
medical record to be sent to you. You
should be aware that I have no legal
obligation to do this.”
Referral to Registration Boards
2000/01 (74)
Medical
 Pharmacy
 Psychologists
 Dental
 Chiropractors
& Osteopath
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45
5
2
16
6
Registration Board Action Taken
2000/01
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Deregistration
Suspension
Conditions of practice
Censure/Reprimand
Fine
No further action
10
10
4
4
1
22
HELPFUL RESPONSE
“The review of your complaint has
provided useful suggestions in terms of
process and staff training issues. As such,
future patients will benefit from the
critical examination of the way in we
manage patient concerns”
Complaint Resolution Processes
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Local Resolution
Assessment
Conciliation
Investigation
Referral to Registration Board
Referral to another entity Eg: Police
Personal Injuries
Proceedings Act 2002
“Expressions of Regret”
Allows an individual to express regret about
an incident without being concerned that
the expression will be used as an
admission of liability or negligence.
This statement cannot then be used in court.
CONCILIATION
A Collaborative approach to resolving
health service complaints
Conciliation Outcomes
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Change in practice or protocol.
Quality assurance changes.
Additional reparative treatment.
Apology.
Full explanation of what went wrong.
Independent assessment of treatment.
Financial settlements - 21%
July 2000 - March 2001 : $1,500,000
Compelling evidence base
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Good communication leads to better health
outcomes
Good communication is professionally
rewarding.
Omission of adequate information about
diagnosis, prognosis, treatment options leads
to patient anxiety and dissatisfaction.
Communication failures as opposed to
technical negligence are significant
complaints.
Sensitive Issues
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Child victims - custody issues
Minors seeking contraception, abortion or drug
counseling
Elderly patients
Patients with gynaecological problems
Sexually transmitted diseases
HIV patients. Victims of sexual assault.
Mental Health Patients
Patients’ difficulties
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Understanding, especially in context of
anxiety.
Low to moderate anxiety can focus attention.
Significant anxiety or depression leads to an
interpretation bias, anxiety about threat,
depression about negative events
Intelligence has a weak but consistent
relationship with recall
Recall of information is low (General medical
outpatients = 54%, oncology = 25%)
Consultation structure and
content and memory
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Patients usually recall the start and very end of
the consultation best (primacy and recency
effects).
Topics of most relevance and importance to
the patient are recalled well (eg medical
information).
More statements made by the clinician the less
the % of information recalled by patient.
Clinician cognitive bias
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Clinician estimates of the amount of information
provided exceed that recalled by up to 900%.
The order in which patients present problems does
not reflect clinical importance
In primary health care 54% of patients complaints
and 45% of concerns not elicited. “What concerns
you about this problem?” is rarely asked.
Patients tend to seek information re prognosis,
diagnosis, causation. Clinicians tend to provide
information re treatment and drug therapy.
Patient Satisfaction
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Empathy, non verbal behaviour, perception of amount
of information provided.
Asking patients about their expectations of the
consultation increases adherence even if expectations
are not met
Recall is enhanced by categorisation, signposting
importance, summarising, repetition
Asking patients to repeat information in their own
words increases recall by 30%
Clinician behaviour
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Unless you invite the patient to ask directly, they
rarely ask important questions (assume Dr would tell
them if important, seems “foolish”, guilt re taking up
time).
Usually little attempt to find out what the patient
wants
Detachment, inhibits patient self disclosure, warmth
and empathy facilitate it.
Non-verbal signs (the way that information is
delivered) are significant.
In High Concern Situations, People Want to
Know That You Care Before They Care What
You Know
(Vincent Covello)
Listening/Caring/Empathy
50% - Assessed in first 9-30
seconds
So What do we do?
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Be clear, open and as direct as we can
Keep It Simple, Stupid!
Repeat
Draw a diagram
Provide a handout to take home
Provide an Internet Site address if available,
and patient has internet access
Summarise
Provide and opportunity for follow-up
Rules for Communication
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Demonstrate respect for patients whoever and whatever they are
Your attitudes will be perceived!
Do not be in a hurry
Be available and accessible in a timely
manner - particularly in the case of an
adverse event or complication.
Rules for Communication
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Listen actively to a patient’s concerns
Always acknowledge a criticism of
treatment or care - and explore in a
reasonable manner.
Do not become defensive and short with
a patient.
Work even harder the more difficult the
patient is
Rules for Communication
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Be open and honest about adverse events
and complications.
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Eg: medication errors
Rules for Communication
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Never criticise another health
practitioner’s care.
“I would not have done that”.
 “If you had only seen me sooner”.
 Disputes in front of patients.
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“By the way, Doc…..”
Case Examples
Breast Cancer
First Episode Psychosis
Voice
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Only 7% communication results from words used
38% verbal behaviour
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tone of voice, timbre, tempo, volume
55% non-verbal
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posture, breathing, skin colour, movements
Birdwhistle, 1970
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Joseph Stalin Leon Trotsky
Body language
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Monitor your own body language
Be aware that you can change deliberately if
needed
Be careful not to overdo the changes
Practice
Exercise
Neurolinguistic Programming
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Effective communication - Suicide Prevention Studies