enhancing clinician-patient communication for every day practice: a workshop on the four habits...

Enhancing Clinician-Patient Communication for Every Day

Practice:

A Workshop on the Four Habits Model of Clinical Communication

21-23 August 2006

___________________________________________________________________________

A (Brief) Tour of the Four Habits A (Brief) Tour of the Four Habits

IntroductionIntroduction “The patient physician relationship is

the center of medicine. As described in the patient physician covenant, it should be ‘a moral enterprise grounded in a covenant of trust’. This trust is threatened by the lack of empathy and compassion that often accompany an uncritical reliance on technology and pressing economic considerations.”

R.M. Glass, JAMA, 1996

“The patient physician relationship is the center of medicine. As described in the patient physician covenant, it should be ‘a moral enterprise grounded in a covenant of trust’. This trust is threatened by the lack of empathy and compassion that often accompany an uncritical reliance on technology and pressing economic considerations.”

R.M. Glass, JAMA, 1996

THE INFORMED PATIENT By LAURA LANDRO

Teaching Doctors How to Interview

Programs Offer Strategies For Quickly Getting to Heart Of Patients' Problems, FearsSeptember 21, 2005; Page D5

The Wall Street Journal

THE INFORMED PATIENT By LAURA LANDRO

Teaching Doctors How to Interview

Programs Offer Strategies For Quickly Getting to Heart Of Patients' Problems, FearsSeptember 21, 2005; Page D5

The Wall Street Journal

THE FOUR HABITS MODELTHE FOUR HABITS MODEL

©1996, 1999, 2003 The Permanente Medical Group, Inc. Physician Education & Development

Revised April 2003 in partnership with the Kaiser Permanente Institute for Culturally Competent Care

___________________________________________________________________________

The Four Habits of Highly Effective DoctorsThe Four Habits of Highly Effective Doctors___________________________________________________________________________

Habit SkillsInvest in the Beginning Create rapport quickly; elicit the patient’s

concerns; let the patient know what to expect

Elicit the Patient’s Perspective Ask for patient’s ideas; determine patient’s specific request or goal; explore the impact on patient’s life

Demonstrate Empathy Be open to the patient’s emotions; make empathetic statements; convey empathy nonverbally (pause, touch, facial expression)

Invest in the End Deliver diagnosis in terms of original concern; explain rationale for tests and treatments; summarize visit and review next steps

©1996, 1999, 2003 The Permanente Medical Group, Inc. Physician Education & Development

Revised April 2003 in partnership with the Kaiser Permanente Institute for Culturally Competent Care

FOUR HABITS APPROACH:

HABIT 1:

Invest in the Beginning


HABIT 1:


“If doctors fail to get at the full spectrum of concerns in the beginning of the encounter and to assess their importance from the patient's point of view, there is likely to be more premature testing, misplaced empathy and support, and the emergence of hidden concerns at the end of the visit.”

“If doctors fail to get at the full spectrum of concerns in the beginning of the encounter and to assess their importance from the patient's point of view, there is likely to be more premature testing, misplaced empathy and support, and the emergence of hidden concerns at the end of the visit.”


HABIT 2

ELICIT THE PATIENT’S

PERSPECTIVE


HABIT 2


PERSPECTIVE

J U LY 2006


HABIT 3

DEMONSTRATE EMPATHY


HABIT 3

DEMONSTRATE EMPATHY

FOUR HABITS APPROACH

HABIT 4

INVEST IN THE END


HABIT 4

INVEST IN THE END

We are what we repeatedly do.

Excellence then, is not an act,

but a habit.

Aristotle

Individual and

OrganizationalCharacteristics

Health CarePerformance

Outcomes

Research Model___________________________________

Essential Attributes of Primary CareMeasured by the Primary Care Assessment Survey (PCAS)

Clinical interaction·communication

·physical exams

Comprehensiveness

·knowledge of patient ·preventive counseling

Integration

Continuity·longitudinal

·visit-based

Access·financial

·organizational

Interpersonal treatment

Trust

Medical Care. 1998; 36(5):728-739.

PrimaryCare

___________________________________________________________________________

Clinician-Patient Relationship Quality as a Driver of Outcomes

Health Outcomes Adherence Symptom Relief Clinical Improvement

Business Outcomes Loyalty to the practice Willingness to recommend Malpractice risk

Relationship Quality Index from the Primary Care Relationship Quality Index from the Primary Care Assessment Survey (PCAS)Assessment Survey (PCAS)

Communication Whole-Person Orientation

Interpersonal treatment

Trust

RelationshipQuality

1996Trust

(percentile)

0 10 20 30 40 50

% Voluntary Disenrollment

11.4%

24.3%

37.1%

95th

75th

50th

25th

5th

14.9%

19.2%

___________________________________________________________________________

Source: Safran et al. JFP 2001; 50:130-136.

Relationship Between Trust and Disenrollment

% Successful Change

32.9%

28.0%

95th

75th

50th

25th

5th

31.7%

29.9%

0 20 25 30 35

24.3%

1996 Trust Scale

(percentile)

___________________________________________________________________________

Source: Safran et al. JGIM 2000; 15 (supp):116.

Patient Trust as a Predictor of Adherence: Successful Behavior Change

Cost-Related Non-Compliance by Quality of Physician-Patient Relationship

Cost-Related Non-Compliance by Quality of Physician-Patient Relationship

___________________________________________________________________________

Source: Wilson et. al., SGIM 2001

02468

101214161820

Lowest Highest

Per

cen

t R

epor

t C

ost-

Rel

ated

N

on-C

omp

lian

ce

MD-Patient Relationship Quality

15%

8%7% 6%

10.59

9.06

10.26 10.61

0

2

4

6

8

10

12

14

Glycosylated HbA1 (%) Glycosylated HbA1 (%)

Experimental Group

Control Group

10.59

9.06

10.26 10.61

0

2

4

6

8

10

12

14

Glycosylated HbA1 (%) Glycosylated HbA1 (%)

Experimental Group

Control Group

Effect of a Patient Involvement Intervention on Diabetes Control

*

* p<0.001Greenfield, S., et al. J Gen Intern Med, 1988; 3:448-457

Pre-Intervention Post-Intervention

0.85

0.19

1.11

0.39

0

0.5

1

1.5

2


Experimental Group

Control Group

0.85

0.19

1.11

0.39

0

0.5

1

1.5

2


Experimental Group

Control Group

1.41

0.98

1.89

2.25

0

0.5

1

1.5

2

2.5

3


Experimental Group

Control Group

Mobility (scored 0 3) Physical (scored 0 5)

Effects of an Intervention on Health-related Quality of Life: Functional Limitations

* p<0.01

*

*

Greenfield, S., et al. J Gen Intern Med, 1988; 3:448-457

19.4

24.3

19.2 18.7

0

5

10

15

20

25

30


Experimental Group

Control Group

19.4

24.3

19.2 18.7

0

5

10

15

20

25

30


Experimental Group

Control Group

Patient Preference for Active Involvement in Medical Decision-Making: Effect of a Patient Involvement Intervention

*

* p<0.001Greenfield, S., et al. Annals of Internal Medicine, 1985; 102:520-528

0.6

2.72

0.83

0.55

0

1

2

3

4


Experimental Group

Control Group

0.6

2.72

0.83

0.55

0

1

2

3

4


Experimental Group

Control Group

0.82

1.38

0.760.8

0

0.5

1

1.5

2


Experimental Group

Control Group

Number of controlling behaviors by patient (including questions, interruptions & directions)

Effectiveness of patient information

seeking

Effects of an Intervention on Patient Involvement in the Physician-Patient Interaction

* p<0.05

* *

Greenfield, S., et al. J Gen Intern Med, 1988; 3:448-457

0

20

40

60

80

100

0 0.2 0.4 0.6 0.8 1

What Drives Patients’ Willingness To Recommend And How Are We Doing (2002)

Correlation to Measure of Willingness to Recommend

Perc

enti

le R

ank

Adj

uste

d

Communication

Interpersonal Treatment

Knowledge of Patient

Health Promotion Patient Trust

Organizational AccessVisit-based Continuity

Integration

Office Staff

Clinical Team

Relationship Duration

Priority Improvements

Relationship Between Physician Communication and Medical Malpractice Risk

19.4

14.511.9 11.2

0

5

10

15

20

25

Facilitation Orientation

Physician Communication Processes

Nu

mb

er o

f U

tter

ance

s p

er 1

5 m

inu

te v

isit

No Claims

Claims

Source: Levinson et al. JAMA 1997; 277:553-559.

Primary Care Relationship Quality & Interactions, 1996-1999

-0.68

-2.97

1.11

-2.06

-1.51

-4 -3 -2 -1 0 1 2

Communication

Interpersonal Treatment

Knowledge of Patient

Physical exams

Trust

p < .001

p < .001

p < .01

p < .01

p < .001

Observed Change in Score

Source: Murphy et al. JFP 2001.

___________________________________________________________________________

0.0

20.0

40.0

60.0

80.0

100.0

1996 1997 1998 1999 2000 2001 2002

Diabetes EyeExams

CervicalCancerScreening

Breast CancerScreening

AdolescentHep BImmunization

Beta BlockerTreatmentFollowing aHeart Attack

Changing Rates of Preventive Care Processes, 1996-2001

HEDIS did not begin testing adolescent Hepatitis B immunization rates until 1997


HABIT 1:



HABIT 1:


Habit 1: Invest in the BeginningHabit 1: Invest in the Beginning

Skills Technique and Examples

Create rapport quickly Introduce self to everyone in the room Refer to patient by last name and Mr. or Ms.

until a relationship has been established Acknowledge wait Make a social comment or ask a non-medical

question to put the patient at ease Convey knowledge of patient's history by

commenting on prior visit or problem Consider patient’s cultural background and use

appropriate XXXX, eye contact, and body language

___________________________________________________________________________



Elicit the patient’s concerns

Start with open-ended questions:

“What would you like help with today?” “I understand that you’re here for … Could you

tell me more about that? Speak directly with patient when using an

interpreter

Plan the visit with the patient

Repeat concerns back to check understanding Let patient know what to expect: “How about if

we start with talking more about … then I’ll do an exam, and then we’ll go over possible test/ways to treat this? Sound OK?”

Prioritize when necessary: “Let’s make sure we talk about X and Y. It sounds like you also want to make sure we cover Z. If we can’t get to the other concerns, let’s …”

___________________________________________________________________________


PayoffsEstablishes a welcoming atmosphereAllows faster access to real reason for visitIncreases diagnostic accuracyRequires less workMinimizes “Oh by the way … “ at the end of visitFacilitates negotiating an agendaDecreases potential for conflict

___________________________________________________________________________

Interrupted Opening

Dr.: Hello Ms. Jones. What problems are you having?Pt.: I have chest pain.Dr.: When did it begin? [Interruption via closed ended question] Pt.: It started about three months ago.Dr.: Can you tell me more about it?Pt.: It’s a gnawing pain that hurts in the center of my chest.Dr.: Does the pain go into your arms or to your neck?Pt.: Yes.Dr.: Is it worse when you get excited?Pt.: Yes.Dr.: Do you smoke cigarettes?Pt.: Yes.Dr.: Are you currently taking any medication?Pt.: No.

Completed Opening

Dr.: Hello Mrs. Jones. What problems are you having?Pt.: I’m having chest pain.Dr.: uh-huh. [Continuer]Pt. It’s a gnawing pain.Dr.: uh-huh. [Continuer] Pt.: It starts in my chest and goes to my arm and jaw.Dr.: (silence) [Continuer]Pt.: It’s really frightening.Dr.: I see. [Acknowledgment]Pt.: You know, my father died from a heart attack and I’m afraid that the same thing may happen to me.Dr.: I can see that you’re concerned, and I’ll certainly talk with you more about your chest pain. Before we start, however, is there anything else that’s concerning you that I need to know about?Pt.: No.

1. Facilitating the Opening of the Interview

Table 1. Relationship Between Interruption and Elapsed Time for 52 Interrupted Opening Statements.

Concerns Expressed Encounters Mean Time toBefore Interruption Interruption

...........................… n ................................. s0 6 6.831 28 16.482 8 25.003 7 37.504 3 37.00

Beckman and Frankel, Ann Int Med 1984


HABIT 2


PERSPECTIVE


HABIT 2


PERSPECTIVE

Habit 2: Elicit the Patient’s PerspectiveHabit 2: Elicit the Patient’s Perspective


Ask for the patient’s ideas

Assess patient’s point of view:

“What do you think might be causing your problem?”

“What worries or concerns you most about this problem?”

“What have you don’t to treat your illness so far?”

Ask about ideas from loved ones or from community

Elicit specific request Determine patient’s goal in seeking care: “How were you hoping I could help?”

Explore the impact on the patient’s life

Check context: “How has the illness affected your daily activities/work/family?”

___________________________________________________________________________

Habit 2: Elicit the Patient’s PerspectiveHabit 2: Elicit the Patient’s Perspective

PayoffsRespects diversityUncovers hidden concerns and diagnostic cluesReveals use of alternative treatments or requests for

tests Improves diagnosis of depression and anxiety

___________________________________________________________________________

Habit 2: Elicit the Patient’s Perspective

Habit 2: Elicit the Patient’s Perspective

Condition: qaug dab peg English translation:The Spirit Catches

You and You Fall down Medical translation: Epilepsy

Condition: qaug dab peg English translation:The Spirit Catches

You and You Fall down Medical translation: Epilepsy

From the Medical RecordFrom the Medical Record

“History of present illness: The patient is an 8 month, Hmong female whose family brought her to the emergency room after they had noticed her shaking and not breathing well for a 20 minute period of time. According to the family the patient has had multiple like episodes in the past, but have never been able to communicate this to emergency room doctors on previous visits secondary to a language barrier.”

“History of present illness: The patient is an 8 month, Hmong female whose family brought her to the emergency room after they had noticed her shaking and not breathing well for a 20 minute period of time. According to the family the patient has had multiple like episodes in the past, but have never been able to communicate this to emergency room doctors on previous visits secondary to a language barrier.”

What is wrong with Lia and what should be done?

What is wrong with Lia and what should be done?

Doctors’ explanatory model: Epilepsy is a sporadic malfunction of the brain during which neural impulses fire in a chaotic rather than orderly pattern. Surgery would be dangerous; anti-convulsive drugs are recommended.

Family’s explanatory model:Qaug dab peg means that the child is imbued with spirits, which is as much an honor as an illness. Therefore, it is unclear whether these symptoms should be strongly discouraged, and if so, the wearing of amulets is recommended.

Doctors’ explanatory model: Epilepsy is a sporadic malfunction of the brain during which neural impulses fire in a chaotic rather than orderly pattern. Surgery would be dangerous; anti-convulsive drugs are recommended.

Family’s explanatory model:Qaug dab peg means that the child is imbued with spirits, which is as much an honor as an illness. Therefore, it is unclear whether these symptoms should be strongly discouraged, and if so, the wearing of amulets is recommended.

Question:How many of the 40+ health care professionals who

treated Lia were aware of the Lee family’s beliefs?

Question:How many of the 40+ health care professionals who

treated Lia were aware of the Lee family’s beliefs?

Answer: One. Reason: She was the only one who

asked.

Answer: One. Reason: She was the only one who

asked.

Habit 2 forms the basis of physician-patient collaboration

Habit 2 forms the basis of physician-patient collaboration

Ask for the patient’s ideas What do you think is causing the problem? What about this problem concerns you the most?

Identify the patient’s goals for the visit. What do you hope we can accomplish today?

Explore the impact on the patient. How has this affected you? Does this keep you from living your life as

you usually do?

Ask for the patient’s ideas What do you think is causing the problem? What about this problem concerns you the most?

Identify the patient’s goals for the visit. What do you hope we can accomplish today?

Explore the impact on the patient. How has this affected you? Does this keep you from living your life as

you usually do?

Questions:Questions:

What happens when you do this well?

What happens when this habit is overlooked or done poorly?

What happens when you do this well?

What happens when this habit is overlooked or done poorly?


HABIT 3

DEMONSTRATE EMPATHY


HABIT 3

DEMONSTRATE EMPATHY

Habit 3: Demonstrate EmpathyHabit 3: Demonstrate Empathy


Be open to the patient’s emotions

Respond in a culturally appropriate manner to changes in body language and voice tone

Make an empathic statement

Look for opportunities to use brief empathic comments: “You seem really worried.”

Compliment patient on efforts to address problem

Convey empathy nonverbally

Use a pause, touch, or facial expression

___________________________________________________________________________

Habit 3: Demonstrate EmpathyHabit 3: Demonstrate Empathy

PayoffsAdds depth and meaning to the visitBuilds trust, leading to better diagnostic information,

adherence, and outcomesMakes limit-setting or saying “no” easier

___________________________________________________________________________

A Doctor’s Story – 25 Years LaterA Doctor’s Story – 25 Years Later

Twenty five years ago when I was a 3rd year student and in the ER, a family including a 10 year old girl and her grandparents came in badly burned… The girl was in arrest and despite all our efforts died. I still remember the smell of charred flesh; it was overpowering. I was sent to ask the mother for an autopsy. Instead of beginning by informing her of the death I began with, “Sorry to bother you at this time but…” and then asked her my question. She screamed and collapsed, hysterical at my feet. I was aghast, guilty, stunned, felt inadequate to make any appropriate response. I still feel awful about it to this today.

Twenty five years ago when I was a 3rd year student and in the ER, a family including a 10 year old girl and her grandparents came in badly burned… The girl was in arrest and despite all our efforts died. I still remember the smell of charred flesh; it was overpowering. I was sent to ask the mother for an autopsy. Instead of beginning by informing her of the death I began with, “Sorry to bother you at this time but…” and then asked her my question. She screamed and collapsed, hysterical at my feet. I was aghast, guilty, stunned, felt inadequate to make any appropriate response. I still feel awful about it to this today.

Three Questions to Ponder?Three Questions to Ponder?

What feelings does this story evoke in you? About the mother? About the physician? About the situation?

What would you do in this situation? What would you want to say to this

physician after he told his story?

What feelings does this story evoke in you? About the mother? About the physician? About the situation?

What would you do in this situation? What would you want to say to this

physician after he told his story?

Early to mid- 20Early to mid- 20thth Century Focus on Century Focus on Objectivity Objectivity

Early to mid- 20Early to mid- 20thth Century Focus on Century Focus on Objectivity Objectivity

Aring: physicians must remain apart from “the enervating morass of the patient’s problems, viewing them detachedly yet interestedly.” JAMA 1958

Blumgart: “neutral empathy;” Detachment is necessary to accurately observe and predict patients’ emotional states. NEJM 1964

Aring: physicians must remain apart from “the enervating morass of the patient’s problems, viewing them detachedly yet interestedly.” JAMA 1958

Blumgart: “neutral empathy;” Detachment is necessary to accurately observe and predict patients’ emotional states. NEJM 1964

The “Value” of Detached ConcernThe “Value” of Detached ConcernThe “Value” of Detached ConcernThe “Value” of Detached Concern Fox and Lief: “The same detachment Fox and Lief: “The same detachment

that enables medical students to that enables medical students to dissect a cadaver without fear or dissect a cadaver without fear or disgust seemingly enables them to disgust seemingly enables them to listen to patients without becoming listen to patients without becoming emotionally involved”. emotionally involved”.

Lief & Lief, eds. The Psychological Basis of Medical Practice, 1963

Fox and Lief: “The same detachment Fox and Lief: “The same detachment that enables medical students to that enables medical students to dissect a cadaver without fear or dissect a cadaver without fear or disgust seemingly enables them to disgust seemingly enables them to listen to patients without becoming listen to patients without becoming emotionally involved”. emotionally involved”.

Lief & Lief, eds. The Psychological Basis of Medical Practice, 1963

The Appeal of DetachmentThe Appeal of DetachmentThe Appeal of DetachmentThe Appeal of Detachment

Detachment was mistakenly equated Detachment was mistakenly equated with:with:

Objective diagnosesObjective diagnosesEffectivenessEffectivenessLess burn-outLess burn-out

Detachment was mistakenly equated Detachment was mistakenly equated with:with:

Objective diagnosesObjective diagnosesEffectivenessEffectivenessLess burn-outLess burn-out

Late 20Late 20thth; Early 21; Early 21stst Century Views are More Century Views are More Evidence-Based Evidence-Based

“ “Keeping considerations of self and professional Keeping considerations of self and professional

together permits us to see work as an expression together permits us to see work as an expression of self, and professional aspirations for of self, and professional aspirations for trustworthiness and virtuous action as trustworthiness and virtuous action as aspirations of our own heart. In a field that aspirations of our own heart. In a field that demands as much of us as medicine, anything demands as much of us as medicine, anything less than this integration of person and less than this integration of person and professional may be unsupportable in the long professional may be unsupportable in the long run.”run.”

Inui, 2003

The Changing Role of Empathy The Changing Role of Empathy

in Medical Carein Medical Care

Until recently, physicians were Until recently, physicians were taught to view their own feelings, taught to view their own feelings, emotions and relationships with emotions and relationships with patients as barriers to making good patients as barriers to making good “objective” decisions.“objective” decisions.

The Changing Role of Empathy The Changing Role of Empathy

in Medical Carein Medical Care

Until recently, physicians were Until recently, physicians were taught to view their own feelings, taught to view their own feelings, emotions and relationships with emotions and relationships with patients as barriers to making good patients as barriers to making good “objective” decisions.“objective” decisions.

Empathy Makes A Difference: Empathy Makes A Difference: The EvidenceThe Evidence

Empathy Makes A Difference: Empathy Makes A Difference: The EvidenceThe Evidence

Empathy & emotional engagement are Empathy & emotional engagement are equated with:equated with:

More thorough diagnosesMore thorough diagnoses Suchman, Markakis, Beckman, Frankel, JAMA, Suchman, Markakis, Beckman, Frankel, JAMA,

1997 (USA)1997 (USA)

AdherenceAdherence Kim, Kaplowitz, Johnston Eval Health Prof 2004 Kim, Kaplowitz, Johnston Eval Health Prof 2004

(Korea)(Korea)

Satisfaction & trustSatisfaction & trust Shields, Epstein, Franks etal (2005)Shields, Epstein, Franks etal (2005)

Empathy & emotional engagement are Empathy & emotional engagement are equated with:equated with:

More thorough diagnosesMore thorough diagnoses Suchman, Markakis, Beckman, Frankel, JAMA, Suchman, Markakis, Beckman, Frankel, JAMA,

1997 (USA)1997 (USA)

AdherenceAdherence Kim, Kaplowitz, Johnston Eval Health Prof 2004 Kim, Kaplowitz, Johnston Eval Health Prof 2004

(Korea)(Korea)

Satisfaction & trustSatisfaction & trust Shields, Epstein, Franks etal (2005)Shields, Epstein, Franks etal (2005)

Zachariae et al (2003)Zachariae et al (2003) 454 cancer patients & 31 physicians at an oncology

outpatient clinic, Aarhus University Hospital, Denmark Measured many aspects of dr-patient relationship Empathy, as perceived by the patient, predicts

satisfaction even after controlling for disease severity, sociodemographic factors, self-efficacy and prior distress

Greater empathy associated with decreased post-visit distress post-visit (after controls)

Empathy associated with greater disease-related self-efficacy

454 cancer patients & 31 physicians at an oncology outpatient clinic, Aarhus University Hospital, Denmark

Measured many aspects of dr-patient relationship Empathy, as perceived by the patient, predicts

satisfaction even after controlling for disease severity, sociodemographic factors, self-efficacy and prior distress

Greater empathy associated with decreased post-visit distress post-visit (after controls)

Empathy associated with greater disease-related self-efficacy

Breaking Bad NewsBreaking Bad News

It is all too common in the life of a physician

Physicians typically have little if any training in it

It often makes physicians, even experienced ones, uncomfortable

It is done poorly more often than not

It is all too common in the life of a physician

Physicians typically have little if any training in it

It often makes physicians, even experienced ones, uncomfortable

It is done poorly more often than not

Styles of Delivery (Friederichsen, Strang, & Carlsen, 2000) 30

patients admitted to a hospital-based home care unit

(Uppsala, Sweden)

Styles of Delivery (Friederichsen, Strang, & Carlsen, 2000) 30

patients admitted to a hospital-based home care unit

(Uppsala, Sweden) The inexperienced messenger The emotionally burdened expert The rough and ready expert The distanced doctor The benevolent but tactless expert The empathic professional

The inexperienced messenger The emotionally burdened expert The rough and ready expert The distanced doctor The benevolent but tactless expert The empathic professional

Delivering Bad News Empathically: Some Guidelines

Delivering Bad News Empathically: Some Guidelines

Find out what the patient knows already Find out what the patient wants to know Share the information simply and honestly Give patient time to absorb the news Acknowledge the patient’s emotions

Name, legitimize, and support any emotions Offer appropriate reassurance, but not false hope

Make plans for follow-up, short and long-term Assess support of family, friends, spiritual beliefs--

involve loved ones

Find out what the patient knows already Find out what the patient wants to know Share the information simply and honestly Give patient time to absorb the news Acknowledge the patient’s emotions

Name, legitimize, and support any emotions Offer appropriate reassurance, but not false hope

Make plans for follow-up, short and long-term Assess support of family, friends, spiritual beliefs--

involve loved ones


HABIT 4

INVEST IN THE END


HABIT 4

INVEST IN THE END

Habit 4: Invest in the EndHabit 4: Invest in the End


Deliver diagnostic information

Frame diagnosis in terms of patient’s original concerns

Provide education Explain rationale for tests and treatments Review possible side effects and expected

course of recovery Discuss options that are consistent with

patient’s lifestyle, cultural values and beliefs Provide resources (e.g., written materials) in

patient’s preferred language when possible

___________________________________________________________________________



Involve the patient in making decisions

Discuss treatment goals: express respect towards alternative healing practices

Assess patient’s ability and motivation to carry out plan

Explore barriers: “What do you think we could do to help overcome any problems you might have with the treatment plan?”

Test comprehension by asking patient to repeat instructions

Set limits respectfully: “I can understand how getting that test makes sense to you. From my point of view, since the results won’t help us diagnose or treat your symptoms, I suggest we consider this instead.”

___________________________________________________________________________



Complete the visit Summarize visit and review next steps Ask for additional questions: “What questions

do you have?” Assess satisfaction: ” Did you get what you

needed?” Close visit in a positive way: “It’s been nice

meeting you. Thanks for coming in.”

___________________________________________________________________________


PayoffsIncreases potential for collaborationInfluences health outcomesImproves adherenceReduces return calls and visitsEncourages self care

___________________________________________________________________________

Antidepressant Non-AdherenceOver Time in 20 Studies

0

10

20

30

40

50

60

70

80

0 5 10 15 20 25 30

# of Weeks into Therapy

PATIENT ADHERENCE TO MEDICATION REGIMEN OVER TIME___________________________________________________________________________

Nonadherence Due to Cost (2003)Nonadherence Due to Cost (2003)

35%35%

26%37%Any cost-related

nonadherence

19%18%

12%18%Took smaller

doses

22%22%

16%23%Skipped doses

25%26%

18%28%Didn't fill Rx 1+

times

___________________________________________________________________________

Source: Safran et al. Health Affairs April 2005.

Total No Rx Coverage Low income Complex chronic

Rates of Cost- and Experience-Related Non-Adherence by Chronic Condition and Coverage Status

Rates of Cost- and Experience-Related Non-Adherence by Chronic Condition and Coverage Status

25.1% 26.3%24.4%

30.0%

50.3% 49.0%

40.5%

51.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

CHF

Diabet

es

Hyper

tens

ion

Compl

ex C

hron

ic

25.1% 26.3%24.4%

30.0%

50.3% 49.0%

40.5%

51.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

CHF

Diabet

es

Hyper

tens

ion

Compl

ex C

hron

ic

Cost-Related Non-Adherence (%)

28.9%25.9% 25.5%

31.5%34.8%

29.8% 29.8%

41.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

CHF

Diabet

es

Hyper

tens

ion

Compl

ex C

hron

ic

Experience-Related Non-Adherence (%)

Seniors with Coverage Seniors without Coverage

___________________________________________________________________________


Rates of Nonadherence By Coverage Status, Poverty, and Disease Burden (2003)

Rates of Nonadherence By Coverage Status, Poverty, and Disease Burden (2003)

52%48%

40%48%Total: Any

Nonadherence

19%17%

15%18%

Nonadherence dueto self-assessed

need

34%28%

25%27%Nonadherence due

to experiences

35%35%

26%37%Nonadherence due

to cost

___________________________________________________________________________


Total No Rx Coverage Low income Complex chronic

PATIENT TRUST AS A PREDICTOR OF ADHERENCE: ATTEMPTED BEHAVIOR CHANGE1996

Trust Scale

(percentile)

% Attempted Change

87.8%

78.4%

71.3%

95th

75th

50th

25th

5th

85.5%

81.9%

0 70 75 80 85 90 10095

___________________________________________________________________________


PATIENT TRUST AS A PREDICTOR OF ADHERENCE: SUCCESSFUL BEHAVIOR CHANGE

% Successful Change

32.9%

28.0%

95th

75th

50th

25th

5th

31.7%

29.9%

0 20 25 30 35

24.3%

1996 Trust Scale

(percentile)

___________________________________________________________________________


MANAGING YOUR DIABETES CARE

In the last 6 months, did your [fill in] talk with you about specific things you could do to keep your diabetes under good control?

95

50

91

9

00

20

40

60

80

100

Yes, definitely Yes, somewhat No

Personal Doctor

Nurse, NP, PA

%

% %

%

%%

In the last 6 months, did your [fill in] give you as much information about managing your diabetes as you needed?

96

40

91

9

00

20

40

60

80

100

Yes, definitely Yes, somewhat No

Personal Doctor

Nurse, NP, PA

%%%

%

%%

MANAGING YOUR DIABETES CARE

Do you need more help from your health care providers in any of the following areas in order to keep your diabetes under good control?

54

4751

43

0

20

40

60

80

100

Choosing theright foods

Losing weight Getting regularexercise

Managing stress

54

4751

43

0

20

40

60

80

100

Choosing theright foods

Losing weight Getting regularexercise

Managing stress

%%

%

%

enhancing clinician-patient communication for every day practice: a workshop on the four habits...

Documents

patients perspective

beginning slide

habits approach

patients ideas

patients emotions

patients life

patients perspectiveask

patient physician covenant