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Effective dr-patient communication skills related to patient:

• Information recall and understanding (Gattellari et al, 1999; Heisler et
al., 2002; Watson & McKinstry, 2009)
• Treatment decisions (Heisler et al., 2002)
• Treatment adherence (Zolnierek & DiMatteo, 2009)
• Coping and self efficacy (Zachariae et al, 2003)
• Self management (Heisler et al., 2002)
• Patient and family satisfaction (Haskard et al, 2008; Zachariae et al,
• Health outcomes (See Stewart, 1995)
• Doctor outcomes (Ramirez et al, 1995)


Patient expectations of health professionals

Patients expect more from their doctors than 30 years ago
• Technical expertise
• Accurate information
• Empathy / emotional support
• Access to services
• Continuity and coordination of care
It is a failure on the part of doctors to communicate caring that lies at the heart of most patient dissatisfaction with their doctors (Dhaliwal, 2012)


Why do patients initiate litigation?

• Levison et al (1997) audiotaped 10 routine visits each with 59 GP’s
and 65 surgeons (general & orthopedic) => 1265
• Communication behaviour differences between sued vs not-sued doctors
• Drs who were NOT SUED:
• longer consultations (only by 3 minutes!)
• explicit agenda for patient
• facilitating behaviours: elicited patient opinions & questions
• used humour & active listening techniques

Second experiment presented participants with N=114 (1/2 sued) 2 x 10 second voice clips, participants could tell from 10 second excerpts which doctors were sued


Bad news

any news that seriously and adversely changes the patient’s view of her/his future. Stressful for both (see slide show/ listen to lecture)


Breaking “bad news”- why is it important?

• Frequent but stressful task
• Clinician may disclose bad news thousands of times over career
• Breaking bad news can be particularly stressful when clinician is inexperienced, the patient is young, or there are limited prospects for successful treatment.

• Patients want the truth
• Most patients (>95%) want to be told of their cancer diagnosis
• Most patients (>85%) want to be given realistic estimate of how long they have
to live

• Ethical and legal imperatives
• Informed consent and patient autonomy create clear legal obligations for clinicians to disclose as much information as patient desires

• Clinical outcomes
• How bad news is discussed can affect the patient’s comprehension of information, satisfaction with medical care, level of hopefulness, and subsequent
psychological adjustment


Breaking “bad news”- SPIKES protocol

S Setting
(privacy, family, rapport/connection, minimise disruptions)

P Patient perception of condition and its seriousness
(assess what patient currently knows/thinks, open ended questions)

I Invitation from the patient to give information
(How would patient like information given, how much detail)

K Knowledge: giving medical facts
(Warning shot, avoid jargon, avoid bluntness, give info in small chunks)

E Explore Emotions and Empathise
(Empathically respond to emotions patient exhibits)

S Strategy and Summary
(Elicit patient’s understanding, discuss any further steps)
(Baile et al, The Oncologist 2000)


How does Spikes help clinicians?

• SPIKES protocol helps clinician to achieve the 4 main objectives of consultation where bad news is delivered
• Gathering information from the patient
• Transmitting the medical information
• Providing support to the patient
• Eliciting the patient's collaboration in developing a strategy or treatment plan for the future.


Eliciting and responding to emotional cues

• A message from the patient that contains some reference to emotional content
• Verbal and/or non-verbal

•Blocking & Facilitating Behaviours (tutorials)
• Active listening
• Empathy
• the ability to understand people from their frame of reference rather than your own


Conveying empathy (verbally and non-verbally)

• Show desire to comprehend. Listen carefully
• Discuss what is important to the patient
• Use responses that refer to the patient’s feelings
• Use responses that bridge or add on to implicit statements by the patient.
• Patients do not tend to discriminate between the levels of empathy offered by health professionals (i.e. very empathic or only a little empathic).


Patient Barriers to disclosing /addressing emotional
cues and psychosocial issues

It’s not a Doctor’s role
Doctor too busy
Normalising /somatising emotions
Wait for Doctor to raise this topic
Feel embarrassed
Fear breaking down, losing control
Don’t have the words to describe how
they feel


Doctor Barriers to disclosing /addressing emotional
cues and psychosocial issues

Insufficient training (I don’t know how)
Lack of evidence (Why should I?)
Difficulty (It’s hard!)
Vulnerability (I can’t cope)
Attitudes (It’s not my job)
Patient reticence (I can’t read minds)
System constraints (I don’t have time)


Factors related to patient (non)-disclosure of
psychosocial issues

Leading / closed questions
Focusing on physical aspects
Moving too quickly to advise and reassure (placating)

Open questions
Focusing on and clarifying psychological issues
Empathic statements, active listening and educated guesses


Empathy makes a difference

• Duric et al (2003): 111 audio-taped consultations
between genetic counsellors and women at high risk of breast cancer
• Patients whose first cue was responded to with empathy gave significantly more cues than those whose cue was ignored
• Women who received more empathic responses to their cues had significantly reduced depressive symptoms 3 weeks later


Why is communication important?

Attending to emotional cues/concerns and providing
adequate information and emotional support in medical consultations leads to:
• Faster recovery amongst patients (average one day reduction in hospitalisation)
• Greater cooperation with treatment (adherence)
• Fewer post-hospital complications & events


Clinicians communication skills

Generally, communication skills do NOT:
• Reflect personality
• Reflect natural talent
• Improve with age
• Improve with professional experience

• Effective communication skills can be taught, maintained and improved
• Few health professionals receive formal training in communication skills (particularly after completing University)


Examples of Clinicians communication skills

• Eliciting and Responding to Emotional Cues
• How to deliver bad news to cancer patients and their families
• Discussing the transition to palliative care with cancer patients, their family and friends
• Discussing sexuality with cancer patients, their families and friends
• Effectively discussing complementary and alternative medicine (CAM) with cancer patients, their family and friends
• Discussing death and dying with cancer patients, their families and friends


Effectiveness of communication skills training
(Fallowfield et al., 2002; RCT)

• 160 oncologists from 34 cancer centres randomised to 4 groups:
1. written feedback followed by CST course;
2. CST course alone;
3. written feedback alone; and
4. control
• CST Course content: structured feedback, videotape review of consultations, role-play with simulated patients, interactive group demonstrations, and discussion led by a trained facilitator.

• 3-months follow up
• Improvements in the communication skills of clinicians randomised to CST training compared with others, including:
• Fewer leading questions, appropriate use of open-ended questions and responses to emotional cues.

• 12 months follow-up:
• Additional skills (not apparent at 3 months) evident:
• 81% fewer interruptions and increased summarising of information to 38%.
Yet, expressions of empathy (54%) declined.
• Enduring effect of the communication intervention
• => Clinicians had integrated key communication skills into clinical practice


What is the best way to present risk?

Each presentation format has its advantages and limits

• If you add radiotherapy to surgery, your chances of the cancer coming back in the same place are MUCH LOWER

• (Mary) I had radiotherapy for my rectal cancer. It was OK. I was glad to have it, I knew I was doing everything I could to stop this cancer getting me. It hasn’t come back.
• (John) I had radiotherapy for my rectal cancer. It was dreadful. I had bad diarrhea (still do) and pain. And then the cancer came back anyway. I’d never recommend it to anyone.

Relative risk:
• Radiotherapy will halve your chances of the cancer coming back

Absolute risk:
After surgery- 8 out of 100 (8%) people will have their cancer come back in the same place
After surgery & radiotherapy- 4 out of 100 (4%) people will have their cancer come back in the same place

Pie charts

• 100 person diagram

-Horizontal bars

-Survival graph


Absolute vs. relative risk- examples

• Treatment effectiveness:
• [RR] “Radiotherapy after surgery for XX cancer will halve your risk of the cancer coming back”
• BUT the chance of cancer coming back in this situation is only 2/100, reduced to 1/100 by radiotherapy!!! and radiotherapy can have longterm
consequences (e.g. chronic diarrhoea, infertility)

• Treatment side effects:
• [RR] “Taking hormonal treatment/drug X will double your risk of developing ovarian cancer”
• BUT the base rate of ovarian cancer is very low – the increase is from 1 in 3,000 to 2 in 3,000

• Active treatment options (e.g. surgery, medication) are chosen more often when outcomes described in terms of RELATIVE rather than ABSOLUTE risk reductions.
• (Moxey et al, 2003; Wills & Holmes-Rovner, 2003)


Patient stories

• Make information more salient, easily imaginable and memorable

• May facilitate informed decision-making by:
• providing insights in how others come to make a decision and make ‘trade-offs’, and reflect on the uniqueness of their situation, and emotional aspects of decision-making.

• OR

• May impede informed decision-making by:
• prioritising another’s rationale instead of one’s own, by making decisions based on a reaction to the other person, and a retrospective account, or by introducing emotion-laden‘natural’ language.

• (IPDAScollaboration,2012:


100/1000 person/dot diagrams BEST

• Results in better understanding among both older and younger patients compared with numerical presentations in either a frequency or probability format (Fuller, Dudley & Blacktop, 2001, 2002)
• Significantly reduces impact of patient stories on hypothetical treatment decisions (Fagerlin et al., 2005)


Simplification of risk of 100/1000 person/dot diagrams

• What does a risk of 3 in 500 mean anyway?
• Most people convert numerical risk into categorical risk => GIST
(high or low – it will happen to me, or it won’t)
• Analogies are helpful
• Low risk: The risk of this cancer coming back is about the same as your risk of getting hit by lightening or winning the lottery
• High risk: The risk of this cancer coming back is about the same as your risk of getting a cold this year


Risk communication: Key points

• Use consistent framing when discussing pros/gains and cons/losses
• Provide base rates of outcomes
• Use absolute risk comparisons
• Provide information about the consequences of the risk (e.g. if the cancer comes back we can’t cure it)
• Preferred graphical formats are not always the best understood
• 100 person diagrams lead to greater accuracy in understanding
• Check and re-check understanding of risk
• Best graphical format will depend on its intended purpose!!!


Family involvement in consultations

• Current medical communication research focuses on doctor-patient interactions.
• But there is often someone else present…
• Family attend 63%-86% of cancer consultations with an adult patient


Why focus on communication with family?

• Family carers are an underserved cancer population
• High expectations to support patient
• High unmet informational and emotional needs
• High burden (physical, psychological)
• Low support

• When engaged and supported > family carers can be effective partners in quality patient care:
• Family can support patients inside consultation (information, decision-making, advocacy, emotional support, practical support)
• And at home (home care)

• When not well managed > family carers can derail consultations
• Family anger/dominance/conflict
• Patients withholding sensitive information
• Conflicting patient-family treatment wishes


Challenges of family involvement

• Characteristics of challenging family members
• Family members who cannot understand/keep up with the information
• Dominant, aggressive, or obstructive family members

• Challenging situations
• Conflicting patient-family treatment wishes
• Discussing sensitive issues (e.g. sexuality) with patient in family’s presence
• Family requests for information
• Too many family members attending consultation
• Family acting as interpreter for non-English speaking patient
• Family taking over

• Costs/trade-offs
• Extra complexity- managing more relationships/dynamics
• Potential loss of patient centredness


Benefits of family involvement

To the patient
• Better informed and more confident about decision
• Less isolation, shared burden

• To the clinician
• Family provide additional information
• Reassured because of family’s provision of informational support
• Reassured that the patient has social support

• To the family member themselves
• Feel included, part of the process, useful
• Better understanding of decisions/prognosis, less misunderstandings, less worry
• More empowered as caregivers


Challenges vs. benefits

• For most clinicians, benefits outweigh the challenges
• Many believed “its worth the extra effort” or “it’s just part of the job”
• Initial investment of time with family is paid back
• Strategies to manage the challenges and to enhance the positive involvement of family are an important part of communicating with family