Communication Difficulties

Time

Reluctance to bother doctor

LanguageFutility

Anxiety

Memory

“I think the doctors maybe feel that the patient

wouldn’t understand anyway if they tried to

explain it to them in little words.”

“Usually I forget something or the other I wanted to talk about.”

“You’re always feeling that you shouldn’t bother them too

much. In fact, they have a sign on the door, ‘only one problem

per visit.’”

“Well you’re already in an inferior position ... with you

sitting down below and they’re standing up, looking down at you, you know, that’s, well,

intimidating.”

“I’m afraid that I feel that I can’t do much about fostering a good

relationship between the doctor and me because I think that’s something they

don’t teach in university and [doctors] don’t learn it in medical school.”“Most of the time I felt that I

was intruding on their time ... I felt that they wanted it to be over and done with in the 4 minutes and 59 seconds.”

Enabling Seniors to Overcome Barriers in Health Care CommunicationWilliam Godolphin1, Angela Towle1, Sheila Dyer2, Donald Cegala3, Jennifer Manklow4, Holly Wiesinger4 & Lionsview Seniors’ Planning Society5

1Informed Shared Decision Making Project, Division of Health Care Communication, College of Health Disciplines, University of British Columbia, Vancouver BC Canada V6T 1Z3, Tel: (604) 822-8002, Email: isdm@interchange.ubc.ca 2Clinical Skills Resource Centre, Standardized Patient Client Program, Vancouver BC Canada 3Professor of Communication and Family Medicine, Ohio State University, Columbus, Ohio USA 4Medical Undergraduate Program, Faculty of Medicine, University of British Columbia, Vancouver BC Canada 5North Vancouver BC Canada

Supported by the Vancouver Foundation 2000, 2002

Communications SkillsTraining for Patients Communications skills training for

patients directly associated with physicians’ offices has been shown in research studies to make a difference in the nature of the interaction (more questions and control by patients) and improved outcomes (disease-related, functional status and adherence to treatment).

But - community-based interventions have the potential for greater dissemination, lower cost and are consistent with the patient empowerment movement.

Objective

To develop, implement and evaluate a community-based workshop to assist seniors to communicate more effectively with their physicians.

Needs Assessment

Though the quality of communication they described appeared to be less than satisfactory they made excuses for the physician.

They described a general sense of dis-empowerment when faced with the medical profession.

They wanted to focus on what the doctor should do.

Conclusions Implications forworkshop design

They could not imagine howthey might make a difference.

provide a vicarious experience

They were very tolerant of poorcommunication - up to a point -beyond that their only responsewas to ‘fire the doc’.

teach them conflictnegotiation skills

It was difficult to focus on whatthey might do to improveCommunication.

provide for problem-solvingand simulated practice

They had no control in themedical interview.

teach them a structure forcommunications

Workshop Model1½ hours with a break for tea & biscuits

1. Use of PACE communications skills structure

2. A simulated office interview between doctor and patient illustrating common health and communications problems

3. Facilitated discussion and role scripting/playing to explore solutions to the communications problems

1. PACE Communications Skills Model

Presenting detailed information about how you are feeling. (information providing)

Asking questions if desired information is not provided. (information seeking)

Checking your understanding of information given to you. (information verifying)

Expressing any concerns about the recommended treatment.

Cegala et al: Patient Educ Counseling 2000; 41: 209-222

Take home booklet(http://patcom.jcomm.ohio-state.edu)

2. Video Scenario Based on personal experience(s) of

seniors involved in ‘standardized patient/client’ program.

A long-term doctor-patient relationship, with good rapport

Peter had unusually severe asthma attacks while his GP Dr Joan was on holiday. Peter now wants to try some ‘alternative’ therapy (eg, yoga suggested by locum). Dr Joan does not approve and is concerned about full investigation of his worsening asthma.

Sources of conflict: • Treatment preference • Peter’s enthusiasm about the locum (doctors have feelings too!)

Peter illustrates each of the elements of PACE and conflict negotiation skills.

7 minute interview in 4 sections: - small talk and presentation - development - impasse - resolution

Dr Joan & Peter

3. Facilitators’ Guide Introductions: What do you expect

when you see your doctor?

Explanation of PACE framework.

1st video clip: Identify skills the patient demonstrates

2nd video clip: What are sources of conflict? What did the patient do that was helpful? Not helpful? What could you do if you are not like the patient?

3rd video clip: Work in pairs to write a dialogue to resolve the conflict and stay on PACE. Facilitators circulate to the groups. Read out (or better yet, act out) the scripts.

4th video clip: Compare outcomes with discussion of scripts.

Closure: What will you try? Hand out booklet.

Workshop on talking with your doctor

Implementation Presented at community centres

associated with ‘keep well’ program for seniors and promoted by co-investigators (community partners: LSPS).

Co-facilitation by professional (co-investigator) and volunteer (senior)

Evaluation & Follow up

EvaluationAcceptability: 57 participants at 5 workshops indicated lots of enthusiasm and support for the project (verbally and in written evaluations). Word-of-mouth prompted other seniors’ organizations, patient support groups and community centres to request workshops.

Effectiveness: Post-workshop ‘opinionnaires’: the most frequently identified learning was about preparation (eg, “How to get ready for our visit”) and presentation (eg, “The importance of giving a clear history of the problem”)

Efficiency: The high cost of professional facilitator cannot be sustained in the community

Follow upTwo months after workshops 9 participants took part in telephone interviews that were audio taped. Interviews were semi-structured and lasted 10-15 minutes.

Interview transcripts were subjected to Grounded Theory analysis

Examples of change were reported ..Communicate expectations:“I learned to be more forthright and tell him exactly what it was I wanted from him.”

Expressing concerns:“There was a bump on my abdomen and he said, ‘Oh what’s that?’ And I just passed it off and then I got home and I was worried about it, ‘ I wonder if I’ve got an aneurysm.’ And so, when I went back I asked him and I might not have done that before the workshop.”

Asking questions:“The specialist - I had some questions that I wanted to know, so I thought about them before going.”

Presenting information:“I might not have told him about how I was feeling without that workshop. I was feeling very vague, not very great. I was rather surprised that he was concerned but I think he was concerned because I do have a chronic condition. Lo and behold it was that. So I’m on antibiotics. Caught it early because I did tell him.”

.. but the subjects identified specific communications difficulties; on analyses these were categorized as:

Next Steps Follow up intervention to

reinforce the learning and support problem-solving.

Embed in existing community programs by training volunteer peer facilitators who are also role models.

Similar workshops for other patient groups. The major difference will be the video scenarios.

‘Endorsement’ from physician professional body, eg, licensing college or medical association.

Our current funding focuses on more seniors’ groups, a support group for stroke patients and a community mental health program.

These are high health care users and in an ‘information’ age they are disadvantaged in accessing information and more likely to be dis-empowered in the doctor-patient encounter.

Conclusions Change is slow and difficult

and needs support and reinforcement.

Sustainability requires embedding in existing programs and training of local facilitators.

Perceived risk to rapport requires endorsement of workshop by physicians.

They need ‘evidence’ (role models, testimonials) of what is possible — countering dis-empowerment by demonstrating it can be done — that they can put these skills into practice.

Change was limited by:

Expressed satisfaction with existing relationship; low drive to change.

Most barriers to communications were attributed to the doctor; beyond patient’s control.

Importance of maintaining good rapport; attempts to make a change are perceived to put rapport at risk.

The difficulty of changing an established relationship; lack of tactics to signal this intent.

Workshop

Focus group .... with 8 seniors interested in a workshop to improve communications with their doctors.

They were asked to describe communications problems and what they would like to be able to do about them.

They shared the information widely with friends and family

A variety of barriers to discussion with their physicians included lack of time, lack of doctor’s interest and ‘doctor knows best’.

Telephone interviews.... with 21 seniors following a community workshop “High blood pressure: What are your risks and can they be reduced with prescription drugs?”.

They were asked if they discussed what they had learned with their physicians and about the response they received.

University-Community Partnership Research

The Seniors Benevolent FundThe Roy and Bertha Wrigley Fund

UNIVERSITY OFBRITISH COLUMBIA