effective communication skills with families and colleagues cmh fellows curriculum august 7, 2007...
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Effective Communication Skills with Families and Colleagues
CMH Fellows CurriculumAugust 7, 2007
Timothy P. Hickman, MD, MEd, MPH
Associate Professor, Department of Pediatrics and Department of Medical Education and Research
Cultural Competency MasterOffice of Cultural Enhancement and Diversity
University of Missouri-Kansas City School of Medicine
Learning Objectives
• Describe research in parent-provider-child communication in pediatrics
• Discuss communication styles and how they might effect interdisciplinary and patient communication
• Identify approaches to taking a history that will elicit health beliefs and traditional medical practices from any patient
• Discuss incorporating a cultural history into the clinical history
ACGME Core Competencies Addressed
• Patient Care
• Interpersonal and Communication Skills
• Professionalism
Communication Quotient Activity
Cincinnati Children's Study
• Methodology– Survey of Attending Physician, Nursing Staff,
and Parents– Probably Case Series Design (Baseline for
RCT)
• Sample– 44 PGY1 residents scheduled for pediatric
rotations (8 not eligible)– Physician, Nurses, Parents: Convenience
sampleBrinkman, 2006
Cincinnati Children's Study
0
20
40
60
80
100
Per
cen
t Y
es
ShowingInterest
Respectful Explained Listened SharedDecisions
Parent and Physician Rating of Residents
Physician
Parent
Brinkman, 2006
Significant Differences
• Physician > Parent Rating of Residents– None
• Parent > Physician Rating of Residents– Sharing Decisions (p<0.3)
Brinkman, 2006
Cincinnati Children's Study
0
20
40
60
80
100
Per
cen
t Y
es
RespectStaff
AcceptSuggest.
RespectConfident.
Comm. withStaff
Comm. WithPt/Fam
Nursing Staff and Physician Rating of Residents
Physician
Nurse
Brinkman, 2006
Significant Differences
• Physician > Nurse Rating of Residents– Treat staff with respect– Accept Suggestions– Good team member– Sensitive and empathetic– Respect confidentiality– Honesty and integrety
• Nurse > Physician Rating of Residents– Effectively plan course of care– Anticipate post discharge needs
Brinkman, 2006
Discussion
• Percentages reflect how often the highest item on a 5 point scale was selected
• Parents mean rating for all items was about 57%
• Physician and parents had similar ratings on resident-parent interaction but physicians frequently marked unable to observe
• Parent and nursing staff provide unique perspectives
Brinkman, 2006
Birmingham Children’s Hospital
• Methodology– Independent analysis of doctor-parent-
communication– Surveys of parents and children– Case Series
• Sample– Convenience sample– 51 outpatient visits, 12 doctors
Wasmer, 2004
Birmingham Children’s Hospital
Percent of Contribution to Visit by Time
67%
28%
5%
Doctor
Patient
Child
Wasmer, 2004
Birmingham Children’s Hospital
Percent of Contribution to Visit by Turn
52%
38%
10%
Doctor
Patient
Child
Wasmer, 2004
Discussion/Conclusions
• Growing evidence that children should participate in clinical encounters including shared decision making
• Most research indicates very low communication by children
Wasmer, 2004
Active Listening Skills
• Attentive body language– Posture and gestures showing involvement
and engagement– Appropriate body movement– Appropriate facial expressions– Appropriate eye contact– Non-distracting environment
Robertson, 2005
Active Listening Skills
• Following skills (Giving the speaker space to tell their story in their own way)– Interested ‘door openers’– Minimal verbal encouragers– Infrequent, timely and considered questions– Attentive silences
Robertson, 2005
Active Listening Skills
• Reflecting skills (Restating the feeling and/or content with understanding and acceptance)– Paraphrase (check periodically that you’ve
understood)– Reflect back feelings and content– Summarize the major issues
Robertson, 2005
Communication Styles
• Direct– Meaning is conveyed through explicit statements
made directly to the people involved. No need to rely on contextual factors such as situation and timing.
• Indirect– Meaning is conveyed by suggestion, implication,
nonverbal behavior or other contextual cues. This allows one to avoid confronting another person or cause them to lose face.
Foreign Affairs Canada and International Trade Canada, 2007
Communication Styles
• Linear– Discussion is conducted in a straight line,
almost like an outline. There is a low reliance on context.
• Circular – Discussion is conducted in a circular manner.
The main point is often left unstated. There is a high reliance on context.
Foreign Affairs Canada and International Trade Canada, 2007
Communication Styles
• Attached– Issues are discussed with feeling and
emotion.
• Detached– Issues are discussed with calmness and
objectivity, conveying the speaker’s ability to weigh all the factors impersonally.
Foreign Affairs Canada and International Trade Canada, 2007
Communication Styles
• Intellectual Engagement– Any disagreement with ideas is stated directly, with
the assumption that only the idea, not the relationship, is being attached. (We’re just having a friendly discussion – don’t take it personally’.)
• Relational Confrontation– Relational issues and problems are confronted
directly, while intellectual disagreement is handled more subtly and indirectly.
Foreign Affairs Canada and International Trade Canada, 2007
Communication Styles
• Concrete (Factual)– Issues are best understood through stories,
metaphors and examples, with an emphasis on the specific, rather than the general.
• Abstract (Big Picture)– Issues are best understood through theories,
principles and data, with emphasis on the general, rather than the specific.
Foreign Affairs Canada and International Trade Canada, 2007
Communication Style Activity
Why Conduct a Culturally Competent History
• Increasing diversity of U.S. population• Importance of health belief
– Diagnosis– Compliance– Traditional Treatments
• Importance of history in diagnosis and decisions about diagnostic and therapeutic options
Culturally Competent Care
• Recognizes the complexity of cultural influences
• Issue specific not culture specific • Takes advantage of epidemiology but
creates a uniform approach to any person• Learn about culture but avoid stereotyping
Parallels with “Discipline” Specific History
• Pediatrics– Developmental Stages– Caregivers vs. Patient– Wide belief in traditional health practices
• Feeding• Discipline• Crying Infant• Disease Susceptibility
Culturally Competent History
• Greeting– Respectful– Addresses formally (Mr., Mrs.)
• Why they came to see the physician
• Health beliefs regarding the illness– Kleinman’s questions
Culturally Competent History
• Avoid showing reaction or making judgments about patient’s beliefs– Avoid judgmental or condescending
statements– Neutral facial expression– Avoid making assumptions– Avoid alienating or emotionally laden terms
Culturally Competent History
• Inquire about medical decision making authority
• Use lay terms
• Show empathy
• Ask final question: “Is there anything else I can help you with or any other questions that you have?”
Questions
1. What do you thinks caused your problem?
2. Why do you think it started when it did?3. What do you think your sickness does to
you? How does it work?4. How severe is you sickness? Will I have
a short or a long course?
Questions?
5. What kind of treatment do you think that you should receive?
6. What are the most important results you hope to receive from this treatment?
7. What are the chief problems your sickness has caused you?
8. What do you fear most about your sickness?
Cultural History Activity
References• Boyd SD. Using active listening: improve your
communication skill with the most powerful tool available. Nurs Manage. 1998;29(7):55.
• Brinkman WB, Geraghty SR, Lanphear BP, Khourey JC, et al. Evaluation of resident communication skills and professionalism: a matter of perspective. Pediatrics. 2006;118(4):1371-1379.
• Carrillo, J. E., Green, A. R. & Betancourt, J. R. Cross cultural primary care: A patient based Approach. Ann Intern Med. 1999;130: 829-834.
References• Foreign Affairs Canada and International Trade
Canada. Virtual Campus: Independent Learning Module on International Work Skills. Cross-Cultural Skills. Available at: http://www.dfait-maeci.gc.ca/ypi-jpi/pdf/Cross-Cultural_Skills-en.pdf Accessed March 27, 2007
• Kleinman A, Eisenberg L, Good G. Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88: 251-258.
• Kreps G, Kunimoto E. Effective communication in multicultural heath care settings. Thousand Oaks, CA: Sage Publications; 1994.
References• Robertson K . Active listening: more than just paying
attention. Australian Fam Phys. 2005;34(12):1053-1055.
• Spector R. Cultural Diversity in Health and Illness. 5th ed. Upper Saddle River, NJ: Appleton and Lange; 2000.
• Wasmer E, Minnaar G, Abdel Aal N, Atkinson AM et al. How do peadiatricians communicate with children and parents? Acta Paeditrica. 2004;93:1501-1506.
Questions