Shiva Sharma, M.D
Pediatric Cardiology Services
Extensive data has linked effective
physician-patient
communication
to
biological, psychological, social, and legal
outcomes of care. It has been tied to better
adherence, shorter hospital stays, better
efficiency and cost effectiveness, less
malpractice, and not surprisingly, increased
physician and patient satisfaction
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Case presentations followed by discussion of
effective communication skills
Work up to more complex scenarios: bad
news/difficult situations and conversations
Prenatal Counseling
Medical error disclosure
Enhancement of quality of care
Increasing satisfaction Patient/Caregivers
Promoting excellence in physicians
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RH, 10 yr WM
F Hx of hyperchol.; Dad MI at 35 yrs
Sedentary, obese, male, Mod.⇧ LDL, ⇩HDL
TLC program initiated.
2nd visit 10% ↓ in LDL,TG with TLC ; ⇪Wt.
Extended meeting with Dad and RH to
understand their perspective, rationalize care,
and elicit their partnership
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Habit 1: Invest in the Beginning
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Habit 2: Elicit the Patient's Perspective
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Habit 3: Demonstrate Empathy
◦ "... to know and understand, obviously is a dimension of being
scientific; ... to feel known and understood, is a dimension of
caring and being cared for.“
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Habit 4: Invest in the End
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Establish rapport & build trust rapidly
Facilitate effective info. exchange
Demonstrate caring &concern
Increase adherence to plan
Improve health outcomes
120-160,000 interviews in a lifetime. Modest improvement in
delivery of care can improve outcomes , satisfaction and cost.
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Reflection--"I can see that you are ... "
Legitimation--"I can understand why you feel
... "
Support--"I want to help."
Partnership--"Let's work together ... "
Respect--"You're doing great."
Listening
Partnership
Patient
Empathy
Individualization
Conveying bad news and engaging in
difficult conversations with patients and
their families are pivotally important,
although anxiety-provoking
components of clinical practice:
“Clinicians may fear they will not be
able to find the “right words”
They will say too much, too little, or
the wrong thing altogether.
Further, clinicians worry that
imparting difficult news may
diminish hope, compound a
family’s suffering, or unleash
emotional responses”
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WT, 15yr, AA male
Exertional chest Pain
Abnomal EKG with T wave inversion
Echo Confirmed IHSS
Family conference
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What do patients want to know?
How do patients experience bad news?
How competent are physicians in giving bad
news?
How should physicians give bad news?
Does how bad news is given make a
difference?
Do cultural differences matter?
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2,331 patients at UK cancer centers:
–98% wanted to know if the illness was cancer
–87% patients preferred “as much information
as possible”
Need to individualize delivery to patient
needs
Jenkins, Br J Cancer 2001;84:48-51
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Bad news results in a cognitive, behavioral, or
emotional deficit in the person receiving the
news that persists
Clinicians can’t change the news
Clinicians can make the news worse, or they can
help give realistic hopes
100 patients diagnosed with cancer:
– Shock
54%
– Fright
46%
– Accept
40%
– Sadness
24%
– Not worried
15%
Lobb, Med J Aust 1999: 290-4
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Three months after parents received bad
news
12 of 23 sets took in “little or none of the
information given”
4 of 23 sets denied that a separate
information session had occurred
10 of 19 sets remembered the information
session, but didn’t understand the content
Eden, Pall Med 1994: 105114
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Technical language frequently unclear
100 women with breast cancer:
◦ 73% misunderstood “median survival”
◦ No agreement on what a “good” chance of
survival meant numerically
Ford, Soc Sci Med 1996: 1511-9
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5 oncologists studied intensively
None predicted patient distress better than
chance
One had negative predictive behavior
All very satisfied with their performance
Little probing about patient emotional state
Clinician
Patient
Stress
Encounter
Time
Ptacek, JAMA 1996: 496-502
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Physicians may feel discomfort with the intense
emotions displayed by parents in response to
the news, such as sadness, anger, and blame.
Physicians may feel guilty or inadequate
regarding their inability to cure the child.
When the child’s illness is sudden, little
opportunity may exist to establish relationships
with parents before communicating bad news,
thus making it hard to anticipate parents’
informational and emotional needs.
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S - ‘‘setting up the interview.’’ This portion of the protocol
recommends a mental rehearsal for physicians before
delivering the news
P – “assessing the patient’s perception.’’ This portion of the
protocol encourages the physician to use open-ended
question to assess how much the patient/parent knows
before breaking the news.
I – “obtaining the patient’s invitation.’’ This step involves
asking the patient/parent at the time of testing how they
would like the results to be explained.
K – ‘‘giving knowledge and information to the patient.’’
E - ‘‘addressing the patient’s emotions with empathetic
responses.’’
S- ‘‘strategy and summary.’’
As prospective parents, when you learn
your baby has a congenital heart defect,
the news can be devastating. Feelings of
helplessness, confusion, fear and
mourning over the loss of a healthy baby
occur. In addition, extremely difficult and
life changing discussions and decisions
need to take place in a relatively short
period of time.
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MJ is a 25 yr WF. 18 wks gestation fetus
found to have CHD and told about it.
Fetal echo: HLHS confirmed with MA and AA
Extended Family conference with Mom and
Dad.
Earlier studies have reported:
• Increased maternal anxiety with prenatal diagnosis
of any fetal anomaly (Detraux et al,1998)
• Considerable psychological distress in mothers(as
compared to fathers) which may be markedly
underestimated by healthcare providers (Leithner et
al, 2004). This may require professional help in the
perinatal period. (Skari et al, 2006)
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Help families cope with the news of CHD
Help families understand
prognosis/diagnosis.
Make transition to post natal life as seamless
as possible
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Try not to overwhelm the parents
Challenge to provide the information in a way
that is easily understood
Only a small fraction of what is said is likely
to be retained
Typically go through normal anatomy and
physiology and then go through the defect
Benefit of multi-disciplinary approach
Respect for patient autonomy is a
cornerstone of the Codes of Medical
Ethics of the American Medical
Association
(AMA)
and
encompasses the rights of patients
to receive all information necessary
to make informed and educated
decisions about their care.
Disclosure of adverse events is
implicit in this principle, because
without it patients are not fully
informed.
Failure to disclose threatens the
trust inherent in a doctor–patient
relationship.
Research
on
patients,
family
members, and attorneys suggests
that patients are less likely to sue if
disclosure has taken place
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What do patients actually expect after an
injurious medical error has occurred?
Numerous studies in adults have examined
this question, and five key messages have
emerged. Patients want:
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An explicit statement that an error occurred
To be told what the error was
To be told why the error occurred
To know what will be done to prevent recurrences
An apology
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Why disclose?
◦ To preserve patient autonomy and patient-physician trust
◦ Because ethically it is the right thing to do
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Who should disclose?
◦ Health care worker with whom the patient has a trusting relationship,
usually the responsible physician
◦ Others involved in the incident (eg, nurse, pharmacist may be
included)
◦ If the physician cannot disclose, another health care worker with an
established relationship with the patient or a member of the hospital
leadership or quality and safety program should do the disclosure.
◦ A senior hospital administrator may need to be involved in serious
cases.
◦ The patient’s primary nurse should be included in the discussions to
be able to support the patient after the disclosure has occurred.
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To whom should the communication be made?
◦ To the patient
◦ If this is not possible, to family members or substitute decision
makers
What types of events should be communicated?
◦ Any incident that has resulted in harm to the patient
◦ Other incidents at the discretion of the responsible physician
What information should be communicated?
◦ Acknowledge that the event occurred and give the facts.
◦ Take responsibility and apologize.
◦ Commit to finding out why.
◦ Explain what impact the event will have on the patient now and in
the future.
◦ Describe steps being taken to mitigate the effects of the injury.
◦ Describe steps being taken to prevent a recurrence.
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When should communication take place?
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As soon as the event is recognized and the patient is physically
and emotionally capable
◦ Ideally within 24 hours after the event is recognized
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Where should the communication take place?
◦ In a private and quiet area
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Normality
Certainty
Health information
Partnership
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Delivery of information
Levels of support
Relationship with the caregiver
Management of events
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Verbal , one on one basis
Nonverbal communication, eye contact
Simple language at level with parents
Supplemental visual, written, websites to
give.
Check out
www.pted.com
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Establish rapport and trust by LISTENING to
parents & patients
Partner with parents
Including older child in conversation
Treat as individuals.
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Contact numbers
Open access
RN contact
Web based support groups
Other families in the area with
similar diagnosis +School staff
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Parents want control over
events
Access to specialized RN,
MD, CHOA type hot line.
Information for school
Professional competence is
defined as the habitual and
judicious use of
communication, knowledge,
technical skills, clinical
reasoning, emotions, values,
and reflection in daily practice
for the benefit of the
individual and community
being served.
Cognitive
 Core knowledge
 Basic communication skills
 Information management
 Applying knowledge to real-world situations
 Using tacit knowledge and personal experience
 Abstract problem-solving
 Self-directed acquisition of new knowledge
 Recognizing gaps in knowledge
 Generating questions
 Using resources (eg, published evidence, colleagues)
 Learning from experience
Technical
 Physical examination skills
 Surgical/procedural skills
Integrative
 Incorporating scientific, clinical, and humanistic judgment
 Using clinical reasoning strategies appropriately (hypotheticodeductive,
 pattern-recognition, elaborated knowledge)
 Linking basic and clinical knowledge across disciplines
 Managing uncertainty
Context
 Clinical setting
 Use of time
Relationship
 Communication skills
 Handling conflict
 Teamwork
 Teaching others (eg, patients, students, and colleagues)
Affective/Moral
 Tolerance of ambiguity and anxiety
 Emotional intelligence
 Respect for patients
 Responsiveness to patients and society
 Caring
Habits of Mind.
 Observations of one’s own thinking,
emotions, and techniques
 Attentiveness
 Critical curiosity
 Recognition of and response to cognitive and
emotional biases
 Willingness to acknowledge and correct
errors
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Heart of medicine is patient-physician
encounter to heal the whole patient
PERCS (Program to Enhance Relational and
Communication Skills)
MD RN, MSW, Students; non-hierarchical:
Promote self awareness, self assessment
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Quality of care depends a lot on good
communication with families
Good communication depends a lot on
listening to our patients and showing
empathy.
Good listening means good care.
Parents are not looking for how much you
know but how much do you care.
Report of the Pew-Fetzer Task Force on
Advancing Psychosocial Health Education
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Reflection--"I can see that you are ... "
Legitimation--"I can understand why you
feel ... "
Support--"I want to help."
Partnership--"Let's work together ... "
Respect--"You're doing great."
Cohen-Cole SA, Bird J. Building rapport and responding to patient's
emotions. In: Cohen-Cole SA. The medical interview: the threefunction approach. St Louis, MO: Mosby Year Book; 1991. p. 21-7.
1. Best practices for:
a) information delivery
b) management of parental anxieties & expectations
c) communication of rare conditions ( the unknowns)
d) communication of bad news
e) empowering families/patients
2. Pre natal Counseling
3. Team Approach: Coordinating care and support
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Reviewing the evidence
Recommendations for clinicians
Cultural considerations
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Prognostic uncertainty may lead to reluctance
in providing information about outcomes.
While bad news may be best provided in the
forum of a family conference, such conferences
are time-consuming and require advanced
planning.
Additionally, societal and family expectations
that death is avoidable through advanced
technology work against physicians’ credibility
when discussing the inevitability of a child’s
death, especially when trust has not been
established.
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Conveying bad news and engaging in difficult
conversations with patients and their families
are pivotally important, although anxietyprovoking components of clinical practice:
◦ Clinicians may fear they will not be able to find the
“right words”
◦ They will say too much, too little, or the wrong
thing altogether.
◦ Further, clinicians worry that imparting difficult
news may diminish hope, compound a family’s
suffering, or unleash emotional responses