Download Patient Communication

Improving Patient
Communication
Part 1 of 3: Nonverbal Communication
Patrick Hunt, MD, MBA
Educational Objectives
• Describe research findings about the relationship of
communication and malpractice claims.
• Identify and demonstrate nonverbal communication
techniques that can lessen malpractice risk as well as
improve clinical outcomes and increase patient
satisfaction.
• Improve skill for decoding patients’ nonverbal
communication.
• Understand how nonverbal communication reveals
underlying emotions
• Integrate improved nonverbal communication skills into
daily practice.
Pre-Questionnaire
1. True or False
A. Medical negligence results in most law suits.
B. A physician can lose personal assets in a malpractice
settlement.
C. Being an excellent clinician is the best guarantee against being
sued.
2. Doctors can expect to be sued once every ___ years.
3. What factors put physicians at the greatest risk of being
sued?
A.
B.
C.
D.
The quality of medical care.
Their chart documentation.
Negligent treatment
Ineffective communication with patients.
Malpractice
• There is no relationship between claims made
and the quality of care.
• Fewer than two percent of patients injured as a
result of negligence sue for malpractice.
• Nearly 5 out of 6 patients who sue pursue claims
without merit.
• You don’t have to do anything wrong to get
sued.
• First case in U.S. was Cross vs. Guthery in 1794
in Connecticut.
Personal Costs of Being Sued
• Emotional stress
• Possible damage to reputation
• Lost time and income while away from
practice in depositions or trial
• You’ve already “lost” no matter the
outcome.
Personal Costs of Being Sued
• Could you lose your personal assets in a
malpractice settlement?
– Yes. A verdict granted in favor of the plaintiff
in excess of the hospital’s insurance coverage
could possibly result in the doctor being
personally liable for the financial settlement in
excess of the insurance coverage.
Goal Today
• Improve communication.
• Show strategies for reducing the
frequency and severity of malpractice
lawsuits.
• Review elements of communication.
Why Patients Sue Doctors
• Quality of medical care?
• Their chart documentation?
• Negligent treatment?
Why Patients Sue Doctors
•
•
•
•
Not quality of medical care.
Not chart documentation.
Not negligent treatment.
Ineffective communication with patients.
• It’s not the practitioners with bad clinical skills
who are sued.
– It’s the ones with BAD COMMUNICATION SKILLS.
Over 70% of patients said failure
of communication was the
primary reason that they filed
suit.
Harvard Medical
Practice Study
• Breakdowns in communication and
patient dissatisfaction are the two critical
factors leading to malpractice litigation.
You may be thinking…
• “I really don’t need this course – I’m
already a good communicator”
Studies Show
• Doctors think they communicate far better
than their patients think they do.
• In fact, physician self-assessments are
dramatically different than patient
perceptions.
• Clinicians usually feel they have good
nonverbal skills.
– Videotaped workshops show a surprising
number don’t.
Louder Than Words
What your body language says to
patients.
Nonverbal Communication
• Sending and receiving message in a
variety of ways without the use of verbal
codes (words).
• Often involuntary with subsequent
“leakage” of attitude.
Nonverbal Communication
• Words are important but they’re not the
only way in which messages are
conveyed.
• Involuntary “leakage” of attitude
– Your posture, gestures, tone of voice,
distance from the patient, eye contact – all
transmit feelings and preferences.
The Medical Interview
• Much of your professional training has
emphasized what you say to patients.
• You’ve perfected interview techniques
– You orient, reinstate, summarize, and
empower with the best of them.
– You’ve experienced the “Zen” of open-ended
questions and, if pushed, can do an H & P in
under 10 minutes.
Silent Messages
Since you’re constantly sending out these
messages each day, it’s worth taking time to
consider what you’re “saying.”
The Three Parts
of Communication
• Visual
• Vocal
• Verbal
Dr. Albert Mehrabian
• Established statistics for the effectiveness
of spoken, face-to-face communications.
• Estimated 93% of the total impact of a
message is the result of nonverbal factors.
How We Really Communicate
• ___% Visual
• ___% Vocal
• ___% Verbal
Relative Contribution of
Verbal and Nonverbal Signals
• Argyle found that all types of nonverbal
cues had 4.3 times the effect of verbal
cues.
• Philpott concluded after doing a statistical
analysis of 23 studies that slightly more
than 2/3’s of communicated meaning can
be attributed to nonverbal.
In a battle of the
communication types,
nonverbal always wins.
Exercise
“When the eyes say one thing,
and the tongue another, a
practiced man relies on the
language of the first.”
Ralph Waldo Emerson
Visual Communication
• Six parts of visual communication
– Eye contact
– Facial expression
– Haptics
– Position
– Gestures
– Appearance
Eye Contact
• Eye contact offers instant proof of
attention – interest, concern or fear.
• Eye contact telegraphs intent: “I’m thinking
about you. You matter to me.”
Eye Contact
• Maximum safe eye-contact time
– 3 to 5 seconds
• Break eye contact every 5 to 10 seconds.
• Look concerned
– Attentiveness during patient history taking
correlates with high levels of patient
satisfaction.
Eye Contact
• Look from the center of your eye, not the
corner which sends a subliminal message
you may not be trustworthy or are not
telling the truth.
• Darting, angled glances suggest you are
hurried or agitated.
Eye Contact
• Writing while the patient talks
– Ask permission to take a few notes as the
patient talks: “Would you mind if I make a few
notes? I don’t want to miss anything.”
– Be sure to look up and make eye contact at
least every 30 seconds.
– Try never to write while you talk.
Eye Contact
• Blinks
– Too much blinking suggests anxiety or
duplicity.
– Try to limit blinks while giving a critical
diagnosis or discussing a sensitive problem.
– Normal number of eye blinks per minute
• 15 to 20
Facial Expression
• Default
– Hint of a smile
Facial Expression
• Neutral Expression
– Is usually interpreted
as negative.
Facial Expression
• Guillaume Duchenne
– French neurologist who triggered muscular
contractions with electrical probes in the
1860’s.
– Determined that “genuine” smiles resulting
from true happiness utilize the muscles not
only of the mouth but also of the eyes.
Facial Expression
• Duchenne’s true
smile
– Activates the
orbicularis oculi and
other muscles that
aren’t under voluntary
control – thus difficult
to fake.
Facial Expression
• “Uncle Benny” smile
– An expression of
courtesy and
politeness.
– Also used by airline
stewardesses,
ballerinas, and doctors
entering an exam
room.
Facial Expression
• When first greeting a patient:
– SMILE
– Try for the Duchenne “true” smile versus the
“Uncle Benny” smile.
Facial Expression
• The brow lift.
• Don’t “double pump”
– it means something
entirely different!
Haptics
• From the Greek ἅπτω, meaning “I fasten
onto, I touch.”
Haptics
• Psychologists have
confirmed that an initial
handshake can be
enough to form an
impression about
someone.
– But, too firm or half-hearted
handshakes can send the
wrong message.
– Some female patients don’t
like to shake hands.
– Also, be aware that the use
of the handshake differs
from one culture to
another.
Haptics
• Handshake
– Okay for “high touch” Hispanic and
Mediterranean cultures.
– Cultures in which male-female behaviors are
highly differentiated are less likely to
encourage female handshaking.
– Most Asian and northern European born
patients prefer less touching and a more
formal approach.
Position
• Face the patient
– “If the physician directly
orients himself toward the
patient, the patient senses
greater interest, listens
more intently, and retains
more information.”
• Remove barriers
– Sit on the same side of the
desk.
– Don’t hold the chart in front
of your chest.
Position
• Talk to the patient at eye level.
• This also removes another barrier – poor
hearing.
• Mirror the patient – it increases comfort
level.
• LEAN FORWARD.
Position
• Forward leaning position
– Vary position during interview.
– Use at beginning and end.
– Use when patient discloses serious physical
or emotional concern – lean in very slowly
and only slightly.
– Avoid suddenly bolting forward – may indicate
you’re really alarmed and worried.
Position
• Leaning back
– Can suggest lack of interest.
– When a clinician leans back in the chair
during an interview, patient satisfaction is
significantly lower.
Gestures
• Use slow, smooth gestures to underline
your important points.
• Too many make you look hurried or
theatrical.
Gestures
• Avoid crossing your
arms.
• Can be interpreted as
boredom, annoyance
or defensiveness.
Gestures
• Touching yourself
– Keep your hands away
from your face – don’t
cover your mouth.
– Avoid touching your
nose – “Pinocchio”
syndrome.
Gestures
• Recommended
neutral position
– Uncrossed knees and
feet
– Slight asymmetry
suggests openness
and that you’re relaxed
with the person.
Gestures
• Nods
– Nods show you’re listening – do it slowly and
thoughtfully at key points during the patient’s
explanation or yours.
– Avoid
• Rapid and frequent nodding while patient is talking
• Patient might assume that you’re thinking, “Okay,
okay, I get it. Come on, I haven’t got all day.”
Gestures
• “OK” sign –Thumb and
forefinger coming
together – “Your
medication seems to be
working great.”
– A common and innocent
gesture?
• Will leave patients from
Russia, Germany, and
Brazil scowling and
shocked. It denotes a
particular body orifice.
Appearance
• Do looks matter?
– When asked if their confidence in a doctor
was based on his or her appearance, 41% of
patients said yes.
• A first impression
– Registers in TWO seconds.
– Sets in FOUR minutes.
– Once made, it’s nearly impossible to change.
Appearance
• Dress the part
• Casual vs. grubby
• McKinsey consultants with grey hair had
higher satisfaction ratings
Nonverbal Communication
• Tune in to the patient’s nonverbal cues.
– Being conscious of your own body language
allows you to be more receptive to the
patient’s silent messages.
Unlock Hidden Concerns
• Reasons for the patient’s visit
– In 42% of visits, the real reason is something other
than the presenting complaint.
– Nonverbal clues are an important way of discovering
this.
• In 96% of cases with a psychosocial problem the
stated reason for the visit was not the principal
complaint.
• Even when concerns were largely somatic, the
presenting complaint was still not the principal
problem in over 25% of cases.
Reading Nonverbal
• Patients with hidden agendas also tend to
do more hand-to-body self touching than
patients with single agendas.
• FBI studies show people who don’t
gesture during interrogations are hiding
something and often assume a flash
frozen position, drawing their arms close
to their bodies.
The Power of Nonverbal
• Decreases the risk of being sued.
• Increases patient satisfaction significantly.
• Nonverbal cues emitted by the patient can
contain important information for the doctor to
use for treatment and diagnosis decisions.
• Doctors good at coding and decoding nonverbal
messages were also found to have better
outcomes, shorter exam times, and better
compliance.
Ideas for Change
• Change starts with awareness.
• Ask a colleague to come in during an
exam and provide feedback.
• Practice a few of these in a safe
environment with family or friends.
• With practice, techniques become part of
your natural style.
Post-Questionnaire
•
True or False
1. The real reason for the patient’s visit is
something other than the presenting
complaint in 15% of visits.
2. Duchenne’s true smile activates muscles
that are under voluntary control
Post-Questionnaire
1.
Physicians using a dominant tone of voice with their
patients have:
A.
B.
C.
D.
2.
Better patient compliance.
Increased patient satisfaction.
Greater likelihood of being sued.
All of the above.
Improving one’s nonverbal communication skills can
lead to:
A.
B.
C.
D.
E.
Less risk of being sued.
Higher patient satisfaction.
More effective and shorter interviews.
Better health outcomes.
All of the above.
References
•
Brennan, TA, et. al., Incidence of adverse events and negligence in hospitalized patients: results
of the Harvard Medical Practice Study I. New England Journal of Medicine. 1991; 324:370-6.
•
Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse
events due to negligence. Results of the Harvard Medical Practice Study III. New England Journal
of Medicine. 1991; 325:245-251.
•
Gerald B. Hickson, MD; Charles F. Federspiel, PhD; James W. Pichert, PhD; Cynthia S. Miller,
MSSW; Jean Gauld-Jaeger, MS; Preston Bost, PhD, Patient Complaints and Malpractice Risk,
JAMA. 2002; 287:2951-2957.
•
Lester, G.W., and Smith, S.G. Listening and Talking to Patients: A Remedy for Malpractice
Suites? Western Journal of Medicine. 1993; 158(3):268-272.
•
G. B. Hickson, E. W. Clayton, S. S. Entman, C. S. Miller, P. B. Githens, K. Whetten-Goldstein and
F. A. Sloan. Obstetricians' prior malpractice experience and patients' satisfaction with care.
JAMA. November 23, 1994. Vol. 272 No. 20.
References
•
Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The
relationship with malpractice claims among primary care physicians and surgeons. JAMA.
February 19,1997; 277(7):553-9.
•
Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and
malpractice: Lessons from plaintiff depositions. Archives of Internal Medicine. 1994; 154:13651370.
•
Brennan, TA, et. al. Incidence of adverse events and negligence in hospitalized patients: results of
the Harvard Medical Practice Study I. New England Journal of Medicine. 1991;324:370-6.
•
Street, R.L., JR., and Weimann, J.M. Differences in How Physicians and Patients perceive
Physician’s Relational Communication. Southern Speed Communication Journal. Summer, 1988;
pp. 420-440.
•
Ong L, de Haes J, Hoos AM, Lammes FB. Doctor-patient communication: a review of the
literature. Social Science Medicine. 1995; 40(7):903-18.
References
•
Giannini AJ, Giannini JD, Bowman RK. Measurement of nonverbal receptive abilities in medical
students. Perceptual & Motor Skills. 2000; 90(3 Pt 2):1145-1150.
•
Mehrabian, Albert & Morton Wiener (1967): Decoding of inconsistent communications. Journal of
Personality and Social Psychology. 6(1): 109-114.
•
Mehrabian, Albert & Susan R. Ferris (1967): Inference of attitudes from nonverbal communication
in two channels. Journal of Consulting Psychology.
31 (3): 248-252.
•
Philpott, J.S. The relative contribution to meaning of verbal and nonverbal channels of
communication…a metaanalysis. Unpublished master’s thesis. University of Nebraska. 1983.
•
Argyle, Michael, Veronica Salter, Hilary Nicholson, Marylin Williams & Philip Burgess. The
communication of inferior and superior attitudes by verbal and non-verbal signals. British Journal
of Social and Clinical Psychology. 1980; 9: 222-231.
•
Robinson, JD. Getting down to business: Talk, gaze and body orientation during openings of
doctor-patient consultations. Health Communication. 1998; 25:97-123.
References
•
DiMatteo MR, Taranta A, Friedman HS, Prince LM. Predicting patient satisfaction from physician’s
nonverbal communication skills. Medical Care. 1980; 18(4):376-387.
•
Larsen K M, Smith, C K. Assessment of nonverbal communication in the patient-physician
interview. Journal of Family Practice. 1981; 12(3):481-488.
•
Goleman, D. When Is a Smile Really a Smile? New York Times. October 26, 1993, pp. B-5 and B10.
•
The Brain Behind That Happy Face. Science. October 15,1993; 262: 336.
•
Williams LM, Senior C, David AS, Loughland CM, Gordon E. In search of the 'Duchenne' smile:
Evidence from eye movements. Journal of Psychophysiology. 2001; 15: 122 - 127.
•
Messinger, D., Fogel, A., & Dickson, K. L. What's in a smile? Developmental Psychology. 1999;
35(3):701-708.
References
•
Chaplin WF, Phillips JB, Brown JD, Clanton NR, Stein JL. Handshaking, gender personality, and
first impressions. Journal of Personality and Social Psychology. 2000; 19(4):110-117.
•
McKinstry, B., and Wang, J. Putting on the Style: What Patients Think of the Way Their Doctor
Dresses. British Journal of General Practice. 1991; 41: 275-278.
•
Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The
relationship with malpractice claims among primary care physicians and surgeons. JAMA.
February 19, 1997; 277(7):553-9.
•
Milmoe S, Rosenthal R, Blane H, Chafetz M. The doctor's voice: Predictor of successful referral
of alcoholic patients. Journal of Abnormal Psychology. 1967; 72(1):78-84.
•
Burack, R.C., Carpenter, R.R., The Predictive Value of the Presenting Compliant. Journal of
Family Practice. 1983; 16(4):749-754.
References
•
Shreve EG, Harrigan JA, Kues JR, Kagas DK. Non-verbal expressions of anxiety in physicianpatient interactions. Psychiatry. 1988; 51:378-84.
•
Ishikawa H, Hashimoto H, Kinoshita M, Fujimori S, Shimizu T, Yano E. Evaluating medical
students' non-verbal communication during the objective structured clinical examination. Medical
Education. December 2006; 40(12):1180-7.
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