CMN 462 FINAL EXAM
what is empatheic physician communication
- a physicians recognition or elicitation and response to pateints' empathic opportunities in order to communicate understanding, alleviate distress, and provide support
how do oncologists rate themselves at BBN and among residents what was the lowest ratings
- good at 41% and fair at 41% -primarily related to eliciting the patient's perspective
what does the E stand for in the SPIKES model and what does it mean
-E: addressing the patient's emotions with empathic responses - 52% of providers says this is the hardest part, patient shock isolation and grief, empathic responses should observe patient's emotions and identify the patient's emotions (may need to ask if contradictory/silent) identify the reason for the emotion you may need to ask, let the patinet know you've connected to the emotion (i know this is upsetting news), allow silence and give time to process asking question (what quesitons do you have not do you have questions) and ignoring distracting or downplaying emotions is not empathetic (you shouldn't say... i know how you're feeling, the same thing happened to one of my own family members, this is very common among x population, i have a lot of patients who also experience x, let's not worry until we find out or deal with x, or it could be worse it could b x)
what did we learn from the AIDS quilt (4)
-HIV/AIDS is still an epidemic and stigma is still very present -there are complicated relationships between PwHIV/AIDS and family and friends -the government did not acknowlege (even say HIV/AIDS) during the earlier years -HIV/AIDS advocacy is a grassroots effort (for and by the people affected) -panels are art and art represents stories themselves
what does the I in the SPIKES model stand for and mean
-I: obtaining the patient's invitation - intense complex uncertainties for patient, some want all of the info some do not (monitor vs blunters) (how would you like me to give you the info about the test results or would you like me to give you all of the info or sketch out the results and spend more time discussing the treatment plan), and offter to answer questions moving forward
what does the K stand for in the SPIKES model and what does it mean
-K: giving knowledge and info to the patient -providing a warning shot that lessens the shock (unfortunately i have some bad news to tell you, i'm sorry to tell you that), be sure to talk at patient's level of comprehension and vocab using thier words use nontechnical words (spread vs metastasized, sample of tissue vs biopsy) and avoid excessive bluntness (unless we treat it right away you will die), give info in chunks and check understanding as you go (what we knew, what we hoped for, what we have now learned), use aids to reinforce and clarify repeating important points and avoid "there's nothing more we/I can do" because this assumes treatment is only goal
what does the P in the SPIKES model stand for and mean
-P: assessing the patient's perception - before you tell ask, open ended questions (what have you been told about your medical situaiton, what is your understanding of the reasons we did the MRI), will help you (correct misinformation and tailor the bad news and gauge illness denial or unrealistic expectations
what does the S in the SPIKES model stand for and mean
-S: setting up the interview -this is arranging for privacy (seperate room/divider, quiet, tissues), involving significant others, brainstorm additional resources for patient including social work services and other specialists, sit down (relaxes patient, signals you wont rush and are on their level), make connection with the patient (eye contact, outching arm or hold hand), and manage time constraints and interruptions (inform patient of time constraints, silent pages, ask colleagues to take them)
what does the S stand for in the SPIKES model and what does it mean
-S: strategy and summary -summarize and decide where to go next clearer plans= less anxious and uncertain, ask if patients are ready to discuss x before continuing this could be treatment options making a follow up appointment addressing prognosis or discussing palliative/hospice care, agreement on a plan that is short term or long term and for communication, summarize concerns, ask how they are left feeling
what are examples of intermediate outcomes and what do they do
-access to care, quality medial decision, commitment to treatment, trust in system, social support, self care skills and emotional management -it comes from the indirect path through communication management to proximal outcomes then to intermediate otucomes and leads to health outcomes
what is bad news and what comes from this
-any news that drastically and negatively alters the patient's view of his or her future -this is news that will change a patient's outlook for the future in a very negative way and such bad news can be about severe illnesses, prospect of death or increasing levels of limitation -no matter the badness or the diagnoses at the end of the day patients will have some common experiences such as uncertainty and anxiety and fundamental needs such as validation information and emotional support
what are some ways that we can practice narrative medicine (there's a lot)
-ask open-ended questions -don't interrupt -ask patients about their illness and allow them to discuss concerns -learn your patient's stories -look for a metaphor/key word -view compliance as a blocked narrative not as patient stubornness -be aware of body language -record encounters with patients -examine your assumptions and stereotypes -ask "what do you think is going on" "how would others describe you" "what is one thing you have not told me" -review your patients chart
what does the enhancing emotional self-management pathway linking communication to outcomes entail
-asks why it is important for a clincian to help patients manage their emotions -clincians do this by presenting diagnostic and treatment information clearly and honestly, by attentive listening and showing interest in the patient's life, and by validating patient's expressions of feelings
what does elicit the patients perspective entail from the four habits model (3)
-assesing patient attribution: their perspective, causes, information -identifying requests for care: actions or services they seek -exploring the impact of symptoms on the patient's well being: gaining info, context
what does the activating social support and advocacy resources pathway linking communication to outcomes entail
-clinician's communication itself is a form of support that can offer encouragement, praise, reassurance, advice and advocacy -clincians can talk with patients about ways to strengthen exisitng social networks to provide tangible help and emotional support; they can also suggest new sources of suuprot such as online support groups -clinicians could potentially counter or at least help adddress the effects of negative social support (e.g., peer pressure to engage in unhealthy behaviors and familial advice on remedies
what does increased patient knowledge and shared understanding pathway linking communication to outcomes entail
-clinicians and patients have different frames of references, patients are personal experience common sense and interpretation of science while clinicians are mixture of clinical evidence personal experience and heuristics (decision making shortcuts) -both need the skill to present their own frame of reference and see the others' point of view, explore their own health beliefs, understand relevant clinical evidence and articulate their values and preferences
what does enhancing therapeutic alliances (among clinicians, patient, and family) pathway linking communication to outcomes entail
-clinicians are optimally informative and show empathy with the patient's circumstances -when patients have an opportunity to express their concerns -when the patient receives consistent messages and coordinated care form the clinical team, continuity of care
what does the access to needed care pathway linking communication to outcomes entail
-communication needed for a test or treatment -providing information about where to get specific health services -facilitating collaboration among health professionals -advocating on behalf of the patient for needed services
what are the challneges that come with breaking bad news (there is a lot) and what are the providers successful at
-complex interaction goals (for self, for patient and relationship, for health outcomes) -verbal component, knowledge and translation -patient's emotional reactions -dealing with stress of patient's expectations -invovlement of multiple family members -how to give hope when situations bleak -fear of not knowing the answers, illness and death, the unkown and untaught, being wrong, being blamed, expressing emotion -they can address the situation's challenges/goals and not make things worse
what does analyzing the training task question and mean for communication skills training
-conduct a needs assessment -how will you conduct a needs assessment (method)?: swat analysis, ask patients and providers using a survery or interview -what will you ask/inquire about?: what skills do you feel the physicians needs or doesn't need, overall be strategic about things you are asking about
what does organize traning content question and mean for communication skills training
-craft and organize content -what will you include in your training? -where will you get your content? what makes it credible/quality? -how much to include? *most trainings shouldn't be more than 20 minutes and each section should be about 5 mins or so, chunk it and break it in parts
what does invest in the beginning entail from the four habits model (3)
-creating rapport quickly: nonverbal particularly for greeting (handshake, eye contact, sit) apoligizing for wait, saying and asking for names and overview of approach -eliciting the full spectrum of patient concerns: watch interrupting, keep attention while at computer, and setting the agenda and avoiding doorknob disclosures -planning the visit: summarizing and checking for accuracy, explicitly planning the rest of the visit, and prioritizing and limit-set postively
what does training methods question and mean for communication skills training
-decide how the training will be delivered and why -how (a)synchronous? which components? why? -what are strengths and weaknesses of your procedures?
what does select training resources question and mean for communication skills training
-decide what tools-materials and technology you will use -powerpoints? software program? include experts? community members? stakeholders? why?
what does develop training objectives question and mean for communication skills training
-delineate what learners should know, feelings/attitudes, or do after completing your training, this shapes the curriculum -any cognitive aspect? why?: thinking and general knowledge like is there a knowledge gap or do they need to be taught things -any affective aspects? why?: emotions attitudes and values, maybe doctors know about conflict and were taught strategies but they don't care -any performative aspects? why?: actually performing it, your training may need to include role play based on different scenarios and there could just be a lack of actually performing
what does invest in the end entail from the four habits model (3)
-delivering diagnostic information: connect to patient's language -providing education and engaging in joint decision making: providing key info (a few key points, use plain language, teach back) and decision making (patient preferences, opinion, barriers, give supplemental material) -completing the visit: asking for additional questions, confirming next steps, ending on a personal note *increasing information retention and understanding increases adherence
what does complete training plans question and mean for communication skills training
-develop your agenda and a particpant guide -what materials will you prepare for yourself and for your participants as plans for the training?
what is the definition of the four habits model and what are the four habits
-families of skills, techniques and benefits from start to finish but are interdependent - invest in the beginning, elicit the patient's perspective, demonstrate empathy, invest in the end
what does assess training question and mean for communication skills training
-follow kirkpatrick's model -how will you assess level 1 being reaction?: it was colorful, engaging, i liked the fonts -how will you assess level 2 being learning?: did you learn anything -how will you assess level 3 being behavior?: are you intending to do a certain behavior you weren't intending on doing before or were you rated better than the first time -how will you assess level 4 being results?: hope that you have improved patient outcomes, certain scores have gone up and patient has relayed better performance
what does the enhancing patient empowerment and agency pathway linking communication to outcomes entail
-helping patients actively seek information, clarify treatment goals, and express concerns and feelings -conversations could focus on autonomy, self-efficacy, specific skills in managing one's health and where to get access to self-care resources (e.g., websites, community groups)
what is THE question we should be asking and why (2)
-how does patient provider communication affect outcomes - because correlation is not equal to causation, we need to ask communication about waht and which outcomes in particular - we also see decontextualized studies (what happens when patients leave the medical office and physiological, personal and social influecnes) and measurement issues (e.g., not shared agreement on shared decision making)
what are examples of communication functions and what does it do
-information exchange, responding to emotions, managing uncertainty, fostering relationships, making decisions, and enabling self management -it comes first and then the indirect path is proximal outcomes while the direct path is health outcomes
what is the importance of breaking bad news among patients and physicians
-it affects patients by bringing them stress and anxiety, miscommunication regarding diagnosis treatment and prognosis and poorer overall health outcomes -it also affects physicans by bringing them stress anxiety and burnout outcomes
what does empathy do and what are the barriers to empathy
-it declines and some specialties are more empathic based on personality, training, experience w/ patients, patient expectations and nature of care -time constraints, chaotic environment, complexity of case, managing own emotions, managing patient's negative affect, sense of elitism in medical schools, emphasis on detachment and objective clinical neutrality, and admission prioritize scores over skills
what are the key concepts about empathetic communication
-it improves patients' health outcomes and can be improved with intervention -personal and systemic barriers will present obstacles to providing empathetic care -empathetic communication requires identifying a patient's emotions, naming the emotion and offering them partnership in their care
when it comes to breaking bad news, which of the following are examples of a way a provider can attend to the "E" model in the SPIKES model
-observe and identify the patients emotions -let the patient know you've connected to the emotion -allow silence and give time to process, ask questions
when do the following occur: communication function proximal outcomes intermediate outcomes health outcomes
-occurring with interaction -occuring during/immediately following the interaction -changing as a result of the interactions and the proximal outcomes, over time, effects beyond the patient provider relationship -end goals- the big picture outcomes you hope for as a result of the preceding processes
what is important about patient provider communication (2)
-patient provider communication has significant effects on patient's health and health behaviors -p-p comm impacts health through proximal and distal outcomes and thse impacts are realized through seven pathways
breaking bad news is difficult for providers to do. give two challenges or struggles they face in breaking bad news effectively
-patient's emotional reactions -involvement of multiple family members -fear of not knowing the answer, illness and death, unknown and untaught, being wrong or blamed, and expressing emotion
what does the higher quality decisions pathway linking communication to outcomes entail
-patients will more likely experience bettwe health when they and clincians reach decisions that are based on the best clinical evidence, are consistent with patient values, are mutually agreed upon, and are feasible to implement
what does demonstrate empathy entail from the four habits model (3)
-responding to patients emotions: sympathy vs empathy -discern opportunities for empathy: sensitivity to nv behavior, being open -expressing empathy: nv behaviors, naming the likely feeling and legitimizing the emotion, NOT stating emotions as fact giving info minimizing or assuming similarity of experience
from haskard-zolnierek why is patient provider communication important (5)
-satisfaction -health outcomes -quality of life -medical adherence/compliance -ligation/malpractice
what are examples of health outcomes and what do they do
-survival, care/remission, less suffering, emotional well being, pain control, functional ability, and vitality -it can be a direct path from communication functions, come from the indirect path of communication function to proximal outcomes then to health outcomes or can be on the indirect path from communication fucntions to proximal outcomes to intermidate outcomes then ending at health outcomes
why is empathy important
-systematic review: 7 RCT's empathic communication -patient health outcomes: enablement, cold duration, Hgb A1C, patient satisfaction, adherence to prescribed plan, psychological support -all 7 RCT's demonstrate postiive results in health outcome -provider health outcomes: lower burnout, higher sense of well being, lower rates of malpractice and improved job satisfaction -prefrontal cortex autonomic activation: feelings of sharing
what is narrative medicine
-the effective practice of medicine requires narrative competence that is the ability to acknowledge absorb interpret and act on the stories and plights of others - some say it's easy for patients to get reduced to a specific illness and narrative medicine is a way of intergrating everything back together, it's a way of staying curious about people -it's a commitment to understanding patient's lives, caring for the caregivers, and giving voice to the suffering
what are examples of proximal outcomes and what does it do
-understanding, satisfaction, clinician patient agreement, trust, feeling known, patiet feels invovled, rapport, and motivation -it is the indirect path from communication function and can either lead to intermediate outcomes or health outcomes
what are the pathways linking patient provider communication to those important outcomes (3)
-what's happening outside of those interactions -what's happening over time -how's communication related to other processes and outcomes in the short term and medium term
what is empathic opportunity and what are the three types
-when patients state or allude to conerns, emotions or stressors -progress statements (something specific a patient does to improve their health such as "i've been able to maintain a mediterranean diet" "i quit smoking"), challenge statements (explicit statement patients makes about a negative effect of a physical/psychological problem or quality of life issue such as "nothing seems to be helping me overcome my addiction" or "my entire family has arthritis i think it is in my genes"), and emotion statements (any statement that includes an expressed and explicit emotion that is happy or upset such as "i'm so happy that i found a medication that got rid of that infection" or "not having an answer for my chronic pain is frusturating me")
you have been asked to give medical students advice on how to break bad news to patients. based on the SPIKES model, what would you specifically tell them to do/not do based on the "E" of the model
-you should: observe patient's emotions and identify the patient's emotions (may need to ask if contradictory/silent), identify the reason for the emotion and you may need to ask, let the patient know you've connected to the emotion (I know this is upsetting news), and allow silence and give time to process and ask questions (what questions do you have or do you have questions) -you should not: ignore distract or downplay emotions because that is not empathetic (don't say i know how you're feeling, the same thing happened to one of my own family members, or this is very common among X population)
medical training: what are the 8 parts that go into analyzing organizational/trainee needs and what does each part involve
1) analyze the training task 2) develop training objectives 3) organize training content 4) determine training method 5) select training resources 6) complete training plans 7) deliver training 8) assess training
from the its not a burden documentary what were common themese of caregiving and describe them (4)
1) duty and obligation: family members felt it was their duty to care for aging parents; it was and should be a priority to them; sometimes it felt like obligation—have to, but perhaps don't always want to 2) love and pride: i have pride in that i care for my parents, sacrifice, give back; they love their parents and/or love motivates them 3) parent and child: both caregiver and care receiver play both roles; there is a kind of role reversal where children have to be parents and parents, because of their needs, are child-like and must be cared for 4) protection and control: i'm in control of their care and their information; i also feel the need to protect them in new situations, with new people, regarding new routines (medical or otherwise)
what are the three empathy components of empahtic physician communication
1) emotional: affective level; experiencing/internalizing feelings of others 2) cognitive: cognitive level; capacity to understand another's perspective 3) behavioral: outward expression: demonstrating empathy through actions
what are the 6 principles of narrative medicine
1) intersubjectivity 2) relationality 3) personhood and embodiment 4) action toward justice 5) close reading (or slow looking) 6) creativity
what were two unsuccessful solutions to the puzzle from the heritage and robinson reading
1) some of the words they are using to frame the question if they have anything else to talk about is often confusing to the patient (such as using the word any vs some) 2) also using the word problems was shown to be unsuccessful (maybe use issues instead although this still didn't work)
what are the seven pathways linking communication to outcomes
1)access to needed care 2) increased patient knowledge and shared understanding 3) enhancing therapeutic alliances (among clincians, patient, and family) 4)enhancing patient empowerment and agency 5) higher quality decisions 6) enhancing emotional self management 7)activating social support and advocacy resources
you are going to see your primary care physician. according to the review of literatue in robinson and heritage how many concerns are you likely to have
3
what is action toward justice in the principles of narrative medicine
ehthics of patient care, doing stories justice and stories for justice, and issues of power and privilege in traditional medicine
dr.brown is working on her communication with her primary care patients. Specifically, she has gotten feedback that she needs to ensure that she explores how patient's symtoms impact their day-to-daay and how they think about their mental health in terms of causes, requests, and sources of information. which of the four habits is dr.brown tryng to improve
elicit the patient's perspective
what type of patient-presented empathic opportunity is this: any statement that includes an expressed and explicit emotion with words such as happy or upset
emotion statement
when breaking bad news, providers cannot "make up for" a lack of __ by giving more information to a patient
emotional support/empathy
according to the lecture on pathways linking patient provider communication to patient outcomes, when providers present information clearly and honestly, are attentive listeners and show interest in the patients' life, and validate patient's feelings, they are helping patients _
enhance emotional self-management
can providers make up for a lack of emotional supportiveness by giving more information to a patient
essentially no, you could try but it would be very hard and have to be very precise and strategic
were emotion statements most commonly respondwd to with invalidation
false
what kind of difficult conversation is this: a physician reviewing the risks of spinal surgery for back pain, including paralysis (informed consent)
high stake decisions
what is creativity in the principles of narrative medicine
imagining what patients undergo; openness to uncertainty/doubts; lets patients articulate events of illness
what explains 95% of breaking bad news acceptability
information and emotional supportiveness, no matter how bad the information is information itself is not good enough and we cannot compensate for lack of emotional supportiveness (patients see them as multiplicative)
from the video on abraham vergese- a doctors touch, why is the physical exam important and what messages do people receive
it is an important RITUAL that carries symbolic meanings/messages and these messages are things like I WILL NOT ABANDON YOU; I WILL ALWAYS BE HERE
what patient characteristic was significantly associated with their empathic opportunity types
levels of anxiety
what is intersubjectivity in the principles of narrative medicine
listening attentively to help co-construct a narrative with the patient
this orientation to patient care and medicine is fundamentally about acknowledging, absorbing, interpreting, and acting on the stories and suffering of others. "It's easy for patients to get reduced to a specific illness. _ is a way of integrating everything back together; it's a way of staying curious about people"
narrative medicine
what was a successful solution to the puzzle from the heritage and robinson reading and what does this mean for patients and their health
no matter how the question is formulated patients read it as new problems or new issues and that patients feel like they can only tell new things and not bring out other concerns that they have wich are normally chronic things
STILL NEED 11/30 QUIZ
ok
what is important about rituslas from the video on abraham vergese- a doctors touch
RITUALS ARE TRANSFORMATIVE, they change people and in medicine they are cathartic for physcians and needed for patients
what is close reading (or slow looking) in the principles of narrative medicine
a close observation of facts detailed and carefully analyzed, and it is temporality symbolic meanings mood situations and voice
from the video on abraham vergese- a doctors touch what is the most important innovation to medicine
a physicans hands, it makes people feel less as a human if you aren't willing to touch them
how did physicans respond to patient's empathic opportunities? the researches found that all of the follwoing was true
challenge statements were most commonly responded to with low empathy responses, emotion statements were nearlt evenly split between low empathy and high empathy responses and progress statements were most commonly responded to with high empathy responses
what kind of difficult conversation is this: a physician recommending resources to a family about end of life care
challenging contexts
what type of patient-presented empathic opportunity is this: any explicit statement that the patient makes about a negative effect of a physical or psychosocial problem or quality of life issues
challenging statement
what kind of difficult conversation is this: a physician telling a patient that their weight is the cause of their health issues
charged topics
why do patients sue? in review of closed malpracitce ligation cases the most frequent themes were what
communication and documentation
the authors reviewed the literature on the efffects of patient-provider communication on patient health outcomes. unfortunately, interventions to improve paitent adherences are about 50% effective. The authors acknowledge that there are many factors associated with communication processes that may be at play what are they
patient denial forgetfullness and schedule, complex and costly treatment regimens and familial and peer factors
robinson and heritage studied how physicians set the agenda (or solicit patient's chief concerns by continuing to solicit patients' concers to exhaustion with questions). the researchers found that in response to provider's solicitations, patients sometimes gave contradictory answers. how so?
patients would say no but then continue to express concerns and patients would shake their head no while giving additional concerns
the authors reviewed a number of patient variables or identity markers associated with poorer communication what groups reported poorer communication from providers
people of color, people who are obese and overweight, people who use substances and people with low incomes
providers should relate to patients as subjects (people) rather than objects (simply bodies/machines) and that "clinical attitudes" can dehumanize caregivers to patients. to which principle of narrative medicine is this referring to
personhood and emodiment
what type of patient-presented empathic opportunity is this: something specific the patient does to improve his or her health outcomes such as cutting down on smoking, a physical ailment to improving or a positive life event such as a child getting married
process statement
why is it difficult for providers to engage in difficult conversations with patients?
providers recognixe these conversations elicit negative emotions (e.g. draining), providers fear losing patient trust, and providers do not know when or how to engage the conversation
robinson and heritage studied how physicians set the agenda (or solicit patient's chief concerns by continuing to solicit patients' concers to exhaustion with questions). the authors were puzzled as to why patients would contradict themselves when asked if they had concerns. through their analysis the researchers concluded that the reason was that
providers set the agenda for the visit in ways that imply only new concerns should be raised
what two outcomes can we think of holistically (more generally) to come up with seven pathways linking to communication outcomes
proximal outcomes and intermediate outcomes
what should we tell physicians based on the findings from the hertiage and robinson reading
reccomendation is to decouple that and take it out of sequence and to engage in the outset and say what are the thing you want to cover today
what is personhood and embodiment in the principles of narrative medicine
relating as a subject (i.e. person) instead of an object (i.e. body) and it causes losses for patients and caregivers when there are power imbalances, it is also a clincial attitude that dehumanizes caregivers and patients
we wathced a ted talk by physician and novelist abraham verghese. he argues to his audience that the patient-provider encounter is "a _ of exceeding importance, and if you (as physicians) shortchange that _ by not undressing the patient, by listening with your stethoscope on top of the nightgown, by not doing a complete exam, you have bypassed on the opportunity to seal the patient-physician relationship
ritual
what kind of difficult conversation is this: a physician telling their patient that they have a incurable cancer
sensitive disclosures
shen et al (2019) examined the empathic opportunities and responses within clincial consultations of lung cancer patients and how these each are assocaited with patient-reported outcomes. which of the following is a progress statement
something specific the patient does to improve his or her health such as cutting down on smoking, a physical ailment to improving, or a positive life event such as a family birth
what is relationality in the principles of narrative medicine
the way two or moer people are connected in a relationship
shen examined the empathic opportunities and responses within clinical consultations of lung cancer patients and how these each are associated with patient reported outcomes. what is the major implication of table 3 in this article, which is also the main takeway from the study
there are age gaps in responding with empathic responses to patients who may be most in need of them- patients presenting challenge statements and those presenting emotion statements
what is the video on abraham vergese- a doctors touch talking about
this video is talking about reclaiming humanity
what is a concept from the AIDS quilt that we can apply from class
uncertainty- an example of how appraisals affect behavior (not getting tested or remaining uncertain> knowing/receiving a fatal diagnosis) or stigma- stigma was very present with HIV/AIDS and is still present today assuming only gay white men could get it and shaming them for it
from the heritage and robinson reading what is the puzzle that the authors are trying to solve
why patient's aren't sharing everything that is bothering them or that they want to talk about, patients will say verbally or non verbally that they don't have anything else and then will go on and talk about it so they are contraindicating themselves
can empathy be taught?
you could train it but it would have to be ongoing efforts, one time trainings will not do a lot and they should be over time and tailored to where that person is in there career (more contextualized)
what does deliver the training mean for communication skills training
you need to deliver the training actually!
