Patient Safety CME Curriculum Patient Safety: The Other Side of the Quality Equation

1. Patient Safety CME CurriculumPatient Safety: The Other Side of the Quality Equation Under a Grant from The Agency for Healthcare Research and Quality Principal Investigator Christel Mottur-Pilson, PhD Director, Scientific Policy ACP-ASIM

2. Patient Safety: The Other Side of the Quality EquationSeven Modules in Ambulatory Care Systems The influence of systems on the practice of medicine. Cognitive Capacity Coping mechanisms under information overload and time pressures Communication Communication barriers, lack, and unclear communication Medication Errors Uniform dosing, look- and sound-alikes, forcing functions A brief overview The following 2 slides identify seven modules reflecting different perspectives of the overall systems approach to patient safety. While a certain amount of overlap is taken to be understood between the modules because of the systems approach, the present module- communication- sheds light on challenges that ineffective communication brings to all levels of health care. And as we know, any disruption in the system affects the quality of health care provided to patients and communication is no exception. The choice of these modules is not arbitrary but is based on the ground breaking Institute of Medicine report, To Err Is Human, published November 1999. This report, more than any other publication, highlighted patient safety problems and captured the attention of the public and the medical profession. A brief overview The following 2 slides identify seven modules reflecting different perspectives of the overall systems approach to patient safety. While a certain amount of overlap is taken to be understood between the modules because of the systems approach, the present module- communication- sheds light on challenges that ineffective communication brings to all levels of health care. And as we know, any disruption in the system affects the quality of health care provided to patients and communication is no exception. The choice of these modules is not arbitrary but is based on the ground breaking Institute of Medicine report, To Err Is Human, published November 1999. This report, more than any other publication, highlighted patient safety problems and captured the attention of the public and the medical profession.

3. Patient Safety: The Other Side of the Quality EquationSeven Modules in Ambulatory Care The Role of Patients Patients as allies in patient safety The Role of Electronics Supportive products and processes Idealized Office Design Medical practice design to support patient safety Before discussing the role of communication in patient safety, let us first provide several logistics for obtaining CME credit for this presentation.Before discussing the role of communication in patient safety, let us first provide several logistics for obtaining CME credit for this presentation.

4. Logistics CME: To receive your CME, please fill out the usual forms Evaluation form CME form Research Grant Surveys Pre-CME assessment of knowledge level Post-CME assessment of knowledge level Six-month follow up to CME Virtual Patient Safety Electronic Community There are three components of the research effort that you are involved in. � Component One refers to your usual CME evaluation that helps the College keep track of the quality of its CME offering. If your particular Chapter receives its CME from another accredited source, they will probably have a similar form of their own. � In addition, there is the College CME form which you need to fill out to receive your CME credit. � Component Two refers to the research questionnaires which will help us determine the staying power of the CME content. � Survey 1 To be filled out before attending the session provides an assessment of your knowledge base on this subject before the lecture. It provides a baseline for future comparisons with survey 2 and survey 3. It is vitally important that you fill this out prior to the CME program. � Survey 2 This survey will focus on your knowledge and attitudes concerning the patient safety curriculum. Please do not neglect to fill this survey out. � Survey 3 Will be mailed six months after the meeting. Survey 3 measures physician behavior change as reported by the respondents. � Component Three is the virtual patient safety community. It will be electronically activated about a month after the CME session has taken place. The purpose of this activity is to share with your peers, electronically, how the take home points from the CME session work in practice, how they may need to be adapted to local circumstances or replaced with similar tools that actually work better. You will receive detailed instructions on how to activate your membership in the virtual patient safety community via letter and e-mail. � Enough of these preliminaries; let�s turn to a discussion of communication in the context of patient safety. There are three components of the research effort that you are involved in. � Component One refers to your usual CME evaluation that helps the College keep track of the quality of its CME offering. If your particular Chapter receives its CME from another accredited source, they will probably have a similar form of their own. � In addition, there is the College CME form which you need to fill out to receive your CME credit. � Component Two refers to the research questionnaires which will help us determine the staying power of the CME content. � Survey 1 To be filled out before attending the session provides an assessment of your knowledge base on this subject before the lecture. It provides a baseline for future comparisons with survey 2 and survey 3. It is vitally important that you fill this out prior to the CME program. � Survey 2 This survey will focus on your knowledge and attitudes concerning the patient safety curriculum. Please do not neglect to fill this survey out. � Survey 3 Will be mailed six months after the meeting. Survey 3 measures physician behavior change as reported by the respondents. � Component Three is the virtual patient safety community. It will be electronically activated about a month after the CME session has taken place. The purpose of this activity is to share with your peers, electronically, how the take home points from the CME session work in practice, how they may need to be adapted to local circumstances or replaced with similar tools that actually work better. You will receive detailed instructions on how to activate your membership in the virtual patient safety community via letter and e-mail. � Enough of these preliminaries; let�s turn to a discussion of communication in the context of patient safety.

5. Presentation Goals Understanding how communication influences care Examples of communication breakdowns and how to avoid them Take home points to help you apply communication skills in your practice This module was developed by Elizabeth C. Bernabeo, MPH and Christel Mottur-Pilson, Ph.D. for the American College of Physicians-American Society of Internal Medicine. The recognition that communication skills are an essential component of care is relatively new to medicine. Research has shown that enhanced communication leads to more accurate diagnosis�a fundamental requirement of patient safety� as well as better understanding by patients, enhanced patient satisfaction and compliance, and thus better health outcomes. For all these reasons, medical schools have begun to teach effective interviewing skills to medical students. To date, The Bayer Institute of Health Care Communications has trained over 20,000 practicing physicians in effective communication techniques. However, despite this progress, a number of barriers remain. This module explains these barriers and illustrates how communication affects health care delivery systems. Case studies exemplify common breakdowns in communication. Finally, relevant take home points will help you apply your new communication skills to your daily practice. Although system constraints frequently affect communications, their effect is at times not as easy to trace as in other patient safety areas. Often the focus here is on the act of communication rather than on system pressures that influence the style of communication, such as hurried communication under time pressure. Nevertheless systems influences will be highlighted whenever possible. The recognition that communication skills are an essential component of care is relatively new to medicine. Research has shown that enhanced communication leads to more accurate diagnosis�a fundamental requirement of patient safety� as well as better understanding by patients, enhanced patient satisfaction and compliance, and thus better health outcomes. For all these reasons, medical schools have begun to teach effective interviewing skills to medical students. To date, The Bayer Institute of Health Care Communications has trained over 20,000 practicing physicians in effective communication techniques. However, despite this progress, a number of barriers remain. This module explains these barriers and illustrates how communication affects health care delivery systems. Case studies exemplify common breakdowns in communication. Finally, relevant take home points will help you apply your new communication skills to your daily practice. Although system constraints frequently affect communications, their effect is at times not as easy to trace as in other patient safety areas. Often the focus here is on the act of communication rather than on system pressures that influence the style of communication, such as hurried communication under time pressure. Nevertheless systems influences will be highlighted whenever possible.

6. Levels of Communication Physician ? Patient Physician ? Physician Staff Communication lies at the heart of medical care and caring. It is one of the most basic and most powerful vehicles to cement the physician-patient relationship without which therapeutic goals are difficult to define, much less to achieve. Missed cues in communication by both physician and patient can lead to patient safety issues. The role and function of communication varies depending on where it is used and for what purpose. For example, effective communication with one�s patients conveys empathy and assurance. The patient, in turn, feels understood and safe. Patient anxiety diminishes, and the patient is able to listen and understand what the physician has to say. Physician communication style is often the result of physician role models observed and emulated during medical training. The strong influence of training� a systems factor� is often not recognized by the physician and therefore hard to overcome. Open communication between physician and staff facilitates team processes of patient care. For example, a team with a history of open communication promotes more effective communication, not only shorter in duration but without sacrifice of clarity under times of stress. Body language or facial demeanor can also enhance or undermine verbal communication. Tapping one�s pen on the note pad, though smiling, conveys impatience to the patient rather than encouragement to speak. Since patients frequently reserve their most anxiety producing question(s) for the end of the interview, not being able to voice these concerns undermines the patient�s ability to focus on the physician�s instructions. Not hearing these concerns may prevent the physician from addressing patient issues fully, and not knowing all the facts may put the physician�s clinical judgment at risk, thereby undermining patient safety. Communication lies at the heart of medical care and caring. It is one of the most basic and most powerful vehicles to cement the physician-patient relationship without which therapeutic goals are difficult to define, much less to achieve. Missed cues in communication by both physician and patient can lead to patient safety issues. The role and function of communication varies depending on where it is used and for what purpose. For example, effective communication with one�s patients conveys empathy and assurance. The patient, in turn, feels understood and safe. Patient anxiety diminishes, and the patient is able to listen and understand what the physician has to say. Physician communication style is often the result of physician role models observed and emulated during medical training. The strong influence of training� a systems factor� is often not recognized by the physician and therefore hard to overcome. Open communication between physician and staff facilitates team processes of patient care. For example, a team with a history of open communication promotes more effective communication, not only shorter in duration but without sacrifice of clarity under times of stress. Body language or facial demeanor can also enhance or undermine verbal communication. Tapping one�s pen on the note pad, though smiling, conveys impatience to the patient rather than encouragement to speak. Since patients frequently reserve their most anxiety producing question(s) for the end of the interview, not being able to voice these concerns undermines the patient�s ability to focus on the physician�s instructions. Not hearing these concerns may prevent the physician from addressing patient issues fully, and not knowing all the facts may put the physician�s clinical judgment at risk, thereby undermining patient safety.

7. Levels of Communication Physician ? Colleagues (referrals) Physician ?Clinical Support Facilities Referring a patient to a specialist colleague requires unambiguous communication, both written and oral, to assure continuity of care and avoid duplication of services. It is also a good idea to discuss with the patient why the referral is appropriate and what to expect from the new physician. If it is a one time consultation, that fact needs to be explained. If treatment will be taken over by the specialist, that has to be addressed as well. Patients can help clarify incomplete or ambiguous information if they have rudimentary knowledge of their disease and why the referral was made. This saves time for physicians and patients. Clear communication with clinical support teams, such as x-ray technicians, can avoid potential harm to the patient. We presented such a case in the systems module and will repeat it here with the other clinical cases. Communication, in all its forms, is the engine that helps the many parts of the medical system run smoothly.Referring a patient to a specialist colleague requires unambiguous communication, both written and oral, to assure continuity of care and avoid duplication of services. It is also a good idea to discuss with the patient why the referral is appropriate and what to expect from the new physician. If it is a one time consultation, that fact needs to be explained. If treatment will be taken over by the specialist, that has to be addressed as well. Patients can help clarify incomplete or ambiguous information if they have rudimentary knowledge of their disease and why the referral was made. This saves time for physicians and patients. Clear communication with clinical support teams, such as x-ray technicians, can avoid potential harm to the patient. We presented such a case in the systems module and will repeat it here with the other clinical cases. Communication, in all its forms, is the engine that helps the many parts of the medical system run smoothly.

8. Why Teach Communication Skills? How we communicate is just as important as what we say Communication makes evidence-based medicine real to patients Communication improves outcomes for both patients and physicians Having spent countless hours delivering patient care, you may be wondering why you should acquire additional skills. The fact is, effective communication is challenging. How we communicate is just as important as what we communicate. It can be difficult to get your message across when the patient is stressed due to chronic illness, pain, or uncertainty about his or her future well being (1). Effective physician-patient communication results in efficient interviewing. Appropriate discussion of evidence-based treatment choices makes these options understandable and less foreign to patients. Research has demonstrated that putting the patient at ease when communicating supports physiological changes that lead to speedier recovery and better functional status. As previously stated, a strong relationship exists between communication and patient satisfaction and compliance. Finally, there is evidence that optimal two-way communication enhances patient recall of the essential points of the discussion (2). In summary, optimal communication skills lead to accurate diagnosis, improved patient satisfaction and thus to compliance, all aiding improved patient outcomes (3). (1) Roter, D., & Hall, J. (1992). Doctors talking with patients, patients talking with doctors. Auburn House: Westport, CT (2) Roter, D., & Hall, J. (1987). Physicians� interviewing styles and medical information obtained from patients. J Gen Intern Med, 2, 325-329. (3) Roter, D., Hall, J., & Katz, N. (1988). Relations between physicians behavior and analogue: patients satisfaction, recall, and impressions. Med Care, 25, 437-451.Having spent countless hours delivering patient care, you may be wondering why you should acquire additional skills. The fact is, effective communication is challenging. How we communicate is just as important as what we communicate. It can be difficult to get your message across when the patient is stressed due to chronic illness, pain, or uncertainty about his or her future well being (1). Effective physician-patient communication results in efficient interviewing. Appropriate discussion of evidence-based treatment choices makes these options understandable and less foreign to patients. Research has demonstrated that putting the patient at ease when communicating supports physiological changes that lead to speedier recovery and better functional status. As previously stated, a strong relationship exists between communication and patient satisfaction and compliance. Finally, there is evidence that optimal two-way communication enhances patient recall of the essential points of the discussion (2). In summary, optimal communication skills lead to accurate diagnosis, improved patient satisfaction and thus to compliance, all aiding improved patient outcomes (3). (1) Roter, D., & Hall, J. (1992). Doctors talking with patients, patients talking with doctors. Auburn House: Westport, CT (2) Roter, D., & Hall, J. (1987). Physicians� interviewing styles and medical information obtained from patients. J Gen Intern Med, 2, 325-329. (3) Roter, D., Hall, J., & Katz, N. (1988). Relations between physicians behavior and analogue: patients satisfaction, recall, and impressions. Med Care, 25, 437-451.

9. Problems in Communication 1 of 5 adults experiences one or more communication problems Physicians overestimate the time they spent on explanation and planning by up to 900% 1 of 4 patients does not always follow physician advice 1 in 7 patients is dissatisfied with the current health care system These are the results of a 2002 survey conducted by the Commonwealth Fund.(1) As you can see, there are substantial communication problems between physicians and patients. For one, many times patients and physicians disagree on the nature of the problem, the course of treatment, or the interpretation of diagnostic symptoms. Physicians frequently overestimate the amount of time they spend with patients (2). In all likelihood they do not separate mental processing from actual speaking. Finally, patient compliance may be attributed to poorly understood directions or insufficient communication, resulting in a loss of trust in the relationship. The Institute of Medicine�s report Closing the Quality Chasm espouses patient centered care as one of the core principles of a reformed health care system. Communication is an essential component of patient centered care. (1). Davis, K., Schoenbaum, S., Collins, K., Tenney, K., Hughes, D., & Audet, A. M (2002). Room for Improvement: Patients Report on the Quality of Their Health Care. The Commonwealth Fund. (2) Makoul, G., Arnston, P., & Scofield, T. (1995). Health promotion in primary care: physician-patient communication and decision about prescription medications. Soc Sci Med, 41, 1241-54.These are the results of a 2002 survey conducted by the Commonwealth Fund.(1) As you can see, there are substantial communication problems between physicians and patients. For one, many times patients and physicians disagree on the nature of the problem, the course of treatment, or the interpretation of diagnostic symptoms. Physicians frequently overestimate the amount of time they spend with patients (2). In all likelihood they do not separate mental processing from actual speaking. Finally, patient compliance may be attributed to poorly understood directions or insufficient communication, resulting in a loss of trust in the relationship. The Institute of Medicine�s report Closing the Quality Chasm espouses patient centered care as one of the core principles of a reformed health care system. Communication is an essential component of patient centered care. (1). Davis, K., Schoenbaum, S., Collins, K., Tenney, K., Hughes, D., & Audet, A. M (2002). Room for Improvement: Patients Report on the Quality of Their Health Care. The Commonwealth Fund. (2) Makoul, G., Arnston, P., & Scofield, T. (1995). Health promotion in primary care: physician-patient communication and decision about prescription medications. Soc Sci Med, 41, 1241-54.

10. Barriers to Effective Communication Time Management Differing Agendas between Doctor and Patient The Art of Asking Questions Working to Achieve Behavioral Change Effective communication is not always easy. There are many barriers to effective communication, some of them quite obvious, others that may be more anticipated than real. Frequently however, the expectation of a barrier can result in a self-imposed barrier. For all these reasons we have devoted six slides to the problem of communication challenges. Slide one focuses on types of barriers; the remaining five slides focus on solutions to barriers, real or perceived. Developing Effective Communication developing rapport in a short amount of time working with difficult patients who have different agendas asking the right questions at the right time while showing sensitivity and concern working with patients to achieve behavioral change, such as counseling to stop smoking Effective communication is not always easy. There are many barriers to effective communication, some of them quite obvious, others that may be more anticipated than real. Frequently however, the expectation of a barrier can result in a self-imposed barrier. For all these reasons we have devoted six slides to the problem of communication challenges. Slide one focuses on types of barriers; the remaining five slides focus on solutions to barriers, real or perceived. Developing Effective Communication developing rapport in a short amount of time working with difficult patients who have different agendas asking the right questions at the right time while showing sensitivity and concern working with patients to achieve behavioral change, such as counseling to stop smoking

11. Solutions to Barriers (1) Remember the SEGUE Framework (adapted by Northwestern University) Set the Stage Elicit Information Give Information Understand the Patient�s Perspective End the Encounter The SEGUE framework, developed and tested by Northwestern University, is a flexible structure that encourages communication styles adaptable to the needs of different patients (1). Keeping these five stages in mind during the patient encounter assures successful give-and-take between physician and patient. Setting the stage and establishing rapport is important for smooth communication and easy transitions between the stages. Eliciting information from the patient regarding his/her fears and thoughts conveys caring and provides, at the same time, an airing of the patient�s perspective, illustrating how and why this perspective may differ from the physician�s view. This knowledge enables the physician to judge how to deal with the difference, how to help the patient focus on appropriate treatment strategies and consider pertinent options. In effect, stage 2 prepares for stage 3. 3) Giving advice and suggesting the course of treatment. 4) Having successfully completed stage 3, the patient�s perspective has to be reevaluated for change when considering the various treatment options. (5) Ending the encounter efficiently, without seeming to be hurried, is just as important as any of the other stages. How the patient perceives the closing of the visit influences the next patient encounter. (1) Makoul, G. (2001). The SEGUE Framework for teaching and assessing communication skills. Patient Education and Counseling, 45, 23-34. The SEGUE framework, developed and tested by Northwestern University, is a flexible structure that encourages communication styles adaptable to the needs of different patients (1). Keeping these five stages in mind during the patient encounter assures successful give-and-take between physician and patient. Setting the stage and establishing rapport is important for smooth communication and easy transitions between the stages. Eliciting information from the patient regarding his/her fears and thoughts conveys caring and provides, at the same time, an airing of the patient�s perspective, illustrating how and why this perspective may differ from the physician�s view. This knowledge enables the physician to judge how to deal with the difference, how to help the patient focus on appropriate treatment strategies and consider pertinent options. In effect, stage 2 prepares for stage 3. 3) Giving advice and suggesting the course of treatment. 4) Having successfully completed stage 3, the patient�s perspective has to be reevaluated for change when considering the various treatment options. (5) Ending the encounter efficiently, without seeming to be hurried, is just as important as any of the other stages. How the patient perceives the closing of the visit influences the next patient encounter. (1) Makoul, G. (2001). The SEGUE Framework for teaching and assessing communication skills. Patient Education and Counseling, 45, 23-34.

12. Solutions to Barriers (2) No need to work faster, just differently Effective communication does not prolong time with patients Investing time now will save time later Adopting the SEGUE framework is not time consuming. Having established rapport, patients will more quickly address what really bothers them, saving the physician�s time. Effective communication does not prolong time with patients, rather it structures this time efficiently. As with investing, an early investment in patient communication reaps benefits for the length of the physician patient relationship. Adopting the SEGUE framework is not time consuming. Having established rapport, patients will more quickly address what really bothers them, saving the physician�s time. Effective communication does not prolong time with patients, rather it structures this time efficiently. As with investing, an early investment in patient communication reaps benefits for the length of the physician patient relationship.

13. Solutions to Barriers (3) Tell the patient what he/she wants to know before explaining what you think he/she is suffering from. After finding out what troubles the patient, encourage the patient to participate in the discussion and decision-making process. There is evidence that clinicians frequently interrupt patients before they have a chance to tell their full story. In fact, one study found that it took just 23 seconds � on average- for the physician to interrupt a patient describing symptoms. Once this happened, only 2% of patients returned to their original agendas. Under these circumstances most physicians reached their diagnosis and how to treat without the benefit of the patient�s insights or desires (1). The result is that 54 percent of patient problems and concerns are missed because they are neither elicited by physicians nor offered by patients. (1) Marvel, M., Epstien, R., Flowers, K., & Beckman, H. (1999). Soliciting the patient�s agenda: have we improved? JAMA, 281, 283-287.After finding out what troubles the patient, encourage the patient to participate in the discussion and decision-making process. There is evidence that clinicians frequently interrupt patients before they have a chance to tell their full story. In fact, one study found that it took just 23 seconds � on average- for the physician to interrupt a patient describing symptoms. Once this happened, only 2% of patients returned to their original agendas. Under these circumstances most physicians reached their diagnosis and how to treat without the benefit of the patient�s insights or desires (1). The result is that 54 percent of patient problems and concerns are missed because they are neither elicited by physicians nor offered by patients. (1) Marvel, M., Epstien, R., Flowers, K., & Beckman, H. (1999). Soliciting the patient�s agenda: have we improved? JAMA, 281, 283-287.

14. Solutions to Barriers (4) Keep patients talking about their symptoms Understanding a patient�s emotions is crucial Asking the right questions is crucial to effective communication. As Robert Smith, MD suggests, there is a certain finesse to the natural flow of the medical interview. Nonverbal cues, such as a sympathetic expression, a motion of the hand, or a change in body language like leaning forward, can be used to keep the patient talking. Utterances such as �oh�, �uh-huh�, �yes�, and �mmm� also keeps the interview moving. Echoing words or phrases reinforce the fact that patients are being heard. Open-ended requests� such as �go on� and �tell me more�� give patients permission to expand or delve deeper into their symptoms. Understanding patients� emotions is important, as we shall see in the next slide. Patients that get off track may be guided back to the interview by simple phrases such as �I appreciate your sharing this with me, however, we need to get back to how you are feeling.� Guiding patients back on track should be relatively simple, as patients are often brief in their emotional expression and responsive to direction by their physicians.Asking the right questions is crucial to effective communication. As Robert Smith, MD suggests, there is a certain finesse to the natural flow of the medical interview. Nonverbal cues, such as a sympathetic expression, a motion of the hand, or a change in body language like leaning forward, can be used to keep the patient talking. Utterances such as �oh�, �uh-huh�, �yes�, and �mmm� also keeps the interview moving. Echoing words or phrases reinforce the fact that patients are being heard. Open-ended requests� such as �go on� and �tell me more�� give patients permission to expand or delve deeper into their symptoms. Understanding patients� emotions is important, as we shall see in the next slide. Patients that get off track may be guided back to the interview by simple phrases such as �I appreciate your sharing this with me, however, we need to get back to how you are feeling.� Guiding patients back on track should be relatively simple, as patients are often brief in their emotional expression and responsive to direction by their physicians.

15. Solutions to Barriers (5) The mnemonic NURS will help you remember the steps: Name the emotion Understand their reactions Respect the difficulties Support the person A visit to the physician is almost always accompanied by emotions. Even such benign visits as an annual check up can put the patient on edge. The patient may silently wonder, �Has my weight increased?� or, �Is this the year that I�ll come down with grandmother�s diabetes?� among a host of other troublesome questions. It is therefore vitally important that the physician is alert to signs of emotional disturbance and to respond to them. The mnemonic NURS summarizes the crucial areas in understanding patients� emotions(1): Show that you properly recognize what has been said when you NAME the emotion: �That sounds sad for you.� Acknowledge an UNDERSTANDING of this patient�s reaction when you respond: �I�ve never had that happen, but I CAN SEE HOW deeply it hurts you.� Exhibit RESPECT for the difficulties your patient may have with a phrase like, �I like the way you�ve hung in there and kept fighting.� You may also say, �It looked like you were really fighting then. Would you be willing to put up another fight if necessary now or tomorrow?� This allows the patient to acknowledge ambivalence concerning chemotherapy or other difficult choices. Talking through these tough decisions avoids the common error of assuming that the patient�s desires are identical to those of the physician. SUPPORT the person and show that decision making is a partnership when you offer: �I�m here to help in any way that I can. Together, you and I can get to the bottom of this.� (1) Smith, RC (1996). The Patient�s Story: Integrating Patient-Doctor Interviewing. Boston: Little; Brown. A visit to the physician is almost always accompanied by emotions. Even such benign visits as an annual check up can put the patient on edge. The patient may silently wonder, �Has my weight increased?� or, �Is this the year that I�ll come down with grandmother�s diabetes?� among a host of other troublesome questions. It is therefore vitally important that the physician is alert to signs of emotional disturbance and to respond to them. The mnemonic NURS summarizes the crucial areas in understanding patients� emotions(1): Show that you properly recognize what has been said when you NAME the emotion: �That sounds sad for you.� Acknowledge an UNDERSTANDING of this patient�s reaction when you respond: �I�ve never had that happen, but I CAN SEE HOW deeply it hurts you.� Exhibit RESPECT for the difficulties your patient may have with a phrase like, �I like the way you�ve hung in there and kept fighting.� You may also say, �It looked like you were really fighting then. Would you be willing to put up another fight if necessary now or tomorrow?� This allows the patient to acknowledge ambivalence concerning chemotherapy or other difficult choices. Talking through these tough decisions avoids the common error of assuming that the patient�s desires are identical to those of the physician. SUPPORT the person and show that decision making is a partnership when you offer: �I�m here to help in any way that I can. Together, you and I can get to the bottom of this.� (1) Smith, RC (1996). The Patient�s Story: Integrating Patient-Doctor Interviewing. Boston: Little; Brown.

16. Working to Achieve Patient Change: The 4 E�s Engage the individual Establish a working agenda Empathize with his/her story Educate the patient Avoid Arguing Establish Trust To achieve patient change, establish trust by making sure patients �buy� the diagnosis and are confident and informed of the intended outcomes. The 4 E�s will help achieve patient change (1)*: Engaging the patient, establishing a working agenda, empathizing with their story, and educating the patient, will build a positive, trusting environment. If there are differences of opinion or understanding they can be talked through without arguing. (1) White M, Keller V (1992). Annotated bibliography of difficult clinician-patient relationships. West Haven (CT): Bayer Institute for Health Care Communication. * Bayer sometimes refers to the 4 E�s as Engage, Empathize, Educate, and Enlist.To achieve patient change, establish trust by making sure patients �buy� the diagnosis and are confident and informed of the intended outcomes. The 4 E�s will help achieve patient change (1)*: Engaging the patient, establishing a working agenda, empathizing with their story, and educating the patient, will build a positive, trusting environment. If there are differences of opinion or understanding they can be talked through without arguing. (1) White M, Keller V (1992). Annotated bibliography of difficult clinician-patient relationships. West Haven (CT): Bayer Institute for Health Care Communication. * Bayer sometimes refers to the 4 E�s as Engage, Empathize, Educate, and Enlist.

17. Difficult Situations The Role of the Family: No Patient is an Island Treating the Elderly Working with Difficult Patients Being Culturally and Gender Sensitive Dealing with patients� families, treating the elderly, working with difficult personalities, and being culturally and gender sensitive may all affect the dynamics of the physician patient relationship (1). Family: As many as 32% of patients bring family members to accompany them to office visits (2). You can use the family as a valuable resource to uncover clues to patients� lives, clues which may help in your assessment of symptoms and ultimate diagnosis. Advancing Age: By 2020, 1 in 5 Americans will be over the age of 65. Yet old age in and of itself is not an automatic explanation for an unsteady gait or a stiff knee. Other Differences: Being sensitive and respectful of any physical or cognitive impairments the patient may have, as well as being cognizant of gender or cultural differences, will help guide effective communication. Hinz, CA (2000). Communicating with Your Patients: Skills for Building Rapport. American Medical Association: Chicago. Medalie, J., Zyzanski, S., Langa, & Strange, K. (1998). The family in family practice: is it a reality? J Fam Pract, 46, 390-96. Dealing with patients� families, treating the elderly, working with difficult personalities, and being culturally and gender sensitive may all affect the dynamics of the physician patient relationship (1). Family: As many as 32% of patients bring family members to accompany them to office visits (2). You can use the family as a valuable resource to uncover clues to patients� lives, clues which may help in your assessment of symptoms and ultimate diagnosis. Advancing Age: By 2020, 1 in 5 Americans will be over the age of 65. Yet old age in and of itself is not an automatic explanation for an unsteady gait or a stiff knee. Other Differences: Being sensitive and respectful of any physical or cognitive impairments the patient may have, as well as being cognizant of gender or cultural differences, will help guide effective communication. Hinz, CA (2000). Communicating with Your Patients: Skills for Building Rapport. American Medical Association: Chicago. Medalie, J., Zyzanski, S., Langa, & Strange, K. (1998). The family in family practice: is it a reality? J Fam Pract, 46, 390-96.

18. Difficult Situations (2) When delivering bad news Remember SPIKES Sharpen your listening skills Pay attention to patients perceptions Invite the patient to discuss details Know the facts Explore emotions and deliver empathy Strategize next steps with patient�s family There are no magic bullets to delivering bad news. Since patients are unique, one size does not fit all. For example, what is trivial to one patient may be horrific to another. Patients� expectations shape how they react to bad news. Knowing those expectations requires uncovering them first. In his book, �Breaking Bad News: A Guide for Health Care Professionals,� Robert Buckman, MD suggests the mnemonic SPIKES as a reminder of how to deal with difficult situations (1). To repeat the slide: Sharpen your listening skills. Pay attention to patients perceptions Invite the patient to discuss the details Know the facts Explore emotions and deliver empathy Strategize next steps with patient�s family Acknowledging your feelings about the news, changing how patients are approached, and paying closer attention to what is said as well as how it is said, will create a useful interaction. Having a sense of who the patient is, how he/she feels, and what he/she knows is critical to delivering bad news empathetically. (1) Buckman, R (1992). How to Break Bad News: A Guide for Health Care Professionals. Baltimore, MD: Johns Hopkins University Press. There are no magic bullets to delivering bad news. Since patients are unique, one size does not fit all. For example, what is trivial to one patient may be horrific to another. Patients� expectations shape how they react to bad news. Knowing those expectations requires uncovering them first. In his book, �Breaking Bad News: A Guide for Health Care Professionals,� Robert Buckman, MD suggests the mnemonic SPIKES as a reminder of how to deal with difficult situations (1). To repeat the slide: Sharpen your listening skills. Pay attention to patients perceptions Invite the patient to discuss the details Know the facts Explore emotions and deliver empathy Strategize next steps with patient�s family Acknowledging your feelings about the news, changing how patients are approached, and paying closer attention to what is said as well as how it is said, will create a useful interaction. Having a sense of who the patient is, how he/she feels, and what he/she knows is critical to delivering bad news empathetically. (1) Buckman, R (1992). How to Break Bad News: A Guide for Health Care Professionals. Baltimore, MD: Johns Hopkins University Press.

19. Case One Patient presents with complaints of shortness of breath Physician is forewarned, from his staff, that the patient has chronic obstructive lung disease. The patient calls ahead for an appointment, speaks to a receptionist who takes his primary complaint, and comes to see his physician for what he describes as difficulty breathing. Here is the physician-patient dialogue: DR: OK, Mr. Smith, what sort of trouble have you been suffering from? PT: Well, I�ve had some trouble with my legs and� DR (Interrupting): Have you had trouble breathing? PT:Well, yes, I always have some trouble with my breathing. See I have emphysema and� DR (Interrupting): Are you coughing? Coughing anything up?PT: No, not really. Its just that� DR: So do you have chest pain?PT: Well, not really, no, no chest pain. DR: What medications are you taking? The result of this interaction was not useful for either the patient or the physician. The physician felt that Mr. Smith did not answer his questions; the patient felt that he was not listened to and that his needs were not met. The physician concentrated on the shortness of breath and ignored the leg pain, thus missing the possibility of DVT/PE. As the patient�s symptoms grew worse, he went to the local hospital ER where he was diagnosed and treated for DVT/PE. The patient calls ahead for an appointment, speaks to a receptionist who takes his primary complaint, and comes to see his physician for what he describes as difficulty breathing. Here is the physician-patient dialogue: DR: OK, Mr. Smith, what sort of trouble have you been suffering from? PT: Well, I�ve had some trouble with my legs and� DR (Interrupting): Have you had trouble breathing? PT:Well, yes, I always have some trouble with my breathing. See I have emphysema and� DR (Interrupting): Are you coughing? Coughing anything up?PT: No, not really. Its just that� DR: So do you have chest pain?PT: Well, not really, no, no chest pain. DR: What medications are you taking? The result of this interaction was not useful for either the patient or the physician. The physician felt that Mr. Smith did not answer his questions; the patient felt that he was not listened to and that his needs were not met. The physician concentrated on the shortness of breath and ignored the leg pain, thus missing the possibility of DVT/PE. As the patient�s symptoms grew worse, he went to the local hospital ER where he was diagnosed and treated for DVT/PE.

20. Case One Take Home Points What are some take home points from Case One? While you will receive take home points when you leave the presentation, it may be instructive to reflect here what might have improved the outcome of this encounter. Case One Take Home Points: Listening requires paying attention to the patient�s complaint in its entirety Avoid leading questions Have no preconceived notions as to what is wrong. Take time for a differential diagnosis Only the patient�s validation can confirm your understanding of the entire symptom complex. Check to make sure you interpret correctly Look for symptoms, but share responsibility with the patient in eliciting them Finally, Do not give in to time pressures While you will receive take home points when you leave the presentation, it may be instructive to reflect here what might have improved the outcome of this encounter. Case One Take Home Points: Listening requires paying attention to the patient�s complaint in its entirety Avoid leading questions Have no preconceived notions as to what is wrong. Take time for a differential diagnosis Only the patient�s validation can confirm your understanding of the entire symptom complex. Check to make sure you interpret correctly Look for symptoms, but share responsibility with the patient in eliciting them Finally, Do not give in to time pressures

21. Case Two Patient presents with long list of symptoms Patient has own agenda of what is wrong, what he needs and wants from the physician Physicians tend to blame patients for most of the difficult interactions they experience, and patients blame physicians. Unfortunately, it does little good to blame each other for the trouble. Remember, it is usually not the physician or patient that is difficult, rather, it is their interaction. This example highlights how a difficult physician patient interaction was satisfactorily resolved for both parties. DR: Mr. Smith, the way I see it, we�d be successful if you finished your course of physical therapy, your pain management therapy, and your vocational rehabilitation. PT: I don�t see it that way at all. I need compensation for my pain and suffering and, by the way, I�m out of those pain medicines. I need you to refill the prescription and fill out those disability papers. DR: So we have really different ideas about what we think success is. PT: Why are you making me suffer like this?DR: I can understand how frustrating it would be to be suffering as you are and then to find that your physician has different goals than yours. PT: You aren�t kidding!DR: Do you see any way that we can work together?PT: I�ll take anything that will make me feel better and get me back on my feet. DR: That sounds like a goal I�d agree with. So what can we do?PT: Well, if I stay in the therapy and the rehab program, can you keep giving me my pain meds?DR: Yes, I think that sounds like a good plan to begin with.Physicians tend to blame patients for most of the difficult interactions they experience, and patients blame physicians. Unfortunately, it does little good to blame each other for the trouble. Remember, it is usually not the physician or patient that is difficult, rather, it is their interaction. This example highlights how a difficult physician patient interaction was satisfactorily resolved for both parties. DR: Mr. Smith, the way I see it, we�d be successful if you finished your course of physical therapy, your pain management therapy, and your vocational rehabilitation. PT: I don�t see it that way at all. I need compensation for my pain and suffering and, by the way, I�m out of those pain medicines. I need you to refill the prescription and fill out those disability papers. DR: So we have really different ideas about what we think success is. PT: Why are you making me suffer like this?DR: I can understand how frustrating it would be to be suffering as you are and then to find that your physician has different goals than yours. PT: You aren�t kidding!DR: Do you see any way that we can work together?PT: I�ll take anything that will make me feel better and get me back on my feet. DR: That sounds like a goal I�d agree with. So what can we do?PT: Well, if I stay in the therapy and the rehab program, can you keep giving me my pain meds?DR: Yes, I think that sounds like a good plan to begin with.

22. Case Two Take Home Points What are the important take home points from Case Two? Instead of getting frustrated with the patient, the physician: Recognized the difficulty early on and gave himself time to think about what he wanted to say instead of acting in frustration. Empathized with the patient�s fellings of fear and anger. He validated those feelings, and the patient felt heard and understood. Shared responsibility with the patient when he asked the patient how they could work together, thus empowering the patient.Instead of getting frustrated with the patient, the physician: Recognized the difficulty early on and gave himself time to think about what he wanted to say instead of acting in frustration. Empathized with the patient�s fellings of fear and anger. He validated those feelings, and the patient felt heard and understood. Shared responsibility with the patient when he asked the patient how they could work together, thus empowering the patient.

23. Case Three Patient�s daughter is upset about the nature and course of her mother�s care The mother has experienced a return of breast cancer In the past, the physician has not shared his decisions sufficiently with the daughter of an elderly breast cancer patient whose cancer has returned. The daughter is unwilling to support his recommendation for additional surgery to be followed by chemotherapy. Since this is a slow-growing tumor and the mother is in good health otherwise, chances are high that she will benefit from this approach. The physician realizes the close connection between mother and daughter, recognizing that he has to win her over first to succeed with his treatment recommendations. In effect, he is establishing trust. DR: It sounds like you are worried about your mother�s health and you are not sure you can trust the very person that is in charge of her care. That must make it pretty tough for you. DAUGHTER: It is just that I want her to have the best care, and I think maybe last time she had this problem we should have called in more specialists. DR: I see. You�re concerned that we perhaps didn�t have enough experts involved. Is there anything else? Anything you are upset with me about that I did or didn�t do in the past?In the past, the physician has not shared his decisions sufficiently with the daughter of an elderly breast cancer patient whose cancer has returned. The daughter is unwilling to support his recommendation for additional surgery to be followed by chemotherapy. Since this is a slow-growing tumor and the mother is in good health otherwise, chances are high that she will benefit from this approach. The physician realizes the close connection between mother and daughter, recognizing that he has to win her over first to succeed with his treatment recommendations. In effect, he is establishing trust. DR: It sounds like you are worried about your mother�s health and you are not sure you can trust the very person that is in charge of her care. That must make it pretty tough for you. DAUGHTER: It is just that I want her to have the best care, and I think maybe last time she had this problem we should have called in more specialists. DR: I see. You�re concerned that we perhaps didn�t have enough experts involved. Is there anything else? Anything you are upset with me about that I did or didn�t do in the past?

24. Case Three Take Home Points What are the take home points from Case Three? Here the physician was willing to discuss the daughter�s distrust, recognizing that it was essential to gain her cooperation and trust. He facilitates effective communication by: Not becoming angry or embarrassed by the daughter�s distrust of him as a physician Sharing with the daughter responsibility for the mother�s course of treatment Listening to the daughter�s concerns Recognizing the patient�s family as a valuable resource in the treatment and recovery process Here the physician was willing to discuss the daughter�s distrust, recognizing that it was essential to gain her cooperation and trust. He facilitates effective communication by: Not becoming angry or embarrassed by the daughter�s distrust of him as a physician Sharing with the daughter responsibility for the mother�s course of treatment Listening to the daughter�s concerns Recognizing the patient�s family as a valuable resource in the treatment and recovery process

25. Case Four Patient with chronic renal failure Workup after complaining of abdominal pain You wrote: �CT of abdomen w/o contrast.� One of your patients with chronic renal failure is complaining of abdominal pain. You send the patient for a CT of the abdomen without IV contrast. You wrote: CT of abdomen w/o contrast. The radiology department has some trouble reading your handwriting. Instead of checking with your office they decide that it reads w/contrast. Additionally, in your haste you did not write the diagnosis of CRF on the order sheet. All that the order sheet shows is diagnosis of abdominal pain. The radiology department does inquire about allergies to the IV contrast and to shellfish. The patient receives the contrast without any post procedure monitoring for hydration. Systems issues that broke down: The use of initials and abbreviations has been shown to cause errors. The radiology department, being busy, does not reconfirm (lack of communication) when in doubt. The secondary diagnosis of CRF is not included (lack of communication). The patient could not contribute to the clarification as he or she had not been briefed on what to expect (lack of communication). The example highlights how communication failures, verbal as well as written contributed to this patient safety problem. Please note that there were multiple failures present. Remedying just one might have avoided the situation. One of your patients with chronic renal failure is complaining of abdominal pain. You send the patient for a CT of the abdomen without IV contrast. You wrote: CT of abdomen w/o contrast. The radiology department has some trouble reading your handwriting. Instead of checking with your office they decide that it reads w/contrast. Additionally, in your haste you did not write the diagnosis of CRF on the order sheet. All that the order sheet shows is diagnosis of abdominal pain. The radiology department does inquire about allergies to the IV contrast and to shellfish. The patient receives the contrast without any post procedure monitoring for hydration. Systems issues that broke down: The use of initials and abbreviations has been shown to cause errors. The radiology department, being busy, does not reconfirm (lack of communication) when in doubt. The secondary diagnosis of CRF is not included (lack of communication). The patient could not contribute to the clarification as he or she had not been briefed on what to expect (lack of communication). The example highlights how communication failures, verbal as well as written contributed to this patient safety problem. Please note that there were multiple failures present. Remedying just one might have avoided the situation.

26. Case Four Take Home Points What are the take home points from Case Four? Here as in the other cases, it is important to remember that it takes multiple systems errors to result in patient harm. Thus, instead of thinking, �Wow this was a mistake; I have to be more careful in the future,� think, �How can I change the system to avoid this or something similar from happening again?� Case Four Take Home Points: Efficiency without due process defeats itself Use your patients as allies of information control Print rather than hand-write orders Do not use abbreviationsHere as in the other cases, it is important to remember that it takes multiple systems errors to result in patient harm. Thus, instead of thinking, �Wow this was a mistake; I have to be more careful in the future,� think, �How can I change the system to avoid this or something similar from happening again?� Case Four Take Home Points: Efficiency without due process defeats itself Use your patients as allies of information control Print rather than hand-write orders Do not use abbreviations

27. Case FiveGastroenterologist Referral 64- year- old male with positive occult blood in stool Internist referral to gastroenterologist �Evaluate for blood in stool� A 64-year old male was evaluated by his general internist for a two-month history of intermittent blood in the stools and a 5-pound weight loss. The physical examination was normal with the exception of positive occult blood in the stool. A referral was made to a gastroenterologist that read, �Evaluate for blood in the stool.� The gastroenterologist evaluated the patient and a note was returned to the referring physician that read, �Suspect colon cancer. Recommend colonoscopy.� The referring physician assumed that the gastroenterologist scheduled the procedure. The gatroenterologist assumed that the referring physician would schedule the procedure since the patient requested that someone �close to my home� do the procedure. Three months later the patient called his internist to inquire about the procedure. Significant time was lost before following through with further evaluation. A 64-year old male was evaluated by his general internist for a two-month history of intermittent blood in the stools and a 5-pound weight loss. The physical examination was normal with the exception of positive occult blood in the stool. A referral was made to a gastroenterologist that read, �Evaluate for blood in the stool.� The gastroenterologist evaluated the patient and a note was returned to the referring physician that read, �Suspect colon cancer. Recommend colonoscopy.� The referring physician assumed that the gastroenterologist scheduled the procedure. The gatroenterologist assumed that the referring physician would schedule the procedure since the patient requested that someone �close to my home� do the procedure. Three months later the patient called his internist to inquire about the procedure. Significant time was lost before following through with further evaluation.

28. Case Five Take Home Points What are the important take home points from case five? The communication in the referral process was too short: Both physicians limited themselves to brief written communication, which lent itself to assumptions that were not necessarily true. Each assumed the other physician would take care of scheduling the colonoscopy. The various alternatives were: The gastroenterologist could have indicated on the return note that the patient preferred that the procedure be done closer to his home and that he therefore left the scheduling of the colonoscopy up to the internist. In addition, he could have told the patient that he should tell his physician to schedule the colonoscopy. The internist could have asked his staff to call the gatroenterologist to confirm that the colonoscopy had been scheduled or he could have asked the patient himself. This case illustrates the importance of explicit communications between generalist and subspecialist. It also points to the patient as a potential source of important missing information. The communication in the referral process was too short: Both physicians limited themselves to brief written communication, which lent itself to assumptions that were not necessarily true. Each assumed the other physician would take care of scheduling the colonoscopy. The various alternatives were: The gastroenterologist could have indicated on the return note that the patient preferred that the procedure be done closer to his home and that he therefore left the scheduling of the colonoscopy up to the internist. In addition, he could have told the patient that he should tell his physician to schedule the colonoscopy. The internist could have asked his staff to call the gatroenterologist to confirm that the colonoscopy had been scheduled or he could have asked the patient himself. This case illustrates the importance of explicit communications between generalist and subspecialist. It also points to the patient as a potential source of important missing information.

29. Case Six 76-year-old male with ischemic heart disease Rx of sublingual nitroglycerin A 76-year old man was admitted to the hospital with new onset left arm squeezing and heaviness with modest exertion, relieved with rest. After a careful evaluation, it was determined that the diagnosis was ischemic heart disease, and medical therapy was chosen as the treatment option. Among his discharge medications was sublingual nitroglycerin. He was instructed to take the nitroglycerine whenever he had chest pain, up to three tablets, five minutes apart. At a following up appointment 2 weeks later, when asked if he had need of his nitroglycerine, the patient responded, �I never had need to take it, but I am still bothered by the left arm squeezing and heaviness when I exert myself.� A 76-year old man was admitted to the hospital with new onset left arm squeezing and heaviness with modest exertion, relieved with rest. After a careful evaluation, it was determined that the diagnosis was ischemic heart disease, and medical therapy was chosen as the treatment option. Among his discharge medications was sublingual nitroglycerin. He was instructed to take the nitroglycerine whenever he had chest pain, up to three tablets, five minutes apart. At a following up appointment 2 weeks later, when asked if he had need of his nitroglycerine, the patient responded, �I never had need to take it, but I am still bothered by the left arm squeezing and heaviness when I exert myself.�

30. Case Six Take Home Points What are the important take home points from case six? The physician did not listen carefully enough to how the ischemic heart disease manifested itself. Left arm squeezing with heaviness is the equivalent to chest pain. However, the physician did not use this symptom, rather he substituted chest pain in the instructions. The patient followed his instructions faithfully, unaware of the equivalence of both symptoms. It is best to give instructions that link directly to how the patient experiences the disease. The physician did not listen carefully enough to how the ischemic heart disease manifested itself. Left arm squeezing with heaviness is the equivalent to chest pain. However, the physician did not use this symptom, rather he substituted chest pain in the instructions. The patient followed his instructions faithfully, unaware of the equivalence of both symptoms. It is best to give instructions that link directly to how the patient experiences the disease.

31. Case Seven 50-year old woman with type 2 diabetes Difficulty controlling blood sugars Rx change A 50-year old woman with type 2 diabetes was evaluated for difficult to control blood sugars. The patient was on metformin 500 mg QID and glyburide 10 mg BID. Despite the regimen, the hemoglobin A1c remained above 9%, and the fasting blood glucose was usually above 200 mg/DL. The physician verbally instructed the patient to stop the metformin and substitute Glucophage XR 2000 mg in the morning, stop the glyburide, and begin NPH insulin prior to dinner. He then corrected himself and instructed the patient to take the NPH insulin only at bedtime. He arranged for the office nurse to instruct the patient on insulin injections and arranged for a follow up appointment in 2 weeks. Two days later the patient was admitted to the hospital with hypoglycemic reaction. In her confusion, she added Glucophage XR to metformin 500mg QID and gave herself the NPH prior to dinner and also at bedtime. A 50-year old woman with type 2 diabetes was evaluated for difficult to control blood sugars. The patient was on metformin 500 mg QID and glyburide 10 mg BID. Despite the regimen, the hemoglobin A1c remained above 9%, and the fasting blood glucose was usually above 200 mg/DL. The physician verbally instructed the patient to stop the metformin and substitute Glucophage XR 2000 mg in the morning, stop the glyburide, and begin NPH insulin prior to dinner. He then corrected himself and instructed the patient to take the NPH insulin only at bedtime. He arranged for the office nurse to instruct the patient on insulin injections and arranged for a follow up appointment in 2 weeks. Two days later the patient was admitted to the hospital with hypoglycemic reaction. In her confusion, she added Glucophage XR to metformin 500mg QID and gave herself the NPH prior to dinner and also at bedtime.

32. Case Seven Take Home Points What are the important take home points for case seven? The physician vocalized his decision making process about the required medication change in front of the patient. The patient understood the importance of the change but was unable to recall precisely what had been eliminated. She also found it difficult to remember whether or not to take the NPH insulin only once, namely before bedtime. Two opportunities were missed here by not providing the patient with written instructions regarding the change. 1. The nurse could have reiterated the instructions to the patient. 2. The patient would have had information to turn to when in doubt about her new treatment regime. The patient probably recalled the physician�s statement, that it was very important to get her blood sugars under control. To do so, more medications made sense to her. Finally, it is best not to reason out loud in front of patients who do not have the requisite knowledge base to track the progression of clinical decision making and may get confused. The physician vocalized his decision making process about the required medication change in front of the patient. The patient understood the importance of the change but was unable to recall precisely what had been eliminated. She also found it difficult to remember whether or not to take the NPH insulin only once, namely before bedtime. Two opportunities were missed here by not providing the patient with written instructions regarding the change. 1. The nurse could have reiterated the instructions to the patient. 2. The patient would have had information to turn to when in doubt about her new treatment regime. The patient probably recalled the physician�s statement, that it was very important to get her blood sugars under control. To do so, more medications made sense to her. Finally, it is best not to reason out loud in front of patients who do not have the requisite knowledge base to track the progression of clinical decision making and may get confused.

33. Electronic Communication Increased access to information Facilitates communication Dangers Privacy Ethics Inaccurate information While we have an entire module devoted to the role of electronics in patient safety, it still is important to touch on it briefly here regarding electronics in communication. The internet increasingly has the potential to change the physician-patient relationship. The physician no longer is the main source of medical information or advice. The internet can be a positive or a negative source of influence on the therapeutic relationship, depending on the accuracy of the information found or the quality and integrity of online support groups. Some health care delivery systems have embraced electronic communication between physician and patients. The benefits of this type of communication are especially apparent in the delivery of chronic care, such as for diabetes. Nevertheless, there are serious concerns over privacy and other ethical issues that need time to be studied and resolved. While we have an entire module devoted to the role of electronics in patient safety, it still is important to touch on it briefly here regarding electronics in communication. The internet increasingly has the potential to change the physician-patient relationship. The physician no longer is the main source of medical information or advice. The internet can be a positive or a negative source of influence on the therapeutic relationship, depending on the accuracy of the information found or the quality and integrity of online support groups. Some health care delivery systems have embraced electronic communication between physician and patients. The benefits of this type of communication are especially apparent in the delivery of chronic care, such as for diabetes. Nevertheless, there are serious concerns over privacy and other ethical issues that need time to be studied and resolved.

34. Outcomes of Effective Communication Improved diagnostic accuracy Greater involvement of the patient in decision making Increased likelihood of adherence to therapeutic regimens Increased patient and clinician satisfaction Effective communication is linked to improved diagnostic accuracy, patient compliance, and improved health outcomes. A well-informed patient is more likely to be satisfied and involved in decision making. As we have seen in our cases, effective communication helps reduce errors in medical settings. Effective communication has positive benefits for everyone involved.Effective communication is linked to improved diagnostic accuracy, patient compliance, and improved health outcomes. A well-informed patient is more likely to be satisfied and involved in decision making. As we have seen in our cases, effective communication helps reduce errors in medical settings. Effective communication has positive benefits for everyone involved.

35. Where do we go from here? Educational Programs work! Open Communication Get to know your patients Define communication roles Empower the patient Know your mnemonics! NURS, SPIKES, SEGUE, the 4 E�s As physicians move to include patients as partners in negotiating and evaluating medical services it is both necessary and useful to participate in communication programs and adopt open communication styles. Getting to know patients, defining communication roles early in the relationship, and empowering patients all contribute to effective communication. Remembering the mnemonics: NURS, SPIKES, SEGUE, and the 4E�s will help you remember how to communicate effectively, especially during some difficult situations. As physicians move to include patients as partners in negotiating and evaluating medical services it is both necessary and useful to participate in communication programs and adopt open communication styles. Getting to know patients, defining communication roles early in the relationship, and empowering patients all contribute to effective communication. Remembering the mnemonics: NURS, SPIKES, SEGUE, and the 4E�s will help you remember how to communicate effectively, especially during some difficult situations.

36. Conclusions Communication is essential to providing patient centered care The lessons learned apply to all interactions, be they medical or not Effective communication is both clinically and personally satisfying As we have seen communication lies at the heart of patient centered care. The principles of effective communication apply to the clinical arena as well as to any interpersonal interaction. The ability to attend to what is said and why is useful in all settings. Once mastered, effective communication is highly satisfying. As we have seen communication lies at the heart of patient centered care. The principles of effective communication apply to the clinical arena as well as to any interpersonal interaction. The ability to attend to what is said and why is useful in all settings. Once mastered, effective communication is highly satisfying.

37. Patient Safety Interactive Learning Community (PSILC) http://www.acponline.org/ptsafety The Patient Safety Interactive Learning Community (PSILC � pronounced like �silk�) has its home page on the ACP-ASIM website. The PSILC website has the content of all seven patient safety modules. It also has a patient safety tip of the week, frequently asked questions, and links to additional information on patient safety. In a few weeks, you�ll be enrolled in our patient safety email discussion group. The email group will allow you to discuss with your colleagues and patient safety experts patient safety issues you�re facing in your practice. We hope to hear a lot of success stories as well any problems/issues that you may be facing. If you decide you don�t want to participate, you�ll also have a chance to �opt-out� of this group at anytime. The Patient Safety Interactive Learning Community (PSILC � pronounced like �silk�) has its home page on the ACP-ASIM website. The PSILC website has the content of all seven patient safety modules. It also has a patient safety tip of the week, frequently asked questions, and links to additional information on patient safety. In a few weeks, you�ll be enrolled in our patient safety email discussion group. The email group will allow you to discuss with your colleagues and patient safety experts patient safety issues you�re facing in your practice. We hope to hear a lot of success stories as well any problems/issues that you may be facing. If you decide you don�t want to participate, you�ll also have a chance to �opt-out� of this group at anytime.

38. Refresher Exercises http://www.acponline.org/ptsafety We're also planning something new to follow up on this session, which is an online refresher exercise. In 2-3 weeks we'll send you an email invitation that will lead to a few questions that will exercise your understanding of what you learned today. After you answer them you'll have a chance to review the slides from this talk related to each question. We hope that you'll all give this a try because this kind of exercise after a time delay is probably the most efficient way to really learn a topic well. We're also planning something new to follow up on this session, which is an online refresher exercise. In 2-3 weeks we'll send you an email invitation that will lead to a few questions that will exercise your understanding of what you learned today. After you answer them you'll have a chance to review the slides from this talk related to each question. We hope that you'll all give this a try because this kind of exercise after a time delay is probably the most efficient way to really learn a topic well.