Therapeutic relationships and the illusion of communication

1. University Hospital Southampton Therapeutic relationships and the illusion of communication Lisa Roberts PhD MCSP Arthritis Research UK Senior Lecturer in Physiotherapy / Consultant Physiotherapist

2. Plan • The challenge of communication • Issues of truth telling • Current research • Opening clinical encounters • Implications for practice

3. Communication is ….. ‘The most important aspect that health professionals have to master’ Weatherall (1998)

4. Communication Importance of: • Verbal communication • Non-verbal (55-97%) • Patient-therapist relationship

5. Poor communication 80% of patients’ complaints arise from a breakdown in communication Towles BMJ;1998:301-4

6. Non-specific treatment effect • Touch • Showing interest (Hawthorne effect) • Professionalism • Actively listening • Environment • Technical equipment • Placebo effect ….

7. The most important thing in communication is to hear what isn't being said. Peter Drucker

8. Why do we tell lies? • To reduce fear • To tolerate stress • To gain control over uncertainty • Superstition • To enhance well-being • To protect privacy / confidentiality • To help others • To be malicious

9. Physiotherapists’ perceptions… …of the most important factors in successful treatment • patient-therapist relationship • patients’ resources More important to success than treatment techniques Stenmar & Nordholm. Physical Therapy 1994;74:1034-9.

10. Aim of the pilot study To measure the content and prevalence of the verbal and non-verbal communication that occur between physiotherapists and patients with low back pain in an outpatient setting. Roberts L & Bucksey SJ. Communicating with patients: what happens in practice? Phys Ther 2007; 87: 586–94

11. Patients (n = 21) Physiotherapists (n = 7) Video recording: Initial treatment session (n=21) • Key findings • Verbal & non-verbal communication can be measured with valid and reliable tools • Affective behaviours were more prevalent among experienced physiotherapists • Video camera was perceived to influence communication, planning and treatment Roberts & Bucksey Physical Therapy 2007;87(5):586-94

12. Funded by Arthritis Research UK 'What communication and clinical decision making takes place in consultations between physiotherapists and people with back pain?' Communication and clinical decision making in low back pain consultations

13. Home visit Observation of initial back pain consultation Physio interview Patient interview

14. Wessex Medical Research: Student Innovation Grant 2009 “Piloting an analysis of verbal communication using Synote in consultations between physiotherapists and people with back pain.” Christopher Whittle University of Southampton

15. Synote http://www.synote.org/synote/

16. Analysis • Grounded theory approach • Data managed through ‘Framework’ • 27 home visits • 25 initial consultations • 25 interviews with physiotherapists • 25 interviews with patients

17. Expectations data • Knowledge: Technical Life • Skills: Technical Interpersonal • Personal attributes: Appearance Manner

18. Opening questions • ‘How can I help you today?’ • ‘Do you want to tell me your story’ • ‘I’ve had this referral through. Tell me what’s happened’ • ‘What problem are you having at the moment?’ • How long have you had back pain for? • It’s your back pain that you’re here for is it?’ • The referral says you’ve got back pain. Is this correct? • ‘What we’ll do today is just have a bit of a chat about your back pain I believe it is. All right?

19. Clinical implications • How do you open your clinical encounters? • How often do you interrupt your patients? • Do you tailor your communication to take account of gender and age? • When was the last time you told a ‘little white lie’? • Have you spent time evaluating your communication skills? • How will you maximise your non-specific treatment effects?