Jackson, Mary Lou

Journal of Visual Impairment & Blindness, August, 2007, Vol.101(8), p.489(5) [Peer Reviewed Journal]

Vision rehabilitation is a clinical discipline in which there is a great deal of discussion with patients--reviewing patients' goals; educating patients about their ocular condition; outlining rehabilitation options; and often conveying "bad news," such as the assessment that a patient can no longer drive or that it is anticipated that a patient's vision will never improve. This article reviews two published models of physician-patient communication and addresses how each may apply to health care professionals in vision rehabilitation who communicate with patients, such as discussing the need to stop driving with patients who have age-related macular degeneration (AMD).

Communication with patients is a core clinical skill for all health care professionals that can be evaluated, taught, and improved. Medical schools historically taught this skill informally and referred to physicians as having or not having a "good bedside manner." Today, more emphasis is placed on communication as a teachable skill in the health care setting, with a shift toward communication skills being more explicitly taught and evaluated. In the United States, the Accreditation Council for Graduate Medical Education requires that "residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates" (Hutul, Carpenter, Tarpley, & Lomis, 2006, p. 401). One can consider how clinicians communicate with patients who have AMD by considering how one would approach a discussion in the following hypothetical scenario:

Mr. B is a spry 80 year old who lives alone. He was diagnosed

with AMD three years ago and has had photodynamic treatment in one

eye and antivascular endothelial growth factor intravitreal

treatment to his left eye. Mr. B's acuity is now 20/100 OD and

20/200 OS. His contrast sensitivity is markedly reduced, and he has

large scotomas in the left eye and scotomas encircling the central

retina in the right eye. His wife recently died, and he moved to a

neighboring city to be closer to his two daughters. Mr. B drives

only during the day. He reported that he is depressed, having

fallen recently and experiencing the symptom of seeing "people and

faces" that he knows are not there. He set his car keys on the desk

beside him when the interview started and cried twice during the

interview.

How does a clinician approach a patient who needs to be told that he cannot continue to drive? How does a clinician approach a patient who begins to cry during the interview? This scenario presents many issues for a vision rehabilitation clinician to discuss with Mr. B.

THE SPIKES STRATEGY

Robert Buchman is an oncologist who wrote both a text, How to Break Bad News: A Guide for Health Care Professionals (Buchman, 1992), and an article entitled, "Breaking Bad News: The SPIKES Strategy" (Buchman, 2005). He defined bad news as any news that is contrary to a patient's expectations. It is the patient's perception of the situation that determines how bad the news is, not the clinician's perception of the significance of the discussion. The SPIKES protocol is a strategy, not a scripted language, for approaching discussions with a patient. It recommends that health care professionals consider the sequential steps outlined by Buchman: setting, perception, invitation, knowledge, empathy, and strategy and summary.

The SPIKES protocol first recommends that clinicians attend to the setting, so that significant news is discussed at a time when privacy is assured, the appropriate individuals are present, the clinician can be comfortably seated at the same level as the patient, and the clinician can be attentive and not rushed. In the second step, perception, the clinician asks before he or she tells. As Buchman (1992, p. 140) noted, "Before you break bad news to your patients, you should glean a fairly accurate picture of their perception of the medical situation--in particular, how they view the seriousness of the condition." Since not all patients want explicit details, the third step is invitation, in which the clinician asks the patient how much detail he or she would like to hear. The physician may say, "Some patients want me to cover every medical detail, but other patients want only the big picture-what would you prefer now?"

In the fourth step, knowledge is conveyed to patients. A "warning shot" can advise a patient that bad news needs to be conveyed; for example, the clinician may say, "We need to discuss your driving before we finish today." This statement gives the patient a little time to prepare. Language similar to the patient's language can be chosen for conveying information, rather than overly technical scientific language, unless a patient answers the clinician's question with this style of language. The rate of offering information is tempered for the patient, and pauses can help a patient grasp what the clinician is saying and offer an opportunity to check that the patient understands. For example, the clinician may say, "I'm going to stop for a minute to see if you have questions."

The fifth step, empathy, involves listening and identifying both the emotions that the patient expresses and the source of the emotions. Clinicians need to demonstrate that they connect the two. Patients who cry are assisted when clinicians pause and allow them a few uninterrupted moments. Clinicians can look away, since few patients appreciate being watched as they cry. The rapid offer of a tissue can communicate that the clinician is uncomfortable with the emotion, rather than that the clinician understands that an emotional response to unexpected news is normal. Clinicians who pause and acknowledge a patient's emotional response show that they understand the human side of a medical issue. In the last step, strategy and summary, the clinician checks that the patient understands both the main point of the discussion and the next steps.

THE FOUR E's

The second model of communication in health care settings is the Four E's--engagement, empathy, education, and enlistment--promoted by the Institute for Healthcare Communication (Foxman, 2006). Engagement with a patient can begin with the clinician assuring that the patient is comfortable, asking open-ended questions that cannot be answered by a rapid yes or no, and not interrupting when the patient is speaking. With empathy, clinicians indicate that they comprehend the problem from the patient's experience and understand that the patient may have an emotional reaction to bad news. Education addresses what bothers patients most in language and with amounts of information that are comprehensible to each patient. Last, enlistment refers to patients as active collaborators, not passive recipients of medical prescriptions. Clinicians cannot be confidant in a patient's ability to carry out a prescribed regimen if they have not ascertained that the patient believes in the efficacy of the treatment.

DISCUSSION

How do these two communication models apply to discussions with patients in the vision rehabilitation setting? Box 1 and Box 2 outline how each model may apply to the clinical scenario of Mr. B with AMD described earlier. Both models include the concept of asking patients how much they already know and how much more detail they would like to know, thus acknowledging that the patient's agenda needs to overlap with the clinician's agenda. Asking questions that allow patients to present more information than yes-or-no answers, not interrupting, and expecting that patients will have a reaction, possibly an emotional reaction such as crying, when they hear what they perceive to be bad news are common elements of each model. Each model emphasizes empathy and seeing the situation from the patient's perspective, and each uses the skill of briefly being silent when the patient displays emotion. Either model can be applied so as to communicate optimally with patients such as those with AMD.

Box 1

The SPIKES Health Care

Communication Model

S--Setting: The clinician is seated, appears

comfortable, and does not interrupt

when the patient speaks.

P--Perception: "What have you been

told about your driving up to now?"

I--Invitation: "How much detail would

you like to know about the licensing

requirements?"

K--Knowledge: "Today I do need to

discuss your driving with you." (Warning

shot)

E--Empathy: "Hearing that you do not

meet the licensing requirements is

clearly a major shock to you. I wish the

news were better."

(The patient cries, and the clinician

pauses and looks away.) "I see that this

news upsets you. Let's just take a break

now until you're ready to start again."

S--Strategy and summary: "So the summary

of all this is that your vision does

not meet the requirements to maintain a

valid driver's license, and, unfortunately,

you will now not be able to drive.

Is that your understanding?"

Box 2

The Four E's Model of health

care communication

Engagement: "Would you like to take

your coat off? We talked about your

vision and the diagnosis of age-related

macular degeneration.in your last visit.

Is there anything else you were wondering

about?"

Empathy: "It is tough to have to think

about alternate ways to get around if you

cannot drive the way you used to."

Education: "What would you like to

know about licensing requirements and

vision standards?"

Enlistment: "I believe we have common

ground here, since neither of us wants

you to be involved in an accident. We

both want to keep you driving safely as

long as possible and make the decision

not to drive at the right time."

Dr. Francis Peabody concluded a 1925 lecture at Harvard Medical School 80 years ago with the statement, "The secret of care of the patient is caring for the patient" (quoted in Foxman, 2006, p. 24). Multiple studies have documented the relationship between the quality of doctor-patient communication and health outcomes, such as compliance with treatment, satisfaction with health care, and functional outcomes of care (Stewart, 1995). Such studies have suggested that Peabody's statement has validity in current health care settings and possible application in vision rehabilitation settings.

REFERENCES

Buchman, R. A. (1992). Breaking bad news: The SPIKES strategy. Community Oncology, 2(2), 138-142.

Buchman, R. (2005). Breaking bad news: The SPIKES strategy. Community Oncology, Mr, 138-142.

Foxman, S. (2006, January-February). Doc talk: The clinical benefits of discussion. MD Dialogue. Retrieved June 25, 2007, from http://cpso.on.ca/Publications/ Dialogue/JanFeb06/doctalk.htm

Hutul, O. A., Carpenter, R. O., Tarpley, J. L., & Lomis, K. D. (2006). Missed opportunities: A descriptive assessment of teaching and attitudes regarding communication skills in a surgical residency. Current Surgery, 63, 401-409.

Stewart, M. A. (1995). Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal, 15, 1423-1433.

Mary Lou Jackson, M.D., FRCS(C), director, Vision Rehabilitation, Department of Opththalmology, Massachusetts Eye and Ear Infirmary, Harvard Department of Ophthalmology, 243 Charles Street, Boston, MA, 02114; e-mail: <Marylou_ [e-mail]>.

Jackson, Mary Lou

Дата добавления: 2015-07-26