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GPs and specialists: a dialogue of the deaf?

 

Ask almost any specialist about their dealings with GPs, and they’re likely to admit that coordination with primary care could be better. And ask any GP about their dealings with specialists, and you may well be on the receiving end of a gripe or two. Melbourne oncologist and Guardian columnist Dr Ranjana Srivastava has recently written that “shared decision-making that involves a specialist and a GP is rare”. She says that for all the talk of teamwork, there’s a lack of communication that has real downsides for the patient. Increasing numbers of patients with chronic comorbidities end up with fragmented care, Dr Srivastava says, with GPs being kept out of the loop due to delayed discharge summaries, and specialists finding it hard to track down busy GPs.

Who’s to blame? According to two large studies, it’s the specialists – if you’re a GP, that is. And of course it’s the GPs, if you’re a specialist. The first study, from the Netherlands, surveyed around 500 doctors – around half of whom were GPs and the rest specialists – about their mutual communications. The vast majority of GPs (85%) thought they were easily accessible by phone. The specialists did not agree: only 32% thought you could easily get a GP on the phone. The specialists were also sniffy about GP referral letters: just 29% of them thought referral letters were generally adequate. Nearly 90% of specialists thought they correctly addressed the issues in the referral letter. Unsurprisingly, the GPs disagreed: only half of them thought specialists adequately addressed the questions.

And did the specialists report back to the GPs in a timely manner? Yes, said 62% of specialists. No, said 78% of GPs. But when they did finally get that specialist report, the GPs overwhelmingly (92%) considered that they followed the specialist’s recommendations. Not so, said the specialists, fewer than half of whom thought the GPs did what was asked of them.

A US study finds similar disagreement between GPs and specialists. This was a considerably larger study involving nearly 50,000 doctors, who were asked about referral and consultations between primary care and specialist physicians. Around 70% of GPs reported that they always or most of the time sent notification of a patient’s history and reason for a referral to a specialist. But there may have been some fibbers among that cohort, as only 35% of specialists said they always or most of the time received such notification. But the imbalance worked both ways: while over 80% of specialists said they always or most of the time sent consultation results to the referring GP, only 62% of GPs agreed that this was the case. Doctors who did not receive timely communications were more likely to report that their ability to provide high-quality care was threatened.

The authors say their study shows the need for “systematic structures, tools and processes for information creation, transfer, receipt, and recognition by the sending and receiving physicians”.

Miscommunication between doctors is widely recognised as one of the main drivers of medical error. The Australian Medical Association has recently published guidelines to improve communications between GPs and other treating doctors. The AMA says specialist outpatient services need to have transparent systems that inform patients and referring doctors of expected wait times for services, and track the priority of referrals.

According to the new guidelines, discharge planning should include telephone, video or face-to-face case conferencing prior to discharge that includes GPs or referring doctors, and a documented plan of care.

“We are delivering very good outcomes for patients in the Australian health system, but we can and should do better. We are confident that the AMA guide will contribute to improved communication and, in turn, better overall care,” AMA President Dr Tony Bartone says.

Is breaking bad news to patients an art you can learn?

 

Being the bearer of bad news is often the unhappy duty of doctors, and can be incredibly challenging. Getting it right is not only hugely important for patients and their families, it’s also critical to the well-being of the doctors themselves.

Some doctors are better at it than others, but the good news is that even for those who don’t feel they manage it well, this is certainly a skill that can be honed.

“One of the lessons of the workshop is that communication skills can be learned and developed,” says Dr Ruvishani Samarasekera, a paediatric registrar at Sydney Children’s Hospital. “There are doctors who are not naturally empathetic or lack an emotional IQ, but they were still able to improve their communications skills to manage these situations better.”

Dr Samarasekera attended the Complex Communication in Health Care workshop under the guidance of Professor Stewart Dunn, a medical psychologist specialised in the psychological care of cancer patients and their families. The workshop uses actors playing patients in realistic scenarios where workshop attendees have to break bad news, often in difficult, complicated scenarios.

“There is not a lot of formal training  in breaking bad news in medical school,” Dr Samarasekera says. “Then, when you are a junior doctor the task is usually done by the most senior doctor. As you progress throughout your career, there is an expectation that you will then learn from what you have witnessed. But that’s not always the case.”

She recalls a very difficult case with a 21 year old patient in ICU who had complications related to morbid obesity early in her career.

“I witnessed the consultant telling the patient’s parents that he had passed away as a result of these complications. I remember how the consultant tactfully brought them into a private room and the non-verbal cues in the consult. I remember thinking how I wanted to communicate with such empathy and learn to use my own style as well.”

She says that learning and trialling diverse techniques in a workshop with actors is a very different experience to interacting and debriefing with colleagues. It is an immersive and safe experience that covers everything from the way doctors should be positioned in the consult to the words they should use, directly approaching the bad news or leading the patient towards it.

“Some scenarios we did were around breaking bad news with oncology patients, others were interactions with family members and telling them the news. And then there were other scenarios around daily communication skills with your colleagues.”

The course gave her more confidence that she could perform these difficult tasks, she says.

“I had a 10-year-old patient who’d been in and out of the ED over the course of two months with vomiting and clinically she had some concerning signs of unsteady gait. This was a red flag and so there was a looming question of whether this could be a brain tumour. Due to my earlier experiences observing my seniors in oncology combined with the practical skills gained in the workshop, I felt better equipped dealing with this emotionally challenging situation. From guiding the parents, preparing them for the likelihood of what the imaging would show and then discussing the results after.”

She says the situation was complicated by the fact that the parents had been in some denial about the symptoms and their child’s unsteadiness and had also at times received reassurance about them.

“You have to deal with this level of complexity; you have to be empathetic but honest, so that they are on your side as they go through the journey of diagnosis and treatment.”

Breaking bad news is one of the most difficult communications challenges in medicine, but not the only one. Dealing with colleagues, particularly at opposite ends of the hierarchy, can be challenging.

“One of the workshop scenarios that really struck a chord with me was one about being a junior doctor and dealing with the consultants,” she says.

The particular scenario involved a registrar being asked to be on call, despite a long-planned commitment towards a birthday party for her own child.

“The consultant very subtly manipulated her and made her feel like she couldn’t say no without losing something in her career. That kind of pressure is a huge part of medicine. The actors played out this scenario and the attendees had to decide whether they would intervene in the scenario they had witnessed. Talk to the consultant, perhaps, or try to empower the junior doctor. Some even thought the situation was not concerning, or that the junior doctor just needed to be more resilient. It was interesting to see how people responded.”

Professor Dunn will be moderating two workshops in Sydney on complex communication in health care this year. The workshops will cover breaking bad news, open disclosure, end-of-life conversations and dealing with conflict in the workplace. Read more about the workshops and sign up here.

What patients understand when you give them bad news

 

When you give bad news to a patient or immediate family, is their understanding likely to be accurate? Not necessarily, even when you are brutally frank about the poor prognosis, according to a recent study.

People tend to mentally soften the blow on hearing bad news, US researchers found in an experimental study involving 200 students who were asked to evaluate a range of prognoses. Even when presented with the stark statement that a patient “will definitely not survive”, participants in the study did not consider that as indicating a 100% likelihood of dying.

The researchers found that positive bias was accentuated the worse the prognosis was. Told that a patient was “very likely to survive”, participants rated the odds that the patient would survive at 89%; but when told that a patient was “very likely to die”, they estimated the odds of death at only 76%.

But they also found that using a more emotionally laden phrase to a prognosis could lessen the effects of positive bias. When told that “it is possible” that a patient would not survive, participants rated that as a 50/50 chance of survival. But if the physician used the phrase “I am concerned that [the patient] won’t survive”, participants downgraded the chances of survival to 35%.

However, the researchers didn’t find any difference in bias regarding the  wording of the prognosis in terms of either dying or surviving. In other words, participants attached the same risk of death to the statement “He is unlikely to survive” as they did to “he is likely to die”.

The study authors say their research, along with previous work by other researchers, shows positive bias to be a universal defensive mechanism in response to negative information. But they add that putting numbers to the prognosis – for example telling patients or relatives that they have a 95% chance of dying within three months – is unlikely to counter the positive bias, as previous research has demonstrated that numerical prognoses are just as prone to bias.

“Practitioners should be aware of the ways in which commonly used non-numeric language may be understood in numeric terms during prognostic discussions, and check recipients’ understanding during consultations for accuracy and potential positive bias,” they conclude.

You can access the study here.

Interested in learning more? Professor Stewart Dunn will be moderating workshops in Sydney in 2018 on complex communication in health care. The workshops will cover open disclosure, breaking bad news, end-of-life conversations and dealing with conflict in the workplace. Read more about the workshops and sign up here.

Tough talk: managing difficult conversations

 

Communication skills are uniquely relevant in the general practice setting, because no other medical practitioner offers the continuity of care that GPs afford their patients. A new workshop, conducted by the multiple award-winning Pam McLean Centre, will address some of the most challenging communications in the context of the long-term doctor-patient relationship – breaking bad news, open disclosure following an adverse event, and initiating discussions about treatment options at the end of life. The common theme is talking about things our patients really don’t want to talk about.

Models abound – SPIKES, ABCDE, BREAKS, ISBAR etc. And models have their place. But putting the models into practice can sometimes be surprisingly hard. This workshop allows doctors to put theory into practice through trial-and-error, working with a highly trained professional actor to negotiate step-by-step through the maze of emotionally-charged communication. Just like learning to intubate on mannequins, working with actors allows us to try various approaches to communication safe in the knowledge that no-one gets hurt. The workshop is based on rigorous research, including one of Prof Dunn’s PhD student’s projects, which measured heart rate and skin conductance in doctors whilst they told a woman that her husband had just died. The results will surprise you.

In this workshop, you will meet two patients (played by two highly experienced actors) who present all these challenges in a panorama of multiple presentations. There are options to practise the delivery of bad news in different emotional contexts, and to explore appropriate responses to an angry relative when there has been a serious adverse event. Finally we will investigate ways of initiating and supporting discussions around disease progression. You will have the opportunity to stop the consultation at any time and seek feedback from the patient and from other workshop participants. And Prof Dunn will provide insights from the relevant literature to help us along the path.

Click here for more information on this workshop.

The fine art of communication in general practice

 

Read about our new workshop exploring complex communication in primary care – breaking bad news, end of life conversation and more…

Communication skills are uniquely relevant in the general practice setting, because no other medical practitioner offers the continuity of care that GPs afford their patients. This workshop, conducted by the multiple award-winning Pam McLean Centre, will address some of the most challenging communications in the context of the long-term doctor-patient relationship – breaking bad news, open disclosure following an adverse event, and initiating discussions about treatment options at the end of life. The common theme is talking about things our patients really don’t want to talk about.

Models abound – SPIKES, ABCDE, BREAKS, ISBAR etc. And models have their place. But putting the models into practice can sometimes be surprisingly hard. This workshop allows us to put theory into practice through trial-and-error, working with a highly trained professional actor to negotiate step-by-step through the maze of emotionally-charged communication. Just like learning to intubate on mannequins, working with actors allows us to try various approaches to communication safe in the knowledge that no-one gets hurt. The workshop is based on rigorous research, including one of Prof Dunn’s PhD student’s projects, which measured heart rate and skin conductance in doctors whilst they told a woman that her husband had just died. The results will surprise you.

In this workshop, you will meet two patients (played by two of our most experienced actors) who present all these challenges in a panorama of multiple presentations. There are options to practise the delivery of bad news in different emotional contexts, and to explore appropriate responses to an angry relative when there has been a serious adverse event. Finally we will investigate ways of initiating and supporting discussions around disease progression. You will have the opportunity to stop the consultation at any time and seek feedback from the patient and from other workshop participants. And Prof Dunn will provide insights from the relevant literature to help us along the path.

Sign up to our Complex Communication in Health Care learning module here.

Dealing with Bad Health News Masterclass – Limited Places Only

 

Don’t miss out on the opportunity to attend the 2017 AMA National Conference at the Sofitel on Collins, Melbourne, from 26– 28 May for a rare and unique glimpse into medico-politics, global health issues and contentious contemporary health policies.

One of the key highlights at this year’s Conference is a pre-conference masterclass facilitated by Professor Stewart Dunn. This hands-on experiential one day workshop will focus on developing doctors’ communication skills in breaking bad health news, dealing with bad health news and end of life conversations through interactive role plays. The workshop will help you understand and interpret human behaviour by recognising, identifying and responding to the most common emotional reactions.

Pre-conference masterclass – details

  • Time: 9:30 – 5:00
  • Date: Thursday, May 25, 2017
  • Venue: Sofitel, 25 Collins Street, Melbourne, VIC 3000
  • Tickets: Conference attendees – $660, AMA members – $770, non-AMA members – $880

Register here for the workshop

Click here to find out more about the AMA National Conference, or contact the Conference organisers at natcon@ama.com.au.

This is an RACGP accredited activity for Category 1 ACRRM Core PDP points. Discounts on registration for AMA members.