Communication and patient-centred care

James talks to Dr Chris Dalton about communication and patient-centred care. Patient-centered care refers to managing patients according to their needs, wants and capabilities, rather than according to the interest of the doctor or hospital.

Summary Writer:  Cynthia Yang

Editor:  Bruce Way

Interviewee:  Chris Dalton

About Dr Chris Dalton

Chris Dalton graduated from the University of Sydney in 1980 with honours and worked in surgical training as a resident and registrar in Sydney. He then trained in obstetrics, paediatrics and anaesthesia obtaining the Diploma in Obstetrics from the Royal Australasian College of Obstetricians and Gynaecologists. After working in rural general practice for a few years, Chris returned to surgical training and obtained the Fellowship of the Royal Australian College of Surgeons in ENT surgery in 1993.

After completing post-surgical fellowships in laryngology with Bruce Benjamin in Sydney and head and neck surgery with David Howard and Valerie Lund in London, he worked at Westmead Adult’s and Westmead Children’s Hospitals as an ENT surgeon, with a particular interest in head and neck oncology and paediatric otolaryngology. Chris also practised in the private sector as an ENT surgeon during this period.

Joining Serco and BUPA

He joined Serco in 2012 as a Medical Director, working in business development, clinical governance and the development of new models of health care delivery, especially involving coordinated care. Chris has also completed a Master of Public Health at the University of Sydney and is currently enrolled in the Master of Biostatistics program there.

Chris joined BUPA as a Medical Director in 2014, where he has roles in claims management, development and implementation of policies for health insurance, clinical governance for BUPA’s health provision services and designing and supporting the clinical aspects of BUPA’s new business development. Currently he is involved in a data analytics project to gain deeper clinical insights into Bupa’s datasets.

Chris also serves on committees for the Prostheses List and the MBS review for the Australian Federal Government.

Communication and patient-centered care

With Dr Chris Dalton, BUPA Medical Director and Ears Nose and Throat Consultant, Sydney, Australia.

Introduction

Good communication is a fundamental skill for any doctor. A lot of complaints arise from communication problems when patients do not hear or understand what the doctor says, when the doctor fails to state important facts and when there is a lack of rapport between the doctor and patients or their families.

Patient-centered care refers to managing patients according to their needs, wants and capabilities, rather than according to the interest of the doctor or hospital.

Patient-focused care is more episodic, dealing with a specific problem for a particular patient. Its emphasis is on long-term plans and preventative strategies.

Hospitals are large, dynamic organisations. Often the patient gets forgotten. Patients have multiple issues, needing numerous specialty inputs and outpatient follow-ups. The role of junior doctors, in addition to managing the immediate issues, includes follow-ups, booking appointments and ensuring sound discharge planning.

Case 1

You are the orthopaedic intern. An 80-year-old lady has been admitted after a fall and sustained a neck-of-femur fracture. She normally lives at home independently. Now she is planning for discharge post-surgery (open reduction and internal fixation). The nursing unit manager asks you when the patient is going home. The patient wants to go home, but her family thinks she needs respite care. The registrar and consultants are in theatres. There has been anortho-geriatric consult requested, but this may be days away.

  • The patient may not have adequate support services at home, despite wanting to return home.
  • The patient can be referred to community nursing and allied health for services at discharge.
  • Sometimes not-for-profit organisations, like churches and the Salvation Army can be helpful.
  • Appropriate follow-up needs to be organised to implement prevention for future falls and fractures. The highest predictor for fracture is a previous fracture. Interventions include vitamin D supplements, management of osteoporosis and attending fracture-prevention clinics.
  • Speaking with the patient and family and updating them on the management plan is important.
  • Keep calm
  • Three rules:
    1. Think with respect– put any prejudice aside.
    2. Speak with courtesy –never escalate to confrontation. Do not get into an argument with patients, their families or staff members.
    3. Act with kindness – Go that extra mile. Even if it doesn’t work out, families and patients see and appreciate your effort.
  • Same three rules as above – always keep calm.
  • Nurses are focused on patient care and the efficient running of the ward. Many are more experienced than junior doctors.
  • If you think their demands are something you cannot fulfil, refer to seniors for help, like the registrar or consultant.
  • Refer to the BMJ learning website with short communication skills videos.
  • Remember the three rules.
  • The main rule about communication is to let the other person speak.
  • Start with open questions, like “How can I help?” and “What is the issue?”
  • Let the patient ventilate/talk; let them know you are listening and taking their concern onboard.

Case 2

You are working in the Emergency Department. A young male with a history of IVDU and benzodiazepine dependence presents to you, requesting for a benzodiazepine script. This is on a weekend and his script has run out. He has had benzodiazepine withdrawal seizures and his usual doctor is unavailable until Monday.

  • This is not unusual in the GP setting. In the Emergency Department, the situation is easier as junior doctors have senior back-up.
  • If there is a strict hospital policy to not dispense drugs of addiction, this should be initially and clearly communicated to the patient at triage and at initial assessment.
    • If the policy doesn’t exist, you could speak with the Drug and Alcohol registrar for advice, especially if the patient is known to the team.
  • If the patient is demanding and aggressive and is not known to the hospital, senior help should be sought. Call security if the patient becomes aggressive.
  • If the patient is reasonable, explain that there are drug and alcohol services that we can refer patients to.
  • Rather than thinking “How can we get rid of the patient from the ED?”, think “How can we optimise the patient’s health in general?”
  • Ideally, there should be a unit lead by a general physician with a team of nurses and allied health for care coordination between the hospital and the community.
  • Currently, this is the job of the junior doctor.
  • Let patients talk. Listen. This can de-escalate the situation. The patient feels that you are listening to their concerns.

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Tags: #BMJ learning,#BUPA,#communication,#communication and patient-centred care,#patient centred care,#quality patient care

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