Time Pressure

quality of discussions between doctor and patient is not a function of time, but of the ability to understand the feelings of the other, as well as employing correct interview techniques. A good discussion certainly does not imply a long discussion, neither does a long conversation guarantee a successful interview. Many doctors will probably only be convinced than understanding discussion does not waste time, when they have had experience in this area.

Time pressure is infectious and can itself create further lack of time.

It is not possible to measure time pressure objectively, as it is the subjective experience of limited supplies of time. This also means that I can influence how I experience time pressure and cope with it. This in turns means that I can train myself to tolerate time pressure, instead of constantly feeling impotent under its influence. Whoever learns to tolerate shortness of time and time pressure will not mention his limited time again and again, thereby releasing the feeling of time pressure in the person he is talking to, and not disturb something very important that has just come up in the discussion.

It has become fashionable not to have much time; full diaries and overcrowded, loaded desks are supposed to be a status symbol; however they are certainly not evidence of an economical way of dealing with the time available. It is also not a sign of composure to brag about one’s lack of time and to wear time pressure like a badge of merit.

make an exact note of the number of times you glance at the time. Something is wrong if this is more than 5 times in half an hour: this can be either your attitude to time or your way of dealing with it.

The most important time-saving factors in discussion are those which, at the same time, are essential to a good discussion: active listening, empathy, an adequate interview technique and the ability to find a mutual reality.

Uncompleted tasks set off restlessness and stress. It is only a completely finished assignment which releases this burden. Because of this, it is advisable to complete one task after another, rather than to try to take on too many at one time. In fact, a completed task brings one much further on than 10 which are incomplete. A task which, in principle, will be repeated many times should be carried out the very first time in such a way (even if it takes longer) that the procedure can be used in similar tasks in the future, and then involve the use of less time.

Tasks should be put into blocks. It is an uneconomical use of time to telephone, to talk to a patient, to visit the laboratory, to chat to a colleague and then leaf through a journal in colourful succession. Putting these tasks into blocks of time means that continuous and effective work can be performed in each of these areas. Putting off a more difficult task by appearing busy (clearing up, reorganization etc) is only a substitute for work, and actually only puts off achievement of the major task.

make a clear offer of time, and stick to it whatever happens. This forces the other person to make his objectives and requirements clear without beating around the bush. If you have made it clear to your discussion partner that you have only 10 minutes available, it is not impolite to signal the dose of the discussion at the end of this time. It is much more difficult if you did not make this clear before the discussion commenced.

Most people are unwilling to delegate work, either because they do not trust those with whom they work or haven’t trained them well enough, or because they have the attitude that they are the only person would could do it all correctly. In fact new tasks can often motivate those that work for you and can be an incentive for a more responsible way of working. Not only the task, but also the responsibility for it should be delegated. The stress is removed when both are passed on.

Check list: to save time

Examine your own attitude to time

Learn to tolerate lack of time

Do not infect others with your time-pressure

Classify tasks into vital, important, and unimportant

It is better to complete one task than start ten

Work in blocks of tasks

Develop an efficient system of reading

Don’t put off tasks by substituting bustle

Match tasks to your own daily efficiency profile

Spring-clean your surroundings

Recognize “time thieves”

Be able to say “No”

Make clearly defined offers of time

Don’t let others interfere with your time plan

Learn how to delegate both a task and responsibility for it

Remember: The best time-saver is the successful discussion between doctor and patient

Tasks which are approached with less enthusiasm and motivation need an over-proportional amount of time. However pleasure in the work is the result of experiencing satisfaction with the results of one’s own work. This completes the circle: the discussion which is successful is the one which is understanding” therefore an understanding discussion is not one that steals time. In fact the successful discussion between doctor and patient represents the optimal economy of time.

The climate of the discussion

The bases for a fruitful climate of discussion are: a trusting atmosphere, openness and willingness to listen, as well as the ability to relate to the patient and to be on the “same wavelength”. No aggression arises in such a discussion, which is factual and not driven by emotions, allows recognition of resonance and does not create anxiety. Respect and appreciation characterize the relationship between the two people, and the discussion proceeds symmetrically.

Where the conversation is optimal, both partners are at the same level in discussion of the subject matter, and are communicating emotionally on the same level. Both sides profit from such a discussion: the patient because he feels that his problem has been accepted and the doctor, who finds it easier to obtain the necessary information.

disclosure & negotiation

• Does "full disclosure" really address conflicts of interest? – Barking up the wrong tree

  "Coming clean about conflicts of interest, they find, can promote less ethical behavior by advisers. People with a conflict gave biased advice to benefit themselves. disclosing the conflict of interest — far from being a solution — actually made advisers act in a more self-serving way." AND people were actually more likely to comply with the advice when the doctor’s bias was disclosed. people feel an increased pressure to take the advice to avoid insinuating that they distrust their doctor. People feel pressure to behave generously even if it’s not in their best interest

  tags: communication insight innocence influence

• Love and Negotiation | Psychology Today

  "When people feel valued, they tend to cooperate. When they don’t feel valued, they resist what feels to them like submission. If you want cooperation, you must show value. If you want resistance, all you have to do is devalue, criticize, demand, or otherwise show ill-will. But don’t think about showing value – that can smell of manipulation. Focus instead on feeling value for your partner. This will lower emotional intensity and shrink the subject under negotiation to manageable proportions. Regardless of your stance on any specific behavior, always remember that you are negotiating with someone you love, who is more important to you than whatever behavior request you want to make."

  tags: marriage starred communication collaboration

Posted from Diigo. The rest of my favorite links are here.

Art of questioning & mirroring

mirroring

advantages:

• allows Pt to get a grip on his internal experiences, feelings, attitudes, ways of behaviour, desires, objectives, & to manage them better.
• allows Dr to choose correct distancing or closeness to his Pt.
• most impressive way of signalling to the Pt that the Dr is listening to him actively.

procedure: not done mechanically by a facade or echo.
foremost to mirror are : all emotional statements, objectives & presumptions/biased judgements.
try to mirror:

• all imp statements as soon as possible, briefly, concretely, clearly.
• make the attempt to workout the meaning for the Pt
• use term ‘you’ not i, we or one
• interject to make sure you understood the Pt
• use synonymns/antonymns to replay/verbalise Pt’s emotions.

if the Pt doent feel undestood: either directly intervene with a verbal confirmation or indirectly imply by describing Pt’s experience.

ability for empathetic behaviour comes from

• ethical attitude & social involvement
• sensibility level & coping level
• perceiving the relation & influencing it

“If you can discover a person
who is peaceful,
without affectation
who, with presence of mind,
with true involvement,
can quietly listen to needs,
who does not interrupt, who does not pose two questions at the same time,
who waits for the answer and grasps it all,
who does not peer into the future or past,
who does not fix you with a studied look, and put you down,
who does not avoid your gaze, looking upwards or downwards,
who is as prudent as he is at ease, then -
then you will think that you have found treasure in a field,
then you will think that you have found a pearl”.

---

art of questioning:

good questioning is like a zipper technique decreasing digressions from flow or contact & increases willingness & trust in communication. it shows that the Dr is interested & understands, so decreases Pt’s anxiety/anger/shame.

bad questioning is always with impricse wording & at an inappropriate timing which increases resistance of the Pt to answer.

open Q conveys interest & attention. Pt describes freely in his own words & attempts to make himself understood, this, increases confrontation with the conflicting matter leading to effective learning & better management. disadv – avoids unpleasant topics & is easier to digress.

closed Q is used only for extracting rapidly some precise info or to keep to the subject from excursions. it shouldnt be used at the onset since it decreases unravelling dimensions or building relations by preventing thinking & active listening.

inappropriate questioning arises from impatience & inexperience:

• multiple Qs overwhelms the Pt. so take time to ask one Q at a time.
• hold up Qs elicits irrelevant or aggressive Ans
• leading Qs have a backdrop of prejudice or wishful thinking of the Dr, exerting subconscious pressure on the Pt to avoid unpleasant topics
• ambush Qs suggest impoliteness or unawareness & makes the Pt defensive or aggressive. its easier to reply painful Qs if the A can be constructed on a preceeding fact.

forbidden Qs do not account for Pt’s autonomy:

• [epistaxis fingering]trap Qs trip up or over ride the A
• [potency, breastfeeding]curiosity satisfies the questioner but doesnt deepen relation & shames the Pt or evokes a climate of police interrogation
• [adi,nonlocalers]socratice Qs gives self-assurance to the questioner that others cannot answer & conveys to the Pt thatt he doesnt know what he believed he knew
• why instead of what reason]judgemental Qs puts Pt on defensive
• [esra doctors]aggressive Qs achieve the very opposite of the intended behaviour
• [status quo girls]flowery rhetorical Qs are hollow & insincere & maintain only superficial flow

questioning behavior of the Pt:

• need for info, contact, help, critism
• why is Pt asking at this time
• what is the overlying real Q
• why doe Pt repeat the same Q
• why doesnt Pt ask – out of anxiety, time pressure, speech barriers, different realities, insufficient stimulus

Patient COMPLIANCE & MOTIVATION.

MOTIVATION  means  teaching one to long for the long boundless sea.

• to achieve a change in the behaviour of the patient, discussion is the predominant instrument for motivation.
• the success of a doctor’s involvement is closely related to his own conviction about the advice & recommendations for therapy.the example of the doctor is itself a motivating & demotivating factor of major importance.
• it is persuasion by logic,psychology & rhetoric.
• it is going into conviction & the objective must be recognizable, attainable, realistic & desired by the patient.
• particular grounds for motivation aggregate from the range of reasons for action such as hopes, ideals, needs.
• it is not manipulation by consciously using prohibited techniques/ doubtful tricks & suggestions or creating anxiety/guilt/shame or attacking deeply established habits/articles of faith lead to demotivation.
• cognitive/intellectual impairment or differrent cultural values block motivation from the very onset.

The art of attaining the most optimal compliance possible finally rests on exhausting all of the measures which encourage motivation  and on clearing away as many factors which lead to non-compliance as possible.

COMPLIANCE  is willingness to follow a recommendation, cooperation as a result of partnership-like-relationship between doctor & patient, not training/instant obedience/patronizing the patients.

• one must  convince about a thing, mere proof is not enough.
• it is less the result of ethics but much more of the art of successful speech.

Non-compliance:

• cannot be taken for granted as natural weakness out of old habits or forgetfulness.
• it arises due to descrepency in subjective estimation & objective findings, & undeveloped trusting relation between doctor & patient.
• its the way one resolves the internal pressure arising out of cognitive dissociation between one’s beliefs & acceptance of truth.

Compliance depends on factors pertaining to the instructions, both the doctor & patient perspectives, the particular therapy & disease.

Instructional factors hindering compliance:

success depends on well-founded recommendations given in a comprehensible content, reasonable extent & empathizing delivery.

• unspecific objective without a quantified value.
• unilaterally exaggerating the objective or overestimation of a certain type of therapy.
• usage of specialized jargon instead of conveying in simple understandable statements.
• cognitive overloading without consideration to the patient’s attention span.
• unprioritized recommendations instead of approaching one step at a time & presenting positive consequences.
• insufficient involvement of patient’s responsibility & independence.
• uncompromising & authoritative pressure on objectives without taking risks & failures into account.
• dealing in differing realities, not fulfilling the expectation of the patient & the opportunity to present his own view & experience.
• impersonal/universal statement instead of focusing on the patient’s situation.
• hypothetical statements instead of presenting a standard & present positive consequences.
• threats/shock/anxiety provoking statements  instead of giving strenght at the point where the patient could not continue any longer & awakening  hope that the therapy will be effective.
• self-worth/ self-respect attacks instead of driving performance through self-assurance & assertion.

Doctor factors:

Doctor should be a trusted confident, helper, psychologist with a motto ‘victory is possible’  & willingness to compromise for aiding sustenance towards objective.

• credibility/competence which the patient ascribes to his doctor.
• extent to which doctor established a trusting relation with the patient.
• not being a respected example.
• cool distant routine approach, not accentuating the importance of prescription.
• unanswered questions hinders the patient’s self-initiative.
• although risks to health are accepted generally, they are not applied to the patient himself.
• lecturing/preaching instead of recommending actions on appropriate facts.
• authoritative behaviour instead of partnership.
• unmotivation from the doctor himself.
• not probing the patient’s personality.

Patient factors for unsuccessful motivation:

These need persistent long-term intervention for successful compliance.

• negative attitude towards health or medicine.
• playing down of the risks to health (often from defence mechanisms).
• passive attitude favorized by excess health insurance, puts off responsibility/ self-initiative.
• habits, prejudices, fixed ideas or psuedo arguments [can balance with sport, till now nothing happened so, one cant live for health alone].
• hypochondria, limited cognition or concentration.
• fear of addiction, high anticipation of side-effects usually from the type of medication or extent of explanation or those around the patient.

Treatment factors causing non-compliance:

• impractical/stressful/incovenient & limits life quality or individual situation.
• taste,shape,size,smell of medication.
• type/extent of side-effects or detailed list of all possible side-effects provokes uncertainity/suspicion.

Disease factors causing non-compliance:

• image of disease in soceity or from media reports/critical approach on behalf of patient.
• extent of suffering.
• objective severity of disease.

Optimal measures :

1. tangible objective -standard, attainable & worthwhile, focusing on situation of patient, one step at a time.
2. present positive consequences – motto ‘victory is possible’
3. take risks & failures into account -show willingness to compromise & agreeing appointments for checking progress. [ not only does this support the patient in the belief that the doctor is really concerned about him and interested in his progress, but it also affords the doctor the chance to check compliance]

Supportive measures:

1. written info as memory aids.
2. involve a key person – concerned & acceptable, introduce a helpful person.
3. encourage self-checking, independence & self-responsibility.

Checking compliance:

1. signs of the major pharmacological response.
2. specific side-effects.
3. direct questioning of the patient.Questions such as: “Many people find it difficult to remember to take their tablets regularly. Do you find that you sometimes forget to take your tablets?” are usually answered.

links on conversation with the patient

# an old online textual source on dialogue between doctor & patient written by Dr.Linus Geisler. i’m typing out some of its chapters in subsequent posts.

# similar to that old text, are these engaging videos’ links: [my bookmarks are in reverse order i.e start with the bottom link]

• I*CARE – Basic Principles – MD Anderson Cancer Centerdisclosing error: without delay, preferrably by a senior, do not blame/excuse & don’t state the error but state the case is being investigated. signpost/opening shot. recap -narrate past & connect it with current. emphasize alligning with their emotions. enlist family member. follow-up strategy & summary.
• M. D. Anderson Flash Playerpearls in delivering bad news: behind emotionally charged questions are concerns that are useful to explore the crux. check for the patient’s emotional expressions. enlist for family support for the patient to digest easily. expressing one’s own regret helps take away the doctor’s responsibility of delivering bad news. don’t set up false hopes. supportive control helps the prospect of death reassurance that he would’nt abandon the patient helps impart hope to sustain in the patient.
• M. D. Anderson Flash Playerinstead of drastically disclosing bad news, consider the impact on the patient’s future: find out the patient’s understanding of his condition ask beforehand if its ok for him to listen to the diagnosis recaptulate the what/how the investigations were done reveal the results in small chunks explaining in lay terms acknowledge & empathise & EMPHASIZE with his emotions strategy & summary
• M. D. Anderson Flash Playerexample of revealing bad news
• M. D. Anderson Flash Playersummary to clearly recaptulate the treatment plan, address any doubts/anxieties, conclude with a clear next contract to evaluate the results
• M. D. Anderson Flash Playera good visualization mismatch table to identify under-prepared/over-concerned patients so as to explore their cause & devise a STRATEGY to increase compliance.
• M. D. Anderson Flash Playeracknowledging emotions
• M. D. Anderson Flash Playerlistening skills
• M. D. Anderson Flash Player
• I*CARE – Basic Principles Introduction – M. D. Anderson Cancer Center
  • When you have to break bad news though, you use the SPIKES variant of that CLASS protocol. When you have to disclose an error, then you use the CONES variant of the CLASS protocol. And then, finally, there’s a sort of a sub-protocol that we call the EVE, which we use inside any encounter when there are emotions present
  • ‘C’ is for Context meaning the physical setting, the physical context in which you hold the interview. It’s actually quite important to get that right at the start.
  • ‘L’ stands for Listening Skills, switching on your listening skills. And there are several of these that you can put into practice very easily. By far, the most important is silence. You maintain silence when the patient is talking. We also, as well as silence, we’ve got several strategies for responding when the patient starts talking to let the patient know that you are listening and to roll the interview along, to facilitate it. And of those techniques, repetition is the most important, repetition of one word. You repeat one word from their last sentence in your first sentence and that simply lets the patient know that they have been heard, that you’ve been listening, that the circuit is complete.
  • ‘A’ for Acknowledging Emotions and Addressing Emotions.
  • ‘S’ for Strategy where you outline your, as it were, your medical plan, your plan for medical management, the diagnosis, the treatment, what you’re going to do, and how you’re going to investigate it.
  • ‘S’ is for Summary
  • ‘P’ is for Perception. Find out their perception. Before you tell, ask. Find out what the patient knows or suspects or perceives about their condition. Then, another pivotal point is ‘I’ for Invitation. Get an invitation from the patient to go ahead and share the information if that’s what the patient wants. Having gotten that invitation then go ahead with the ‘K’ for Knowledge, giving the medical facts which starts at the level of the patient’s understanding as you heard it in their response to the ‘P’ for Perception. And then, the all important ‘E’ is for Emotions. It is very important that emotions are addressed at the time they occur, as they occur.
  • sudden deterioration in the patient’s medical condition or, of course, when you’re talking to a relative about bereavement, and a sudden, a death, or of course, when a medical error has occurred. These are all examples when you have to give the information
  • ‘O’ which stands for Opening Shot.
  • ‘N’ stands for a process that we call the Narrative Approach which is a usual way of explaining the chronological sequence of events
  • EVE sub-protocol, is something you must do at any point, at any moment in an interview where an emotion erupts.
  • The first ‘E’ is for Exploration. Find out more about what the emotion is and what’s causing it. ‘V’ is for Validation in which you show the patient that the emotion they have expressed is intelligible and understandable and/or ‘E’ is the third, the second ‘E’, the third point of the EVE protocol is for the Emphatic Response showing that you have seen the emotion and that you can understand its course or origin. It acknowledges and automatically validates as well
  • communication is a factor of just having the right personality. It isn’t. It’s not something you’re born with. It’s not basically intuitive. You can learn it. It’s a matter of tuition not intuition. The fact is that anybody can adopt these techniques or behaviors. You can practice them. You can learn them and you can teach them. And the quality of every clinical encounter when they are used is enhanced.