Professionalism and Communication by Dr. Gina
Geis.
Hello, my name is Gina Geis and I'm an Attending
Neonatologist at Albany Medical Center and
Assistant Professor of Pediatrics at Albany
Medical College.
This module will address the topics of professionalism,
the parent-physician relationship, communication,
and the prenatal consult. I have no disclosures
or conflicts of interest.
We all know that communication is important
in the field of medicine. But there are nuances
in the field of neonatology that can make
effective communication particularly important
and challenging. Communication and professionalism
are core concepts within bioethics. And we
will address them here, as they pertain to
neonatology.
We will identify the key competencies for
effective communication. We will define the
essential components of professionalism as
outlined by the American Board of Pediatrics.
We will look at the various ethical principles
and how they apply to this area of focus.
We will also delve a bit deeper into the prenatal
consultation. And examine how the written
literature can guide us through this process.
We will also look a bit into the parental
perspective and identify which elements of
communication they deem most important.
Effective Communication.
So we can all agree that communication is
important. But why? It's a part of everything
we do in medicine. It is the most important
and common procedure in medicine. The use
of the word procedure is interesting as it
applies that there's something performed when
we communicate. We will get into this a little
more, later in the slides.
Over time, there has been a transition from
paternalism to joint decision-making. Effective
communication is essential to achieve this
partnership. Even though we are jointly making
these medical decisions, we still emphasize
the importance of autonomy.
Typically, we talk about patient autonomy.
But in pediatrics, in most cases, it is the
parent that acts as a surrogate for patient
autonomy. We assign this role based upon the
assumption that the parent has the best understanding
of the best interests of their child.
But what about provider autonomy? Provider
autonomy states that the medical provider
should be able to practice medicine as she
or he deems appropriate. Effective communication
helps us to uphold both patient and provider
autonomy. And promotes the achievement of
shared goals of care.
We know that communication influences both
patient and provider experience. Patients
report greater satisfaction with their healthcare
experience when communication was effective.
Also, the ability to effectively communicate
enhances our satisfaction as providers and
improves outcomes.
Finally, we practice in an increasingly complex
healthcare system. Effective communication
is essential to navigate through these complexities,
increase efficiency, and minimize burnout.
Effective communication is responsive to the
needs of the whole patient and family dynamic.
It is essential to the patient-centered and
family-centered care, the basic building block
of the medical home concept, endorsed by the
American Academy of Pediatrics as the cornerstone
of care.
You can see that with this definition, there's
an emphasis on the patient perspective. In
other words, to make communication effective
we must make this a bidirectional process.
Communication is not only given, but received.
There should be a flow back and forth.
In 2008, the American Academy of Pediatrics
and the Committee on bioethics released a
technical report to guide communication with
families and children. In this report, they
identified three elements of effective physician,
parent, child communication.
The first is informativeness. This refers
to the act of providing information with a
focus on both the quality and quantity of
information. The quality component has us
focusing on the delivery of information. This
is in where the skill lies. The second is
interpersonal sensitivity. This emphasizes
how our effective behaviors impact the other
person. These behaviors reflect our level
of interest to the other person. The third
element is partnership building. This highlights
the dynamic nature of communication and invites
the parent to partner in this endeavor.
So why are we spending so much time discussing
something that is so ubiquitous and inherent
in all that we do as physicians?
In 2008, the AAP and the Committee on Bioethics
released a policy statement that addresses
the needs of increased attention to this area.
This statement reveals that communication
is a skill that is teachable and therefore
must be taught. There is a growing concern
that there is a loss of empathy by medical
providers. Part of our lack of skill might
be attributable to a lack of skilled mentors.
The AAP proposed that one solution is a train
the trainer model. In this model, non-physician
mentors, who are trained in communication
such as social workers, child-life therapists,
child psychologists, and members of the American
Academy on Communication in Healthcare can
help positions and faculty develop these skills.
Components of Professionalism.
Professionalism has a strong presence in the
field of bioethics and has been a defining
feature in medicine dating back to Hippocrates.
There have been many definitions of professionalism.
Some central themes in this concept are that
professionals have a focus on knowledge and
education. One key component is that professionals
self-govern, implying a great deal of responsibility
to practice at a certain level.
In 2007, that AAP and the Committee on Bioethics
issued a technical report that outlined the
ideal standards of behavior and professional
practice for pediatricians. In this statement,
they identified eight components of professionalism
that were endorsed by the ABP as the most
appropriate for teaching and evaluation.
The first is honesty and integrity. This embodies
the principles of fairness and the provider's
ability to meet commitments to the patient
and family. Reliability and responsibility
represents an accountability to the patient
and family and requires an acceptance of responsibility
for errors made in addressing them with honesty
and integrity. Respect for others involves
treating all persons with respect and dignity.
Include sensitivity and confidentiality when
appropriate.
Compassion and empathy is the ability to understand
the children's and family members' reactions
to pain, discomfort, or anxiety from their
point of view. Self-improvement involves the
commitment to lifelong learning and education.
Self-awareness and knowledge of limits requires
a level of maturity to recognize when a problem
involves some knowledge or skill beyond the
experience of the provider and charges them
to ask for consultation or assistance in those
situations.
Communication and collaboration has us partner
with patients' families to work cooperatively
and communicate effectively as to achieve
best patient care outcomes. Altruism and advocacy
refers to an unselfish devotion to the welfare
of others. This has the patients' well-being
as the primary motivating factor for what
we do as physicians.
Application of Ethical Approaches.
The basic principles of bioethics can be applied
to the element of communication, the parent-physican
relationship, and prenatal consult, but with
specific nuances that are important to address.
The first is autonomy. We spoke a little about
parents and providers as autonomous decision-makers.
But what about a newborn? What about an older
child? Do they have autonomy? Should a fetus?
We mentioned how we assume that parents make
the best surrogates for decision-making for
their children, but is this always the right
assumption? We mentioned physician autonomy,
which can be applied to the concept of professionalism.
This concept of self-government promotes our
autonomy. But this is obviously rich with complexities.
And again, what if these two autonomous decisions
are in conflict? Again, we emphasize the importance
of effective communication as a tool for conflict
resolution.
We can also apply the principle of beneficence
to these areas of focus. When we promote the
good, are we talking about an overall well-being?
The neonatal population has an enormous potential
for health years. How do we factor in this
potential when we talked to parents about
risks and benefits of treatment?
Similarly, when we apply the principle of
non-maleficence, how do we determine what
is an acceptable amount of harm? Is the goal
to achieve survival? Survival without morbidity?
The NICHD Outcomes Estimator attempts to address
this question for the extremely preterm population.
They report statistical outcomes, referring
to percent survival, percent survival without
significant morbidity, and percent survival
without moderate morbidity.
How do we utilize resources to partner with
families and communicate effectively? We can
also apply the principle of justice and distributive
justice. Justice applies to fairness in treatment,
and refers to the individual, the patient.
Distributive justice applies to issues such
as resource allocation, healthcare dollars,
and is more of a public health perspective.
Feminist ethics has an interesting application
here, particularly as we discussed the prenatal
consult and decision-making in the setting
of a maternal fetal dyad.
Care ethics, or ethics of care, is another
normative ethical theory, like consequentialism
or deontology. Care ethics focuses on our
dependence on one another and the dynamic
nature of our coexistence. It has us factor
in the context of a given situation to determine
what is morally right. This situational thinking
and importance on response can be applied
to communication, relationship-building between
physician and parent, and the way we conduct
a prenatal consult.
Prenatal Consultations.
The prenatal consult is a perfect example
of communication in neonatology put into action.
Some indications for a pre-natal consult may
include pre-term delivery, congenital malformations,
concern for fetal or neonatal prognosis, need
for further decision making, or whenever parents
request. Goals and strategies of the prenatal
consult should be clearly defined. They should
meet the goals of both parents and physicians,
they should be individualized to the situation,
provide comprehensive information, use sensitive
language, create a trusting relationship,
provide a supportive environment, and above
all else, it should benefit the patient.
Important Elements of Communication.
So if the goal is to benefit the patient--
and in the field of neonatology, the patient
and family-- what can we learn from the literature
to help us achieve this goal? A study by Meert
and colleagues addressed this very question.
In this study, parents were asked to prioritize
the following areas as they evaluate the physician-parent
communication. They ranked the most important
quality as availability. They wanted to have
their physician present.
Next was honesty and comprehensiveness. How
honest are they with the information that
they're delivering? And how understandable
is it for the patient and family?
The third, affect.
The fourth, maintenance of full disclosure
and preventing false hope. The next, avoidance
of complex vocabulary and appropriate pacing
of information delivery.
And finally, avoidance of expressing contradictory
information and negative body language.
As you can see, there are many skills listed
here that could be practiced through mentoring,
workshops, and feedback sessions. So in conclusion,
I hope that you will take away that effective
communication is a skill. This skill can be
taught and must be fostered.
We have discussed how various ethical frameworks
can be applied to these topics of professionalism,
parent-physician relationship, communication,
and prenatal consult. And finally, we must
strive to achieve the standards of professionalism
as outlined for pediatrics.
I want to thank you for joining me today and
welcome any questions or feedback you may
have. Please feel free to contact me via email
any time. Thank you.
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