Dimensions of trust: the tensions and challenges in provider--interpreter trust

In this study we examined the challenges to providers' and interpreters' collaboration in bilingual health care. We conducted in-depth interviews and focus groups with 26 medical interpreters (speaking 17 languages) and 32 providers (from four specialties) in the United States to provide an empirically based framework of provider-interpreter trust. Constant comparative analysis was used for data analysis. We identified four dimensions of trust, theoretical constructs that can strengthen or compromise provider-interpreter trust: interpreter competence, shared goals, professional boundaries, and established patterns of collaboration. In this article we describe how these dimensions highlight tensions and challenges that are unique in provider-interpreter relationships. We conclude with practical guidelines that can enhance provider-interpreter trust, and propose future research directions in bilingual health care.

Enhancing Disease Surveillance Event Communication Among Jurisdictions

Automated disease surveillance systems are becoming widely used by the public health community. However, communication among non-collocated and widely dispersed users still needs improvement. A web-based software tool for enhancing user communications was completely integrated into an existing automated disease surveillance system and was tested during two simulated exercises and operational use involving multiple jurisdictions. Evaluation of this tool was conducted by user meetings, anonymous surveys, and web logs. Public health officials found this tool to be useful, and the tool has been modified further to incorporate features suggested by user responses. Features of the automated disease surveillance system, such as alerts and time series plots, can be specifically referenced by user comments. The user may also indicate the alert response being considered by adding a color indicator to their comment. The web-based event communication tool described in this article provides a common ground for collaboration and communication among public health officials at different locations.

Multimodal communication by captive chimpanzees (Pan troglodytes)

Many studies have shown that apes and monkeys are adept at cross-modal matching tasks requiring the subject to identify objects in one modality when information regarding those objects has been presented in a different modality. However, much less is known about non-human primates' production of multimodal signaling in communicative contexts. Here, we present evidence from a study of 110 chimpanzees demonstrating that they select the modality of communication in accordance with variations in the attentional focus of a human interactant, which is consistent with previous research. In each trial, we presented desirable food to one of two chimpanzees, turning mid-way through the trial from facing one chimpanzee to facing the other chimpanzee, and documented their communicative displays, as the experimenter turned towards or away from the subjects. These chimpanzees varied their signals within a context-appropriate modality, displaying a range of different visual signals when a human experimenter was facing them and a range of different auditory or tactile (attention-getting) signals when the human was facing away from them; this finding extends previous research on multimodal signaling in this species. Thus, in the impoverished circumstances characteristic of captivity, complex signaling tactics are nevertheless exhibited by chimpanzees, suggesting continuity in intersubjective psychological processes in humans and apes.

Development of decision-support intervention for Black women with breast cancer

BACKGROUND

Adjuvant therapy improves breast cancer survival but is underutilized by Black women. Few interventions have addressed this problem. This preliminary report describes the process we used to develop a decision-support intervention for Black women eligible for adjuvant therapy. Aims were to use qualitative methods to describe factors that influence Black women's adjuvant therapy decisions, use these formative data to develop messages for a treatment decision-support intervention, and pilot test the acceptability and utility of the intervention with community members and newly diagnosed women.

METHODS

Thirty-four in-depth interviews were conducted with breast cancer patients in active treatment, survivors and cancer providers to gather qualitative data. Participant ages ranged from 38 to 69 years. A cultural framework was used to analyze the data and to inform intervention messages. Most women relied on their providers for treatment recommendations. Several women reported problems communicating with providers and felt unprepared to ask questions and discuss adjuvant treatment options. Other factors related to treatment experiences were: spiritual coping, collectivism and sharing breast cancer experiences with other Black survivors.

RESULTS

Using these formative data, we developed an intervention that is survivor-based and includes an in-person session which incorporates sharing personal stories, communication skills training and decision support. Intervention materials were reviewed by community members, researchers/clinicians and patients newly diagnosed with breast cancer.

CONCLUSION

Patients reported satisfaction with the intervention and felt better prepared to talk with providers. The intervention will be tested in a randomized trial to enhance decision support and increase use of indicated adjuvant treatment.

Development of a Web-based educational intervention to improve cross-cultural communication among hospice providers

In this article, the authors describe the theoretical foundation, development, and content of a Web-based educational intervention to improve cross-cultural communication about end-of-life concerns and report on the preliminary evaluation of this intervention using a qualitative study design. The data were collected with non-structured questions in a convenience sample of 21 hospice providers. Participants reported that they found the training appropriate and useful. Participants also reported finding the online delivery convenient and the interactive format valuable. Improving the quality of cross-cultural patient-provider communication can contribute to reducing disparities at end-of-life.

An evolutionary examination of telemedicine: a health and computer-mediated communication perspective

Telemedicine, the use of advanced communication technologies in the healthcare context, has a rich history and a clear evolutionary course. In this paper, the authors identify telemedicine as operationally defined, the services and technologies it comprises, the direction telemedicine has taken, along with its increased acceptance in the healthcare communities. The authors also describe some of the key pitfalls warred with by researchers and activists to advance telemedicine to its full potential and lead to an unobstructed team of technicians to identify telemedicine's diverse utilities. A discussion and future directions section is included to provide fresh ideas to health communication and computer-mediated scholars wishing to delve into this area and make a difference to enhance public understanding of this field.

Exploring the basis for gender differences in the demand-withdraw pattern

During marital conflict, wives tend to demand and husbands tend to withdraw. These behaviors were historically thought to stem from essential differences between men and women. An alternative explanation implicates one form of power differences-wives desire more change and, therefore, demand; husbands desire less change and withdraw to maintain status quo. Studying same-sex as well as cross-sex couples enables an evaluation of both explanations. We examined demand-withdraw behaviors in 63 heterosexual, gay, and lesbian couples. The demand-withdraw pattern was seen regardless of type of couple. Further, for all couples, differences in the amount of change desired in partners during a conflict interaction predicted differences in demand and withdraw behaviors. These results offer further evidence that an often-observed difference in heterosexual relationships may result from social conventions that afford men greater power and women less power.

Can we rapidly identify traditional, complementary and alternative medicine users in the primary care encounter? A RIOS Net study

OBJECTIVE

Pressed for time to address competing clinical demands within the brief clinical encounter, primary care clinicians often rely on observations of patients to select topics to address. Use of traditional, complementary, or alternative medicine (TM/CAM) may be an important topic for discussion with a patient, but identification of patients using TM/CAM is problematic. We conducted this study to determine if observable characteristics--among southwestern Hispanic and Native American persons--might suggest to the clinician that a patient is likely to use TM/CAM.

DESIGN

A combination of clinic staff focus groups, patient and clinician interviews, and a clinician focus group was used to explore possible predictors of TM/CAM use among primary care patients in practices serving predominantly Hispanic and Native American communities.

RESULTS

No easily observable characteristics were identified that clinicians might use to predict TM/CAM use in their patients. Less readily observable characteristics--identification with culture, family of origin, health condition--were more likely to be associated with TM/CAM use, but not infallibly so.

CONCLUSIONS

Rather than attempt to predict TM/CAM use by an individual patient, clinicians may be better served by assuming its use by all, by applying strategies for rapid and effective communications with patients about the topic, by selecting which patients to discuss TM/CAM use with based on clinical circumstances, and/or by gathering information about TM/CAM use as part of routine initial database development.

Health literacy and communication quality in health care organizations

The relationship between limited health literacy and poor health may be due, in part, to poor communication quality within health care delivery organizations. We explored the relationship between health literacy status and receiving patient-centered communication in clinics and hospitals serving communication-vulnerable patient populations. Thirteen health care organizations nationwide distributed a survey to 5929 patients. All patients completed seven items assessing patient-centered communication. One third also completed three items assessing health literacy. The majority of patients had self-reported health literacy challenges, reporting problems learning about their medical condition because of difficulty understanding written information (53%), a lack of confidence in completing medical forms by themselves (61%), and needing someone to help them read hospital/clinic materials (57%). Logistic regression models showed that, after adjustment for patient demographic characteristics and health care organization type, patients with limited health literacy were 28% to 79% less likely than those with adequate health literacy to report their health care organization "always" provides patient-centered communication across seven communication items. Using a scaled composite of these items, limited health literacy remained associated with lower reported communication quality. These results suggest that improving communication quality in health care organizations might help to address the challenges facing patients with limited health literacy. They also highlight that efforts to address the needs of patients with limited health literacy should be sensitive to the range of communication challenges confronting these patients and their caregivers.

Relationship between communication manners of head nurses with job satisfaction of nurses under their supervision in educational hospitals of Isfahan University of Medical Sciences in 2006

BACKGROUND

Interpersonal communication is considered as an important and effective factor of job satisfaction and efficiency and has special significance in nursing career because of the face to face relationship with patients. This study aimed to determine the association between head nurses' interpersonal communication and job satisfaction of nurses under their supervision. The study was conducted in educational hospitals of Isfahan University of Medical Sciences in 2006.

METHODS

This was a descriptive and analytical study on 203 nursing personnel working in educational hospitals of Isfahan University of Medical Sciences in 2006. Data were collected using Job Descriptive Index (JDI) developed by Smith and Kendall and interpersonal communication was measured using a researcher-made questionnaire. Data were analyzed using SPSS software and Pearson's test and presented in tables and diagrams.

RESULTS

The majority of the participants (148 subjects, 73%) believed that head nurses' interpersonal communication was excellent and in general Pearson's test showed a significant association between head nurses' interpersonal communication and their personnel's job satisfaction (p < 0.011).

CONCLUSIONS

Based on the results of this study on the relationship between interpersonal communication of the head nurses and job satisfaction of their personnel, we can improve the job satisfaction of nursing personnel as well as patients' satisfactory and level of services by developing educational courses and workshops on importance and effectiveness of interpersonal communication for head nurses.

Variation on a theme: vibrational signaling in caterpillars of the rose hook-tip moth, Oreto rosea

Vibrational communication in hook-tip moth caterpillars is thought to be widely used and highly variable across species, but this phenomenon has been experimentally examined in only two species to date. The purpose of this study is to characterize and describe the function of vibrational signaling in a species, Oreta rosea Walker 1855 (Lepidoptera: Drepanidae), that differs morphologically from previously studied species. Caterpillars of this species produce three distinct types of vibrational signals during territorial encounters with conspecifics--mandible drumming, mandible scraping and lateral tremulation. Signals were recorded using a laser-doppler vibrometer and characterized based on temporal and spectral components. Behavioural encounters between a leaf resident and a conspecific intruder were staged to test the hypothesis that signaling functions as a territorial display. Drumming and scraping signals both involve the use of the mandibles, being hit vertically on, or scraped laterally across, the leaf surface. Lateral tremulation involves quick, short, successive lateral movements of the anterior body region that vibrates the entire leaf. Encounters result in residents signaling, with the highest rates observed when intruders make contact with the resident. Residents signal significantly more than intruders and most conflicts are resolved within 10 minutes, with residents winning 91% of trials. The results support the hypothesis that vibrational signals function to advertise leaf occupancy. Signaling is compared between species, and evolutionary origins of vibrational communication in caterpillars are discussed.

Can you hear me now? The experience of a deaf family member surrounding the death of loved ones

INTRODUCTION

Individuals who are Deaf face challenges both similar and unique from those faced by hearing individuals when a family member is dying. This study was guided by the question, ''What are the challenges faced by a Deaf family member when a loved one is dying?''

METHODS

This qualitative study is guided by critical theory and an interpretive perspective. Robert, a college-educated older adult who has been Deaf from birth was interviewed in American Sign Language using a death history format.

RESULTS

There are challenges for Deaf family members that affect communication with both the dying person and health care professionals. Patient-family communication issues included physical challenges and financial challenges. Lack of cultural competence concerning the Deaf community created challenges communicating with professionals. Decision-making was also a challenge.

CONCLUSIONS

These findings provide a framework for future research concerning the needs of Deaf individuals facing the end of life and provide guidance for clinicians.

Doctor-patient communication: a review

Effective doctor-patient communication is a central clinical function in building a therapeutic doctor-patient relationship, which is the heart and art of medicine. This is important in the delivery of high-quality health care. Much patient dissatisfaction and many complaints are due to breakdown in the doctor-patient relationship. However, many doctors tend to overestimate their ability in communication. Over the years, much has been published in the literature on this important topic. We review the literature on doctor-patient communication.

Discuss now, document later: CIS/CPOE perceived to be a 'shift behind' in the ICU

Effective communication is essential to safe and efficient patient care. We aimed to understand the current patterns and perceptions of communication of common goals in the ICU using the distributed cognition and clinical communication space theoretical frameworks. We conducted a focus group and 5 interviews with ICU clinicians and observed 59.5 hours of interdisciplinary ICU morning rounds. Clinicians used a CIS/CPOE system and paper artifacts for documentation; yet, preferred verbal communication as a method of information exchange because they perceived that the documentation was often not updated or efficient for information retrieval. These perceptions that the CIS/CPOE is a "shift behind" may lead to a further reliance on verbal information exchange, which is a valuable clinical communication activity, yet, is subject to information loss. Electronic documentation tools that, in real time, capture information that is currently verbally communicated may increase the effectiveness of communication.

Organizational considerations for the implementation of a computerized physician order entry

Several studies stressed that the introduction of CPOE applications deteriorates the doctor-nurse communication. But there are many factors that might influence communication behaviors, as for example the way these communications are organized. The present study aims at showing that the impact of a CPOE system on the cooperative activities can be controlled given that a good understanding of the cooperative workflows support the implementation. By analyzing the doctors-nurses communications during the medication use process, the study demonstrates that the technical system has no impact on the cooperative activities within a given organization. CPOE does not induce differences in the dialogs' durations and contents.

An explorative study

AIM OF THE STUDY

With this study, we wanted to examine the needs of men with fertility problems in terms of communication, care and coping with the diagnosis.

METHODOLOGY

data gathered prospectively by means of a written questionnaire (quantitative data), and semi-structured interviews (qualitative data).

SAMPLE

78 subfertile men who consulted for subfertility at the department for reproductive medicine at the University Hospital of Ghent, Belgium were included in the assessment; of these, 23 were interviewed for qualitative evaluation.

RESULTS AND CONCLUSIONS

More than one fifth of the participants was dissatisfied with the way they had been informed about their fertility status. There was no significant difference in satisfaction with the care received immediately after diagnosis whether it was given by a general practitioner or by a specialist. A significant influence of nationality was noted on the satisfaction about being informed, Dutch men being much less satisfied than Flemish men. Some men suggested to have a consult with the doctor on a structural basis about a week after the diagnosis. The internet seemed to be a good medium for obtaining medical information IT COULD BE USEFUL TO CREATE AN EXTRA FUNCTION: a 'coach' supporting the couple throughout the entire process., adding another argument to the need for professional psychological support of patients attending clinics for human reproduction. The subfertile men often felt that they were watching from the sideline, and wanted to be more actively involved in the treatment.

A structured implicit abstraction method to evaluate whether content of counseling before prostate cancer screening is consistent with recommendations by experts

OBJECTIVE

To assess the content of counseling about prostate-specific antigen (PSA) screening. Guidelines recommend informed consent before screening because of concerns about benefits versus risks. As part of the professional practice standard for informed consent, clinicians should include content customarily provided by experts.

METHODS

40 transcripts of conversations between medicine residents and standardized patients were abstracted using an instrument derived from an expert Delphi panel that ranked 10 "facts that experts believe men ought to know."

RESULTS

Transcripts contained definite criteria for an average of 1.7 facts, and either definite or partial criteria for 5.1 facts. Second- and third-year residents presented more facts than interns (p=0.01). The most common facts were "false positive PSA tests can occur" and "use of the PSA test as a screening test is controversial." There was an r=0.88 correlation between inclusion by residents and the experts' ranking.

CONCLUSION

Counseling varied but most transcripts included some expert-recommended facts. The absence of other facts could be a quality deficit or an effort to prioritize messages and lessen cognitive demands on the patient.

PRACTICE IMPLICATIONS

Clinicians should adapt counseling for each patient, but our abstraction approach may help to assess the quality of informed consent over larger populations.

Some considerations for the communication of results of air pollution health effects tracking

Communicating effectively and efficiently on air quality and its health impacts is an important but difficult and complex task. It requires careful consideration of the audience one wants to reach, the messages one is trying to present, the venue through which the message will be delivered. The audience, context, technique, and content factors may affect how well it is heard and how appropriately it is interpreted. In this short paper, I describe many of these concerns and provide some suggestions for how best to address them. However, since every audience differs in goals, characteristics, and nature, what is most important is implementing an effective communications program. This program should include frequent two-way communication, repeated and on-going evaluation of how well the audience understands the messages, and consideration of how to improve the delivery.

The role of caregiver prosody in conversations with persons who have Alzheimer's disease

This research was supported in part by funding from the British Columbia Medical Services Foundation (BCM02-0115). The funding source had no role in the design, methods, participant recruitment, data collection, interpretation of the study, or in the preparation of the manuscript for publication. Approval for the study was granted by the University of British Columbia Behavioural Ethics Review Board, and participants provided informed consent. This study investigated whether aspects of family caregivers' prosody (pitch and loudness) would be associated with successful or unsuccessful conversations with spouses who have Alzheimer's disease (AD). Secondary analysis was conducted of 12 caregivers' speech when interacting with spouses who have AD. Acoustic analyses were conducted to calculate the fundamental frequency (pitch) and intensity (loudness) of caregivers' speech. The results showed no significant overall differences between the caregivers' pitch or loudness in either successful or unsuccessful conversations. However, for 1 subgroup of caregivers, an increase in pitch variation and loudness was associated with unsuccessful communication, whereas for another subgroup the opposite pattern was observed-reduced pitch variation and loudness with unsuccessful communication. The results provide preliminary directions for helping family caregivers become aware of how characteristics of their speech prosody may relate to the quality of communication when interacting with persons who have AD.

Verbal communication among Alzheimer's disease patients, their caregivers, and primary care physicians during primary care office visits

OBJECTIVE

Primary care visits of patients with Alzheimer's disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual's verbal participation in these triadic interactions.

METHODS

To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty-three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed.

RESULTS

PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver's own verbal participation.

CONCLUSION

Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less.

PRACTICE IMPLICATIONS

Encouraging verbal participation by AD patients and their caregivers may increase the AD patient's active role and caregiver satisfaction with primary care visits.

Communicating with Muslim parents: "the four principles" are not as culturally neutral as suggested

The "four principles approach" has been popularly accepted as a set of universal guidelines for biomedical ethics. Based on four allegedly trans-cultural principles (respect for autonomy, nonmaleficence, beneficence and justice), it is supposed to fulfil the need of a 'culturally neutral approach to thinking about ethical issues in health care'. On the basis of a case-history, this paper challenges the appropriateness of communicating in terms of these four principles with patients with a different background. The case describes the situation in which Muslim parents bring forward that their religion keeps them from consenting to end-of-life decisions by non-religious paediatricians. In a literature analysis, the different meanings and roles of the relevant principles in non-religious and Islamic ethics are compared. In non-religious ethics, the principle of nonmaleficence may be used to justify withholding or withdrawing futile or damaging treatments, whereas Islamic ethics applies this principle to forbid all actions that may harm life. And while the non-religious version of the principle of respect for autonomy emphasises the need for informed consent, the Islamic version focuses on "respect for the patient". We conclude that the parties involved in the described disagreement may feel committed to seemingly similar, but actually quite different principles. In such cases, communication in terms of these principles may create a conflict within an apparently common conceptual framework. The four principles approach may be very helpful in analysing ethical dilemmas, but when communicating with patients with different backgrounds, an alternative approach is needed that pays genuine attention to the different backgrounds.

Relations of Parent-Youth Interactive Exchanges to Adolescent Socioemotional Development

This study examined the relations of parent-youth agreement and disagreement during a joint problem-solving task and multi-methodological indices of socioemotional outcomes in adolescents (Mean age = 13). One hundred and sixty seven parents and their adolescent children participated. Each parent-youth pair played the interactive game Jenga, and their interactions were analyzed for frequency of elaborations (agreement during three or more conversational turns) and negotiations (disagreement during three or more conversational turns). Elaborations during parent-youth interactions were related to less negative classroom behavior, better self-regulation, and more task persistence in youth. Findings are discussed in light of the importance of parent-youth interaction and youth autonomy in adolescent socioemotional development.

Impact of localizing physicians to hospital units on nurse-physician communication and agreement on the plan of care

BACKGROUND

A significant barrier to communication among patient care providers in hospitals is the geographic dispersion of team members.

OBJECTIVE

To determine whether localizing physicians to specific patient care units improves nurse-physician communication and agreement on patients' plans of care.

METHODS

We conducted structured interviews of a cross-sectional sample of nurses and physicians before and after an intervention to localize physicians to specific patient care units. Interviews characterized patterns of nurse-physician communication and assessed understanding of patients' plans of care. Two internists reviewed responses and rated nurse-physician agreement on six aspects of the plan of care as none, partial, or complete agreement.

RESULTS

Three hundred eleven of 342 (91%) and 291 of 294 (99%) patients' nurses and 301 of 342 (88%) and 285 of 294 (97%) physicians completed the interview during the pre- and post-localization periods. Two hundred nine of 285 (73%) patients were localized to physicians' designated patient care units in the post-localization period. After localization, a higher percentage of patients' nurses and physicians was able to correctly identify one another (93% vs. 71%; p < 0.001 and 58% vs. 36%; p < 0.001, respectively). Nurses and physicians reported more frequent communication after localization (68% vs. 50%; p < 0.001 and 74% vs. 61%; p < 0.001, respectively). Nurse-physician agreement was significantly improved for two aspects of the plan of care: planned tests and anticipated length of stay.

CONCLUSIONS

Although nurses and physicians were able to identify one another and communicated more frequently after localizing physicians to specific patient care units, there was little impact on nurse-physician agreement on the plan of care.

Why do shrews twitter? Communication or simple echo-based orientation

Shrews are very vocal animals. We tested behaviourally whether the high-pitched laryngeal 'twittering' calls of as-yet unclear function serve for communication or echo-based orientation. We used a representative species from each of the two largest phylogenetic groups of shrews. In both species, experimental manipulation of substrate density, but not of the likelihood of conspecific presence, affected the shrews' call rate when exploring an unknown environment. This adaptation of call rate to the degree of habitat clutter parallels bat echolocation and suggests that shrews may use the echoes and reverberations of their calls for identifying routes through their habitat or for probing habitat type. To assess the acoustic feasibility of shrew echo orientation, we ensonified shrew habitats in the field with an 'artificial shrew' (small speaker mounted close to a sensitive microphone). The data showed that shrew-like calls can indeed yield echo scenes useful for habitat assessment at close range, but beyond the range of the shrews' vibrissae.

A method to quantify and compare clinicians' assessments of patient understanding during counseling of standardized patients

OBJECTIVE

To introduce a method for quantifying clinicians' use of assessment of understanding (AU) questions, and to examine medicine residents' AU usage during counseling of standardized patients about prostate or breast cancer screening.

METHODS

Explicit-criteria abstraction was done on 86 transcripts, using a data dictionary for 4 AU types. We also developed a procedure for estimating the "load" of informational content for which the clinician has not yet assessed understanding.

RESULTS

Duplicate abstraction revealed reliability kappa=0.96. Definite criteria for at least one AU were found in 68/86 transcripts (79%). Of these, 2 transcripts contained a request for a teach-back ("what is your understanding of this?"), 2 contained an open-ended AU, 46 (54%) contained only a close-ended AU, and 18 (21%) only contained an "OK?" question. The load calculation identified long stretches of conversation without an AU.

CONCLUSION

Many residents' transcripts lacked AUs, and included AUs were often ineffectively phrased or inefficiently timed. Many patients may not understand clinicians, and many clinicians may be unaware of patients' confusion.

PRACTICE IMPLICATIONS

Effective AU usage is important enough to be encouraged by training programs and targeted by population-scale quality improvement programs. This quantitative method should be useful in population-scale measurement of AU usage.

Barriers and facilitators to routine HIV testing in VA primary care

BACKGROUND

Approximately 21% of the 1.1 million HIV-infected persons in the United States are unaware of their HIV status. The Centers for Disease Control (CDC) recommend routine opt-out HIV testing for all patients aged 13-64. Yet little is known about patient and provider perspectives on routine HIV testing.

OBJECTIVE

We sought to understand patient and provider perspectives on the adoption of routine HIV testing within the US Department of Veterans Affairs.

DESIGN

We conducted four focus groups with patients and two focus groups with primary care providers to explore perceptions of, communication about, and barriers and facilitators to routine HIV testing in primary care.

PARTICIPANTS

Convenience sample of patients and primary care providers at two geographically diverse Veterans' Affairs Medical Centers.

APPROACH

We conducted grounded thematic analyses of transcribed audio-recordings of focus groups to identify major themes, identifying similarities and differences between patient and provider perspectives.

MAIN RESULTS

Patients and providers concurred that implementation of routine HIV testing, treating HIV like other chronic diseases, and removing requirements for written informed consent and pre-test counseling were of benefit to patients and to public health. Patients, however, wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested. Veterans also stated that routinizing testing would help destigmatize HIV. Six steps to communicating about routine testing ("the 6 R's") were identified.

CONCLUSIONS

Patients and providers appear ready for implementation of routine HIV testing. However, providers should use patient-centered communication strategies to ease patients' concerns about confidentiality and stigma associated with HIV disease.

Sugar-coaters and straight talkers: communicating about developmental delays in primary care

OBJECTIVES

The goals were to investigate parents' and early intervention (EI) specialists' beliefs and experiences regarding discussing child development in primary care and to identify communication barriers and opportunities.

METHODS

Focus groups were held with (1) mothers of young children with typical development, (2) mothers of young children who received EI services, and (3) EI specialists. Seven groups (N = 46 participants) were conducted in the greater Cleveland, Ohio, area. Meetings were audio-recorded, transcribed, coded, and analyzed, to identify themes.

RESULTS

Most mothers reported a preference for a nonalarmist style of communication when developmental delays are suspected. In contrast, some mothers preferred a more direct style, including the use of labels to help them understand their child's development. The importance of preparation to accept information about developmental delays emerged as a theme in all groups. Elements contributing to preparedness included information about expected developmental skills, suggestions for promoting skills, and a specific time frame for follow-up evaluation. Mothers of children with disabilities perceived that early reassurance of normalcy by providers in response to their concerns led to self-doubt and increased difficulty accepting the diagnosis.

CONCLUSIONS

Mothers and EI specialists have clear ideas about factors that promote or impede communication regarding child development. This information can inform primary care providers' approaches to monitoring and screening the development of young children and to communicating with parents regarding suspected developmental delays.

Communication, encouragement, and cancer screening in families with and without mutations for hereditary nonpolyposis colorectal cancer: a pilot study

PURPOSE

Known and suspected mutation carriers for hereditary nonpolyposis colorectal cancer are advised to have colonoscopies every 1 to 2 years to detect colorectal cancer. Little is known about colonoscopy completion in families suspected of having hereditary nonpolyposis colorectal cancer but without identified mutations.

METHODS

This study examined the effect of communication and encouragement on colonoscopy in families with and without known mutations. Twenty-three respondents from 11 families with indeterminate genetic test results were matched with 23 respondents from 11 families with mutation-positive results. Hierarchical modeling examined the effects of relational characteristics on time since last colonoscopy in index cases and their first-degree relatives.

RESULTS

Nearly one fifth of respondents were not screening appropriately. Time since last screening did not differ according to family mutation status. However, respondents who communicated about risk and received encouragement to screen from a greater proportion of named family members, and those who had a greater proportion of named family members involved in both communication and encouragement were significantly more likely to have a shorter time interval since last colonoscopy.

CONCLUSION

Identifying patterns of interaction within at-risk families, regardless of gene mutation status, may be one avenue for promoting screening adherence.

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

BACKGROUND

Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem.

METHODS

We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up.

RESULTS

Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (>1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment.

CONCLUSIONS

Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area.

Physicians' experience with surrogate decision making for hospitalized adults

BACKGROUND

Hospitalized patients frequently lack decision-making ability, yet little is known about physicians' approaches to surrogate decision making.

OBJECTIVE

To describe physicians' experiences with surrogate communication and decision making for hospitalized adults.

DESIGN

Cross-sectional written survey.

PARTICIPANTS

Two hundred eighty-one physicians who recently cared for adult inpatients in one academic and two community hospitals.

MEASUREMENTS

Key features of physicians' most recent surrogate decision-making experience, including the nature of the decision, the physician's reaction, physician-surrogate communication and physician-surrogate agreement about the best course of action.

RESULTS

Nearly three fourths of physicians (73%, n = 206) had made a major decision with a surrogate during the past month. Although nearly all patients (90%) had a surrogate, physicians reported trouble contacting the surrogate in 21% of cases. Conflict was rare (5%), and a majority of physicians agreed with surrogates about the medical facts (77%), prognosis (72%) and best course of action (65%). After adjustment for patient, physician and decision characteristics, agreement about the best course of action was more common among surrogates for older patients [prevalence ratio (PR) = 1.17 for each decade; 95% confidence interval (CI) 1.02-1.31], ICU patients (PR = 1.40; CI 1.14-1.51) and patients who had previously discussed their wishes (PR = 1.60; CI 1.30-1.76), and less common when surrogates were difficult to contact (PR = 0.59; CI 0.29-0.92) or when the physician self-identified as Asian (PR = 0.60; CI 0.30-0.94).

CONCLUSION

Surrogate decision making is common among hospitalized adults. Physician-surrogate decision making may be enhanced if patients discuss their preferences in advance and if physician contact with surrogate decision makers is facilitated.

Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety

PURPOSE

Clear and complete communication between health care providers is a prerequisite for safe patient management and is a major priority of the Joint Commission's 2008 National Patient Safety Goals. The goal of this study was to describe nurses' perceptions of nurse-physician communication in the long-term care (LTC) setting.

METHODS

Mixed-method study including a self-administered questionnaire and qualitative semistructured telephone interviews of licensed nurses from 26 LTC facilities in Connecticut. The questionnaire measured perceived openness to communication, mutual understanding, language comprehension, frustration, professional respect, nurse preparedness, time burden, and logistical barriers. Qualitative interviews focused on identifying barriers to effective nurse-physician communication that may not have previously been considered and eliciting nurses' recommendations for overcoming those barriers.

RESULTS

Three hundred seventy-five nurses completed the questionnaire, and 21 nurses completed qualitative interviews. Nurses identified several barriers to effective nurse-physician communication: lack of physician openness to communication, logistic challenges, lack of professionalism, and language barriers. Feeling hurried by the physician was the most frequent barrier (28%), followed by finding a quiet place to call (25%), and difficulty reaching the physician (21%). In qualitative interviews, there was consensus that nurses needed to be brief and prepared with relevant clinical information when communicating with physicians and that physicians needed to be more open to listening.

CONCLUSIONS

A combination of nurse and physician behaviors contributes to ineffective communication in the LTC setting. These findings have important implications for patient safety and support the development of structured communication interventions to improve quality of nurse-physician communication.

Understanding their options: determinants of hospice discussion for older persons with advanced illness

BACKGROUND

Clinicians' discussions about hospice with patients and families are important as a means of communicating end-of-life options.

OBJECTIVE

To identify determinants of clinicians' hospice discussions and the impact of such discussions on hospice use.

DESIGN

We interviewed 215 patients age > or = 60 years with advanced cancer, chronic obstructive pulmonary disease (COPD), or heart failure (HF) at least every 4 months for up to 2 years. Participants provided information about their health status and treatment preferences. Clinicians completed a questionnaire every 6 months about their estimates of patient life expectancy and their communication with the patient and family about hospice.

RESULTS

In their final survey, clinicians reported discussing hospice with 46% of patients with cancer, compared to 10% with COPD and 7% with HF. Apart from diagnosis of cancer, the factors most strongly associated with hospice discussion were clinicians' estimate of and certainty about patient life expectancy (P < 0.001). However, clinicians were unable to anticipate the deaths of a considerable portion of patients (40%). Although patient unwillingness to undergo minor medical interventions was associated with hospice discussion (P < 0.05), a sizeable portion of clinicians (40%) whose patients reported this characteristic did not have the discussion. Clinicians' discussion of hospice independently increased the likelihood of hospice use (OR = 5.3, 95% CI = 2.3-13).

CONCLUSIONS

Clinicians' discussion of hospice for patients with advanced illness, and, ultimately, patients' use of hospice, relies largely on clinician estimates of patient life expectancy and the predictability of disease course. Many clinicians whose patients might benefit from learning about hospice are not having these discussions.

Negative emotions in cancer care: do oncologists' responses depend on severity and type of emotion?

OBJECTIVE

To examine how type and severity of patients' negative emotions influence oncologists' responses and subsequent conversations.

METHODS

We analyzed 264 audio-recorded conversations between advanced cancer patients and their oncologists. Conversations were coded for patients' expressions of negative emotion, which were categorized by type of emotion and severity. Oncologists' responses were coded as using either empathic language or blocking and distancing approaches.

RESULTS

Patients presented fear more often than anger or sadness; severity of disclosures was most often moderate. Oncologists responded to 35% of these negative emotional disclosures with empathic language. They were most empathic when patients presented intense emotions. Responding empathically to patients' emotional disclosures lengthened discussions by an average of only 21s.

CONCLUSION

Greater response rates to severe emotions suggest oncologists may recognize negative emotions better when patients express them more intensely. Oncologists were least responsive to patient fear and responded with greatest empathy to sadness.

PRACTICE IMPLICATIONS

Oncologists may benefit from additional training to recognize negative emotions, even when displayed without intensity. Teaching cancer patients to better articulate their emotional concerns may also enhance patient-oncologist communication.

Making therapeutic decisions in inflammatory bowel disease: the role of patients

PURPOSE OF REVIEW

The treatment of inflammatory bowel disease (IBD) is becoming more complex due to the introduction of new medications and evolving treatment algorithms. Data suggest that more aggressive treatment will yield improved clinical results. Although promising, it is not clear if patients will agree to this new approach. This review aims to describe what we know about patients' perceptions of risks and benefits of treatment, how much risk IBD patients are willing to accept, and to introduce ideas to facilitate better patient communication.

RECENT FINDINGS

Patients and parents of children with IBD appear to be willing to accept the known risks associated with IBD therapies, but demand substantial treatment benefit to make this tradeoff. As patients with IBD have misperceptions about the risks and benefits of treatment, it is important to develop better methods of communicating medical information.

SUMMARY

There are now more treatment options for patients with IBD. To increase patients' participation in medical decisions, it is critical to fairly present the tradeoffs of risks versus benefits of treatment. Tools are being developed to more clearly present clinical trial data, risks of medication side effects and for calculating individualized risks of disease complications and response to therapy.

Communication and outcomes of visits between older patients and nurse practitioners

BACKGROUND

Effective patient-clinician communication is at the heart of good healthcare and may be even more vital for older patients and their nurse practitioners (NPs).

OBJECTIVES

The objectives of this study were to examine 1)contributions of older patients' and NPs' characteristics and the content and relationship components of their communication to patients' proximal outcomes (satisfaction and intention to adhere) and longer term outcomes (changes in presenting problems, physical health, and mental health), and 2) contributions of proximal outcomes to longer term outcomes.

METHODS

Visits were video-recorded for a statewide sample of 31 NPs and 155 older patients. Patients' and NPs' communications during visits were measured using the Roter Interaction Analysis System for verbal activities, a check sheet for nonverbal activities, and an inventory of relationship dimension items. Proximal outcomes were measured with single items after visits. At 4 weeks, change in presenting problems was measured with a single item, and physical and mental health changes were measured with the SF-12 Version 2 Health Survey. Mixed-model regression with backward deletion was conducted until only predictors with p

RESULTS

With the other variables in the models held constant, better outcomes were related to background characteristics of poorer baseline health, nonmanaged care settings, and more NP experience; to a content component of seeking and giving biomedical and psychosocial information; and to a relationship component of more positive talk and greater trust and receptivity and affection, depth, and similarity. Poorer outcomes were associated with higher rates of lifestyle discussion and NPs' rapport building that patients may have perceived to be patronizing. Greater intention to adhere was associated with greater improvement in presenting problems.

DISCUSSION

Older patient-NP communication was effective regarding seeking and giving biomedical and psychosocial information other than that involving lifestyle. Studies of ways to improve older patient-NP lifestyle discussions and rapport building are needed.

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Key Words

• communication
• nurse-patient relations
• outcome assessment (health care)
• aged
• nurse practitioner
• ambulatory care
• mixed models

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MESH Headings

• Aged
• Aged, 80 and over
• Communication
• Female
• Health Services for the Aged
• Humans
• Male
• New England
• Nurse Practitioners
• Nurse-Patient Relations
• Outcome Assessment, Health Care
• Patient Compliance
• Patient Satisfaction
• Regression Analysis

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Grants

• R01 NR008020-01A1 NINR NIH HHS
• R01-NR00820 NINR NIH HHS

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Affiliation(s)

Dorothy Ann Gilbert School of Nursing, University of Massachusetts Amherst, Amherst, MA 01003, USA.
Eileen Hayes

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Disclosing a cancer diagnosis to friends and family: a gendered analysis of young men's and women's experiences

Little is known about how young adults disclose their cancer diagnosis to family and friends, and whether there are similarities or differences between men and women. This article compares young adults' experiences of disclosing a cancer diagnosis, drawing on narrative interviews with 37 respondents aged 18 to 34 years. Most respondents were open about their diagnosis, and there were striking similarities in the difficulties that men and women described and in their desire to protect relatives. However, men made up most of the minority of respondents who were more secretive about their diagnosis. Men also made more explicit connections between their gendered identity and disclosure; worries about being perceived differently by peers resulted in some men hiding their diagnosis and others using humor to pre-empt sympathy. These findings are discussed in the context of gender stereotypes of "expressive" women and "stoical" men.

Unraveling the relationship between literacy, language proficiency, and patient-physician communication

OBJECTIVE

To examine whether the effect of health literacy (HL) on patient-physician communication varies with patient-physician language concordance and communication type.

METHODS

771 outpatients rated three types of patient-physician communication: receptive communication (physician to patient); proactive communication (patient to physician); and interactive, bidirectional communication. We assessed HL and language categories including: English-speakers, Spanish-speakers with Spanish-speaking physicians (Spanish-concordant), and Spanish-speakers without Spanish-speaking physicians (Spanish-discordant).

RESULTS

Overall, the mean age of participants was 56 years, 58% were women, 53% were English-speakers, 23% Spanish-concordant, 24% Spanish-discordant, and 51% had limited HL. Thirty percent reported poor receptive, 28% poor proactive, and 56% poor interactive communication. In multivariable analyses, limited HL was associated with poor receptive and proactive communication. Spanish-concordance and discordance was associated with poor interactive communication. In stratified analyses, among English-speakers, limited HL was associated with poor receptive and proactive, but not interactive communication. Among Spanish-concordant participants, limited HL was associated with poor proactive and interactive, but not receptive communication. Spanish-discordant participants reported the worst communication for all types, independent of HL.

CONCLUSION

Limited health literacy impedes patient-physician communication, but its effects vary with language concordance and communication type. For language discordant dyads, language barriers may supersede limited HL in impeding interactive communication.

PRACTICE IMPLICATIONS

Patient-physician communication interventions for diverse populations need to consider HL, language concordance, and communication type.

Considering culture in physician-- patient communication during colorectal cancer screening

Racial and ethnic disparities exist in both incidence and stage detection of colorectal cancer (CRC). We hypothesized that cultural practices (i.e., communication norms and expectations) influence patients' and their physicians' understanding and talk about CRC screening. We examined 44 videotaped observations of clinic visits that included a CRC screening recommendation and transcripts from semistructured interviews that doctors and patients separately completed following the visit. We found that interpersonal relationship themes such as power distance, trust, directness/ indirectness, and an ability to listen, as well as personal health beliefs, emerged as affecting patients' definitions of provider-patient effective communication. In addition, we found that in discordant physician-patient interactions (when each is from a different ethnic group), physicians did not solicit or address cultural barriers to CRC screening and patients did not volunteer culture-related concerns regarding CRC screening.

Language, literacy, and characterization of stroke among patients taking warfarin for stroke prevention: Implications for health communication

OBJECTIVE

Warfarin is a medication commonly prescribed to prevent strokes associated with certain medical conditions such as atrial fibrillation; however, little is known about how people taking warfarin perceive the goal of therapy and how they describe strokes. We assessed the stroke-related health literacy of anticoagulated patients to inform ways in which to improve health communication among people taking warfarin.

METHODS

We conducted a mixed-methods study of an ethnically and linguistically diverse sample of people taking warfarin to prevent stroke (N=183) and measured literacy using the short-form Test of Functional Health Literacy in Adults. We asked participants to (1) describe their indication for warfarin, and (2) describe a stroke. Transcribed answers were coded as concordant or discordant with established indications for warfarin and definitions of stroke.

RESULTS

Forty-three percent of participants provided a discordant response when describing their indication for warfarin. Only 9.3% reported that the purpose of taking warfarin was to prevent stroke. Not speaking English [OR=2.4 (1.1-5.6)] and less than a college education [OR=3.3 (1.4-7.3)] were independently associated with discordant answers about warfarin. Nearly 40% of subjects had inaccurate perceptions of stroke, and only one-third of subjects described a symptom or sign of stroke. Among English and Spanish-speaking participants, inadequate literacy was strongly associated with discordant responses about stroke [OR=5.8 (2.1-15.6)].

CONCLUSION

Among high-risk people taking warfarin to prevent stroke, significant gaps in stroke-related health literacy exist. These gaps likely represent mismatches in the ways clinicians teach and patients learn.

PRACTICE IMPLICATIONS

Since stroke risk awareness and early recognition of the signs and symptoms of stroke are critical aspects of stroke prevention and treatment, clinicians should more strongly link warfarin therapy to stroke prevention and ensure that patients know the presenting symptoms and signs of stroke. Public health communication strategies regarding stroke prevention need to target individuals with limited literacy and limited English proficiency.

Reflecting on the delivery of a longitudinal coping intervention amongst junior national netball players

Recent research suggests that appropriately-tailored interventions can assist adolescents enhance their coping skills (Frydenberg and Lewis, 2004). The present paper reflects upon the delivery of a longitudinal coping intervention utilized by junior national netball players. Reflection is focused on issues such as the rationale for the intervention, operational issues surrounding the delivery and management of the work. It is also focused on interpersonal issues relating to intervention implementation. We contend that being explicit about developmental and applied processes may enable theoretically sound and efficacious practices to be identified. In addition, unpacking operational issues related to delivery may assist applied sport and exercise psychologists in the development of related work. Key pointsThis paper exemplifies the potential benefits of reflective practice and offers an insight into the lessons learned during longitudinal applied research.We conclude that intervention-based research must accommodate the idiosyncrasies of an organization and requires the sport organisation to buy into the value of the work.Whilst thoughts and associations are offered, readers are encouraged to consider these and alternative associations.

The effect of pain question phrasing on older adult pain information

The aim of this study was to test how practitioners' pain communication affected the pain information provided by older adults. A post-test only, double-blind experiment was used to test how the phrasing of practitioners' pain questions-open-ended and without social desirability bias; closed-ended and without social desirability bias; or open-ended and with social desirability bias-affected the pain information provided by 312 community-living older adults with osteoarthritis pain. Older adults were randomly assigned to one of the three pain phrasing conditions to watch and orally respond to a computer-displayed videotape of a practitioner asking about their pain. All responded to a second videotape of the practitioner asking if there was anything further they wanted to communicate. Lastly, all responded to a third videotape asking if there was anything further they wanted to communicate about their pain. Transcripts of the audiotaped responses were content analyzed using 16 a priori criteria from national guidelines to identify important pain information for osteoarthritis pain management. Older adults described significantly more pain information in response to the open-ended question without social desirability. The two follow-up questions elicited significant additional information for all three groups, but did not compensate for the initial reduced pain information from the closed-ended and social desirability-biased groups. Initial use of an open-ended pain question without social desirability bias and use of follow-up questions significantly increase the amount of important pain information provided by older adults with osteoarthritis pain.

Communication plays a critical role in web-based monitoring

BACKGROUND

Patient-health care practitioner (HCP) interaction via a Web-based diabetes management system may increase patient monitoring of their blood glucose (BG) levels.

METHODS

A three-center, nonrandomized, prospective feasibility study of 109 Native Americans with poorly controlled type 1 diabetes mellitus and type 2 diabetes mellitus were recruited from Alabama, Idaho, and Arizona. The study intervention included the use of a Web-based diabetes management application (MyCareTeam) that allowed timely interaction between patients and HCPs. Information about diabetes, nutrition, and exercise was also available. Finally, patients were able to provide BG readings to their HCP via the MyCareTeam system.

RESULTS

As a result, 59.6% of the patients sent one or more messages to their HCP, 92.67% received one or more messages from their HCP, and 78.89% received one or more person-centered messages from their HCP. Additionally, the number of times a patient logged into the system and the frequency with which they tested their blood sugar were correlated with (a) the number of messages sent to their HCP, (b) the total number of messages received from their HCP, and (c) the number of person-centered messages received from their HCP. Thus patients who sent more messages also tested their BG more frequently, as measured by the number of BG readings uploaded from their meter to the MyCareTeam database. Person-centered messages seem to be particularly important to motivating the patient to monitor their BG levels and use the Web-based system.

CONCLUSIONS

These results suggest that patient-HCP interaction and, in particular, more personalized interactions increases patient frequency of BG monitoring.

Patient initiation of information: exploring its role during the mental health intake visit

OBJECTIVE

Describe the role of patients' initiation of information in patient-provider communication during mental health intake visits.

METHODS

One hundred and twenty-nine mental health intake visits of diverse racial/ethnic patients were videotaped. Semi-structured interviews were conducted with patients and providers following each intake visit. We qualitatively analyzed the interviews to identify themes related to patients' initiation of information. We quantitatively analyzed the videos of the intake visits utilizing a checklist that identified whether the patient or the provider initiated the information exchanged.

RESULTS

Patient initiation of information affected providers' evaluation of the credence of the information, assessment of rapport and appraisal of the success of the intake visit. Patients' initiation of information varied with patients' race, age and prior treatment experience; and provider's age, discipline and experience. Patients expressed a personal preference either to not be interrupted or to be asked questions by their providers.

CONCLUSION

Our findings illuminate the role of patient initiation of information in provider decision-making and highlight the importance of tailoring the communication style to patients' preferences.

PRACTICE IMPLICATIONS

Encouraging explicit communication with patients about expectations related to information exchange styles is recommended. Improving provider awareness of assumptions regarding their decision-making is also suggested.

Improvisational exercises to improve pharmacy students' professional communication skills

OBJECTIVE

To create and implement improvisational exercises to improve first-year pharmacy students' communication skills.

DESIGN

Twelve 1-hour improvisational sessions were developed and added to an existing/established patient communication course to improve 3 basic skills: listening, observing and responding. Standardized patient examinations were used to evaluate student communication skills, and course evaluations and reflective journaling were used to evaluate students' perceptions of the improvisational exercises.

ASSESSMENT

The improvisational exercises markedly improved the students' performance in several aspects of standardized patient examination. Additionally, course evaluations and student comments reflected their perception that the improvisational exercises significantly improved their communication skills.

SUMMARY

Improvisational exercises are an effective way to teach communication skills to pharmacy students.

Iridescence: a functional perspective

In animals, iridescence is generated by the interaction of light with biological tissues that are nanostructured to produce thin films or diffraction gratings. Uniquely among animal visual signals, the study of iridescent coloration contributes to biological and physical sciences by enhancing our understanding of the evolution of communication strategies, and by providing insights into physical optics and inspiring biomimetic technologies useful to humans. Iridescent colours are found in a broad diversity of animal taxa ranging from diminutive marine copepods to terrestrial insects and birds. Iridescent coloration has received a surge of research interest of late, and studies have focused on both characterizing the nanostructures responsible for producing iridescence and identifying the behavioural functions of iridescent colours. In this paper, we begin with a brief description of colour production mechanisms in animals and provide a general overview of the taxonomic distribution of iridescent colours. We then highlight unique properties of iridescent signals and review the proposed functions of iridescent coloration, focusing, in particular, on the ways in which iridescent colours allow animals to communicate with conspecifics and avoid predators. We conclude with a brief overview of non-communicative functions of iridescence in animals. Despite the vast amount of recent work on animal iridescence, our review reveals that many proposed functions of iridescent coloration remain virtually unexplored, and this area is clearly ripe for future research.

Participation of adolescent girls in a study of sexual behaviors: balancing autonomy and parental involvement

STUDY OBJECTIVE

The process of research with adolescents should balance parental involvement and adolescent autonomy. The attendance of parents and peers at research study visits of girls participating in a 6-month study of topical microbicide acceptability is described, as well as the participants' conversations with their parents.

METHODS

Girls, 14 through 21 years, were recruited from previous studies (3%), advertisements (14%), clinics (17%), and recommendations by friends (66%) to participate. Girls under 18 years were required to have parental consent, but parents could provide verbal phone consent as long as a signed consent form was returned before participation.

RESULTS

The 208 participants were 41% African-American, 30% Hispanic, and 29% Caucasian. Girls averaged 18 years of age, and 95 (46%) were under 18. Seventeen percent of parents attended the first visit; only 1 parent attended with a daughter older than 18 years of age. The mothers of older adolescents were less likely to attend the appointment with them. More Caucasian than African-American girls came with a mother. Parental attendance decreased at follow-up visits. Thirty-seven percent of girls brought a peer to the first visit; there were no age or race/ethnic differences. There was no relationship between attending with a parent or peer and talking to a parent about the study. Some adolescents obtained parental consent to participate in the study while keeping their sexual behaviors private.

CONCLUSIONS

Parental attendance at study visits may not be marker of parental involvement with the study. Creative ways for balancing concerns about confidentiality, promotion of autonomy, and adult involvement should be considered.

Early Identification of Autism: Early Characteristics, Onset of Symptoms, and Diagnostic Stability

In the first year of life, infants who later go on to develop autistic spectrum disorders (ASD) may exhibit subtle disruptions in social interest and attention, communication, temperament, and head circumference growth that occur prior to the onset of clinical symptoms. These disruptions may reflect the early course of ASD development and may also contribute to the later development of clinical symptoms through alterations in the child's experience of his or her environment. By age 2, developmental precursors of autism symptoms can be used to diagnose children reliably, and by age 3, the diagnosis is thought to be relatively stable. The downward extension of the autism diagnosis poses important questions for therapists in designing interventions that are applicable for infants who demonstrate early risk factors. We review current knowledge of the early signs of ASD in the infancy period (0-12 months) and the manifestation of symptoms in toddlerhood (12- 36 months), noting the importance of considering the variability in onset and trajectory of ASD. Finally, we consider the implications of this emerging research for those who work or interact with young children, including the importance of early monitoring and the development and evaluation of age-appropriate interventions.

Slipped lips: onset asynchrony detection of auditory-visual language in autism

BACKGROUND

It has frequently been suggested that individuals with autism spectrum disorder (ASD) have deficits in auditory-visual (AV) sensory integration. Studies of language integration have mostly used non-word syllables presented in congruent and incongruent AV combinations and demonstrated reduced influence of visual speech in individuals with ASD. The aim of our study was to test whether adolescents with high-functioning autism are able to integrate AV information of meaningful, phrase-length language in a task of onset asynchrony detection.

METHODS

Participants were 25 adolescents with ASD and 25 typically developing (TD) controls. The stimuli were video clips of complete phrases using simple, commonly occurring words. The clips were digitally manipulated to have the video precede the corresponding audio by 0, 4, 6, 8, 10, 12, or 14 video frames, a range of 0-500ms. Participants were shown the video clips in random order and asked to indicate whether each clip was in-synch or not.

RESULTS

There were no differences between adolescents with ASD and their TD peers in accuracy of onset asynchrony detection at any slip rate.

CONCLUSION

These data indicate that adolescents with ASD are able to integrate auditory and visual components in a task of onset asynchrony detection using natural, phrase-length language stimuli. We propose that the meaningful nature of the language stimuli in combination with presentation in a non-distracting environment allowed adolescents with autism spectrum disorder to demonstrate preserved accuracy for bi-modal AV integration.

Colon cancer patient information seeking and the adoption of targeted therapy for on-label and off-label indications

BACKGROUND

Despite the rise in publicly available cancer information, little is known about the association between patient information seeking and the adoption of cancer technologies. The authors of this report investigated the relation between patient information seeking and awareness about and receipt of novel targeted therapy (TT) for colon cancer among patients for whom therapy is approved by the US Food and Drug Administration (FDA) and among patients for whom therapy is not FDA approved.

METHODS

A retrospective, population-based survey of 633 colon cancer patients were identified through the Pennsylvania Cancer Registry. Outcome measures were self-reported awareness about and receipt of TT (bevacizumab and cetuximab).

RESULTS

After adjusting for sociodemographic characteristics, high levels of treatment information seeking were associated strongly with hearing about TT (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.49-5.38) and receiving TT (OR, 3.22; 95% CI, 1.36-7.62). These associations were present for patients with metastatic disease, for whom the use of TT is FDA approved, and for patients with localized disease, for whom the use of TT is not FDA approved (P for interactions = .29). Internet use (OR, 2.88; 95% CI, 1.40-5.94) and newspaper/magazine use (OR, 3.44; 95% CI, 1.34-8.84) were associated with hearing about TT. Seeking information from nontreating physicians was associated with hearing about TT (OR, 1.95; 95% CI, 1.03-3.68) and receiving TT (OR, 2.64; 95% CI, 1.16-5.97).

CONCLUSIONS

Patient information seeking was related to the adoption of TT for colon cancer in both appropriate and inappropriate clinical settings. These findings emphasize the importance of exploring patient influence on physician prescribing patterns and understanding the impact of information seeking on cancer outcomes.