The patient-doctor relationship: a synthesis of the qualitative literature on patients' perspectives

BACKGROUND

The patient-doctor relationship is an important but poorly defined topic. In order to comprehensively assess its significance for patient care, a clearer understanding of the concept is required.

AIM

To derive a conceptual framework of the factors that define patient-doctor relationships from the perspective of patients.

DESIGN OF STUDY

Systematic review and thematic synthesis of qualitative studies.

METHOD

Medline, EMBASE, PsychINFO and Web of Science databases were searched. Studies were screened for relevance and appraised for quality. The findings were synthesised using a thematic approach.

RESULTS

From 1985 abstracts, 11 studies from four countries were included in the final synthesis. They examined the patient-doctor relationship generally (n = 3), or in terms of loyalty (n = 3), personal care (n = 2), trust (n = 2), and continuity (n = 1). Longitudinal care (seeing the same doctor) and consultation experiences (patients' encounters with the doctor) were found to be the main processes by which patient-doctor relationships are promoted. The resulting depth of patient-doctor relationship comprises four main elements: knowledge, trust, loyalty, and regard. These elements have doctor and patient aspects to them, which may be reciprocally related.

CONCLUSION

A framework is proposed that distinguishes between dynamic factors that develop or maintain the relationship, and characteristics that constitute an ongoing depth of relationship. Having identified the different elements involved, future research should examine for associations between longitudinal care, consultation experiences, and depth of patient-doctor relationship, and, in turn, their significance for patient care.

Healthcare provider-child-parent communication in the preoperative surgical setting

OBJECTIVES

Although preoperative preparation programs were once common, most children currently undergoing outpatient surgery are first exposed to the hospital on the day of the procedure. It is advocated that these outpatient children undergo the preparation just prior to surgery.

AIM

To assess the amount of time that healthcare providers spend with children and families on the day of surgery in the preoperative area.

MATERIALS AND METHODS

The study used video infrastructure in the preoperative holding area of Yale New Haven Children's Hospital to record all interactions between children, families, and healthcare providers. Videotapes were coded to characterize and quantify behaviors of healthcare professionals.

RESULTS

On the day of surgery, healthcare providers spent medians of 2.75-4.81 min interacting with children and parents in the preoperative area. Families spent a median of 46.5 min in the preoperative area. Healthcare professionals spent the most time in medical talk (averages of 42.5-48.2% of time spent with family) and little time was spent in nonmedical talk (range of 6.2-6.9% of time spent with family). Anesthesiologists and surgeons spent 28% and 18% of the interview in talk to children; admitting nurses spent more of the interview talking to children (43%).

CONCLUSIONS

Families interact with healthcare providers for only a small proportion of the time they spent in the preoperative area. This is likely to be a result of increased production pressure in the perioperative settings and has implications for providing preparation for surgery on the morning of the procedure.

Language Characteristics of Individuals with Down Syndrome

On average, language and communication characteristics of individuals with Down syndrome (the most common genetic cause of intellectual disability) follow a consistent profile. Despite considerable individual variability, receptive language is typically stronger than expressive language, with particular challenges in phonology and syntax. We review the literature on language and literacy skills of individuals with Down syndrome, with emphasis on the areas of phonology, vocabulary, syntax, and pragmatics. We begin by describing the hearing, oral-motor, cognitive, social, and prelinguistic and early nonverbal communication characteristics of individuals with Down syndrome. We conclude with a discussion of clinical implications and research directions.

Genes, cognition, and communication: insights from neurodevelopmental disorders

Twin and family studies have demonstrated that most cognitive traits are moderately to highly heritable. Neurodevelopmental disorders such as dyslexia, autism, and specific language impairment (SLI) also show strong genetic influence. Nevertheless, it has proved difficult for researchers to identify genes that would explain substantial amounts of variance in cognitive traits or disorders. Although this observation may seem paradoxical, it fits with a multifactorial model of how complex human traits are influenced by numerous genes that interact with one another, and with the environment, to produce a specific phenotype. Such a model can also explain why genetic influences on cognition have not vanished in the course of human evolution. Recent linkage and association studies of SLI and dyslexia are reviewed to illustrate these points. The role of nonheritable genetic mutations (sporadic copy number variants) in causing autism is also discussed. Finally, research on phenotypic correlates of allelic variation in the genes ASPM and microcephalin is considered; initial interest in these as genes for brain size or intelligence has been dampened by a failure to find phenotypic differences in people with different versions of these genes. There is a current vogue for investigators to include measures of allelic variants in studies of cognition and cognitive disorders. It is important to be aware that the effect sizes associated with these variants are typically small and hard to detect without extremely large sample sizes.

Pediatric hospitalists and primary care providers: a communication needs assessment

BACKGROUND/OBJECTIVE

Existing research on hospitalist-primary care provider (PCP) communication focuses mainly on adult hospitalist models with little known about the quality of current pediatric hospitalist-PCP communication. Our objective was to perform a needs assessment by exploring important issues around communication between pediatric hospitalists and PCPs.

METHODS

Six previously identified issues around hospitalist-PCP communication from the adult hospitalist literature were abstracted and incorporated into an open-ended and closed-ended questionnaire. The questionnaire was pretested, revised, and administered by phone to 10 pediatric hospitalists and 12 pediatric PCPs residing in our 5-state catchment area. Interviews were transcribed and openly coded, and themes compared using qualitative methods.

RESULTS

The 6 identified issues were: quality of communication, barriers to communication, methods of information sharing, key data element requirements, critical timing, and perceived benefits. Hospitalists and PCPs rated overall quality of communication from "poor" to "very good." Both groups acknowledge that significant barriers to optimal communication currently exist, yet the barriers differ for each group. Hospitalists and PCPs agree on what information is important to transmit (diagnoses, medications, follow-up needs, and pending laboratory test results) and critical times for communication during the hospitalization (at discharge, admission, and during major clinical changes). Both groups also agree that optimal communication could improve many aspects of patient care.

CONCLUSIONS

Identifying and addressing barriers to these 6 issues may help both hospitalists and PCPs implement targeted interventions aimed at improving communication. Future studies will need to demonstrate the link between improved hospitalist-PCP communication and improved patient care and outcomes.

Is there a relationship between patient beliefs or communication about generic drugs and medication utilization?

BACKGROUND

Insurers and policymakers strive to stimulate more cost-effective prescribing and, increasingly, are educating beneficiaries about generics.

OBJECTIVES

To evaluate the relationship between patient beliefs and communication about generic drugs and actual drug use.

RESEARCH DESIGN AND SUBJECTS

We performed a national mailed survey of a random sample of 2500 commercially-insured adults. Patient responses were linked to pharmacy claims data to assess actual generic medication use.

MEASURES

We used factor analysis to develop 5 multi-item scales from patient survey responses that measured: (1) general preferences for generics, (2) generic safety/effectiveness, (3) generic cost/value, (4) comfort with generic substitution, and (5) communication with providers about generics. The relationship between each scale and the proportion of prescriptions filled for generics was assessed using linear regression, controlling for demographic, health, and insurance characteristics. Separate models were created for each scale and then all 5 scales were included simultaneously in a fully-adjusted model.

RESULTS

The usable response rate was 48%. When evaluated independently, a 1 SD increase in each of the 5 scales was associated with a 3.1% to 6.3% increase in generic drug use (P < 0.05 for each). In the fully adjusted model, only 2 scales were significantly associated with generic drug use: comfort with generic substitution (P = 0.021) and communication with providers about generic drugs (P = 0.012).

CONCLUSIONS

Generic drug use is most closely associated with the 2 actionable items we evaluated: communication with providers about generics and comfort with generic substitution. Educational campaigns that focus on these 2 domains may be most effective at influencing generic drug use.

Dependence and caring in clinical communication: the relevance of attachment and other theories

OBJECTIVE

Clinical relationships are usually asymmetric, being defined by patients' dependence and practitioners' care. Our aims are to: (i) identify literature that can contribute to theory for researching and teaching clinical communication from this perspective; (ii) highlight where theoretical development is needed; and (iii) test the utility of the emerging theory by identifying whether it leads to implications for educational practice.

METHODS

Selective and critical review of research concerned with dependence and caring in clinical and non-clinical relationships.

RESULTS

Attachment theory helps to understand patients' need to seek safety in relationships with expert and authoritative practitioners but is of limited help in understanding practitioners' caring. Different theories that formulate practitioners' care as altruistic, rewarded by personal connection or as a contract indicate the potential importance of practitioners' emotions, values and sense of role in understanding their clinical communication.

CONCLUSION

Extending the theoretical grounding of clinical communication can accommodate patients' dependence and practitioners' caring without return to medical paternalism.

PRACTICE IMPLICATIONS

A broader theoretical base will help educators to address the inherent subjectivity of clinical relationships, and researchers to distinguish scientific questions about how patients and clinicians are from normative questions about how they should be.

'They don't ask me so I don't tell them': patient-clinician communication about traditional, complementary, and alternative medicine

PURPOSE

Although high rates of traditional medicine and complementary and alternative medicine (TM/CAM) use have been well documented, there has been less attention to the factors influencing communication between patients and their primary care clinicians about TM/CAM. Such communication can be important in anticipating possible drug-herb interactions and in assuring agreement about therapeutic plans.

METHODS

We used sequential, multistage, qualitative methods, including focus groups, in-depth interviews, and a video vignette, to explore communication about TM/CAM between patients and their primary care clinicians. The study was conducted in RIOS Net (Research Involved in Outpatient Settings Network), a Southwestern US practice-based research network, situated largely in Hispanic and American Indian communities where TM/CAM is an important part of self-care.

RESULTS

One hundred fourteen patients, 41 clinic staff members, and 19 primary care clinicians in 8 clinic sites participated. The degree and nature of TM/ CAM communication is based on certain conditions in the clinical encounter. We categorized these findings into 3 themes: acceptance/nonjudgment, initiation of communication, and safety/efficacy. Perceived clinician receptivity to and initiation of discussion about TM/CAM strongly influenced patients' decisions to communicate; perceived clinician expertise in TM/CAM was less important. Clinicians' comfort with patients' self-care approaches and their level of concern about lack of scientific evidence of effectiveness and safety of TM/CAM influenced their communication about TM/CAM with patients.

CONCLUSIONS

Specific communication barriers limit patient-clinician communication about TM/CAM. Clinicians who wish to communicate more effectively with their patients about these topics and better integrate the types of care their patients use can change the communication dynamic with simple strategies designed to overcome these barriers.

Patient datasheets and generic evaluation sheets: tools for improving patient care, patient satisfaction, and chart documentation while decreasing physician frustrations

A medical record system that utilizes a patient datasheet and pretyped generic patient evaluation sheets is described. When completed, the patient datasheet facilitates quick access to all of the pertinent patient medical information, improves transmission of instructions to the patient, simplifies record-keeping of patient visits, prevents the rewriting of repetitive information (such as a long list of medications and dosages and instructions after each visit), facilitates the tracing of the patient medication history, and improves communication with the patient and with other physicians. The "generic evaluation sheets" have a near-complete medical history and physical examination already typed with areas where information can be easily added or deleted and provides a place for the patient assessment and medical treatment plan. This approach to outpatient medical record-keeping not only results in the ready availability of patient medical information, thus decreasing some of the frustrations of patient care, but also markedly improves patient care documentation while facilitating referral letters and in-hospital patient records.

Getting by: underuse of interpreters by resident physicians

BACKGROUND

Language barriers complicate physician-patient communication and adversely affect healthcare quality. Research suggests that physicians underuse interpreters despite evidence of benefits and even when services are readily available. The reasons underlying the underuse of interpreters are poorly understood.

OBJECTIVE

To understand the decision-making process of resident physicians when communicating with patients with limited English proficiency (LEP).

DESIGN

Qualitative study using in-depth interviews.

PARTICIPANTS

Internal medicine resident physicians (n = 20) from two urban teaching hospitals with excellent interpreter services.

APPROACH

An interview guide was used to explore decision making about interpreter use.

RESULTS

Four recurrent themes emerged: 1) Resident physicians recognized that they underused professional interpreters, and described this phenomenon as "getting by;" 2) Resident physicians made decisions about interpreter use by weighing the perceived value of communication in clinical decision making against their own time constraints; 3) The decision to call an interpreter could be preempted by the convenience of using family members or the resident physician's use of his/her own second language skills; 4) Resident physicians normalized the underuse of professional interpreters, despite recognition that patients with LEP are not receiving equal care.

CONCLUSIONS

Although previous research has identified time constraints and lack of availability of interpreters as reasons for their underuse, our data suggest that the reasons are far more complex. Residents at the study institutions with interpreters readily available found it easier to "get by" without an interpreter, despite misgivings about negative implications for quality of care. Findings suggest that increasing interpreter use will require interventions targeted at both individual physicians and the practice environment.

Fall TIP: validation of icons to communicate fall risk status and tailored interventions to prevent patient falls

This paper reports on the development and validation of a set of icons designed to communicate fall risk status and tailored interventions to prevent patient falls in hospitals. The icons will populate a fall prevention toolkit to provide actionable alerts to nurses, nursing assistants, and other interdisciplinary health care team members and educational materials for patients and families in acute hospital settings.

Discussing coronary risk with patients to improve blood pressure treatment: secondary results from the CHECK-UP study

OBJECTIVES

Hypertension is common among patients with dyslipidemia but is often poorly treated. The objective of this analysis was to evaluate how a decision aid, used by primary care physicians to improve lipid therapy, impacted on the treatment of hypertension.

STUDY DESIGN

Data were analyzed from patients enrolled in a randomized trial focusing primarily on the treatment of dyslipidemia. Patients received usual care or a coronary risk profile every three months to monitor the risk reduction following lifestyle changes and/or pharmacotherapy to treat dyslipidemia. Hypertension management was assessed based on a post hoc analysis of individuals whose blood pressure exceeded current national hypertension guidelines.

RESULTS

There were 2,631 subjects who completed the study. Among 1,352 patients without diagnosed hypertension, 30% were above target on at least three consecutive visits. Among 1,279 individuals with known hypertension, 69% were above target on at least two consecutive visits. Overall, patients receiving risk profiles were more likely to receive appropriate antihypertensive therapy (OR = 1.40, 95% CI 1.11-1.78) compared to those receiving usual care. After adjustment for inter-physician variability and potential confounders, the use of the risk profile was associated with an increased likelihood of starting therapy (OR = 1.78, 95% CI 1.06-3.00) or modifying therapy (OR = 1.40, 95% CI 1.03-1.91).

CONCLUSIONS

In this clinical trial of dyslipidemia management, inadequately controlled hypertension was common, occurring in nearly 50% of individuals. Ongoing coronary risk assessment was associated with more appropriate blood pressure management. Cardiovascular risk assessment decision aids should be further evaluated in a randomized trial of hypertension therapy.

Imitation and communication skills development in children with pervasive developmental disorders

This study evaluates the correlation between failure to develop spontaneous imitation and language skills in pervasive developmental disorders. Sixty-four children between the age of 3 and 8 years were assessed using the Autism Diagnostic Interview-Revised (ADI-R), the Childhood Autism Rating Scale (CARS), and the Autism Diagnostic Observation Schedule (ADOS), as well as direct observation of imitation. The sample was subdivided into a verbal and a nonverbal group. Analysis of mean scores on the CARS "imitation" items and of ADI-R "spontaneous imitation" and "pointing to express interest" revealed a statistically significant difference between verbal and nonverbal groups, with more severe impairment/higher scores in the nonverbal than the verbal group. These results suggest that nonverbal children have specifically impaired imitation and pointing skills.

Intimate partner violence screening and pregnant Latinas

Little is known about factors associated with health care screening of intimate partner violence (IPV) for Latinas during pregnancy. This study builds on current research examining IPV-associated outcomes among Latinas by analyzing 210 pregnant Latina responses to a patient survey. A multivariate logistic regression model examined factors associated with being screened for IPV. One-third of pregnant women reported being screened for IPV. Factors related to being screened for IPV are reported and did not match those associated with having experienced IPV. While most pregnant Latinas were not screened for IPV, having systematic processes in place for IPV screening and fostering good patient-provider communication may facilitate identification of IPV. Having a greater awareness of the risk factors associated with IPV may also provide cues for clinicians to better address the issue of IPV.

Inter-organisation communication for end of life care

Background Poor communication between in-hours and out-of-hours (OoH) general practitioners (GPs) causes unwanted admissions to hospital of patients who want to die at home Setting A GP OoH service in West London (London Central and West Unscheduled Care Service) used by 159 general practices from four primary care trusts Question What helps to avoid hospital admission of patients who want to die at home when a crisis occurs in the OoH period? Methods Whole system participatory action research, with four stages: 1. engage stakeholders; 2. understand the initial situation; 3. re-design the system; 4. action for change Results The following help to avoid undesirable hospital admission of a dying person who has a crisis in the OoH period: 1. a register of vulnerable adults; 2. records at home; 3. key worker(s); 4. home interventions; 5. day-time practitioner communication; 6. a development and governance group; 7. speedy discharge from hospital; 8. decision support for OoH GPs. Discussion This project revealed a useful set of policies to help avoid unnecessary OoH admission to hospital, especially improved communication between day-time GPs and OoH GPs. The approach combined whole system participatory action research with systems modelling and this helped the issues to be revealed quickly and cheaply. Furthermore, including leaders from partner organisations at each stage of the inquiry has encouraged shared purpose and produced champions to move forward the project recommendations. Some changes have already happened.

Staff engagement during complex pediatric medical care: the role of patient, family, and treatment variables

OBJECTIVE

To examine the role of patient, family, and treatment variables on self-reported engagement for physicians and nurses working with pediatric complex care patients.

METHODS

Sixty-eight physicians and 85 registered nurses at a children's hospital reviewed eight case scenarios that varied by the patient and patient's family (each cooperative versus difficult) and the length of hospitalization (<30 days versus >30 days). Participants rated their engagement from highly engaged/responsive to distancing/disconnected behaviors.

RESULTS

Nurses were more likely than physicians to engage in situations with a difficult patient/cooperative family but less likely to engage in situations with a cooperative patient/difficult family.Nurses were more likely to consult a colleague regarding the care of a difficult patient/difficult family,while physicians were more likely to refer a difficult patient/difficult family to a psychosocial professional.

CONCLUSIONS

Differences were found for engagement with "difficult" patients/families, with physicians more likely to distance themselves or refer to a psychosocial professional, while nurses were more likely to consult with a colleague.

PRACTICE IMPLICATIONS

Communication between health care team members is essential for optimal family-centered health care. Thus, interventions are needed that focus on communication and support for healthcare teams working with pediatric complex care patients and their families.

The construct of breast cancer risk perception: need for a better risk communication?

Breast cancer risk assessment and communication are much neglected aspects of women's health care. Breast cancer is the most prevalent cancer-related disease that touches the deepest of a women's feelings and the subject thus attracts much of the attention of the media. Disease prevalence and media coverage are the roots of inappropriate breast cancer risk perception. Many women overestimate their personal breast cancer risk. Inappropriate risk perception precedes inappropriate health behaviour and it is pivotal to understand the underlying mechanisms in order to plan intervention. Whether interventions such as patient education through counselling and objective risk assessment are effective in restoring inappropriate breast cancer risk perception remains a question unanswered, but the tools to measure breast cancer risk are available and were validated.

The primate cortical auditory system and neural representation of conspecific vocalizations

Over the past decade, renewed interest in the auditory system has resulted in a surge of anatomical and physiological research in the primate auditory cortex and its targets. Anatomical studies have delineated multiple areas in and around primary auditory cortex and demonstrated connectivity among these areas, as well as between these areas and the rest of the cortex, including prefrontal cortex. Physiological recordings of auditory neurons have found that species-specific vocalizations are useful in probing the selectivity and potential functions of acoustic neurons. A number of cortical regions contain neurons that are robustly responsive to vocalizations, and some auditory responsive neurons show more selectivity for vocalizations than for other complex sounds. Demonstration of selectivity for vocalizations has prompted the question of which features are encoded by higher-order auditory neurons. Results based on detailed studies of the structure of these vocalizations, as well as the tuning and information-coding properties of neurons sensitive to these vocalizations, have begun to provide answers to this question. In future studies, these and other methods may help to define the way in which cells, ensembles, and brain regions process communication sounds. Moreover, the discovery that several nonprimary auditory cortical regions may be multisensory and responsive to vocalizations with corresponding facial gestures may change the way in which we view the processing of communication information by the auditory system.

Impact of patient race on patient experiences of access and communication in HIV care

BACKGROUND

Patient-centered care--including the domains of access and communication--is an important determinant of positive clinical outcomes.

OBJECTIVE

To explore associations between race and HIV-infected patients' experiences of access and communication.

DESIGN

This was a cross-sectional survey.

PARTICIPANTS

Nine hundred and fifteen HIV-infected adults receiving care at 14 U.S. HIV clinics.

MEASUREMENTS

Dependent variables included patients' reports of travel time to their HIV care site and waiting time to see their HIV provider (access) and ratings of their HIV providers on always listening, explaining, showing respect, and spending enough time with them (communication). We used multivariate logistic regression to estimate associations between patient race and dependent variables, and random effects models to estimate site-level contributions.

RESULTS

Patients traveled a median 30 minutes (range 1-180) and waited a median 20 minutes (range 0-210) to see their provider. On average, blacks and Hispanics reported longer travel and wait times compared with whites. Adjusting for HIV care site attenuated this association. HIV care sites that provide services to a greater proportion of blacks and Hispanics may be more difficult to access for all patients. The majority of patients rated provider communication favorably. Compared to whites, blacks reported more positive experiences with provider communication.

CONCLUSIONS

We observed racial disparities in patients' experience of access to care but not in patient-provider communication. Disparities were explained by poor access at minority-serving clinics. Efforts to make care more patient-centered for minority HIV-infected patients should focus more on improving access to HIV care in minority communities than on improving cross-cultural patient-provider interactions.

A multidisciplinary teamwork training program: the Triad for Optimal Patient Safety (TOPS) experience

INTRODUCTION

Communication and teamwork failures are a common cause of adverse events. Residency programs, with a mandate to teach systems-based practice, are particularly challenged to address these important skills.

AIM

To develop a multidisciplinary teamwork training program focused on teaching teamwork behaviors and communication skills.

SETTING

Internal medicine residents, hospitalists, nurses, pharmacists, and all other staff on a designated inpatient medical unit at an academic medical center.

PROGRAM DESCRIPTION

We developed a 4-h teamwork training program as part of the Triad for Optimal Patient Safety (TOPS) project. Teaching strategies combined didactic presentation, facilitated discussion using a safety trigger video, and small-group scenario-based exercises to practice effective communication skills and team behaviors. Development, planning, implementation, delivery, and evaluation of TOPS Training was conducted by a multidisciplinary team.

PROGRAM EVALUATION

We received 203 evaluations with a mean overall rating for the training of 4.49 +/- 0.79 on a 1-5 scale. Participants rated the multidisciplinary educational setting highly at 4.59 +/- 0.68.

DISCUSSION

We developed a multidisciplinary teamwork training program that was highly rated by all participating disciplines. The key was creating a shared forum to learn about and discuss interdisciplinary communication and teamwork.

Acupuncture practitioner-patient communication in Japan

We evaluated acupuncture practitioner–patient communication using pairs of practitioners and patients. Our primary objective was to evaluate the concordance of practitioner and patient perceptions in terms of explanations regarding consultation, therapy, and patient satisfaction. The subjects were 250 practitioners and their 1250 patients in Fukuoka, Japan. Answers were obtained from 91 acupuncture practitioners (36.40%) and 407 patients (32.56%). Of these, responses from 125 pairs without missing values were used for the analysis. When practitioner–patient communication, as evaluated by the difference between the patients’ and the practitioners’ perceptions with respect to the level of practitioner explanation, was good, patient outcome (ie, satisfaction with therapy, improvement in health) was also good. Factors related to poor practitioner–patient communication included age of the practitioner, the number of practitioners at a clinic, the experience of the practitioner, and the age of the patient. These findings may be useful in improving practitioner–patient communication.

An interdisciplinary and collaborative initiative in palliative care research

The scale and complexity of palliative care increasingly demands that researchers move beyond their own discipline and explore interdisciplinary collaboration. At a Palliative Care Research Retreat held in January 2006 at the Toronto Sunnybrook Regional Cancer Centre, researchers from multiple care settings with the center and from other Toronto hospitals came together with the vision of becoming Canadian leaders in palliative care research. As a result of this retreat, five interdisciplinary groups were formed to pursue research in the areas of pain and symptom management, access to services, translational research, education, and communication. An overview of the retreat and direction of research for each group is provided.

Cultural evolution: implications for understanding the human language faculty and its evolution

Human language is unique among the communication systems of the natural world: it is socially learned and, as a consequence of its recursively compositional structure, offers open-ended communicative potential. The structure of this communication system can be explained as a consequence of the evolution of the human biological capacity for language or the cultural evolution of language itself. We argue, supported by a formal model, that an explanatory account that involves some role for cultural evolution has profound implications for our understanding of the biological evolution of the language faculty: under a number of reasonable scenarios, cultural evolution can shield the language faculty from selection, such that strongly constraining language-specific learning biases are unlikely to evolve. We therefore argue that language is best seen as a consequence of cultural evolution in populations with a weak and/or domain-general language faculty.

Communication and decision making about life-sustaining treatment: examining the experiences of resident physicians and seriously-ill hospitalized patients

BACKGROUND

Despite evidence-based recommendations for communication and decision making about life-sustaining treatment, resident physicians' actual practice may vary. Few prior studies have examined these conversations qualitatively to uncover why ineffective communication styles may persist.

OBJECTIVE

To explore how discussions about life-sustaining treatment occur and examine the factors that influence physicians' communicative practices in hopes of providing novel insight into how these processes can be improved. PARTICIPANTS AND APPROACH: We conducted and recorded 56 qualitative semi-structured interviews with participants from 28 matched dyads of a resident physician and a hospitalized patient or their surrogate decision maker with whom cardiopulmonary resuscitation was discussed. Transcripts were analyzed and coded using the constant comparative method to develop themes.

MAIN RESULTS

Resident physicians introduced decisions about resuscitation in a scripted, depersonalized and procedure-focused manner. Decision makers exhibited a poor understanding of the decision they were being asked to make and resident physicians often disagreed with the decision. Residents did not advocate for a particular course of action; however, the discussions of resuscitation were framed in ways that may have implicitly influenced decision making.

CONCLUSIONS

Residents' communication practices may stem from their attempt to balance an informed choice model of decision making with their interest in providing appropriate care for the patient. Physicians' beliefs about mandatory autonomy may be an impediment to improving communication about patients' choices for life-sustaining treatment. Redefining the role of the physician will be necessary if a shared decision making model is to be adopted.

Recent advances in shared decision making for mental health

PURPOSE OF REVIEW

Shared decision making (SDM) in nonmental health populations has documented positive services and health benefits. To advance integration of SDM into mental healthcare, researchers have outlined several priorities for future research. These include (1) clarifying the role of SDM in mental healthcare; (2) understanding patient and provider perspectives on SDM; (3) assessment of SDM practice in mental health settings; and (4) outcomes of SDM in mental health populations. This article will review recent advances in these areas.

RECENT FINDINGS

The current literature shows that SDM can play a role in the mental health treatment process from entry into care to recovery. Patients and providers find SDM acceptable and express a willingness to engage in SDM for reasons that are multifactorial. Barriers to SDM exist in mental health decision making including patient preferences and provider-level biases. Lastly, outcome research provides encouraging preliminary evidence for feasibility and effectiveness of SDM during the mental health encounter.

SUMMARY

Although there have not been a great number of SDM studies in mental health to date, the positive effects of SDM are comparable to those documented in general nonmental health patient groups, suggesting that future research has the potential to result in findings that are likely to be helpful for patients with psychiatric disorders.

Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment

CONTEXT

Talking about death can be difficult. Without evidence that end-of-life discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm.

OBJECTIVE

To determine whether end-of-life discussions with physicians are associated with fewer aggressive interventions.

DESIGN, SETTING, AND PARTICIPANTS

A US multisite, prospective, longitudinal cohort study of patients with advanced cancer and their informal caregivers (n = 332 dyads), September 2002-February 2008. Patients were followed up from enrollment to death, a median of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later.

MAIN OUTCOME MEASURES

Aggressive medical care (eg, ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients' mental health and caregivers' bereavement adjustment.

RESULTS

One hundred twenty-three of 332 (37.0%) patients reported having end-of-life discussions before baseline. Such discussions were not associated with higher rates of major depressive disorder (8.3% vs 5.8%; adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 0.54-3.32), or more worry (mean McGill score, 6.5 vs 7.0; P = .19). After propensity-score weighted adjustment, end-of-life discussions were associated with lower rates of ventilation (1.6% vs 11.0%; adjusted OR, 0.26; 95% CI, 0.08-0.83), resuscitation (0.8% vs 6.7%; adjusted OR, 0.16; 95% CI, 0.03-0.80), ICU admission (4.1% vs 12.4%; adjusted OR, 0.35; 95% CI, 0.14-0.90), and earlier hospice enrollment (65.6% vs 44.5%; adjusted OR, 1.65;95% CI, 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient quality of life (6.4 vs 4.6; F = 3.61, P = .01) and higher risk of major depressive disorder in bereaved caregivers (adjusted OR, 3.37; 95% CI, 1.12-10.13), whereas longer hospice stays were associated with better patient quality of life (mean score, 5.6 vs 6.9; F = 3.70, P = .01). Better patient quality of life was associated with better caregiver quality of life at follow-up (beta = .20; P = .001).

CONCLUSIONS

End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.

Affective forecasting: an unrecognized challenge in making serious health decisions

Patients facing medical decisions that will impact quality of life make assumptions about how they will adjust emotionally to living with health declines and disability. Despite abundant research on decision-making, we have no direct research on how accurately patients envision their future well-being and how this influences their decisions. Outside medicine, psychological research on "affective forecasting" consistently shows that people poorly predict their future ability to adapt to adversity. This finding is important for medicine, since many serious health decisions hinge on quality-of-life judgments. We describe three specific mechanisms for affective forecasting errors that may influence health decisions: focalism, in which people focus more on what will change than on what will stay the same; immune neglect, in which they fail to envision how their own coping skills will lessen their unhappiness; and failure to predict adaptation, in which people fail to envision shifts in what they value. We discuss emotional and social factors that interact with these cognitive biases. We describe how caregivers can recognize these biases in the clinical setting and suggest interventions to help patients recognize and address affective forecasting errors.

Empathy and life support decisions in intensive care units

BACKGROUND

Although experts advocate that physicians should express empathy to support family members faced with difficult end-of-life decisions for incapacitated patients, it is unknown whether and how this occurs in practice.

OBJECTIVES

To determine whether clinicians express empathy during deliberations with families about limiting life support, to develop a framework to understand these expressions of empathy, and to determine whether there is an association between more empathic statements by clinicians and family satisfaction with communication.

DESIGN

Multi-center, prospective study of audiotaped physician-family conferences in intensive care units of four hospitals in 2000-2002.

MEASUREMENTS

We audiotaped 51 clinician-family conferences that addressed end-of-life decisions. We coded the transcripts to identify empathic statements and used constant comparative methods to categorize the types of empathic statements. We used generalized estimating equations to determine the association between empathic statements and family satisfaction with communication.

MAIN RESULTS

There was at least one empathic statement in 66% (34/51) of conferences with a mean of 1.6 +/- 1.6 empathic statements per conference (range 0-8). We identified three main types of empathic statements: statements about the difficulty of having a critically ill loved one (31% of conferences), statements about the difficulty of surrogate decision-making (43% of conferences), and statements about the difficulty of confronting death (27% of conferences). Only 30% of empathic statements were in response to an explicit expression of emotion by family members. There was a significant association between more empathic statements and higher family satisfaction with communication (p = 0.04).

CONCLUSIONS

Physicians vary considerably in the extent to which they express empathy to surrogates during deliberations about life support, with no empathic statements in one-third of conferences. There is an association between more empathic statements and higher family satisfaction with communication.

Making fewer depression diagnoses: beneficial for patients?

Currently, general practitioners actively search for depressive disorders in their patients. When they diagnose 'depressive disorder', they tell their patients that they have a disease and can be treated accordingly. This is probably an important reason for the huge prescription rates of anti-depressants. In doing so, general practitioners implement specialised, psychiatric diagnostic methods in a setting characterised by patients with symptoms that superficially may resemble those of depressive disorder but in reality mainly arise from normal problems in everyday life due to losses of valued relations or failure to achieve desired goals. We argue that it might be beneficial for patients if general practitioners, in a stepped care approach, hold back on specialised methods of psychiatry and instead use a more generalist approach as first step, in which patients' problems are formulated in their own words, and efforts are directed in helping patients regain their self-confidence to solve them. Our arguments for directing attention away from diagnosing depressive disorder are: depressive disorder is a diagnosis by agreement and therefore relative, so there are other ways to look at problems than though psychiatric glasses; depression has unclear boundaries with other mental disorders and with normality; depression is often not an adequate summary of the real problems of the patient; the patient often has a very different conception about what is wrong and often does not agree with the proposed presence of a mental disorder; to diagnose depressive disorder may have more disadvantages than advantages for the patient;. the efficacy of anti-depressants is very modest.

Effectively using communication to enhance the provision of pediatric palliative care in an acute care setting

The capability of effectively communicating is crucial when providing palliative care, especially when the patient is a child. Communication among healthcare professionals with the child and family members must be clear, concise, and consistent. Use of a communication tool provides documentation for conversations, treatment plans, and specific desires related to care. This paper describes communication theory, portrays the use of this theory to develop a communication tool, and illustrates the use of this tool by multidisciplinary members of a healthcare team to provide pediatric palliative care.

In-office discussions of migraine: results from the American Migraine Communication Study

BACKGROUND

Research indicates that successful migraine assessment and treatment depends on information obtained during patient and healthcare professional (HCP) discussions. However, no studies outline how migraine is actually discussed during clinical encounters.

OBJECTIVE

Record naturally occurring HCP-migraineur interactions, analyzing frequency and impairment assessment, and preventive treatment discussions.

DESIGN

HCPs seeing high volumes of migraineurs were recruited for a communication study. Patients likely to discuss migraine were recruited immediately before their normally scheduled appointment and, once consented, were audio- and video-recorded without a researcher present. Separate post-visit interviews were conducted with patients and HCPs. All interactions were transcribed.

PARTICIPANTS

Sixty patients (83% female; mean age 41.7) were analyzed. Patients were diagnosed with migraine 14 years and experienced 5 per month, on average.

APPROACH

Transcripts were analyzed using sociolinguistic techniques such as number and type of questions asked and post-visit alignment on migraine frequency and impairment. American Migraine Prevalence and Prevention Study guidelines were utilized.

RESULTS

Ninety-one percent of HCP-initiated, migraine-specific questions were closed-ended/short answer; assessments focused on frequency and did not focus on attention on impairment. Open-ended questions in patient post-visit interviews yielded robust impairment-related information. Post-visit, 55% of HCP-patient pairs were misaligned regarding frequency; 51% on impairment. Of the 20 (33%) patients who were preventive medication candidates, 80% did not receive it and 50% of their visits lacked discussion of prevention.

CONCLUSIONS

Sociolinguistic analysis revealed that HCPs often used narrowly focused, closed-ended questions and were often unaware of how migraine affected patients' lives as a result. It is recommended that HCPs assess impairment using open-ended questions in combination with the ask-tell-ask technique.

Collaborative discourse facilitates efficient communication and new learning in amnesia

In previous work we reported robust collaborative learning for referential labels in patients with hippocampal amnesia, resulting in increasingly rapid and economical communication or "common ground" with their partners [Duff, M. C., Hengst, J., Tranel, D., & Cohen, N. J. (2006). Development of shared information in communication despite hippocampal amnesia. Nature Neuroscience, 9(1), 140-146]. The current paper reports the results of discourse analysis, describing the communicative resources and practices used in extended, repeated collaborative interactions, as partners successfully referenced the target cards, managed the task itself, and engaged in non-task talk. Although amnesic pairs showed a normal rate of reduction across trials in the number of words and time-to-completion, their communicative effort was higher overall, particularly the discourse associated with task management, they exhibited a general lack of flexibility in their referential expressions, and they showed a number of striking differences in use of personal and communal knowledge and of multiple perspectives. The interactive sessions provided a potent learning environment, but also a very challenging task in the face of memory impairment. The results give insight into the acquisition of common ground and the manner in which amnesic patients accommodate their memory deficits during real-world interactions, and they have significant implications for memory intervention.

Understanding healing relationships in primary care

PURPOSE

Clinicians often have an intuitive understanding of how their relationships with patients foster healing. Yet we know little empirically about the experience of healing and how it occurs between clinicians and patients. Our purpose was to create a model that identifies how healing relationships are developed and maintained.

METHODS

Primary care clinicians were purposefully selected as exemplar healers. Patients were selected by these clinicians as having experienced healing relationships. In-depth interviews, designed to elicit stories of healing relationships, were conducted with patients and clinicians separately. A multidisciplinary team analyzed the interviews using an iterative process, leading to the development of case studies for each clinician-patient dyad. A comparative analysis across dyads was conducted to identify common components of healing relationships

RESULTS

Three key processes emerged as fostering healing relationships: (1) valuing/creating a nonjudgmental emotional bond; (2) appreciating power/consciously managing clinician power in ways that would most benefit the patient; and (3) abiding/displaying a commitment to caring for patients over time. Three relational outcomes result from these processes: trust, hope, and a sense of being known. Clinician competencies that facilitate these processes are self-confidence, emotional self-management, mindfulness, and knowledge.

CONCLUSIONS

Healing relationships have an underlying structure and lead to important patient-centered outcomes. This conceptual model of clinician-patient healing relationships may be generalizable to other kinds of healing relationships.

A longitudinal medical Spanish program at one US medical school

INTRODUCTION

Policymakers have recommended recruiting or training (or both) more US physicians who can provide care in Spanish. Few longitudinal medical Spanish programs have been described and evaluated.

OBJECTIVE

This study aims to describe development and evaluation of the preclinical phase of a 4-y program designed to graduate physicians who can provide language-concordant care in Spanish.

SETTING

Study was done in one public medical school in southeastern USA.

PROGRAM DESCRIPTION

The program targeted intermediate/advanced Spanish speakers. Standardized fluency assessments were used to determine eligibility and evaluate participants' progress. Curriculum included didactic coursework, simulated patients, socio-cultural seminars, clinical skills rotations at sites serving Latinos, service-learning, and international immersion.

PROGRAM EVALUATION

For the first two cohorts (n = 45) qualitative evaluation identified program improvement opportunities and found participants believed the program helped them maintain their Spanish skills. Mean interim (2-y) speaking proficiency scores were unchanged from baseline: 9.0 versus 8.7 at baseline on 12-point scale (p = 0.15). Mean interim listening comprehension scores (second cohort only, n = 25) increased from a baseline of 77 to 86% (p = 0.003). Proportions "passing" the listening comprehension test increased from 72 to 92% (p = 0.06).

DISCUSSION

We describe development of a longitudinal Spanish program within a medical school. Participation was associated with improved Spanish listening comprehension and no change in speaking proficiency.

A framework for health numeracy: how patients use quantitative skills in health care

Our objective of this study is to develop a conceptual framework for the construct of health numeracy based on patient perceptions, using a cross-sectional, qualitative design. Interested participants (n=59) meeting eligibility criteria (age 40-74, English speaking) were assigned to one of six focus groups stratified by gender and educational level (low, medium, high). Fifty-three percent were male, and 47% were female. Sixty-one percent were white non-Hispanic, and 39% were of minority race or ethnicity. Participants were randomly selected from three primary care sites associated with an academic medical center. Focus group discussions were held in May 2004 and focused on how numbers are used in the health care setting. Data were presented from clinical trials to further explore how quantitative information is used in health communication and decision making. Focus groups were audio and videotaped; verbatim transcripts were prepared and analyzed. A framework of health numeracy was developed to reflect the themes that emerged. Three broad conceptual domains for health numeracy were identified: primary numeric skills, applied health numeracy, and interpretive health numeracy. Across domains, results suggested that numeracy contains an emotional component, with both positive and negative affect reflected in patient numeracy statements. We conclude that health numeracy is a multifaceted construct that includes applied and interpretive components and is influenced by patient affect.

A tool to teach communication skills to pharmacy students

OBJECTIVE

To develop a tool to teach pharmacy students assertive communication skills to use when talking with physicians over the telephone.

DESIGN

As an assignment for their Communication Skills and Counseling course, students were asked to write a script involving a patient care issue or problem covering 3 different communication styles that could be used when contacting a prescriber by telephone: passive, aggressive, and assertive. Students worked in groups to write and act out the scripts for the class.

ASSESSMENT

Eight scripts were developed by students and rated by peers and faculty members. The script that received the highest ratings was used in the development of a multimedia educational CD.

CONCLUSION

The development of hypothetical scripts describing a drug therapy problem and illustrating the types of interactions between physicians and pharmacists while discussing the problem allowed pharmacy students to explore different communication techniques and improve their communication skills.

Being Lister: ethos and Victorian medical discourse

Stylistic analysis and rhetorical theory are used in this study to inform our understanding of impediments to the successful uptake of a new medical idea. Through examination of the work of the Victorian surgeon Joseph Lister, who was described by one biographer as suffering from "stylistic ham-handedness", the study provides insights into the difficulty that Lister had in explaining his theory of antiseptic surgery. Using three comparisons-Lister's scientific style in public discourse with that of his students, and Lister's scientific style in private discourse with those of both a surbordinate and a superior-the study suggests that the rhetorical concept of ethos played a major role in his communication difficulties. In this way, it presents a more nuanced perspective on modern presentations of "model" communications versus communication failures: that is, that problematic written discourse offers as useful a heuristic device as does exemplary discourse.

Saving the best for last: how adults treat social partners of different ages

Older adults report more positive feelings and fewer problems in their relationships than do younger adults. These positive experiences may partially reflect how people treat older adults. Social partners may treat older adults more kindly due to their sense that time remaining to interact with these older adults is limited. Younger (n = 87, age 22 to 35) and older (n = 89, age 65 to 77) participants indicated how positively they would behave (i.e., express affection, proffer respect, send sentimental cards) and what types of conflict strategies they would use in response to hypothetical negative interactions with two close social partners, a younger adult and an older adult. Multilevel models revealed that participants were more avoidant and less confrontational when interacting with older adults than when interacting with younger adults. Time perspective of the relationship partially mediated these age differences. Younger and older participants were also more likely to select sentimental cards for older partners than for younger partners. Findings build on socioemotional selectivity theory and the social input model to suggest that social partners facilitate better relationships in late life.

Engagement in multiple steps of the advance care planning process: a descriptive study of diverse older adults

OBJECTIVES

To assess engagement in multiple steps of the advance care planning (ACP) process 6 months after exposure to an advance directive. In this study, ACP is conceptualized similarly to the behavior change model.

DESIGN

Descriptive study.

SETTINGS

County general medicine clinic in San Francisco.

PARTICIPANTS

One hundred seventy-three English or Spanish speakers, aged 50 and older (mean 61) given a standard (12th-grade reading level) and an easy-to-read (5th-grade reading level) advance directive.

MEASUREMENTS

Six months after exposure to two advance directives, self-reported ACP contemplation; discussions with family, friends discussions with clinicians; and documentation were measured. Associations were examined between ACP steps and between subject characteristics ACP engagement.

RESULTS

Most participants (73%) were nonwhite and 31% had less than a high school education. Sixty-one percent contemplated ACP, 56% discussed ACP with family or friends, 22% discussed ACP with clinicians, and 13% documented ACP wishes. Subjects who had discussed ACP with their family or friends were more likely to discuss ACP with their clinicians (36% vs 2%, P<.001) and document ACP wishes (18% vs 4%, P=.009) than those who had not. Latinos and subjects with less than a high school education discussed ACP more often with family or friends (P<.06) and clinicians (P<.03) than other ethnic groups and subjects with more education.

CONCLUSIONS

ACP involves distinct steps including contemplation, discussions, and documentation. The ACP paradigm should be broadened to include contemplation and discussions. Promoting discussions with family and friends may be one of the most important targets for ACP interventions, and literacy- and language-appropriate advance directives may help reverse patterns of sociodemographic disparities in ACP.

Can contextualization increase understanding during man-machine communication? A theory-driven study

The Internet offers unlimited possibilities for finding health information. However, the user is often faced with the problem of understanding it. Contextualization has a role to play in enhancing the user’s comprehension. We report on a study which addresses this issue, using a theoretical model of communication whose central theme is that of context. A randomized controlled experimental design was chosen, using as a test-bed the website SeniorGezond we had previously developed. The study was composed of a pre-test, the intervention with the website and a post-test. Participants (n=40) were randomly assigned to exposure or no exposure to contextualization with the website. Results show that contextualization increases understanding for non-knowledgeable users. Furthermore, the participant’s cognitive style was found to be a significant factor on understanding. We also found that participants bring their own contexts such as social context and psychological context to support their understanding.

Knowledge, Perceptions, and Communication about Colorectal Cancer Screening among Chinese American Primary Care Physicians

Objective

To assess Chinese American primary care physicians' knowledge, attitude, and barriers to recommending colorectal cancer (CRC) screening to their Chinese American patients.

Methods

Chinese American primary care physicians serving Chinese American patients in two metropolitan areas were invited to complete a mailed survey on CRC screening knowledge, attitudes toward shared decision making and CRC screening, and CRC screening recommendation patterns.

Results

About half of the 56 respondents did not know CRC incidence and mortality figures for Chinese Americans. Those aged 50 and younger, graduating from U.S. medical schools, or working in non-private settings had higher knowledge scores (p < 0.01). Physicians graduating from U.S. medical schools had more favorable attitudes toward shared decision making (p < 0.01). Lack of health insurance, inconsistent guidelines, and insufficient time were the most frequently cited barriers to recommending CRC screening.

Conclusions

Most Chinese American physicians had knowledge, attitude, and communication barriers to making optimal CRC screening recommendations.

Reducing diagnostic errors through effective communication: harnessing the power of information technology

Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps. We describe a comprehensive framework that integrates the potential sources of communication breakdowns within the diagnostic process and identifies vulnerable steps in the diagnostic process where various types of communication breakdowns can precipitate error. We then discuss potential information technology-based interventions that may have efficacy in preventing one or more forms of these breakdowns. These possible intervention strategies include using new technologies to enhance communication between health providers and health systems, improve patient involvement, and facilitate management of information in the medical record.

"It's not what you say ...": racial disparities in communication between orthopedic surgeons and patients

BACKGROUND

Excellent communication between surgeons and patients is critical to helping patients to make informed decisions and is a key component of both high quality of care and patient satisfaction. Understanding racial disparities in communication is essential to provide quality care to all patients.

OBJECTIVE

To examine the content and process of informed decision-making (IDM) between orthopedic surgeons and elderly white versus African American patients. To assess the association of race and patient satisfaction with surgeon communication.

RESEARCH DESIGN

Analysis of audiotape recordings of office visits between orthopedic surgeons and patients.

PARTICIPANTS

Eighty-nine orthopedic surgeons and 886 patients age 60 years or older in Chicago, Illinois.

METHODS

Tapes were analyzed by coders for content using 9 elements of IDM and for process using 4 global ratings of the relationship-building component of communication (responsiveness, respect, listening, and sharing). Ratings by race were compared using chi analysis. Patients completed a questionnaire rating satisfaction with surgeon communication and the visit overall. Logistic analysis was used to assess the effect of race on satisfaction.

RESULTS

Overall there were practically no significant differences in the content of the 9 IDM elements based on race. However, coder ratings of relationship were higher on 3 of 4 global ratings (responsiveness, respect, and listening) in visits with white patients compared with African American patients (P < 0.01). Patient ratings of communication and overall satisfaction with the visit were significantly higher for white patients.

CONCLUSIONS

The content of IDM conversations does not differ by race. Yet differences in the process of relationship building and in patient satisfaction ratings were clearly present. Efforts to enhance cultural communication competence of surgeons should emphasize the skills of building relationships with patients in addition to the content of IDM.

Patients' beliefs and preferences regarding doctors' medication recommendations

BACKGROUND

An estimated 20-50% of patients do not take medications as recommended. Accepting a doctor's recommendation is the first step in medication adherence, yet little is known about patients' beliefs and preferences about how medications are prescribed.

OBJECTIVE

To explore patients' beliefs and preferences about medication prescribing to understand factors that might affect medication adherence.

METHODS

Fifty members from 2 health plans in Massachusetts participated in in-depth telephone interviews. Participants listened to an audio-vignette of a doctor prescribing a medication to a patient and were asked a series of questions related to the vignette. Responses were reviewed in an iterative process to identify themes related to participants' beliefs and preferences about medication prescribing.

RESULTS

Participants' beliefs and preferences about medication prescribing encompassed 3 major areas: patient-doctor relationships, outside influences, and professional expertise. Important findings included participants' concerns about the pharmaceutical industry's influence on doctors' prescribing practices and beliefs that there is a clear "best" medication for most health problems.

CONCLUSIONS

Patients' beliefs and preferences about medication prescribing may affect medication adherence. Additional empiric studies that explore whether doctors' relationships with pharmaceutical representatives impact medication adherence by affecting trust are indicated. In addition, it would be worthwhile to explore whether discussions between patients and doctors regarding equipoise (no clear scientific evidence for 1 treatment choice over another) affect medication adherence.

Children in chronic pain: promoting pediatric patients' symptom accounts in tertiary care

This paper examines how clinicians promote pediatric patients' symptom accounts at the beginning of visits in three pediatric tertiary care clinics at a university hospital in the United States: pain, gastroenterology and neurology. Quantitative and qualitative data were collected for 69 patient-parent pairs, including videotaped intake visits. Two forms of child account promotion, together with their corresponding distribution across clinics, were identified: (1) Epistemic prefaces were used to upgrade the patient's epistemic status and to establish the child as primary informant; and, (2) non-focused questioning was used to permit children latitude in the formulation of symptoms and experiences. In general, epistemic prefaces were characteristic of the gastroenterology and neurology visits, while non-focused questioning was found overwhelmingly in the pain encounters.

Medication use in the transition from hospital to home

After hospital discharge, correct understanding and use of medications are key components of patient safety. The current discharge process does not provide adequate fail-safes to ensure quality post-discharge care. This often leads to preventable medication errors as well as nonadherence. Several barriers to successful discharge counselling, including use of medical jargon, lack of educational and administrative resources, time constraints, and low health literacy, contribute to ineffective communication between hospital physicians and patients. Other obstacles include inaccurate or incomplete documentation of the medication history, lack of social support, financial constraints, and poor transfer of information to outpatient physicians. Solutions to improve medication use in the transition period after hospital discharge require effective communication with patients through the use of easily understood language, highlighting key information, and ensuring patient comprehension through the "teach back" technique. More timely communication with outpatient physicians in addition to a more comprehensive transfer of information further facilitates the transition home. Finally, a systematic process of medication reconciliation also aids in decreasing the incidence of medication errors. Hospital-based physicians who attend to key details in the process of discharging patients can have a profound impact on improving medication adherence, avoiding medication errors, and decreasing adverse outcomes in the post-discharge period.

Acute myocardial infarction length of stay and hospital mortality are not associated with language preference

BACKGROUND

Language barriers between patients and providers may influence the process and quality of care.

OBJECTIVE

To examine the association of language preference with length of stay (LOS) and in-hospital mortality for patients admitted for acute myocardial infarction (AMI).

DESIGN, SETTING, AND PARTICIPANTS

Electronic administrative hospital discharge data for all non-disabled Medicaid beneficiaries age 35 years and older admitted to all acute care California hospitals with a diagnosis of AMI between 1994 and 1998.

METHODS

We used multivariate regression to explore whether observed differences in the hospital LOS and in-hospital mortality between non-English preference (NEP) and English preference (EP) individuals could be explained by individual and/or hospital level factors. We adjusted for patient level characteristics using 24 covariates from a previously validated prediction model of mortality after hospitalization for AMI.

RESULTS

Of 12,609 Medicaid patients across 401 California hospitals, 2,757 (22%) had NEP. NEP was associated with a 3.9% increased LOS (95% CI 0.7, 7.1; p = 0.02) in unadjusted analysis and a 3.8% increased LOS (95% CI 0.3, 7.3; p = 0.03) after controlling for patient level characteristics. Differences in LOS were no longer significant after adjusting receipt of cardiac procedure/ surgery (2.8%; 95% CI -0.6, 6.2; p = 0.1) or after adjusting for hospital (0.9%; 95% CI -2.5, 4.3; p = 0.6). Non-English language preference was associated with lower in-hospital mortality in unadjusted analysis (odds ratio [OR] = 0.80; 95% CI 0.69, 0.94; p = 0.005), but was not significant after adjusting for patient level characteristics (adjusted OR [AOR] 0.95; 95% CI 0.78, 1.27; p = 0.6). Adjusting for receipt of cardiac procedure/ surgery (AOR 0.97; 95% CI 0.79, 1.18; p = 0.7) and hospital (AOR 0.97; 95% CI 0.78; 1.21; p = 0.8) did not alter this finding.

CONCLUSIONS

Language preference is not associated with AMI mortality, and the small increase in length of stay associated with non-English preference is accounted for by hospital level factors. Our results suggest that system level differences are important to consider in studies of the effect of language barriers in the health care setting.

Relationship between stuttering severity in children and their mothers speaking rate

CONTEXT AND OBJECTIVE

Stuttering is a complex disease that influences occupational, social, academic and emotional achievements. The aim of this study was to correlate the stuttering severity index with speaking rates of mothers and children.

DESIGN AND SETTING

Cross-sectional study, at the child rehabilitation clinics of Tehran city.

METHODS

35 pairs of mothers and their children who stuttered were studied. There were 29 boys and six girls, of mean age 8.5 years (range: 5.1-12.0). Speech samples from the mother-child pairs were audiotaped for approximately 15 minutes, until a reciprocal verbal interaction had been obtained. This sample was then analyzed in accordance with a stuttering severity index test and speaking rate parameters.

RESULTS

The research results outlined a significant relationship between the mothers speaking rate and their childrens stuttering severity.

CONCLUSION

The results suggest that the mothers speaking rate should be incorporated in the assessment and treatment of stuttering.

Cancer and communication in the health care setting: experiences of older Vietnamese immigrants, a qualitative study

BACKGROUND

As patients grow older, accurate communication with health care providers about cancer becomes increasingly important. However, little is known about the cancer communication experiences of older Asian immigrants.

OBJECTIVE

To learn about the cancer-related communication experiences of older Vietnamese immigrants from the insider perspective.

DESIGN

Qualitative study (grounded theory, constant comparative method) using individual interviews with older Vietnamese immigrants with the purpose of discussing how they learn about cancer. Interviews were conducted in Vietnamese.

PARTICIPANTS

Vietnamese immigrants aged 50-70 years, recruited through community-based organizations. Most had low education and limited English proficiency. The sample size of 20 was sufficient to achieve theoretical saturation.

RESULTS

We identified 3 categories of themes concerning informants' experiences with cancer communication in the health care setting: (1) attitudes about addressing screening with providers, (2) issues/problems communicating with physicians about cancer, and (3) language/translation difficulties. There was substantial overlap between informants who mentioned each theme category, and 40% of the participants mentioned all 3 categories.

CONCLUSION

Clinicians should be aware of and act upon specific cancer communication needs/challenges of their older immigrant patients. Moreover, health care systems need to be prepared to address the needs of an increasingly multiethnic and linguistically diverse patient population. Finally, community-level interventions should address baseline knowledge deficits while encouraging immigrant patients to engage their doctors in discussions about cancer screening.