Assessing communication skills of clinical call handlers working at an out-of-hours centre: development of the RICE rating scale

BACKGROUND

Out-of-hours centres provide telephone support to patients with medical problems. In most of these centres specially-trained nurses handle incoming telephone calls. They assess patients' needs, the degree of urgency, and determine the level of care required. Assessment of the medical problem and the quality of 'care-by-phone' depend on the medical and communication skills of the call handlers.

AIM

To develop a valid, reliable, and practical rating scale to evaluate the communication skills of call handlers working at an out-of-hours centre and to improve quality of communication.

DESIGN OF STUDY

Qualitative study with focus groups followed by validation of the rating scale and measurement of reliability (internal consistency).

SETTING

Out-of-hours centres in the Netherlands.

METHOD

A focus group developed the rating scale. Experts with experience in training and evaluating communication skills of medical students and GPs commented on the scale to ensure content validity. The reliability of the rating scale was tested in a pilot in which ten specially-trained assessors scored six telephone calls each.

RESULTS

The scale, known as the RICE rating scale, has 17 items divided over four different phases of the telephone consultation: Reason for calling; Information gathering; Conclusion; and Evaluation (RICE). Content validity of the scale was assessed by two experts. Reliability of the scale tested in the pilot was 0.73 (Cronbach's alpha).

CONCLUSION

Establishing a rating scale to assess the communication skills of call handlers which meets common scientific demands, such as content validity and reliability, proved successful. This instrument can be used to give feedback to call handlers.

Knowledge exchange for Attention Deficit Hyperactivity Disorder Research: an integrated evidence and knowledge exchange framework leading to more effective research dissemination practices

INTRODUCTION

Knowledge Exchange refers to activities that help to create and support the conditions and culture that lead to the most effective access, implementation, utilization, and evaluation of the most credible evidence for improved mental health outcomes for children and youth in Ontario. Although knowledge exchange and associated concepts such as knowledge transfer and translation are increasingly well developed in other aspects of health and healthcare, it is underdeveloped in mental health generally. This paper introduces some of the basic concepts of knowledge exchange and calls for more development of knowledge exchange in the area of Attention Deficit Hyperactivity Disorder Research.

METHODS

This is a discussion paper that presents a general overview of the Centre's approach to knowledge exchange. It links the discussion to related concepts and to the need to overcome the research to practice gap. The Integrated Evidence and Knowledge Exchange Framework of the Provincial Centre of Excellence for Child and Youth Mental Health is introduced. Areas of active development in knowledge exchange are categorized into three objectives: context, content, and capacity.

RESULTS

The use of an Integrated Evidence and Knowledge Exchange Framework for the Centre's Grants and Awards program activities and evaluation has begun to explicitly and transparently link the evidence on effective knowledge exchange with the evidence on effective treatment for children and youth with mental health difficulties including ADHD. This framework is expected to produce greater transparency as well as improved attainment of outputs, outcomes, and impacts of these grants and awards in child and youth mental health.

CONCLUSIONS

Knowledge exchange activities may reduce the confusion for parents & care-givers, practitioners, researchers, and administrators, seeking the most credible data, information and knowledge about the most effective treatments for ADHD. An active process that seeks to improve knowledge exchange for ADHD is needed.

Getting back to the rough ground: deception and 'social living'

At the heart of the social intelligence hypothesis is the central role of 'social living'. But living is messy and psychologists generally seek to avoid this mess in the interests of getting clean data and cleaner logical explanations. The study of deception as intelligent action is a good example of the dangers of such avoidance. We still do not have a full picture of the development of deceptive actions in human infants and toddlers or an explanation of why it emerges. This paper applies Byrne & Whiten's functional taxonomy of tactical deception to the social behaviour of human infants and toddlers using data from three previous studies. The data include a variety of acts, such as teasing, pretending, distracting and concealing, which are not typically considered in relation to human deception. This functional analysis shows the onset of non-verbal deceptive acts to be surprisingly early. Infants and toddlers seem to be able to communicate false information (about themselves, about shared meanings and about events) as early as true information. It is argued that the development of deception must be a fundamentally social and communicative process and that if we are to understand why deception emerges at all, the scientist needs to get 'back to the rough ground' as Wittgenstein called it and explore the messy social lives in which it develops.

Cooperation and human cognition: the Vygotskian intelligence hypothesis

Nicholas Humphrey's social intelligence hypothesis proposed that the major engine of primate cognitive evolution was social competition. Lev Vygotsky also emphasized the social dimension of intelligence, but he focused on human primates and cultural things such as collaboration, communication and teaching. A reasonable proposal is that primate cognition in general was driven mainly by social competition, but beyond that the unique aspects of human cognition were driven by, or even constituted by, social cooperation. In the present paper, we provide evidence for this Vygotskian intelligence hypothesis by comparing the social-cognitive skills of great apes with those of young human children in several domains of activity involving cooperation and communication with others. We argue, finally, that regular participation in cooperative, cultural interactions during ontogeny leads children to construct uniquely powerful forms of perspectival cognitive representation.

Maxillary herpes zoster with corneal involvement in a HIV positive pregnant woman

Corneal involvement in maxillary herpes zoster is very rare. This report presents the case of a 32 years old 7 months pregnant para2+1 female, who presented with vesiculopapular rashes with hyperpigmented crusts over the maxillary area of the face on the left side with periocular oedema, conjunctivitis and mild punctate keratitis in the left eye. She was HIV positive and was on treatment with the highly active antiretroviral therapy. She was treated with topical and systemic acyclovir with rapid resolution of the ocular features.

Jazz and the 'art' of medicine: improvisation in the medical encounter

Improvisation is an important aspect of patient-physician communication. It is also a defining feature of jazz music performance. This essay uses examples from jazz to illustrate principles of improvisation that relate to an individual communication act (ie, building space into one's communication), a physician's communicative style (ie, developing one's voice), and the communicative process of the medical encounter (ie, achieving ensemble). At all 3 levels, the traditions of jazz improvisation can inform efforts to research and teach medical interviewing by fostering a contextualized view of patient-physician communication.

Patient access to U.S. physicians who conduct internet or e-mail consults

BACKGROUND

E-mail communication has the potential to improve communication between patients and doctors.

OBJECTIVE

The objective of the study is to describe the access of patients to physicians who conduct e-mail consults.

METHODS

We analyzed data from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative cross-sectional survey of office-based physician visits, in 2001, 2002, and 2003. The main outcome measure was the percentage of visits to a provider who reported doing internet or e-mail consults.

RESULTS

There was fewer than 1 in 10 outpatient visits in 2001 (9.2%) to physicians who reported doing internet or e-mail consults, and this did not increase in 2002 (5.8%) or 2003 (5.5%). Access to these physicians was greater among patients who were male, nonminority, lived in the Western United States, seen for pre-/postoperative care, seen by a primary care provider, and not seen by a nurse during their visit. Access to physicians who conducted internet or e-mail consults was independent of other patient (e.g., chronic conditions), provider (e.g., office setting), and visit (e.g., medications prescribed) characteristics.

CONCLUSIONS

Access to physicians who do internet or e-mail consults is generally low and did not increase between 2001 and 2003, despite growth in internet access and in other internet-related activities.

Being lesbian--does the doctor need to know?

BACKGROUND

A lesbian woman will have to choose whether to disclose or not in every new encounter, including when consulting her general practitioner (GP). She may fear a negative reaction in the doctor, based on knowledge of marginalization and prejudice of homosexuals throughout history.

OBJECTIVES

To explore patients' experiences concerning disclosure of their lesbian orientation to general practitioners (GPs), focusing on why they find it important, and what GPs can do to promote disclosure.

METHODS

One group interview was conducted, audiotaped, and transcribed verbatim. Qualitative analysis was conducted by systematic text condensation inspired by Giorgi's phenomenological approach. Six women aged 28-59 years, who self-identified as lesbian, were recruited through a web-based, publicly accessible network for research on homosexuality. Main outcome measures. Accounts of experiences where the patient thought that information of a lesbian sexual orientation was of importance in the consultation with a GP.

RESULTS

Disclosure can imply information of medical relevance, explain circumstances, and generate a feeling of being seen as one's true self. The intentional use of common consultation techniques may facilitate disclosure.

CONCLUSION

Lesbian patients may want to disclose their sexual orientation to the general practitioner but they experience certain barriers. These can be overcome when the GP provides an open and permissive context. GPs can benefit from knowledge concerning sexual orientation in their work with lesbian patients.

Genetic counseling communication with an African American BRCA1 kindred

We studied communication in genetic counseling sessions conducted with an African American, Breast Cancer 1, Early Onset (BRCA1) kindred in the USA. The Roter Interaction Analysis System (RIAS) was used to code and compare two sessions of 46 participants (26 females and 20 males) before and after they underwent genetic testing. Three certified genetic counselors and one medical geneticist conducted the sessions. When compared to pre-test communication, most of the providers' post-test communication was devoted to the provision of biomedical information (including screening recommendations) with fewer questions and psychosocial statements. Clients contributed a similar proportion to the total session dialogue in pre- and post-test sessions (40%). A larger proportion of their post-test session was devoted to indicating receptiveness to provider information than in the pre-test session. We found when providers were informing clients that they were BRCA1 mutation carriers, they provided more biomedical and psychosocial information and asked more psychosocial questions than when talking with non-carriers. This study provides the first description of genetic counseling communication for pre- and post-test BRCA1 sessions with African American individuals.

A headache at the end of the day

This essay presents a family medicine office visit with a child and both parents; details have been modified to protect patient and physician confidentiality. A child's headache, which has gone away before the start of the office visit, provides a window into the relationship between the parents and into the sources of their worries about their child's health. The essay highlights the multiple medical and behavioral concerns that the physician must keep in mind during relatively brief office encounters, and the intellectual challenge of maintaining appropriate attention to all these threads, and understanding their interactions, while completing the visit in a timely fashion.

Correlated evolution between hearing sensitivity and social calls in bats

Echolocating bats are auditory specialists, with exquisite hearing that spans several octaves. In the ultrasonic range, bat audiograms typically show highest sensitivity in the spectral region of their species-specific echolocation calls. Well-developed hearing in the audible range has been commonly attributed to a need to detect sounds produced by prey. However, bat pups often emit isolation calls with low-frequency components that facilitate mother-young reunions. In this study, we examine whether low-frequency hearing in bats exhibits correlated evolution with (i) body size; (ii) high-frequency hearing sensitivity or (iii) pup isolation call frequency. Using published audiograms, we found that low-frequency hearing sensitivity is not dependent on body size but is related to high-frequency hearing. After controlling for high-frequency hearing, we found that low-frequency hearing exhibits correlated evolution with isolation call frequency. We infer that detection and discrimination of isolation calls have favoured enhanced low-frequency hearing because accurate parental investment is critical: bats have low reproductive rates, non-volant altricial young and must often identify their pups within large crèches.

Are birth-preparedness programmes effective? Results from a field trial in Siraha district, Nepal

The birth-preparedness package (BPP) promotes active preparation and decision-making for births, including pregnancy/postpartum periods, by pregnant women and their families. This paper describes a district-wide field trial of the BPP implemented through the government health system in Siraha, Nepal, during 2003-2004. The aim of the field trial was to determine the effectiveness of the BPP to positively influence planning for births, household-level behaviours that affect the health of pregnant and postpartum women and their newborns, and their use of selected health services for maternal and newborn care. Community health workers promoted desired behaviours through inter-personal counselling with individuals and groups. Content of messages included maternal and newborn-danger signs and encouraged the use of healthcare services and preparation for emergencies. Thirty-cluster baseline and endline household surveys of mothers of infants aged less than one year were used for estimating the change in key outcome indicators. Fifty-four percent of respondents (n=162) were directly exposed to BPP materials while pregnant. A composite index of seven indicators that measure knowledge of respondents, use of health services, and preparation for emergencies increased from 33% at baseline to 54% at endline (p=0.001). Five key newborn practices increased by 19 to 29 percentage points from baseline to endline (p values ranged from 0.000 to 0.06). Certain key maternal health indicators, such as skilled birth attendance and use of emergency obstetric care, did not change. The BPP can positively influence knowledge and intermediate health outcomes, such as household practices and use of some health services. The BPP can be implemented by government health services with minimal outside assistance but should be comprehensively integrated into the safe motherhood programme rather than implemented as a separate intervention.

Adolescent girls' communication with "mothers" about topical microbicides

STUDY OBJECTIVE

Topical microbicides, a female-initiated method to protect against sexually transmitted infections (STI) and pregnancy, will only be effective if found acceptable. Mothers may have an influence on acceptability and use among adolescent girls. The current study examined the communication between girls and mothers to understand the potential predictors and nature of conversations regarding surrogate microbicide products.

DESIGN

Sexually experienced girls, 14 to 21 years, were recruited for a 6-month study examining microbicide acceptability. During face-to-face interviews, qualitative data were collected regarding communication between girls and mothers. Two independent raters coded the responses, which were organized into themes. Themes were interpreted according to the conceptual understanding of mother-daughter communication.

RESULTS

Fifty percent of the 171 girls with codable responses had a conversation with their mother. Higher levels of indirect parental monitoring were related to being more likely to have a conversation. Concrete events related to the study (i.e. receiving phone call from the researcher, having an appointment, or seeing the product) or inquiries by mothers appeared to promote conversation. Barriers to conversation included the private nature of the information and relationship issues between the mother and daughter. Conversations often addressed issues related to girls' participation in the study, although some conversations included global issues related to sexuality.

CONCLUSIONS

Girls may talk to their mothers about new products for STI prevention, and such conversations may provide opportunities to promote use.

Types of information physicians provide when prescribing antidepressants

BACKGROUND

Providing antidepressant information to patients may foster greater adherence to therapy.

OBJECTIVE

To assess physician information-giving while prescribing antidepressants, and to identify factors that influence the provision of information.

DESIGN

Randomized experiment using standardized patients (SPs). Standardized patients roles were generated by crossing 2 clinical conditions (major depression or adjustment disorder) with 3 medication request types (brand-specific, general, or none).

PARTICIPANTS

One hundred and fifty-two general internists and family physicians recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%.

MEASUREMENTS

We assessed physician information-giving by analyzing audio-recordings of interactions between physicians and SPs, and collected physician background information by survey. Generalized estimating equations were used to examine the influence of patient and physician factors on physicians' provision of information.

RESULTS

One hundred and one physicians prescribed antidepressants, accounting for 131 interactions. The mean age of physicians was 46.3 years; 69% were males. Physicians mentioned an average of 5.7 specific topics of antidepressant-related information (of a possible maximum of 11). The most frequently mentioned topic was purpose (96.1%). Physicians infrequently provided information about the duration of therapy (34.9%) and costs (21.4%). Standardized patients who presented with major depression received less information than those with adjustment disorder, and older and solo/private practice physicians provided significantly less information to SPs.

CONCLUSIONS

Physicians provide limited information to patients while prescribing antidepressants, often omitting critical information that may promote adherence. Mechanisms are needed to ensure that patients receive pertinent antidepressant information.

Measuring communicative participation: a review of self-report instruments in speech-language pathology

PURPOSE

To assess the adequacy of self-report instruments in speech-language pathology for measuring a construct called communicative participation.

METHOD

Six instruments were evaluated relative to (a) the construct measured, (b) the relevance of individual items to communicative participation, and (c) their psychometric properties.

RESULTS

No instrument exclusively measured communicative participation. Twenty-six percent (n = 34) of all items (N = 132) across the reviewed instruments were consistent with communicative participation. The majority (76%) of the 34 items were associated with general communication, while the remaining 24% of the items were associated with communication at work, during leisure, or for establishing relationships. Instruments varied relative to psychometric properties.

CONCLUSIONS

No existing self-report instruments in speech-language pathology were found to be solely dedicated to measuring communicative participation. Developing an instrument for measuring communicative participation is essential for meeting the requirements of our scope of practice.

BiDil: assessing a race-based pharmaceutical

Isosorbide and hydralazine in a fixed-dose combination (BiDil) has provoked controversy as the first drug approved by the Food and Drug Administration marketed for a single racial-ethnic group, African Americans, in the treatment of congestive heart failure. Family physicians will be better prepared to counsel their patients about this new drug if they understand a number of background issues. The scientific research leading to BiDil's approval tested the drug only in African American populations, apparently for commercial reasons, so the drug's efficacy in other populations is unknown. Race as a biological-medical construct is increasingly controversial; BiDil offers a good example of how sociocultural factors in disease causation may be overlooked as a result of an overly simplistic assumption of a racial and hence presumed genetic difference. Past discrimination and present disparities in health care involving African American patients are serious concerns, and we must welcome a treatment that promises to benefit a previously underserved group; yet the negative aspects of BiDil and the process that led to its discovery and marketing set an unfortunate precedent. Primary care physicians should be aware of possible generic equivalents that will affect the availability of this drug for low-income or uninsured patients.

Communication between South Asian patients and GPs: comparative study using the Roter Interactional Analysis System

BACKGROUND

The UK South Asian population has poorer health outcomes. Little is known about their process of care in general practice, or in particular the process of communication with GPs.

AIM

To compare the ways in which white and South Asian patients communicate with white GPs.

DESIGN OF STUDY

Observational study of video-recorded consultations using the Roter Interactional Analysis System (RIAS).

SETTING

West Yorkshire, UK.

METHOD

One hundred and eighty-three consultations with 11 GPs in West Yorkshire, UK were video-recorded and analysed.

RESULTS

Main outcome measures were consultation length, verbal domination, 16 individual abridged RIAS categories, and three composite RIAS categories; with comparisons between white patients, South Asian patients fluent in English and South Asian patients nonfluent in English. South Asians fluent in English had the shortest consultations and South Asians non-fluent in English the longest consultations (one-way ANOVA F = 7.173, P = 0.001). There were no significant differences in verbal domination scores between the three groups. White patients had more affective (emotional) consultations than South Asian patients, and played a more active role in their consultations, as did their GPs. GPs spent less time giving information to South Asian patients who were not fluent in English and more time asking questions. GPs spent less time giving information to South Asian patients fluent in English compared with white patients.

CONCLUSIONS

These findings were expected between patients fluent and non-fluent in English but do demonstrate their nature. The differences between white patients and South Asian patients fluent in English warrant further explanation. How much of this was due to systematic differences in behaviour by the GPs, or was in response to patients' differing needs and expectations is unknown. These differences may contribute to differences in health outcomes.

Teaching self-concept and self-esteem in a clinical communications course

Effective interpersonal communication skills are needed for pharmacists to deliver patient-centered care. To achieve this outcome with pharmacists, communication skills are emphasized in pharmacy school in required coursework, such as a clinical communication course. One important concept to include in communication coursework is content on perceptions because perceptions influence communication interactions. Specific emphasis should include a focus on self-perceptions and self-concept, because related empirical literature demonstrates that accurate academic self-concepts predict academic success. These results were extrapolated to a pharmacy clinical communications course where a lecture and laboratory series was designed to emphasize self-concept and facilitate communication skills improvement. The instructional design of this series promoted the advancement of students' communication skills by using communication inventories, self-reflection activities, peer and class discussion, and lecture content. Class discussions, self-reflections, and baseline, and follow-up counseling activities throughout the semester provided evidence of improvements.

Four physician communication styles in routine Japanese outpatient medical encounters

BACKGROUND

Few studies have explored how physicians approach medical encounters in Japan.

OBJECTIVE

This study examined how Japanese physicians conduct routine medical encounters in the context of outpatient care to patients with nonmalignant disorders.

DESIGN

Qualitative study using semi-structured interviews and direct observation.

SETTING

The outpatient department of a general hospital located in an urban area of Japan.

PARTICIPANTS

Physicians and nurses providing care and patients receiving care for nonmalignant disorders.

RESULTS

A 2-dimensional model was developed, with patient communication (how physician interacted with patients) along 1 axis, and nurse communication (how physicians collaborated with nursing staff) along the other axis. Four physician communication styles (individually adaptive, individually defined, collaboratively adaptive, and collaboratively defined) were identified as typical ways in which the Japanese physicians in the sample interacted with patients and nurses during routine medical encounters.

CONCLUSIONS

Results suggest the need for a multiprovider-patient model of medical communication among physician, nurse, and patient. Further research is needed to establish the applicability of this model to the communication styles of physicians in other countries.

How primary care providers talk to patients about alcohol: a qualitative study

BACKGROUND

Alcohol misuse is a common and well-documented source of morbidity and mortality. Brief primary care alcohol counseling has been shown to benefit patients with alcohol misuse.

OBJECTIVE

To describe alcohol-related discussions between primary care providers and patients who screened positive for alcohol misuse.

DESIGN

An exploratory, qualitative analysis of audiotaped primary care visits containing discussions of alcohol use.

PARTICIPANTS

Participants were 29 male outpatients at a Veterans Affairs (VA) General Internal Medicine Clinic who screened positive for alcohol misuse and their 14 primary care providers, all of whom were participating in a larger quality improvement trial.

MEASUREMENTS

Audiotaped visits with any alcohol-related discussion were transcribed and coded using grounded theory and conversation analysis, both qualitative research techniques.

RESULTS

Three themes were identified: (1) patients disclosed information regarding their alcohol use, but providers often did not explore these disclosures; (2) advice about alcohol use was typically vague and/or tentative in contrast to smoking-related advice, which was more common and usually more clear and firm; and (3) discomfort on the part of the provider was evident during alcohol-related discussions.

LIMITATIONS

Generalizability of findings from this single-site VA study is unknown.

CONCLUSION

Findings from this single site study suggest that provider discomfort and avoidance are important barriers to evidence-based brief alcohol counseling. Further investigation into current alcohol counseling practices is needed to determine whether these patterns extend to other primary care settings, and to inform future educational efforts.

A typology of preferences for participation in healthcare decision making

Classifying patients as "active" or "passive" with regard to healthcare decision making is misleading, since patients have different desires for different components of the decision-making process. Distinguishing patients' desired roles is an essential step towards promoting care that respects and responds to individual patients' preferences. We included items on the 2004 Wisconsin Longitudinal Study mail survey measuring preferences for four components of the decision-making process: physician knowledge of patient medical history, physician disclosure of treatment choices, discussion of treatment choices, and selection of treatment choice. We characterized preference types for 5199 older adults using cluster analysis. Ninety-six percent of respondents are represented by four preference types, all of which prefer maximal information exchange with physicians. Fifty-seven percent of respondents wanted to retain personal control over important medical decisions ("autonomists"). Among the autonomists, 81% preferred to discuss treatment choices with their physician. Thirty-nine percent of respondents wanted their physician to make important medical decisions ("delegators"). Among the delegators, 41% preferred to discuss treatment choices. Female gender, higher educational attainment, better self-rated health, fewer prescription medications, and having a shorter duration at a usual place of care predicted a significantly higher probability of the most active involvement in discussing and selecting treatment choices. The overwhelming majority of older adults want to be given treatment options and have their physician know everything about their medical history; however, there are substantial differences in how they want to be involved in discussing and selecting treatments.

An E-mail for Your Thoughts

Engaging adolescents is one of many challenges facing Child and Adolescent Mental Health Services today. However, taking advantage of the technology available can bring professionals a step closer to their patients by providing an alternative means of interaction. In this article we explore the use of e-mail as a method of engaging adolescents. The advantages and disadvantages of e-mailing patients are discussed along with recommendations for its safe use.

Sí, doctora

Experience with seeing Latino patients at a community health center has taught a family physician that the patient's response, "Sí, doctora [Yes, doctor]" can have multiple meanings. Patients might say "yes" during consultations to avoid conflict or to defer to the more powerful doctor. The clinician's understanding had to move to deeper levels when a visiting Ecuadorian friend learning English used "yes" multiple times in conversation, but not as an indicator of agreement or even comprehension. The family doctor realized that she could not assume what the patient implies by this simple expression. The apparent agreement of "yes" requires more. When a patient says, "Sí, doctora," the doctor must probe with more questions and listen hard to the answers.

Evaluating the accuracy of health news publications in a drug literature evaluation course

OBJECTIVES

To design an assignment for second-professional year pharmacy students to assess the accuracy and quality of health information published in the news.

DESIGN

Students in a literature evaluation course were assigned a health-related news publication to review and find the original published research article. They then critically evaluated the quality and accuracy of the news publication based on the original research. All students wrote a critique focusing on the quality and accuracy of the news article and potential responses the lay public might have.

ASSESSMENT

Eighty-four percent of students agreed the writing assignment reinforced critical literature evaluation skills, while 90% agreed the assignment contributed to completion of course objectives.

CONCLUSIONS

A writing assignment requiring comparison of a news publication to the original research reinforces critical literature evaluation and communication skills, as well as stimulates thought about the accuracy, quality, and public responses to health information published in the news.

"Blogging" about course concepts: using technology for reflective journaling in a communications class

OBJECTIVE

Web log technology was applied to a reflective journaling exercise in a communication course during the second-professional year at the University of Mississippi School of Pharmacy, to encourage students to reflect on course concepts and apply them to the environment outside the classroom, and to assess their communication performance.

DESIGN

Two Web log entries per week were required for full credit. Web logs were evaluated at three points during the term. At the end of the course, students evaluated the assignment using a 2-page survey instrument.

ASSESSMENT

The assignment contributed to student learning and increased awareness level for approximately 40% of the class. Students had few complaints about the logistics of the assignment.

CONCLUSION

The Web log technology was a useful tool for reflective journaling in this communications course. Future versions of the assignment will benefit from student feedback from this initial experience.

Effective improvement of doctor-patient communication: a randomised controlled trial

BACKGROUND

Doctor-patient communication is an essential component of general practice. Improvement of GPs' communication patterns is an important target of training programmes. Available studies have so far failed to provide conclusive evidence of the effectiveness of educational interventions to improve doctor-patient communication.

AIM

To examine the effectiveness of a learner-centred approach that focuses on actual needs, to improve GPs' communication with patients.

DESIGN OF STUDY

Randomised controlled trial.

SETTING

One hundred volunteer GPs in the Netherlands.

METHOD

The intervention identified individual GPs' deficiencies in communication skills by observing authentic consultations in their own surgery. This performance assessment was followed by structured activities in small group meetings, aimed at remedying the identified shortcomings. Outcomes were measured using videotaped consultations in the GPs' own surgery before and after the intervention. Communication skills were rated using the MAAS-Global, a validated checklist.

RESULTS

The scores in the intervention group demonstrated a significant improvement compared with those of the control group (95% confidence interval = 0.04 to 0.75). The effect size was moderate to large (d-value = 0.66). The level of participation significantly contributed to the effectiveness. Largest improvement was found on patient-centred communication skills.

CONCLUSION

The approach of structured individual improvement activities based on performance assessment is more effective in improving communication skills than current educational activities.

Use of a modified informed consent process among vulnerable patients: a descriptive study

BACKGROUND

Little is known about patient characteristics associated with comprehension of consent information, and whether modifications to the consent process can promote understanding.

OBJECTIVE

To describe a modified research consent process, and determine whether literacy and demographic characteristics are associated with understanding consent information.

DESIGN

Descriptive study of a modified consent process: consent form (written at a sixth-grade level) read to participants, combined with 7 comprehension questions and targeted education, repeated until comprehension achieved (teach-to-goal).

PARTICIPANTS

Two hundred and four ethnically diverse subjects, aged > or = 50, consenting for a trial to improve the forms used for advance directives.

MEASUREMENTS

Number of passes through the consent process required to achieve complete comprehension. Literacy assessed in English and Spanish with the Short Form Test of Functional Health Literacy in Adults (scores 0 to 36).

RESULTS

Participants had a mean age of 61 years and 40% had limited literacy (s-TOHFLA<23). Only 28% of subjects answered all comprehension questions correctly on the first pass. After adjustment, lower literacy (P=.04) and being black (P=.03) were associated with requiring more passes through the consent process. Not speaking English as a primary language was associated with requiring more passes through the consent process in bivariate analyses (P<.01), but not in multivariable analyses (P>.05). After the second pass, most subjects (80%) answered all questions correctly. With a teach-to-goal strategy, 98% of participants who engaged in the consent process achieved complete comprehension.

CONCLUSIONS

Lower literacy and minority status are important determinants of understanding consent information. Using a modified consent process, little additional education was required to achieve complete comprehension, regardless of literacy or language barriers.

Unwritten rules of talking to doctors about depression: integrating qualitative and quantitative methods

PURPOSE

We wanted to understand concordance and discordance between physicians and patients about depression status by assessing older patient's views of interactions with their physicians.

METHODS

We used an integrated mixed methods design that is both hypothesis testing and hypothesis generating. Patients aged 65 years and older, who identified themselves as being depressed, were recruited from the offices of primary care physicians and interviewed in their homes using a semistructured interview format. We compared patients whose physicians rated them as depressed with those whose physicians who did not according to personal characteristics (hypothesis testing). Themes regarding patient perceptions of their encounters with physicians were then used to generate further hypotheses.

RESULTS

Patients whose physician rated them as depressed were younger than those whose physician did not. Standard measures, such as depressive symptoms and functional status, did not differentiate between patients. Four themes emerged in interviews with patients regarding how they interacted with their physicians; namely, "My doctor just picked it up," "I'm a good patient," "They just check out your heart and things," and "They'll just send you to a psychiatrist." All patients who thought the physician would "just pick up" depression and those who thought bringing up emotional content would result in a referral to a psychiatrist were rated as depressed by the physician. Few of the patients who discussed being a "good patient" were rated as depressed by the physician.

CONCLUSIONS

Physicians may signal to patients, wittingly or unwittingly, how emotional problems will be addressed, influencing how patients perceive their interactions with physicians regarding emotional problems.

Meeting report: national workshops for the communication of air pollution and health information: summary of four workshops in different regions of Europe

AIRNET was a thematic network project (2002-2004) initiated to stimulate the interaction between researchers in air pollution and health in Europe. As part of AIRNET's communication strategy, a standardized workshop model was developed to organize national meetings on air pollution and health (AIRNET network days) . Emphasis was given to tailor the national workshop information and related activities to the specific needs of a wider range of stakeholders (e.g., policy makers, nongovernmental organizations, industry representatives) . In this report we present an overview of the results of four workshops held in western, northern, central/eastern, and southern regions of Europe in 2004. Overall, workshop experiences indicated that by actively involving participants in the planning of each meeting, AIRNET helped create an event that addressed participants' needs and interests. A wide range of communication formats used to discuss air pollution and health also helped stimulate active interaction among participants. Overall, the national workshops held by AIRNET offered a way to improve communication among the different stakeholders. Because a broad stakeholder involvement in decision making can positively affect the development of widely supported policies, such meetings should be continued for Europe and elsewhere.

Patients' perceptions of cholesterol, cardiovascular disease risk, and risk communication strategies

PURPOSE

Despite some recent improvement in knowledge about cholesterol in the United States, patient adherence to cholesterol treatment recommendations remains suboptimal. We undertook a qualitative study that explored patients' perceptions of cholesterol and cardiovascular disease (CVD) risk and their reactions to 3 strategies for communicating CVD risk.

METHODS

We conducted 7 focus groups in New England using open-ended questions and visual risk communication prompts. The multidisciplinary study team performed qualitative content analysis through immersion/crystallization processes and analyzing coded reports using NVivo qualitative coding software.

RESULTS

All participants were aware that "high cholesterol" levels adversely affect health. Many had, however, inadequate knowledge about hypercholesterolemia and CVD risk, and few knew their cholesterol numbers. Many assumed they had been tested and their cholesterol concentrations were healthy, even if their physicians had not mentioned it. Standard visual representations showing statistical probabilities of risk were assessed as confusing and uninspiring. A strategy that provides a cardiovascular risk-adjusted age was evaluated as clear, memorable, relevant, and potentially capable of motivating people to make healthful changes. A few participants in each focus group were concerned that a cardiovascular risk-adjusted age that was greater than chronological age would frighten patients.

CONCLUSIONS

Complex explanations about cholesterol and CVD risk appear to be insufficient for motivating behavior change. A cardiovascular risk-adjusted age calculator is one strategy that may engage patients in recognizing their CVD risk and, when accompanied by information about risk reduction, may be helpful in communicating risk to patients.

Thoughts on communication

Living without the ability to communicate is humbling. Time spent on a sabbatical in Florence, Italy, taught me that my outgoing manner, my interactional skills, and my ability to establish rapport, all personality traits and skills that I thought would overcome my inadequacies as a communicator in Italian are not immutable. I gained some understanding of what our nonnative English-speaking patients might feel. I learned the following lessons: (1) be cautious-what appears to be a lack of interest may be a lack of understanding; (2) our perceptions of aptitude may be mistaken if based on patients' facial expressions and body language; (3) we should not adjust our words and speed of speech just because we think a patient cannot understand what we are saying; and (4) language is an amazingly powerful tool-the inability to communicate transforms us.

Evidence-based healthcare and health informatics: derivations and extension of epidemiology

Epidemiology provides extremely valid information and evidence regarding human health. Epidemiologic findings with regard to major illnesses must be amassed, enhanced, and expanded further into related areas as a foundation for evidence-based medicine that is based on clinical practice, as well as for evidence-based healthcare that includes public health-related issues. Epidemiology should be recognized not only by epidemiologists but also by a variety of people, including specialists in other areas for healthcare and medicine, people in law and media, policy makers, and the general public. A system is needed that can create information for facilitating appropriate decision-making with issues related to clinical medicine and public health. The principles and methodology of epidemiology are used as a base for developing a field of health informatics. The objective of health informatics is to establish a system for facilitating the flow and circulation of health and medical information. Health informatics has potential applications for the creation, communication, and use of information, and the discipline is being expanded as a practical applied science in search of solutions. This report represents an effort to expand the scope of health informatics and extend the applications of epidemiology by working with individuals in other disciplines and the public.

Perceived vulnerability to heart disease in patients with familial hypercholesterolemia: a qualitative interview study

PURPOSE

Knowledge about the ways patients perceive their vulnerability to disease is important for communication with patients about risk and preventive health measures. This interview study aimed to explore how patients with a diagnosis of heterozygous familial hypercholesterolemia understand and perceive their vulnerability to coronary heart disease.

METHODS

We did a qualitative study of 40 patients with familial hypercholesterolemia who were recruited through a lipid clinic in Norway. We elicited participants' perceptions about their vulnerability to heart disease in semistructured interviews. Data were analyzed by systematic text condensation inspired by Giorgi's phenomenological method.

RESULTS

We found that participants negotiated a personal and dynamic sense of vulnerability to coronary heart disease that was grounded in notions of their genetic and inherited risk. Participants developed a sense of their vulnerability in a 2-step process. First, they consulted their family history to assess their genetic and inherited risk, and for many a certain age determined when they could expect to develop symptoms of coronary heart disease. Second, they negotiated a personal sense of vulnerability by comparing themselves with their family members. In these comparisons, they accounted for individual factors, such as sex, cholesterol levels, use of lipid-lowering medications, and lifestyle. Participants' personal sense of vulnerability to heart disease could shift dynamically as a result of changes in situational factors, such as cardiac events in the family, illness experiences, or becoming a parent.

CONCLUSIONS

Patients with a diagnosis of familial hypercholesterolemia negotiate a personal and dynamic sense of vulnerability to coronary heart disease that is grounded in their understanding of their genetic and inherited risk. Doctors should elicit patients' understanding of their family history and their personal vulnerability to individualize clinical management.

Internal medicine residents' perceptions of cross-cultural training. Barriers, needs, and educational recommendations

BACKGROUND

Physicians increasingly face the challenge of managing clinical encounters with patients from a range of cultural backgrounds. Despite widespread interest in cross-cultural care, little is known about resident physicians' perceptions of what will best enable them to provide quality care to diverse patient populations.

OBJECTIVES

To assess medicine residents' (1) perceptions of cross-cultural care, (2) barriers to care, and (3) training experiences and recommendations.

DESIGN, SETTING, AND PATIENTS

Qualitative individual interviews were conducted with 26 third-year medicine residents at Massachusetts General Hospital in Boston (response rate=87%). Interviews were recorded, transcribed, and analyzed.

RESULTS

Despite significant interest in cross-cultural care, almost all of the residents reported very little training during residency. Most had gained cross-cultural skills through informal learning. A few were skeptical about formal training, and some expressed concern that it is impossible to understand every culture. Challenges to the delivery of cross-cultural care included managing patients with limited English proficiency, who involve family in critical decision making, and who have beliefs about disease that vary from the biomedical model. Residents cited many implications to these barriers, ranging from negatively impacting the patient-physician relationship to compromised care. Training recommendations included making changes to the educational climate and informal and formal training mechanisms.

CONCLUSIONS

If cross-cultural education is to be successful, it must take into account residents' perspectives and be focused on overcoming residents' cited barriers. It is important to convey that cross-cultural education is a set of skills that can be taught and applied, in a time-efficient manner, rather than requiring an insurmountable knowledge base.

A profile of communication in primary care physician telephone consultations: application of the Roter Interaction Analysis System

BACKGROUND

Telephone consultations are a part of everyday practice, there is surprisingly little research on the subject.

AIM

To describe the variation of consulting skills within a body of telephone consultations in primary care, highlighting the performance of one method of assessing the process of the consultation-- the Roter Interaction Analysis System-- with telephone consultations.

DESIGN OF STUDY

Cross sectional study of 43 recordings of telephone consultations with GPs.

SETTING

One rural county in the Midlands.

METHOD

Recordings were made of 8 GPs, purposively selected for maximum variance in one region of the UK. Forty-three consultations were coded using the Roter Interaction Analysis System. From the descriptive categories, six composite categories were compiled reflecting a number of domains of interaction in a consultation: rapport, data gathering, patient education and counselling, partnership building, doctor dominance and patient-centredness. Analysis of variance was undertaken to explain variations between consultations for the different domains. Comparison was made to findings from similar work for face-to-face consultations.

RESULTS

These telephone consultations feature more biomedical information exchange than psychosocial or affective communication. Length of interaction accounts for much of the variation seen between consultations in the domains of rapport, data gathering, patient education and counselling and partnership. Male doctors are more patient centred in this study. There is the suggestion of more doctor dominance and a less patient-centred approach when comparisons are made with previous work on face-to-face consultations.

CONCLUSIONS

Although the telephone is increasingly being used to provide care, this study highlights the fact that telephone consultations cannot be taken as equivalent to those conducted face to face. More work needs to be done to delineate the features of telephone consultations.

Development of progressive oral presentations in a therapeutics course series

OBJECTIVES

To develop and implement a series of progressive evidence-based, oral presentation activities within the therapeutics series to strengthen interprofessional oral communication and literature evaluation skills.

DESIGN

A step-wise progression of oral presentations was created to establish interprofessional communication skills and reinforce such skills in successive modules. Students progressed from a basic oral presentation to a brief clinical trial presentation, followed by a full journal club, culminating with a therapeutic debate. Guidelines and assessment tools were developed for each presentation focusing on style, content and organization, and analytic approach. Feedback was obtained from students and faculty members through the administration of survey instruments at the midpoint of advanced pharmacy practice experiences (APPE).

ASSESSMENT

The majority of students successfully completed each oral presentation. Most felt prepared for APPE presentations due to increased Microsoft PowerPoint skills, literature exposure/evaluation, and comfort/confidence in presenting before an audience. Faculty members stated that the innovation organized students' thoughts and increased presentation clarity, resulting in less need to offer student assistance during APPEs.

CONCLUSION

Our progressive approach to oral presentations has been successful and well received by students and faculty members. Our innovation has fostered oral interprofessional communication skills in our pharmacy students, and we will continue to utilize this approach.

The acceptability of routine inquiry about domestic violence towards women: a survey in three healthcare settings

BACKGROUND

Domestic violence is frequently only disclosed when healthcare staff directly inquire. Healthcare staff worry that inquiry may offend.

AIM

To identify the characteristics of women who find inquiry about domestic violence by healthcare staff unacceptable.

DESIGN OF STUDY

Anonymous interview based cross-sectional study.

SETTING

Three general practice surgeries, one antenatal clinic and one emergency department in Cambridge, England, with a total of 2306 women attending for health care.

METHOD

Cross-sectional survey.

RESULTS

In total 1452 completed questionnaires were returned; response rate 63%. One hundred and twenty-two women (8.4%) indicated that they found inquiry by healthcare staff unacceptable. Women at the emergency department and GP surgeries were more likely to find inquiry unacceptable (odds ratio [OR] = 3.3, 95% confidence interval [CI] = 1.1 to 9.9) and (OR = 3.9, 95% CI = 1.3 to 11.5) respectively, than in the antenatal clinic. Women at the antenatal clinic reported lower rates of abuse within 1 year than at the emergency department or antenatal clinic. Abuse within 1 year was strongly associated with finding inquiry unacceptable (OR = 4.5, 95% CI = 1.8 to 11.4), but not lifetime abuse (OR = 0.9, 95% CI = 0.5 to 1.9).

CONCLUSIONS

Inquiry about domestic violence by healthcare staff is acceptable to most women. Acceptability is highest in women who have not been abused in the last year and who are attending the antenatal clinic. Women who attend the antenatal clinic have lower rates of abuse within 1 year.

Medical professionalism--who cares?

Who cares about medical professionalism? It seems doctors, patients and, surprisingly, the media do. The relevance of medical professionalism for these three groups is examined from the journalist's/patient's point of view. The report and findings of the Royal College of Physicians Working Party on Medical Professionalism is discussed. In conclusion there is a synopsis of recommendations and future action required by individuals from all three groups to enable progress to be made in this important area of communication.

Health care system accessibility. Experiences and perceptions of deaf people

BACKGROUND

People who are deaf use health care services differently than the general population; little research has been carried out to understand the reasons.

OBJECTIVE

To better understand the health care experiences of deaf people who communicate in American Sign Language.

DESIGN

Qualitative analyses of focus group discussions in 3 U.S. cities.

PARTICIPANTS

Ninety-one deaf adults who communicate primarily in American Sign Language.

MEASUREMENTS

We collected information about health care communication and perceptions of clinicians' attitudes. We elicited stories of both positive and negative encounters, as well as recommendations for improving health care.

RESULTS

Communication difficulties were ubiquitous. Fear, mistrust, and frustration were prominent in participants' descriptions of health care encounters. Positive experiences were characterized by the presence of medically experienced certified interpreters, health care practitioners with sign language skills, and practitioners who made an effort to improve communication. Many participants acknowledged limited knowledge of their legal rights and did not advocate for themselves. Some participants believed that health care practitioners should learn more about sociocultural aspects of deafness.

CONCLUSIONS

Deaf people report difficulties using health care services. Physicians can facilitate change to improve this. Future research should explore the perspective of clinicians when working with deaf people, ways to improve communication, and the impact of programs that teach deaf people self-advocacy skills and about their legal rights.

A practice-sponsored Web site to help patients pursue healthy behaviors: an ACORN study

PURPOSE

We tested whether patients are more likely to pursue healthy behaviors (eg, physical activity, smoking cessation) if referred to a tailored Web site that provides valuable information for behavior change.

METHODS

In a 9-month pre-post comparison with nonrandomized control practices, 6 family practices (4 intervention, 2 control) encouraged adults with unhealthy behaviors to visit the Web site. For patients from intervention practices, the Web site offered tailored health advice, a library of national and local resources, and printouts for clinicians. For patients from control practices, the Web site offered static information pages. Patient surveys assessed stage of change and health behaviors at baseline and follow-up (at 1 and 4 months), Web site use, and satisfaction.

RESULTS

During the 9 months, 932 patients (4% of adults attending the practice) visited the Web site, and 273 completed the questionnaires. More than 50% wanted physician assistance with health behaviors. Stage of change advanced and health behaviors improved in both intervention and control groups. Intervention patients reported greater net improvements at 1 month, although the differences approached significance only for physical activity and readiness to change dietary fat intake. Patients expressed satisfaction with the Web site but wished it provided more detailed information and greater interactivity with clinicians.

CONCLUSIONS

Clinicians face growing pressure to offer patients good information on health promotion and other health care topics. Referring patients to a well-designed Web site that offers access to the world's best information is an appealing alternative to offering handouts or impromptu advice. Interactive Web sites can facilitate behavior change and can interface with electronic health records. Determining whether referral to an informative Web site improves health outcomes is a methodological challenge, but the larger question is whether information alone is sufficient to promote behavior change. Web sites are more likely to be effective as part of a suite of tools that incorporate personal assistance.

Workgroup report: Implementing a national occupational reproductive research agenda--decade one and beyond

The initial goal of occupational reproductive health research is to effectively study the many toxicants, physical agents, and biomechanical and psychosocial stressors that may constitute reproductive hazards in the workplace. Although the main objective of occupational reproductive researchers and clinicians is to prevent recognized adverse reproductive outcomes, research has expanded to include a broader spectrum of chronic health outcomes potentially affected by reproductive toxicants. To aid in achieving these goals, the National Institute for Occupational Safety and Health, along with its university, federal, industry, and labor colleagues, formed the National Occupational Research Agenda (NORA) in 1996. NORA resulted in 21 research teams, including the Reproductive Health Research Team (RHRT). In this report, we describe progress made in the last decade by the RHRT and by others in this field, including prioritizing reproductive toxicants for further study; facilitating collaboration among epidemiologists, biologists, and toxicologists; promoting quality exposure assessment in field studies and surveillance; and encouraging the design and conduct of priority occupational reproductive studies. We also describe new tools for screening reproductive toxicants and for analyzing mode of action. We recommend considering outcomes such as menopause and latent adverse effects for further study, as well as including exposures such as shift work and nanomaterials. We describe a broad domain of scholarship activities where a cohesive system of organized and aligned work activities integrates 10 years of team efforts and provides guidance for future research.

Emotional intelligence instruction in a pharmacy communications course

OBJECTIVES

To determine the benefits of incorporating emotional intelligence instruction into a required pharmacy communications course.

DESIGN

Specific learning objectives were developed based upon the emotional intelligence framework and how it can be applied to pharmacy practice. Qualitative data on student perceptions were collected and analyzed using theme analysis.

ASSESSMENT

Students found instruction on emotional intelligence to be a positive experience. Students reported learning the taxonomy of emotional intelligence--a concept that previously was difficult for them to articulate or describe, and could use this knowledge in future pharmacy management situations. Students also recognized that their new knowledge of emotional intelligence would lead to better patient outcomes.

CONCLUSION

Students had positive perceptions of the importance of emotional intelligence. They valued its inclusion in the pharmacy curriculum and saw practical applications of emotional intelligence to the practice of pharmacy.

The zeitgeist of online health search. Implications for a consumer-centric health system

BACKGROUND

Health care queries rank among the most frequent topics of information-seeking activity initiated by users of commercial search engines. The quality of information located through existing search engine technology has received little attention, especially when considering the widely varied knowledge levels of internet users.

OBJECTIVE

This study sought to create a benchmark technology assessment of online health search trends and practices, with corresponding evaluation of its applicability within the Federal Health Architecture (FHA) plan for a nationwide, interoperable health information infrastructure.

DESIGN

Exploratory technology assessment, analyzing focus group participants' views on barriers to effective health information searching, using existing commercial search engine technologies and methods.

SETTING AND PARTICIPANTS

Focus group, national leaders in electronic health care (e-health).

RESULTS

A variety of web-based assessment tools are available for consumers to be able to identify reliable health websites; however, many may be too difficult for the layperson to use or understand. Existing search technologies are increasingly powerful, although the expanding volume of information on the internet suggests the need for better mediated searching. Search engines provide consumers a means for quickly bypassing information that appears too technical for their individual knowledge level, and at times, searchers often overlook critical information most relevant to their needs. Overall, existing search technologies need to be more interactive, visible, and context-driven, and supported by better technology assessment methodologies, scalability of information, and enhanced access by underserved subgroups.

CONCLUSION

Future technology assessments are needed to provide structure for interoperability of health information systems, especially where consumers, providers, and payer systems intersect. State-of-the-art search engine technologies are still not widely available to those who can benefit most from them.

Duality in context: the process of preparedness in communicating with at-risk children

The goal of this study was to explore the cultural meaning of parent-child communication behaviors in inner-city children at risk for common behavioral problems. Following participation in a preventive intervention called Insights Into Children's Temperament, 40 parents of first and second-grade children were interviewed. The data were analyzed using a constant comparative method derived from grounded-theory techniques. Findings indicate that a complex communication process was used by parents with their at-risk inner-city school-age children. The immediacy of safety concerns for the child, the child's temperament, and the current parental state informed the choice of communication behaviors chosen by the parent. The ultimate goal of communication for these participants was to equip their children with tools to assist them to safely navigate their school and community environments. Participants also offered several recommendations that could be useful for practitioners and researchers to incorporate into their work with inner-city families.

Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science

Complexity science teaches that relationships among health care providers are key to our understanding of how quality care emerges. The authors sought to compare the effects of differing patterns of medicine-nursing communication on the quality of information flow, cognitive diversity, self-organization, and innovation in nursing homes. Two facilities participated in 6-month case studies using field observations, shadowing, and depth interviews. In one facility, the dominant pattern of communication was a vertical "chain of command" between care providers, characterized by thin connections and limited information exchange. This pattern limited cognitive diversity and innovation in clinical problem solving. The second facility used an open communication pattern between medical and frontline staff. The authors saw higher levels of information flow, cognitive diversity, innovation, and self-organization, although tempered by staff turnover. The patterns of communication between care providers in nursing facilities have an important impact on their ability to provide quality, innovative care.

The scent of senescence: age-dependent changes in the composition of the cephalic gland secretion of the male European beewolf, Philanthus triangulum

The process of aging inevitably leads to changes in physiology, performance and fertility of eukaryotic organisms and results in trade-offs in the resource allocation between current and future reproduction and longevity. Such constraints may also affect the production of complex and costly signals used for mate attraction and might therefore be important in the context of mate choice. We investigated age-related changes in the amount and composition of the cephalic gland secretion that male European beewolves, Philanthus triangulum (Hymenoptera, Crabronidae) use to mark their territories. The secretion mainly consists of eleven long-chain compounds with large proportions of a carbon acid, a ketone and two alcohols, and small proportions of several alkanes and alkenes. Both the total amount and the composition of the gland content varied with age. The four compounds with functional groups were present in much lower proportions in very young and very old males compared to middle-aged males, suggesting that these components may be more costly than the alkanes and alkenes. Thus, physiological constraints may cause the delayed onset and early decline of these substances in the cephalic gland. There were also minor but significant changes in four components among the middle-aged males. These age-related changes in the amount and composition of the male marking secretion might provide reliable indicators for female choice.

Communication on end-of-life decisions with patients wishing to die at home: the making of a guideline for GPs in Flanders, Belgium

BACKGROUND

Communication with patients on end-of-life decisions is a delicate topic for which there is little guidance.

AIM

To describe the development of a guideline for GPs on end-of-life communication with patients who wish to die at home, in a context where patient autonomy and euthanasia are legally regulated.

DESIGN OF STUDY

A three-phase process (generation, elaboration and validation). In the generation phase, literature findings were structured and then prioritised in a focus group with GPs of a palliative care consultation network. In the elaboration phase, qualitative data on patients' and caregivers' perspectives were gathered through a focus group with next-of-kin, in-depth interviews with terminal patients, and four quality circle sessions with representatives of all constituencies. In the validation phase, the acceptability of the draft guideline was reviewed in bipolar focus groups (GPs-nurses and GPs-specialists). Finally, comments were solicited from experts by mail.

SETTING

Primary home care in Belgium.

SUBJECTS

Participants in this study were terminal patients (n = 17), next-of-kin of terminal patients (n = 17), GPs (n = 25), specialists (n = 3), nurses (n = 8), other caregivers (n = 2) and experts (n = 41).

RESULTS

Caregivers and patients expressed a need for a comprehensive guideline on communication in end-of-life decisions. Four major communication themes were prioritised: truth telling; exploration of the patient's wishes regarding the end of life; dealing with disproportionate interventions; and dealing with requests for euthanasia in the terminal phase of life. Additional themes required special attention in the guideline: continuity of care by the GP; communication on foregoing food and fluid; and technical aspects of euthanasia.

CONCLUSION

It was feasible to develop a guideline by combining the three cornerstones of evidence-based medicine: literature search, patient values and professional experience.

Involving patients in primary care consultations: assessing preferences using discrete choice experiments

BACKGROUND

Shared decision making (SDM) involves patients and doctors contributing as partners to treatment decisions. It is not known whether or to what extent SDM contributes to the welfare arising from a consultation, and how important this contribution is relative to other attributes of a consultation.

AIM

To identify patient preferences for SDM relative to other utility bearing attributes of a consultation.

DESIGN OF STUDY

In parallel with a randomised trial in training GPs in SDM competencies and risk communication skills, a discrete choice experiment exercise was conducted to assess patients' utilities.

SETTING

Twenty general practices in South Wales, UK.

METHOD

Five hundred and eighty-four responders from 747 patients attending the randomised trial (response rate = 78%). All patients had one of four conditions (atrial fibrillation, menorrhagia, menopausal symptoms or prostatism) and attended a consultation with a doctor in their own practice. Patients were randomised to attend a consultation either with a doctor who had received no training in the study or risk communication training alone or SDM training alone, or both combined.

RESULTS

Five key utility bearing attributes of a consultation were identified. All significantly influenced patient's choice of preferred consultation style (P<0.001). Larger increases in utility were associated with changes on "doctor listens" attribute, followed by easily understood information, a shared treatment decision, more information and longer consultation. Utilities were influenced by whether the doctor had received risk communication training alone or SDM training alone, or both combined, prior to the consultations. The randomised trial itself had identified that the communication processes of these consultations changed significantly, with greater patient involvement in decision making, after the training interventions.

CONCLUSION

Shared treatment decisions were valued less than some other attributes of a consultation. However, patient utilities for such involvement appeared responsive to changes in experiences of consultations. This suggests that SDM may gain greater value among patients once they have experienced it.

Shared decision making and the experience of partnership in primary care

PURPOSE

Communication has been researched either as a set of behaviors or as a facet of the patient-physician relationship, often leading to conflicting results. To determine the relationship between these perspectives, we examined shared decision making (SDM) and the subjective experience of partnership for patients and physicians in primary care.

METHODS

From a convenience sample of experienced primary care physicians in 3 clinics, we recruited a stratified sample of 18 English- or Spanish-speaking patients. Direct observation of visits was followed by videotape-triggered stimulated recall sessions with patients and physicians. We coded decision moments for objective evidence of SDM, using a structured instrument. We classified patients' and physicians' subjective experience of partnership as positive or negative by a consensus analysis of stimulated recall sessions. We combined results from these 2 analyses to generate 4 archetypes of engagements and used grounded theory to identify themes associated with each archetype.

RESULTS

The 18 visits yielded 125 decisions, 62 (50%) of which demonstrated SDM. Eighty-two decisions were discussed in stimulated recall and available for combined analysis, resulting in 4 archetypes of engagement in decision making: full engagement (SDM present, subjective experience positive)--22%; simulated engagement (SDM present, subjective experience negative)--38%; assumed engagement (SDM absent, subjective experience positive)--21%; and nonengagement (SDM absent, subjective experience negative)--19%. Thematic analysis revealed that both relationship factors (eg, trust, power) and communication behavior influenced subjective experience of partnership.

CONCLUSIONS

Combining direct observation and assessment of the subjective experience of partnership suggests that communication behavior does not ensure an experience of collaboration, and a positive subjective experience of partnership does not reflect full communication. Attempts to enhance patient-physician partnership must attend to both effective communication style and affective relationship dynamics.

The dark bridal canopy

Physician narratives in family medicine have the potential to convey the vibrant spirit of our field and provide meaningful insights into disease, illness, suffering, and the nature of healing. They may also complement empirical research, education, and practice through their integrative, expressive nature. This true story depicts a challenge faced by the author while serving as a family physician in a desolate, desert region in Israel's southern Aravah Valley (south of the Dead Sea), where he was privileged to practice for a decade. The episode, a fatal car crash in which a newlywed Druse woman (a member of a secretive sect) was killed, involved much more than just the terse details listed in the emergency log. An example of a family medicine physician-and-self drama, this piece takes the reader beyond the basic medical facts into the experience and sensations of the event. It also provides a stark contrast to the usual medical description and emphasizes the importance of stories as reflective opportunities for improving health care, sustaining ourselves as practitioners, and maintaining the vitality of our field.