The unexpected in primary care: a multicenter study on the emergence of unvoiced patient agenda

PURPOSE

Within the time constraints of a typical physician-patient encounter, the full patient agenda will rarely be voiced. Unexpectedly revealed issues that were neither on the patient's list of items for discussion nor anticipated by the physician constitute an emerging agenda. We aimed to quantify the occurrence rate of emerging agendas in primary care practices and to explain the variation between patients and practices.

METHODS

This observational cross-sectional study involved 182 primary care practices in 9 European cultural regions. Consecutive primary care consultations were videotaped and rated. Patients completed preconsultation and postconsultation questionnaires assessing their expectations and perceived care. Emerging agenda, determined by using 11-item preconsultation and postconsultation questionnaires, was defined as care perceived by the patient to be in addition to expected care, after adjustment for cultural variations of patient expectations.

RESULTS

For consultations involving 2,243 patients (mean age, 44.8 years, 58.4% women), every sixth (15.8%) consultation revealed emerging psychosocial agenda. Biomedical agenda emerged in 14.5% of the consultations. Rates for unmet expectations were 13.6% and 10.3%, respectively, for psychosocial and biomedical problems. Practices showed considerable heterogeneity of occurrence of emerging agenda (biomedical, median 13%, range 0%-67%; psychosocial, median 14%, range 0%-53%). After controlling for region and patient baseline characteristics, variables significantly related to emerging agenda were patient expectations and biomedical or psychosocial discourse content, but not consultation time or sex of the patient. A large proportion of the variance attributable to physicians remained concealed in a practice dummy variable (explaining up to 8% of the variance).

CONCLUSION

Unexpected agenda emerges in every sixth to seventh consultation in outpatient primary care visits.

Personal and professional development: a mind of one's own

One of the aims of both postgraduate and undergraduate medical education is to help doctors to think for themselves, or to have minds of their own, in the complex process of interpreting evidence and adapting it to fit individual patients. But phrases such as ‘thinking for oneself’ or ‘having a mind of one's own’ conceal an important ambiguity. The ambiguity is between the process of developing independence of mind and that of developing individuality of mind. Medical education overstresses independence of mind at the expense of individuality of mind. But both processes are necessary for personal and professional development. The humanities have a role to play in correcting the balance.

Low literacy Chinese patients: how are they affected and how do they cope with health matters? A qualitative study

BACKGROUND

Low literacy is common in Hong Kong and China, especially among the females and the elderly. These are often the patients with the greatest health care needs. However little is known about how low literacy affects the ability of patients to obtain adequate medical care and comply with the recommendations of health professionals.

METHODS

Qualitative study of subjects' opinions using semi-structured group and individual interviews. Thirty-six participants took part in 6 group and 9 individual interviews.

RESULTS

Participants' opinions towards low literacy were explored in the interviews. They expressed diverse views on how they perceived low literacy. Some thought they were handicapped by it but others felt it was not a problem. Age, gender, chronic illnesses and their attitudes towards self were found to be major factors affecting their perception. Despite their low literacy, some had their specific ways to overcome the difficulties, for example, drawing symbols to help with the timing of taking the medications. Most of them felt better explanation by the health care workers was most important.

CONCLUSIONS

It is highly relevant for health care workers to be aware of the low literacy status of their patients and to explain information so that patients understand it.

The good doctor: the carer's perspective

Carers are family members, friends, and neighbours who perform medical tasks and personal care, manage housekeeping and financial affairs, and provide emotional support to people who are ill, disabled, or elderly. From a carer's perspective, the primary requisite for a good doctor is competence. Assuming equal technical skills and knowledge, the difference between 'good' and 'bad' doctors comes down to attitudes and behaviour-communication. An important aspect of communication is what doctors say to carers, and how they interpret what carers say to them. Body language-stances, gestures and expression-communicates as well. Good doctors are surrounded by courteous, helpful and efficient assistants. Doctors can make two types of errors in dealing with carers. Type 1 errors occur when doctors exclude the carer from decision making and information. Type 2 errors occur when doctors speak only to the carer and ignore the patient. Good doctors, patients and carers confront the existential meaning of illness together.

[Information given to patients and their participation in clinical decision-making]

OBJECTIVES

To evaluate the information provided by physicians during consultations, the information requested by patients, and patients' participation in decision-making.

DESIGN

Descriptive, cross-sectional study based on observations of visits to the doctor's office and subsequent telephone interview.

SETTING

Primary care centers in Toledo, Spain.Participants. 152 clinical interviews.Interventions. Questionnaire with items on age, sex, types of information provided by the physician, information requested by the patient, and evaluation of the patient's participation in decision-making and degree of satisfaction.

MAIN MEASURES AND RESULTS

Mean age of the patients was 41.1 years, and 55.9% were women. The type of information given most frequently to patients was related to treatment (88.3%). Of the 152 patients whose visits were observed, 55 (36.2%) did not request additional information. The information requested most frequently when not provided spontaneously by the physician concerned treatment (35.3%) and cause of the symptoms (29.7%). Almost all patients (94.0%) considered the information received to be sufficient. However, 22.7% stated that when they left the doctor's office there was something they wished they had asked about, and 18.6% said they understood the doctor's explanations "in part." According to the observers, 69.4% of the patients did not take part in the decision about their treatment.

CONCLUSIONS

The information provided by the physician was not as complete as it might have been. Patients usually ask few questions, and a large percentage of patients had something they wished they had asked about, or did not fully understand the information. Patients' participation in decision-making was low.

Aspects of plant intelligence: an answer to Firn

In a recent 'Invited Review', I stated the case for plant intelligence, provided definitions and outlined some of the consequences, illustrating them with examples. A short critique of this concept by Firn is given in the preceding 'Viewpoint' and rebuttals of the criticisms it contains are presented in the present article. The importance of plant intelligence as an emergent property resulting from interactions and communication of the component tissues is re-stated. The contentions made by Firn that plants are collectives of physically joined organs but acting in relative isolation of each other is subject to critical analysis and found to be contradicted by much established literature. Viewing plants as expressing intelligent behaviour should lead to better understanding of their ecological success and indicate experiments to test the basic concept.

An exploratory study of communication with Spanish-speaking patients

OBJECTIVE

We studied physician-patient dyads to determine how physician self-rated Spanish-language ability and cultural competence affect Spanish-speaking patients' reports of interpersonal processes of care.

SETTING/PARTICIPANTS

Questionnaire study of 116 Spanish-speaking patients with diabetes and 48 primary care physicians (PCPs) at a public hospital with interpreter services.

MEASURES

Primary care physicians rated their Spanish ability on a 5-point scale and cultural competence by rating: 1) their understanding of the health-related cultural beliefs of their Spanish-speaking patients; and 2) their effectiveness with Latino patients, each on a 4-point scale. We assessed patients' experiences using the interpersonal processes of care (IPC) in diverse populations instrument. Primary care physician responses were dichotomized, as were IPC scale scores (optimal vs nonoptimal). We analyzed the relationship between language and two cultural competence items and IPC, and a summary scale and IPC, using multivariate models to adjust for known confounders of communication.

RESULTS

Greater language fluency was strongly associated with optimal IPC scores in the domain of elicitation of and responsiveness to patients, problems and concerns [Adjusted Odds Ratio [AOR], 5.25; 95% confidence interval [CI], 1.59 to 17.27]. Higher score on a language-culture summary scale was associated with three IPC domains - elicitation/responsiveness (AOR, 6.34; 95% CI, 2.1 to 19.3), explanation of condition (AOR, 2.7; 95% CI, 1.0 to 7.34), and patient empowerment (AOR, 3.13; 95% CI, 1.2 to 8.19)-and not associated with two more-technical communication domains.

CONCLUSION

Physician self-rated language ability and cultural competence are independently associated with patients' reports of interpersonal process of care in patient-centered domains. Our study provides empiric support for the importance of language and cultural competence in the primary care of Spanish-speaking patients.

Racial/Ethnic Differences in Parent-Child Smoking Communication

A cross-sectional study of parents and children who presented to the ED at a Cincinnati hospital showed high parental smoking rates and lower rates of anti-smoking communication in African American parents, unlike prior studies.

Managing the difficult consultation

Patients are more likely to develop psychological problems if their concerns are unresolved and their information needs unmet. However, many health professionals are uncertain how to elicit patients' concerns or tailor information appropriately. These difficulties may also lead to psychological problems for the health professional. Feeling inadequately trained in communication skills has been linked to burnout amongst senior doctors working in cancer. Clinicians find that some consultations are particularly hard to manage; for example, when patients are highly distressed, angry, withdrawn or in denial. Barriers to effective communication are patient-led as well as doctor- or nurse-led but relevant training can help overcome those barriers. The article described one training model that is effective in improving health professionals' skills. Specific strategies are suggested that can help in the more difficult consultations and so enable clinicians to talk to patients about their concerns and worries more freely.

Community reaction to bioterrorism: prospective study of simulated outbreak

To assess community needs for public information during a bioterrorism-related crisis, we simulated an intentional Rift Valley fever outbreak in a community in the southern part of the United States. We videotaped a series of simulated print and television "news reports" over a fictional 9-day crisis period and invited various groups (e.g., first-responders and their spouses or partners, journalists) within the selected community to view the videotape and respond to questions about their reactions. All responses were given anonymously. First-responders and their spouses or partners varied in their reactions about how the crisis affected family harmony and job performance. Local journalists exhibited considerable personal fear and confusion. All groups demanded, and put more trust in, information from local sources. These findings may have implications for risk communication during bioterrorism-related outbreaks.

Communication patterns of primary care physicians in the United States and the Netherlands

BACKGROUND

While international comparisons of medical practice have noted differences in length of visit, few studies have addressed the dynamics of visit exchange.

OBJECTIVES

To compare the communication of Dutch and U.S. hypertensive patients and their physicians in routine medical visits.

DESIGN

Secondary analysis of visit audio/video tapes contrasting a Dutch sample of 102 visits with 27 general practitioners and a U.S. sample of 98 visits with 52 primary care physicians.

MEASUREMENTS

The Roter Interaction Analysis System applied to visit audiotapes. Total visit length and duration of the physical exam were measured directly.

MAIN RESULTS

U.S. visits were 6 minutes longer than comparable Dutch visits (15.4 vs 9.5 min, respectively), but the proportion of visits devoted to the physical examination was the same (24%). American doctors asked more questions and provided more information of both a biomedical and psychosocial nature, but were less patient-centered in their visit communication than were Dutch physicians. Cluster analysis revealed similar proportions of exam-centered (with especially long physical exam segments) and biopsychosocial visits in the 2 countries; however, 48% of the U.S. visits were biomedically intensive, while only 18% of the Dutch visits were of this type. Fifty percent of the Dutch visits were socioemotional, while this was true for only 10% of the U.S. visits.

CONCLUSIONS

U.S. and Dutch primary care visits showed substantial differences in communication patterns and visit length. These differences may reflect country distinctions in medical training and philosophy, health care system characteristics, and cultural values and expectations relevant to the delivery and receipt of medical services.

Migrants and health: a cultural dilemma

Culture profoundly affects what those who come to the UK as migrants believe about disease and thus how they behave during illness. Their beliefs may be very different from the beliefs of healthcare professionals and so there can be difficulties in understanding and barriers which inhibit effective clinical management. The behaviour of healthcare professionals towards those of a different race can lead to feelings of discrimination and lack of sympathy, so that a gulf can be allowed to develop. This gulf can be bridged if simple measures are adopted: training in communication, culturally sensitive health-promotion programmes, specific programmes relevant for those of defined ethnic groups and, as a basic means to increase confidence and trust, elementary skills in the language of the migrants.

Physicians' use of and attitudes toward electronic mail for patient communication

To assess physicians' use of and attitudes toward electronic mail (e-mail) for patient communication, we conducted a mail-in survey of physicians who see patients in outpatient clinics affiliated with a large academic medical center (N = 283). Seventy-two percent of physicians reported using e-mail to communicate with patients, averaging 7.7 e-mails from patients per month. The lowest level of use was by community-based primary care physicians (odds ratio, 0.22; 95% confidence interval, 0.08 to 0.59). Those physicians who reported using e-mail with patients reported high satisfaction with its use. Although physicians were concerned about the confidentiality of e-mail, few discussed this issue with patients.

Collaborative e-learning using streaming video and asynchronous discussion boards to teach the cognitive foundation of medical interviewing: a case study

BACKGROUND

Advances in electronic technology have created opportunities for new instructional designs of medical curricula.

OBJECTIVE

We created and evaluated a 4-week online elective course for medical students to teach the cognitive basis for interviewing skills.

METHODS

Ten students, from 2 medical schools, studied online modules on interviewing concepts and viewed videos illustrating the concepts. They then participated in asynchronous discussion groups designed to reinforce course concepts, stimulate reflective learning, and promote peer learning.

RESULTS

In qualitative evaluations, learners reported improvements in self-awareness; increased understanding of interviewing concepts; and benefits of online learning vs face to face learning. Participants reported high levels of satisfaction with online learning and with achievement of course objectives. Self-reported knowledge scores increased significantly from pre-course completion to post-course completion.

CONCLUSIONS

Online education has significant potential to augment curriculum on the medical interview, particularly among students trained in community settings geographically distant from their academic medical center.

Serotonin modulates the electric waveform of the gymnotiform electric fish Brachyhypopomus pinnicaudatus

The gymnotiform electric fish Brachyhypopomus pinnicaudatus communicates with a sexually dimorphic electric waveform, the electric organ discharge (EOD). Males display pronounced circadian rhythms in the amplitude and duration of their EODs. Changes in the social environment influence the magnitudes of these circadian rhythms and also produce more transient responses in the EOD waveforms. Here we show that injections of serotonin produce quick, transient, dose-dependent enhancements of the male EOD characters similar to those induced by encounters with another male. The response to serotonin administered peripherally begins 5-10 min post injection and lasts approximately 3 h. The magnitude of the response to serotonin is tightly associated with the magnitude of the day-to-night swing of the circadian rhythm prior to injection. Taken together these findings suggest that the male's social environment influences his response to serotonin by altering the function of some part of the downstream chain between the serotonin receptors and the ion channels involved in control of the EOD waveform. Although chronic activation of serotonin circuitry is widely known to elicit subordinate behavior, we find that 5-HT initially increases a dominance signal in these fish. These findings are consistent with the emerging view that serotonin facilitates different adaptive responses to acute and chronic social challenge and stress.

Doctors who are using e-mail with their patients: a qualitative exploration

BACKGROUND

Despite the potential for rapid, asynchronous, documentable communication, the use of e-mail for physician-patient communication has not been widely adopted.

OBJECTIVE

To survey physicians currently using e-mail with their patients daily to understand their experiences.

METHODS

In-depth phone interviews of 45 physicians currently using e-mail with patients were audio taped and transcribed verbatim. Two investigators independently qualitatively coded comments. Differences were adjudicated by group consensus.

RESULTS

Almost all of the 642 comments from these physicians who currently use e-mail with patients daily could be grouped into 1 of 4 broad domains: (1) e-mail access and content, (2) effects of e-mail on the doctor-patient relationship, (3) managing clinical issues by e-mail, and (4) integrating e-mail into office processes. The most consistent theme was that e-mail communication enhances chronic-disease management. Many physicians also reported improved continuity of care and increased flexibility in responding to nonurgent issues. Integration of e-mail into daily workflow, such as utilization of office personnel, appears to be a significant area of concern for many of the physicians. For other issues, such as content, efficiency of e-mail, and confidentiality, there were diverging experiences and opinions. Physicians appear to be selective in choosing which patients they will communicate with via e-mail, but the criteria for selection is unclear.

CONCLUSION

These physician respondents did perceive benefits to e-mail with a select group of patients. Several areas, such as identifying clinical situations where e-mail communication is effective, incorporating e-mail into office flow, and being reimbursed for online medical care/communication, need to be addressed before this mode of communication diffuses into most practices.

Lack of communication between healthcare professionals and women with ovarian cancer about sexual issues

Gynaecological cancer has been shown to affect women's sexual functioning, yet evidence suggests that healthcare professionals rarely discuss sexual issues with women diagnosed with a gynaecological cancer. Few studies have investigated why there is a lack of communication between healthcare professionals and women about sexual issues. Our study investigated the attitudes and behaviours of the 27 doctors and 16 nurses treating women with ovarian cancer in our centre towards the discussion of sexual issues, and also investigated women's experiences of such communication. Our findings showed that although most healthcare professionals thought that the majority of women with ovarian cancer would experience a sexual problem, only a quarter of doctors and a fifth of nurses actually discussed sexual issues with the women. Reasons for not discussing sexual issues included 'it is not my responsibility', 'embarrassment', 'lack of knowledge and experience' and 'lack of resources to provide support if needed'. While some of these reasons were also viewed as barriers by the women, the results demonstrate that there is a need from the women's perspective to improve communication about sexual issues, although the most appropriate approach to this remains to be investigated.

'If only someone had told me . . .' A review of the care of patients dying in hospital

Approximately half of all patients who die do so in hospital. Despite the advent of palliative care in the UK, there is evidence that the care that many patients receive in the final phase of their illness in hospital is poor. Building on a study of bereaved relatives' views of the information provided by an inner city hospital trust during an admission in which a patient died, this article explores the factors that may contribute to sub-optimal care for patients dying in hospital. In particular, a lack of open communication, difficulties in accurate prognostication and a lack of planning of end-of-life care can all result in poor care. Strategies to improve care, such as the use of integrated care pathways, advance directives and education initiatives, are discussed.

Helping journalists get it right: a physicians's guide to improving health care reporting

News reports are the way that most people, including many physicians and scientists, first learn about new developments in medicine. Because these reports can raise awareness, influence behavior, and confer credibility, physicians should share responsibility with the media for accurate reporting. Physicians can work with reporters to avoid sensationalizing tentative findings, overstating benefits, and making inappropriate generalizations. This article includes pragmatic suggestions for crafting effective news releases and explaining numerical data. It details "rules of the road" for interviews. Working collaboratively with news reporters to improve the quality of medical stories in the lay press benefits patients and physicians alike.

Mass media release of medical research results: an analysis of antihypertensive drug prescribing in the aftermath of the calcium channel blocker scare of March 1995

BACKGROUND

Disclosure of medical research results to the public creates tension between lay medical reporters and the medical profession.

OBJECTIVE

To explore the early effect of media attention on the risks associated with short-acting calcium channel blockers (CCBs) for treating hypertension after publication at a national meeting and following publication.

DESIGN

Time-series analysis of prescription claims data. SETTING AND DATA SOURCE: National third-party pharmaceutical benefits manager.

PATIENTS

Employed or retired persons and their families, 18 years of age or older, receiving prescription benefits from 1 of 4 national companies that contracted with the pharmaceutical benefits manager exclusively for prescription drug coverage.

MEASUREMENTS

Prescription claims for antihypertensive drugs by fill date converted to a percentage of all cardiovascular drug claims. Data were grouped into weekly intervals before and immediately after the national release of negative information about CCBs on March 10, 1995 and following publication of the results on August 23, 1995.

RESULTS

The most prevalent antihypertensive drugs were diuretics (21% of cardiovascular prescription claims) and calcium channel blockers (19%). A 10% decline in prescriptions filled for CCBs occurred 4 weeks following the intense media attention. Only prescriptions for long-acting calcium channel blockers declined. Alpha-1-blocker prescriptions increased by approximately the same amount that prescriptions for CCBs declined, suggesting substitution of one drug for the other. Changes in diuretic or beta-blocker prescriptions filled were not statistically significant. No immediate change in other cardiovascular drug classes occurred following journal publication.

CONCLUSIONS

Intense media publicity regarding a controversial study measurably and unpredictably changed prescription claims.

Application of information and communication technologies in medical education

The recognition that information and communication technologies should play an increasingly important role in medical education is a key to educating physicians in the 21(st) century. Computer use in medical education includes, Internet hypermedia/multimedia technologies, medical informatics, distance learning and telemedicine. Adaptation to the use of these technologies should ideally start from the elementary school level. Medical schools must introduce medical informatics courses very early in the medical curriculum. Teachers will need regular CME courses to prepare and update themselves with the changing circumstances. Our infrastructure must be prepared for the new developments with computer labs, basic skill labs, close circuit television facilities, virtual class rooms, smart class rooms, simulated teaching facilities, and distance teaching by tele-techniques. Our existing manpower including, doctors, nurses, technicians, librarians, and administration personal require hands-on training, while new recruitment will have to emphasize compulsory knowledge of and familiarity with information technology. This paper highlights these subjects in detail as a means to prepare us to meet the challenges of the 21(st) century.

Use of the Internet by women with breast cancer

BACKGROUND

Recently, many cancer patients have been using the Internet for information with which to make informed choices. We are not aware of any studies that investigate this Internet use among breast cancer patients or women.

OBJECTIVE

We investigate the prevalence and predictors of Internet use for medical information among women with breast cancer.

METHODS

We used a cross-sectional design and approached 251 women with breast cancer being treated at a university-based hospital. We successfully interviewed 188 (74.9%), through mailed self-report questionnaires. Medical information was obtained from the hospital tumor registry. We used t tests and chi-square tests to assess differences in Internet use for breast health issues and binary logistic regression to estimate the odds ratio (OR) for predictors of Internet use for breast health issues.

RESULTS

In our sample, 41.5% of patients used the Internet for medical information. Internet users differed from nonusers on income level, educational level, and by race/ethnicity. After controlling for the other predictors, Internet users had a higher income (OR = 3.10; 95% CI = 1.09-8.85) and tended to be more educated (OR = 2.59; 95% CI = 0.87-7.74) than nonusers. There was also a suggestion that those of nonwhite ethnicity were less likely to use the Internet (OR = 0.39; 95% CI = 0.14-1.11). Increasing age, length of time since diagnosis, and breast cancer stage had no effect.

CONCLUSIONS

A substantial proportion of breast cancer patients used the Internet as a source of information. Patients with higher income or education, and patients of white race/ethnicity are more likely to use the Internet for breast health issues.

Users of Internet health information: differences by health status

BACKGROUND

Millions of consumers have accessed health information online. However, little is known about their health status.

OBJECTIVE

To explore use of Internet health information among those who were sicker (fair/poor general health status) compared with those reported being healthier.

METHODS

A national, random-digit telephone survey by the Pew Internet & American Life Project identified 521 Internet users who go online for health care information. Our primary independent variable was general health status rated as excellent, good, fair, or poor. Patterns of Internet use, and types of information searched were assessed.

RESULTS

Among the 521 users, 64% were female, most (87%) were white, and median age was 42 years. Most individuals indicated that they learned something new online (81%) and indicated that they believe most information on the Internet (52%). Compared with those with excellent/good health, those with fair/poor health (N = 59) were relative newcomers to the Internet but tended to use the Internet more frequently, were more likely to use online chats, were less likely to search for someone other than themselves, and were more likely to talk about the new information with their physician (odds ratio 3.3 [95% confidence interval 1.8-6.3]), after adjustment for age, education and income.

CONCLUSIONS

Health care professionals should be aware that their sicker patients are more likely to ask them about information they found online. Physicians, public health professionals, and eHealth developers should work together to educate patients about searching for health information online and to provide tools for them to navigate to the highest quality information.

Teaching pre-clinical medical students an integrated approach to medical interviewing: half-day workshops using actors

Teaching medical students to integrate patient-centered skills into the medical interview is challenging. Longitudinal training requires significant curricular and faculty time. Unsupervised students risk harm if they uncover and inappropriately manage psychosocial issues in actual patients. They fear saying the wrong thing in emotionally charged situations. Two half-day workshops for pre-clinical students integrate patient- and physician-centered interviewing. The first occurs early in the first year. The second, late in the second year, presents interview challenges (e.g., breaking bad news). Ten professional actors portray standardized patients (SPs). Groups of 10 to 15 students interview an SP, each eliciting a part of the patient's story. Qualitative evaluation revealed that, for many students, SPs afford the opportunity to experiment without harming real patients. Students view the workshops as effective (mean score for first-year students, 6.6 [standard deviation (SD), 1.0], second-year students, 7.1 [SD, 0.7] on a Likert-type scale: 1 = not at all effective to 8 = very effective).

Effect of Spanish interpretation method on patient satisfaction in an urban walk-in clinic

OBJECTIVE

To examine the effect of Spanish interpretation method on satisfaction with care.

DESIGN

Self-administered post-visit questionnaire.

SETTING

Urban, university-affiliated walk-in clinic.

PARTICIPANTS

Adult, English- and Spanish-speaking patients presenting for acute care of non-emergent medical problems.

MEASUREMENTS AND MAIN RESULTS

Satisfaction with overall clinic visit and with 7 provider characteristics was evaluated by multiple logistic regression, controlling for age, gender, ethnicity, education, insurance status, having a routine source of medical care, and baseline health. "Language-concordant" patients, defined as Spanish-speaking patients seen by Spanish-speaking providers and English-speaking patients, and patients using AT&T telephone interpreters reported identical overall visit satisfaction (77%; P = .57), while those using family or ad hoc interpreters were significantly less satisfied (54% and 49%; P < .01 and P = .007, respectively). AT&T interpreter use and language concordance also yielded similar satisfaction rates for provider characteristics (P > .2 for all values). Compared to language-concordant patients, patients who had family members interpret were less satisfied with provider listening (62% vs 85%; P = .003), discussion of sensitive issues (60% vs 76%; P = .02), and manner (62% vs 89%; P = .005). Patients who used ad hoc interpreters were less satisfied with provider skills (60% vs 83%; P = .02), manner (71% vs 89%; P = .02), listening (54% vs 85%; P = .002), explanations (57% vs 84%; P = .02), answers (57% vs 84%; P = .05), and support (63% vs 84%; P = .02).

CONCLUSIONS

Spanish-speaking patients using AT&T telephone interpretation are as satisfied with care as those seeing language-concordant providers, while patients using family or ad hoc interpreters are less satisfied. Clinics serving a large population of Spanish-speaking patients can enhance patient satisfaction by avoiding the use of untrained interpreters, such as family or ad hoc interpreters.

The geography of thinking

People in different cultures are taught to think differently. How we gather information, process, rationalise, justify and communicate our ideas is culturally determined. Europe is divided between the pragmatic, inductive thinking of North Sea cultures and the rationalist thinking of the rest of the continent. Westerners and Asians have different mental skills and capacities deriving from the nature of written and spoken language, the relative importance of learning by rote or investigation and the social environment. Western children are expected to ask questions and test ideas for themselves, while in Asia it is unacceptable to question anyone senior in age or authority, including teachers. Westerners base thinking on reason; Asians base thinking on harmony. Whenever people of different cultures work together, different ways of thinking create barriers to understanding and communication. This applies to many spheres of work, including the medical profession.

Survey of primary care physicians and home care clinicians

CONTEXT

Providing home care in the United States is expensive, and significant geographic variation exists in the utilization of these services. However, few data exist on how well physicians and home care providers communicate and coordinate care for patients.

OBJECTIVE

To assess communication and collaboration between primary care physicians (PCPs) and home care clinicians (HCCs) within 1 primary care network.

DESIGN

Mail survey.

SETTING

Boston.

PARTICIPANTS

Sixty-seven PCPs from 1 academic medical center-affiliated primary care network and 820 HCCs from 8 regional home care agencies.

MEASUREMENTS

Provider responses

RESULTS

Ninety percent of PCPs and 63% of HCCs responded. The majority (54%) of PCPs reported that they only "rarely" or "occasionally" read carefully the home care order forms sent to them for signature. Further, when asked to rate their prospective involvement in the decision making about home care, only 24% of PCPs and 25% of HCCs rated this as "excellent" or "very good." Although more HCCs (79%) than PCPs (47%) reported overall satisfaction with communication and collaboration, 28% of HCCs felt they provided more services to patients than clinically necessary.

CONCLUSIONS

PCPs from 1 provider network and the HCCs with whom they coordinate home care were both dissatisfied with many aspects of communication and collaboration regarding home care services. Moreover, neither group felt in control of home care decision making. These findings are of concern because poor coordination of home care may adversely affect quality and contribute to inappropriate utilization of these services.

Improving communication between health professionals and women in maternity care: a structured review

OBJECTIVE

To review trials of the effectiveness of interventions aimed at improving communication between health professionals and women in maternity care.

SEARCH STRATEGY

The electronic databases Medline, PsycLit, The Cochrane Library, BIDS Science and Social Science Indexes, Cinahl and Embase were searched. Final searches were carried out in April 2000.

INCLUSION CRITERIA

Controlled trials of interventions explicitly aimed at improving communication between health professionals and women in maternity care were included. Other trials were included where two reviewers agreed that this was at least part of the aim.

DATA EXTRACTION AND SYNTHESIS

95 potentially eligible papers were identified, read by one reviewer and checked against the inclusion criteria. The 11 included trials were read, assessed for quality and summarized in a structured tabular form.

RESULTS

The included trials evaluated interventions to improve the presentation of information about antenatal testing, to promote informed choice in maternity care, woman-held maternity records and computer-based history taking. Four trials in which women were provided with extra information about antenatal testing in a variety of formats suggested that this was valued by women and may reduce anxiety. Communication skills training for midwives and doctors improved their information giving about antenatal tests. The three trials of woman-held maternity records suggested that these increase women's involvement in and control over their care.

CONCLUSIONS

The trials identified by this review addressed limited aspects of communication and focused solely on antenatal care. Further research is required in several areas, including trials of communication skills training for health professionals in maternity care and other interventions to improve communication during labour and in the postnatal period.

Computer-based quality of life questionnaires may contribute to doctor-patient interactions in oncology

It is well recognized that oncologists should consider patients' quality of life and functioning when planning and delivering anticancer treatment, but a comprehensive assessment of how a patient feels requires a thorough inquiry. A standardized measurement of patients' quality of life may support clinicians in identifying important problems for discussion during the limited time of the medical consultations. The aim of this study was to assess the feasibility of computer-administered individual quality of life measurements in oncology clinics with immediate feedback of results to clinicians and to examine the impact of the information on consultations. The study employed a prospective non-randomized design with pre-test post-test within subjects comparisons and involved three medical oncologists and 28 cancer patients receiving chemotherapy. The intervention consisted of completion of quality of life questionnaires before the consultations and informing clinicians of the results. The main outcome measures were patients' perceptions of the content of baseline and intervention consultations and satisfaction with communication. A qualitative analysis of clinicians' interviews was performed. When clinicians had the quality of life results they enquired more often about daily activities (Z= -2.71, P=0.007), emotional problems (Z= -2.11, P=0.035) and work related issues (Z= -1.89, P=0.058). There was an increase in the number of issues discussed during the intervention consultation (Z= -1.89, P=0.059). Patients were highly satisfied with both consultations. The computer measurement was well accepted by patients who felt that the questionnaires were a useful tool to tell the doctors about their problems. The clinicians perceived that the quality of life data broadened the range of the clinical inquiry and helped them identify issues for discussion. Having symptoms and functional problems expressed quantitatively on a scale was useful for detection of change over time.

Collaboration Between Athletic Training Clinical and Classroom Instructors

OBJECTIVE: The education of an athletic training student involves a balance between theory and application, which can be stated as a balance between classroom and clinical education. The instructors in these settings should work together to promote the overall educational process. Our primary purpose was to measure the observations and perceptions of physical presence, cooperation, and communication between clinical and classroom instructors and secondarily to determine if these have a perceived effect on the education of the student. SUBJECTS: Clinical instructors, classroom instructors, and athletic training students in Commission on Accreditation of Allied Health Education Programs-accredited and National Athletic Trainers' Association-approved athletic training education programs. MEASUREMENTS: Data were analyzed using various correlation techniques, a general linear model, and a one-way analysis of variance. DESIGN AND SETTING: We designed a questionnaire to measure the observations and perceptions of physical presence, cooperation, and communication between the clinical and classroom instructors. RESULTS: Of the 30 athletic training educational programs solicited for involvement in this study, 19 responded (63%). A total of 737 questionnaires were distributed, and 547 were returned (74%). Classroom instructors rated observations of cooperation between clinical and classroom instructors at a significantly higher frequency than did clinical instructors. Students rated observations of communication at a significantly lower frequency than did the clinical and classroom instructors. All 3 groups agreed that the physical presence, cooperation, and communication between the clinical and classroom instructors has a large effect upon the education of the student. CONCLUSIONS: Clinical instructors must be educators as well as care providers. At the same time, classroom instructors must make efforts to include clinical instructors in all aspects of the educational process. Also, athletic training students should be exposed to the inner workings of their educational programs, so they may have a better understanding and appreciation of how theory and application tie together.

Linking human and veterinary health: trends, directions and initiatives

The objective of this brief article is to provide an overview of some of the important harmonization efforts that are currently under way within the animal health community. Topics include: scientific networks and interdisciplinary communication; organizations that address animal-related public health concerns; the role of the veterinary pharmaceutical scientist within human health-oriented professional organizations; recent publications pertaining to veterinary pharmacology, pharmaceutics and therapeutics; and the role of global networking in veterinary product research and development.

How are patients' specific ambulatory care experiences related to trust, satisfaction, and considering changing physicians?

CONTEXT

Few data are available regarding the consequences of patients' problems with interpersonal aspects of medical care.

OBJECTIVE

To assess the relationships between outpatient problem experiences and patients' trust in their physicians, ratings of their physicians, and consideration of changing physicians. We classified as problem experiences patients' reports that their physician does not always 1) give them enough time to explain the reason for the visit, 2) give answers to questions that are understandable, 3) take enough time to answer questions, 4) ask about how their family or living situation affects their health, 5) give as much medical information as they want, or 6) involve them in decisions as much as they want.

DESIGN

Telephone survey during 1997.

PARTICIPANTS

Patients (N=2,052; 58% response) insured by a large national health insurer.

MEASUREMENTS

Patient trust, overall ratings of physicians, and having considered changing physicians.

RESULTS

Most patients (78%) reported at least 1 problem experience. In multivariable analyses, each problem experience was independently associated with lower trust (all P <.001) and 5 of 6 with lower overall ratings (P <.001). Three problem experiences were independently related to considering changing physicians: physicians not always giving answers to questions that are understandable (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3 to 3.0), not always taking enough time to answer questions (OR, 3.3; 95% CI, 2.2 to 5.2), and not always giving enough medical information (OR, 4.0; 95% CI, 2.4 to 6.6).

CONCLUSIONS

Problem experiences in the ambulatory setting are strongly related to lower trust. Several are also associated with lower overall ratings and with considering changing physicians, particularly problems related to communication of health information. Efforts to improve patients' experiences may promote more trusting relationships and greater continuity and therefore should be a priority for physicians, educators, and health care organizations.

Beyond the examination room: primary care performance and the patient-physician relationship for low-income women

OBJECTIVE

To assess whether primary care performance of low-income women's primary care delivery sites is associated with the strength of their relationships with their physicians.

DESIGN

Random-digit-dial and targeted household telephone survey of a population-based sample.

SETTING

Washington, D.C. census tracts with > or =30% of households below 200% of federal poverty threshold.

PARTICIPANTS

Women over age 40 (N=1,205), 82% of whom were African American.

MEASUREMENTS AND MAIN RESULTS

The response rate was 85%. Primary care performance was assessed using women's ratings of their systems' accessibility (organizational, geographic, and financial), continuity, comprehensiveness, and coordination. Respondents' ratings of trust in their physicians, communication with their physicians, and compassion shown by their physicians were used to operationalize the patient-physician relationship. Controlling for population and insurance characteristics, 4 primary care features were positively associated with women's trust in and communication with their physicians: continuity with a single clinician, organizational accessibility of the practice, comprehensive care, and coordination of specialty care services. Better organizational access, but not geographic or financial access, was associated with greater levels of trust, compassion, and communication (odds ratios [ORs], 3.2, 7.4, and 6.9, respectively; P < or =.01). Women who rated highest their doctor's ability to take care of all of their health care needs (highest level of comprehensiveness) had 11 times the odds of trusting their physician (P < or =.01) and 6 times the odds of finding their physicians compassionate and communicative (P < or =.01), compared to those with the lowest level of comprehensiveness.

CONCLUSIONS

Primary care delivery sites organized to be more accessible, to link patients with the same clinician for their visits, to provide for all of a woman's health care needs, and to coordinate specialty care services are associated with stronger relationships between low-income women and their physicians. Primary care systems that fail to emphasize these features of primary care may jeopardize the clinician-patient relationship and indirectly the quality of care and health outcomes.

Giving tape recordings or written summaries of consultations to people with cancer: a systematic review

OBJECTIVE

To examine the effects of providing recordings or summaries of consultations to people with cancer and their families.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, Cancerlit, EMBASE and other electronic bibliographic databases. Bibliographies of relevant papers.

SELECTION CRITERIA

Randomized and non-randomized controlled trials of the provision of taped recordings or written summaries of consultations to people with cancer and/or their families.

MAIN RESULTS

Eight randomized controlled trials were found, all involving adult participants. No non-randomized controlled trials were found. The quality of the studies was generally poor. Between 83% and 96% of people who received recordings or summaries found them useful to remind them of what was said and/or to inform family members and friends about their illness and treatment. Of seven studies that assessed recall of information given during the consultation, four reported better recall among the groups that received recordings or summaries than among control groups. Receiving a recording or summary had no significant effect on anxiety or depression between the groups. None of the included studies assessed survival or health outcomes other than psychological outcomes.

CONCLUSIONS

Wider use of consultation tapes and summary letters could benefit many adults with cancer, without causing additional anxiety or depression, but consideration should be given to individuals' circumstances and preferences.

Using survival curve comparisons to inform patient decision making can a practice exercise improve understanding?

BACKGROUND

Patients often face medical decisions that involve outcomes that occur and change over time. Survival curves are a promising communication tool for patient decision support because they present information about the probability of an outcome over time in a simple graphic format. However, previous studies of survival curves did not measure comprehension, used face-to-face explanations, and focused on a VA population.

METHODS

In this study, 246 individuals awaiting jury duty at the Philadelphia County Courthouse were randomized to receive one of two questionnaires. The control group received a questionnaire describing two hypothetical treatments and a graph with two survival curves showing the outcomes of each treatment. The practice group received the same questionnaire preceded by a practice exercise asking questions about a graph containing a single curve. Subjects' ability to interpret survival from a curve and ability to calculate change in survival over time were measured.

RESULTS

Understanding of survival at a single point in time from a graph containing two survival curves was high overall, and was improved by the use of a single curve practice exercise. With a practice exercise, subjects were over 80% accurate in interpreting survival at a single point in time. Understanding of changes in survival over time was lower overall, and was not improved by the use of a practice exercise. With or without a practice exercise, subjects were only 55% accurate in calculating changes in survival.

CONCLUSION

The majority of the general public can interpret survival at a point in time from self-administered survival curves. This understanding is improved by a single curve practice exercise. However, a significant proportion of the general public cannot calculate change in survival over time. Further research is necessary to determine the effectiveness of survival curves in improving risk communication and patient decision making.

Learning oral presentation skills: a rhetorical analysis with pedagogical and professional implications

OBJECTIVE

Oral presentation skills are central to physician-physician communication; however, little is known about how these skills are learned. Rhetoric is a social science which studies communication in terms of context and explores the action of language on knowledge, attitudes, and values. It has not previously been applied to medical discourse. We used rhetorical principles to qualitatively study how students learn oral presentation skills and what professional values are communicated in this process.

DESIGN

Descriptive study.

SETTING

Inpatient general medicine service in a university-affiliated public hospital.

PARTICIPANTS

Twelve third-year medical students during their internal medicine clerkship and 14 teachers.

MEASUREMENTS

One-hundred sixty hours of ethnographic observation. including 73 oral presentations on rounds. Discoursed-based interviews of 8 students and 10 teachers. Data were qualitatively analyzed to uncover recurrent patterns of communication.

MAIN RESULTS

Students and teachers had different perceptions of the purpose of oral presentation, and this was reflected in performance. Students described and conducted the presentation as a rule-based, data-storage activity governed by "order" and "structure." Teachers approached the presentation as a flexible means of "communication" and a method for "constructing" the details of a case into a diagnostic or therapeutic plan. Although most teachers viewed oral presentations rhetorically (sensitive to context), most feedback that students received was implicit and acontextual, with little guidance provided for determining relevant content. This led to dysfunctional generalizations by students, sometimes resulting in worse communication skills (e.g., comment "be brief" resulted in reading faster rather than editing) and unintended value acquisition (e.g., request for less social history interpreted as social history never relevant).

CONCLUSIONS

Students learn oral presentation by trial and error rather than through teaching of an explicit rhetorical model. This may delay development of effective communication skills and result in acquisition of unintended professional values. Teaching and learning of oral presentation skills may be improved by emphasizing that context determines content and by making explicit the tacit rules of presentation.

Psychiatric morbidity and its recognition by doctors in patients with cancer

Psychiatric morbidity in patients with cancer is high and without appropriate treatment unremitting. We assessed the ability of 143 doctors to establish the psychological status of 2297 patients during outpatient consultations in 34 cancer centres and hospitals in the UK. Prior to seeing the doctor, consenting patients completed a short self-report questionnaire (GHQ12), designed for the psychological screening of large populations. At the end of the consultation, doctors completed visual analogue scales rating patients' distress. 837/2297 (36.4%) patients had GHQ scores suggestive of psychiatric morbidity. The doctors' sensitivity (true positive rate) was 28.87% (SD 25.29), specificity (true negative rate) 84.79% (SD 17.44). The misclassification rate was 34.7% (SD 13.79) meaning that for 797 patients the wrong assessment was probably made. These data show that much of the probable psychiatric morbidity experienced by patients with cancer goes unrecognized and therefore untreated. Doctors need communication skills training to elicit problems during consultations. Appropriate referrals to psychological services are necessary when patients requiring help are identified and ought to be an integral part of cancer care.

Conversation analysis: a method for research into interactions between patients and health-care professionals

BACKGROUND

It is clear that much of the success of health-care provision depends on the quality of interactions between health professionals and patients. For instance, it is widely recognized that patients are more likely to take medication effectively if they have been involved in discussions about treatment options, and understand and support the decision about what is prescribed (patient concordance). Hence, patient participation is important for the success of medical outcomes. The key is to explore how communicative choices made by health professionals impact on the quality of interactions in general, and of patient participation in particular. However, to date there has not been an appropriate method for investigating this connection or impact.

OBJECTIVE

To outline the perspective and method of Conversation Analysis (CA). Developed within sociology and linguistics, CA offers a rigorous method (applicable to large data sets) to the study of interaction in health settings.

STRATEGY

The method of CA is illustrated through a review of CA studies of doctor-patient interactions. Two such studies, one from the US and the other from Finland, are reviewed, in order to show how CA can be applied to identifying both forms of patient participation, and the interactional conditions which provide opportunities for patient participation. These studies focus principally on the medical examination and diagnostic stages of the consultation. Further research will examine the forms and conditions of patient participation in decision-making.

Women's preferences for discussion of prognosis in early breast cancer

OBJECTIVES

To determine preference for prognostic information in women with early breast cancer.

DESIGN

Cross sectional survey.

PARTICIPANTS

100 women with early stage breast cancer attending six teaching hospitals in Sydney, Australia.

MAIN OUTCOME MEASURES

Women's preference for prognostic information.

RESULTS

This study identifies new elements to consider in the prognostic consultation. Whilst 91% of women wanted to know their prognosis prior to commencing adjuvant treatment, 63% wanted their cancer specialist to check with them first before giving it. Seventy-seven percent wanted to be asked if they would like a second opinion. Seventy-five percent wanted to know about complementary therapies. Most wanted their cancer specialist to check their understanding, provide an opportunity to ask questions, and explain medical terms (98%). The majority wanted information summarized (94%), supported by published information (88%) and written down (79%). Ninety-seven percent wanted their fears and concerns listened to and 79% wanted emotional support. In addition 80% of women wanted their cancer specialist to tell them where they could go to get additional emotional support for themselves and their families. Seventy-two percent of women wanted their cancer specialist to make sure they had a relative or friend with them.

CONCLUSIONS

Data from this study suggests that a variety of techniques are needed to communicate prognosis. Whilst acknowledging individual women's preferences, and not wanting to appear prescriptive, recommendations emerge for effective discussion of prognosis with women with early stage breast cancer.

The World Trade Center attack. Observations from New York's Bellevue Hospital

This report describes selected aspects of the response by Bellevue Hospital Center to the World Trade Center attack of 11 September 2001. The hospital is 2.5 miles (4 km) from the site of the attack. These first-hand observations and this analysis may aid in future preparations. Key issues described relate to communication, organization, injuries treated, staffing, and logistics.

A Spanish and international perspective through bibliometric analysis]

OBJECTIVES

1. To find the scientific output on communication and health both in Spain and internationally. 2. To compare the two outputs according to the type of articles published and the design of the research.

DESIGN

Descriptive and bibliometric study.

MATERIAL

The data bases MEDLINE (1995-2000) and IME (1990-2000) and the books summarising papers from semFYC Congresses (1995-2000) were used.

MEASUREMENTS

The number of articles on MEDLINE published and indexed with the description <<physician-patient relationships>>, plus a series of subject describers that could be included under the heading <<communication and health>>, were counted. On the IME and in the semFYC congress summaries the describers <<communication, clinical interview, doctor-patient relationship, doctor-sick person communication and doctor-patient communication>> were used. The articles indexed on MEDLINE-IME were compared for their classification as original articles, clinical practice guidelines, review, editorial or letter to the editor. Original articles were classified in randomised and non-randomised trials, meta-analysis and observation studies.

MAIN RESULTS

6766 articles were found on MEDLINE, 42 on the IME (0.046% of the total indexed) and 34 summaries from semFYC congresses (1.47% of the total). Among the most commonly studied questions were found patients' information and education, professional stress and psychological interviews; among the least studied were difficult and aggressive patients, negotiation and people accompanying patients. The original articles on MEDLINE and IME were 70% and 37%; and review articles, 11% and 44%. 1.4% of MEDLINE articles were randomised trials; and 0.08%, meta-analysis.

CONCLUSIONS

Communication and health research is a young field that still requires descriptive studies. There is little scientific output in this area in Spain, with few original papers and too many reviews.

A qualitative study of women's views about how health professionals communicate about infant feeding

OBJECTIVE: To look at how communication by health professionals about infant feeding is perceived by first time mothers. DESIGN: Qualitative semi-structured interviews early in pregnancy and 6-10 weeks after birth. SUBJECTS AND SETTING: Twenty-one white, low income women expecting their first baby were interviewed mostly at home, often with their partner or a relative. RESULTS: The personal and practical aspects of infant feeding which were important to women were seldom discussed in detail in ante-natal interviews. In post-natal interviews women described how words alone encouraging them to breastfeed were insufficient. Apprenticeship style learning of practical skills was valued, particularly time patiently spent watching them feed their baby. Women preferred to be shown skills rather than be told how to do them. Some felt pressure to breastfeed and bottle feeding mothers on post-natal wards felt neglected in comparison. Women preferred their own decision-making to be facilitated rather than being advised what to do. Some women experienced distress exposing their breasts and being touched by health professionals. Continuity of care and forming a personal relationship with a health professional who could reassure them were key factors associated with satisfaction with infant feeding communication. CONCLUSIONS: The infant feeding goal for many women is a contented, thriving baby. In contrast, women perceive that the goal for health professionals is the continuation of breastfeeding. These differing goals can give rise to dissatisfaction with communication which is often seen as 'breastfeeding centred' rather than 'woman centred.' Words alone offering support for breastfeeding were often inadequate and women valued practical demonstrations and being shown how to feed their baby. Spending time with a caring midwife with whom the woman had developed a personal, continuing relationship was highly valued. Women were keen to maintain ownership, control and responsibility for their own decision-making about infant feeding.

Communication breakdown in the outpatient referral process

OBJECTIVE

To evaluate primary care and specialist physicians' satisfaction with interphysician communication and to identify the major problems in the current referral process.

DESIGN

Surveys were mailed to providers to determine satisfaction with the referral process; then patient-specific surveys were e-mailed to this group to obtain real-time referral information.

SETTING

Academic tertiary care medical center.

PARTICIPANTS

Attending-level primary care physicians (PCPs) and specialists.

MEASUREMENTS AND MAIN RESULTS

The response rate for mail surveys for PCPs was 57% and for specialists was 51%. In the mail survey, 63% of PCPs and 35% of specialists were dissatisfied with the current referral process. Respondents felt that major problems with the current referral system were lack of timeliness of information and inadequate referral letter content. Information considered important by recipient groups was often not included in letters that were sent. The response rate for the referral specific e-mail surveys was 56% for PCPs and 53% for specialists. In this e-mail survey, 68% of specialists reported that they received no information from the PCP prior to specific referral visits, and 38% of these said that this information would have been helpful. In addition, four weeks after specific referral visits, 25% of PCPs had still not received any information from specialists.

CONCLUSIONS

Substantial problems were present in the referral process. The major issues were physician dissatisfaction, lack of timeliness, and inadequate content of interphysician communication. Information obtained from the general survey and referral-specific survey was congruent. Efforts to improve the referral system could improve both physician satisfaction and quality of patient care.

Different subthreshold mechanisms underlie song selectivity in identified HVc neurons of the zebra finch

Songbirds learn and maintain their songs via auditory experience. Neurons in many telencephalic nuclei important to song production and development are song selective, firing more to forward auditory playback of the bird's own song (BOS) than to reverse BOS or conspecific songs. Elucidating circuits that generate these responses can localize where auditory experience influences vocalization, bridging cellular and systems analyses of song learning. Song-selective responses in many song nuclei, including the vocal premotor nucleus robustus archistriatalis (RA) and the basal ganglia homolog area X, are thought to originate in nucleus HVc (used as a proper name), which contains interneurons and relay cells that innervate either RA or area X. Previous studies indicated that only X-projecting neurons have auditory responses, leaving open the source of RA's auditory input and the degree to which song selectivity may be refined in HVc. Here, in vivo intracellular recordings from morphologically and electrophysiologically identified HVc neurons revealed that both relay cell types fire song-selectively. However, their firing arises via markedly different subthreshold processes, and only X-projecting neurons appear to be sites for auditory refinement. RA-projecting neurons exhibited purely depolarizing subthreshold responses that were highly song selective and that were excitatory. In contrast, subthreshold responses of X-projecting neurons included less-selective depolarizing and highly selective hyperpolarizing components. Within individual birds, these BOS-evoked hyperpolarizations closely matched interneuronal firing, suggesting that HVc interneurons make restricted inputs onto X-projecting neurons. Because of the two relay cell types' subthreshold differences, factors affecting their resting membrane potentials could enable them to transmit distinct song representations to their targets.

Reasons for accepting or declining to participate in randomized clinical trials for cancer therapy

This paper reports on the reasons why patients agreed to or declined entry into randomized trials of cancer following discussions conducted by clinicians in both District General and University Hospitals. Two hundred and four patients completed a 16-item questionnaire following the consultation, of these 112 (55%) were women with breast cancer. Overall results showed that 147 (72.1%) patients accepted entry to a randomized clinical trial (RCT). The main reasons nominated for participating in a trial were that 'others will benefit' (23.1%) and 'trust in the doctor' (21.1%). One of the main reasons for declining trial entry was that patients were 'worried about randomization' (19.6%). There was a significantly higher acceptance rate for trials providing active treatment in every arm 98 (80.6%) compared with those trials with a no treatment arm 46 (60.5%), chi2 test P= 0.003. The study outlines a number of factors that appear to influence a patient's decision to accept or decline entry into an RCT of cancer therapy. An important factor is whether or not the trial offers active treatment in all arms of the study. Communication that promotes trust and confidence in the doctor is also a powerful motivating influence.

Improving the letters we write: an exploration of doctor-doctor communication in cancer care

Referral and reply letters are common means by which doctors exchange information pertinent to patient care. Twenty-eight semi-structured interviews were conducted exploring the views of oncologists, referring surgeons and general practitioners. Twenty-seven categories of information in referral letters and 32 in reply letters after a consultation were defined. The letters to and from six medical oncologists relating to 20 consecutive new patients were copied, and their content analysed. Oncologists, surgeons and general practitioners Australia wide were surveyed using questionnaires developed on data obtained above. Only four of 27 categories of referral information appear regularly (in > 50%) in referral letters. Oncologists want most to receive information regarding the patient's medical status, the involvement of other doctors, and any special considerations. Referring surgeons and family doctors identified delay in receiving the consultant's reply letter as of greatest concern, and insufficient detail as relatively common problems. Reply letters include more information regarding patient history/background than the recipients would like. Referring surgeons and family doctors want information regarding the proposed treatment, expected outcomes, and any psychosocial concerns, yet these items are often omitted. Consultants and referring doctors need to review, and modify their letter writing practices.

Contributions of social cues and photoperiod to seasonal plasticity in the adult avian song control system

In seasonally breeding birds, the vernal growth of the song system is thought to result primarily from increased daylength and the associated increase in circulating testosterone. Other environmental factors such as social cues between mates influence the timing of reproduction, but less is known about how social cues might affect the song system and song behavior. We used white-crowned sparrows (Zonotrichia leucophrys gambelii) to test the hypothesis that the presence of a female in breeding condition influences song nuclei and song behavior of adult males. There were four treatment groups: (1) eight males housed individually in the same room on long days and paired with estradiol-implanted females; (2) eight males housed similarly on long days but without females; (3) four males isolated on long days; and (4) four males isolated on short days. The volumes of two song nuclei, HVc and RA, were significantly larger in males housed with females than in any other treatment group. Males isolated on short days had smaller HVc, RA, and area X volumes than all other groups. The volumes of Rt (a thalamic nucleus not involved in song) and the telencephalon did not differ among groups. Plasma androgen levels did not differ among the three long-day, social treatment groups at the times sampled, but were lower in the short-day isolates. Males paired with females sang at a higher maximum rate than males housed together, who sang at a higher rate than long-day isolates. These results suggest that seasonal plasticity in the adult song system is influenced by social cues.

Communication and decision-making in labour: do birth plans make a difference?

OBJECTIVES: To assess usage of birth plans, and examine differences in social and obstetric characteristics, and intrapartum experiences of women who did and did not use a birth plan. DESIGN: Population-based survey distributed by hospitals and home birth practitioners, 6-7 months post-natally. SETTING AND PARTICIPANTS: Women who gave birth in Victoria, Australia over a 2-week period in September, 1993, excluding those who had a stillbirth or neonatal death. MAIN OUTCOME MEASURES: Use of a written birth plan; perceived helpfulness, advantages and disadvantages of birth plans; relationship between use of birth plans and overall rating of intrapartum care, and involvement in decision-making. RESULTS: Twenty per cent of women (270/1336) had prepared a written birth plan and discussed it with caregivers. Women who made use of a birth plan were more likely to be satisfied with pain relief (OR = 1.74[1.3-2.3]), but did not differ from women not completing a birth plan in terms of their overall rating of intrapartum care, or involvement in making decisions about their care. CONCLUSIONS: The lack of association between use of a written birth plan and variables assessing women's views of intrapartum care suggest there are insufficient grounds for continuing to advocate a policy of encouraging pregnant women to complete written birth plans, unless it is within the context of a well-designed randomized trial able to provide further evidence regarding their effectiveness.

Exploring a model of symbolic social communication: the case of 'magic' johnson

We propose a model of symbolic social communication to explain the process whereby sociocultural identity mediates relationships among receivers, sources and messages to shape message effects. This exploratory study examines how two at-risk groups of African American men responded to various HIV prevention messages delivered by celebrity and professional sources. We interviewed 47 men from a homeless shelter and 50 male college students. Members of both groups were likely to select Johnson as the best person to deliver HIV prevention messages among a list of African American celebrity and professional sources. Results suggest the symbolic meanings embedded in celebrities and message topics are important and enduring influences on message effects. The images and ideas that a source represents are transferred to the advocated behavior, attitude or knowledge change and thus shape how messages are interpreted and received. Further understanding of how culture influences the effects of persuasive messages is critical for the improvement of health-communication campaigns.