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Henry SG, Czarnecki D, Kahn VC, Chou WS, Fagerlin A, Ubel PA, Rovner DR, Alexander SC, Knight SJ, Holmes‐Rovner M. Patient-physician communication about early stage prostate cancer: analysis of overall visit structure. Health Expect 2015; 18:1757-68. [PMID: 24372758 PMCID: PMC4370798 DOI: 10.1111/hex.12168] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2013] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND We know little about patient-physician communication during visits to discuss diagnosis and treatment of prostate cancer. OBJECTIVE To examine the overall visit structure and how patients and physicians transition between communication activities during visits in which patients received new prostate cancer diagnoses. PARTICIPANTS Forty veterans and 18 urologists at one VA medical centre. METHODS We coded 40 transcripts to identify major communication activities during visits and used empiric discourse analysis to analyse transitions between activities. RESULTS We identified five communication activities that occurred in the following typical sequence: 'diagnosis delivery', 'risk classification', 'options talk', 'decision talk' and 'next steps'. The first two activities were typically brief and involved minimal patient participation. Options talk was typically the longest activity; physicians explicitly announced the beginning of options talk and framed it as their professional responsibility. Some patients were unsure of the purpose of visit and/or who should make treatment decisions. CONCLUSION Visits to deliver the diagnosis of early stage prostate cancer follow a regular sequence of communication activities. Physicians focus on discussing treatment options and devote comparatively little time and attention to discussing the new cancer diagnosis. Towards the goal of promoting patient-centred communication, physicians should consider eliciting patient reactions after diagnosis delivery and explaining the decision-making process before describing treatment options.
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Østbye T, Lyna P, Bodner ME, Alexander SC, Coffman C, Tulsky JA, Dolor R, Pollak K. The Effect of Parental Presence on Weight-Related Discussions Between Physicians and Their Overweight Adolescent Patients. Clin Pediatr (Phila) 2015; 54:1218-20. [PMID: 25575503 PMCID: PMC4568823 DOI: 10.1177/0009922814566027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gramling R, Gajary-Coots E, Stanek S, Dougoud N, Pyke H, Thomas M, Cimino J, Sanders M, Alexander SC, Epstein R, Fiscella K, Gramling D, Ladwig S, Anderson W, Pantilat S, Norton SA. Design of, and enrollment in, the palliative care communication research initiative: a direct-observation cohort study. BMC Palliat Care 2015; 14:40. [PMID: 26286538 PMCID: PMC4544824 DOI: 10.1186/s12904-015-0037-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 08/11/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Understanding the characteristics of communication that foster patient-centered outcomes amid serious illness are essential for the science of palliative care. However, epidemiological cohort studies that directly observe clinical conversations can be challenging to conduct in the natural setting. We describe the successful enrollment, observation and data collection methods of the ongoing Palliative Care Communication Research Initiative (PCCRI). METHODS The PCCRI is a multi-site cohort study of naturally occurring inpatient palliative care consultations. The 6-month cohort data includes directly observed and audio-recorded palliative care consultations (up to first 3 visits); patient/proxy/clinician self-report questionnaires both before and the day after consultation; post-consultation in-depth interviews; and medical/administrative records. RESULTS One hundred fourteen patients or their proxies enrolled in PCCRI during Enrollment Year One (of Three). Seventy percent of eligible patients/proxies were invited to hear about a communication research study (188/269); 60% of them ultimately enrolled in the PCCRI (114/188), resulting in a 42% sampling proportion (114/269 eligible). All PC clinicians at study sites were invited to participate; all 45 participated. CONCLUSIONS Epidemiologic study of patient-family-clinician communication in palliative care settings is feasible and acceptable to patients, proxies and clinicians. We detail the successful PCCRI methods for enrollment, direct observation and data collection for this complex "field" environment.
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Lu A, Mohan D, Alexander SC, Mescher C, Barnato AE. The Language of End-of-Life Decision Making: A Simulation Study. J Palliat Med 2015; 18:740-6. [PMID: 26186668 DOI: 10.1089/jpm.2015.0089] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Framing is known to influence decision making. OBJECTIVE The study objective was to describe language used by physicians when discussing treatment options with a critically and terminally ill elder. METHODS High-fidelity simulation was used, involving an elder with end-stage cancer and life-threatening hypoxia, followed by a debriefing interview. Subjects were hospitalist, emergency medicine, and critical care physicians from three academic medical centers. Measures were observation of encounters in real time followed by content analysis of simulation and debriefing interview transcripts. During the simulation we identified the first mention ("broaching") of principal treatment options--intubation and mechanical ventilation (life-sustaining treatment [LST]) and palliation in anticipation of death (palliation)--and used constant comparative methods to identify language used. We identified physician opinions about the use of LST in this clinical context during the debriefing interviews, and compared language used with opinions. RESULTS Among 114 physician subjects, 106 discussed LST, 86 discussed palliation, and 84 discussed both. We identified five frames: will (decided), must (necessary), should (convention), could (option), and ask (elicitation of preferences). Physicians broached LST differently than palliation (p<0.01), most commonly framing LST as necessary (53%), while framing palliation as optional (49%). Among physicians who framed LST as imperative (will or must), 16 (30%) felt intubation would be inappropriate in this clinical situation. CONCLUSIONS In this high-fidelity simulation experiment involving a critically and terminally ill elder, the majority of physicians framed the available options in ways implying LST was the expected or preferred choice. Framing of treatment options could influence ultimate treatment decisions.
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Alexander SC, Fortenberry JD, Pollak KI, Østbye T, Bravender T, Tulsky JA, Dolor R, Shields CG. Disclosure of Sexual Intercourse by Teenagers: Agreement Between Telephone Survey Responses and Annual Visit Disclosures. Clin Pediatr (Phila) 2015; 54:529-33. [PMID: 25857726 PMCID: PMC4568819 DOI: 10.1177/0009922815580074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Physicians can help guide teenagers in their emerging sexuality; however, teens rarely inform physicians about their sexual activity. METHODS We audio-recorded annual visits between 365 teenagers and 49 physicians. Before the recorded visit, the teens were asked in a confidential telephone survey whether they had ever engaged in sexual intercourse. Recordings were coded for teenage disclosures about previous sexual intercourse. We measured agreement between telephone survey responses and annual visit disclosures, and examined factors associated with agreement between the two. RESULTS Fifty-six teenagers (15%) reported previous sexual intercourse in either the telephone survey or to their physician. Among those who reported sexual intercourse, 57% shared this information to both the telephone survey and their physician (κ = .72, confidence interval = 0.63-0.82). CONCLUSIONS Although a slight majority of teenagers disclosed their sexual activity to both the telephone survey and their doctor, a significant number disclosed to just one source.
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Pollak KI, Alexander SC, Bennett G, Lyna P, Coffman CJ, Bilheimer A, Farrell D, Bodner ME, Swamy GK, Østbye T. Weight-related SMS texts promoting appropriate pregnancy weight gain: a pilot study. PATIENT EDUCATION AND COUNSELING 2014; 97:256-60. [PMID: 25153313 PMCID: PMC4512734 DOI: 10.1016/j.pec.2014.07.030] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 06/18/2014] [Accepted: 07/29/2014] [Indexed: 05/20/2023]
Abstract
OBJECTIVES Excessive gestational weight gain (GWG) puts women and children at risk of obesity. We piloted an SMS-texting intervention to promote healthy GWG among overweight and obese women. METHODS We recruited 35 women and randomized them in a 2:1 fashion to: a tailored SMS-texting intervention (Preg CHAT) vs. a generic texting intervention (Txt4baby). Preg CHAT texts provided personalized feedback based on women's intake of sweetened beverages, fruits and vegetables, fast food, daily steps taken, and weight. We abstracted women's weights from charts and surveyed women at baseline and 32 weeks gestation. RESULTS Few women refused the study; many (30%) did not complete the study, however. Of those in the Preg CHAT arm, 86% responded to texts, and 80% said they would recommend this program to a friend. For women who completed the surveys (n=23), those in the Preg CHAT arm had a mean gain of 6 less pounds than women in the Txt4Baby arm (95% CI -15.9, 4.0; p=0.24). CONCLUSIONS This pilot study shows feasibility, acceptability, and potential efficacy of a low-intensity and disseminable intervention to help overweight and obese women reduce GWG. PRACTICE IMPLICATIONS An SMS texting program might help overweight women reduce excessive GWG.
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Bravender T, Lyna P, Tulsky JA, Østbye T, Alexander SC, Dolor RJ, Coffman CJ, Lin PH, Pollak KI. Physicians' assurances of confidentiality and time spent alone with adolescents during primary care visits. Clin Pediatr (Phila) 2014; 53:1094-7. [PMID: 24322956 PMCID: PMC4050042 DOI: 10.1177/0009922813512022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Alexander SC, Fortenberry JD, Pollak KI, Bravender T, Østbye T, Shields CG. Physicians Use of Inclusive Sexual Orientation Language During Teenage Annual Visits. LGBT Health 2014; 1:283-91. [PMID: 26789857 DOI: 10.1089/lgbt.2014.0035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Physicians are encouraged to use inclusive language regarding sexuality in order to help all adolescent patients feel accepted. Non-inclusive language by physicians may influence relationships with adolescent patients, especially those with still-developing sexual identities. The aim of this study was to identify patterns of physicians' use of inclusive and non-inclusive language when discussing sexuality. METHOD A total of 393 conversations between 393 adolescents and 49 physicians from 11 clinics located throughout the Raleigh-Durham, North Carolina, area were audio recorded. Conversations were coded for the use of inclusive talk (language use that avoids the use of specific gender, sex, or sexual orientation language), direct non-inclusive talk (language use that assumes the teenager is heterosexual or exclusively engages in heterosexual sexual activity), and indirect non-inclusive talk (language use that frames talk heterosexually but does not pre-identify the adolescent as heterosexual). RESULTS Nearly two-thirds (63%, 245) of the visits contained some sexuality talk. Inclusive talk rarely occurred (3.3%) while non-inclusive language was predominant (48.1% direct and 48.6% indirect). There were no significant differences in language use by gender, age, adolescent race, or visit length. These non-significant findings suggest that all adolescents regardless of race, gender, or age are receiving non-inclusive sexuality talk from their providers. CONCLUSION Physicians are missing opportunities to create safe environments for teenagers to discuss sexuality. The examples of inclusive talk from this study may provide potentially useful ways to teach providers how to begin sexuality discussions, focusing on sexual attraction or asking about friends' sexual behavior, and maintain these discussions.
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Pollak KI, Coffman CJ, Alexander SC, Østbye T, Lyna P, Tulsky JA, Bilheimer A, Dolor RJ, Lin PH, Bodner ME, Bravender T. Weight's up? Predictors of weight-related communication during primary care visits with overweight adolescents. PATIENT EDUCATION AND COUNSELING 2014; 96:327-332. [PMID: 25130793 PMCID: PMC4145021 DOI: 10.1016/j.pec.2014.07.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 07/15/2014] [Accepted: 07/21/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Physicians' use of Motivational Interviewing (MI) techniques when discussing weight with adolescent patients is unknown. METHODS We coded audio-recorded encounters between 49 primary care physicians and 180 overweight adolescent patients. During weight discussions, we used the MITI 3.0 to assess: Empathy, MI Spirit, open-ended questions, reflections, MI consistent behaviors (e.g., praising) and MI inconsistent behaviors (e.g., confronting). We examined associations of patient and physician characteristics with (1) MI techniques, (2) time discussing weight, and (3) encounter time. RESULTS Physicians used more MI consistent techniques with female patients (p=0.06) and with heavier patients (p=0.02). Physicians with prior MI training also used more MI consistent techniques (p=0.04) and asked more open-ended questions (p=0.05). Pediatricians had a higher MI Spirit score than family physicians (p=0.03). Older patient age was associated with physicians spending less time discussing weight-related topics (p=0.04) and higher BMI percentile was associated with physicians spending more time discussing weight-related topics (p=0.01). Increased use of MI inconsistent techniques was associated with longer encounters (p=0.02). CONCLUSION Physicians' weight discussions vary based on adolescent and physician characteristics. Importantly, not using MI lengthened encounter time. PRACTICE IMPLICATIONS Physicians might consider using MI techniques more and attempt to use these equally with all adolescents.
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Alexander SC, Ladwig S, Norton SA, Gramling D, Davis JK, Metzger M, DeLuca J, Gramling R. Emotional distress and compassionate responses in palliative care decision-making consultations. J Palliat Med 2014; 17:579-84. [PMID: 24588656 DOI: 10.1089/jpm.2013.0551] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Seriously ill hospitalized patients and their loved ones are frequently faced with complex treatment decisions laden with expressions of emotional distress during palliative care (PC) consultations. Little is known about these emotional expressions or the compassionate responses providers make and how common these are in PC decision-making conversations. OBJECTIVES To describe the types and frequency of emotional distress that patients and loved ones express and how providers respond to these emotions during PC decision-making consultations with seriously ill hospitalized patients. METHODS We used a quantitative descriptive approach to analyze 71 audio-recorded inpatient PC decision-making consultations for emotional distress and clinicians' responses to those emotions using reliable and established methods. RESULTS A total of 69% of conversations contained at least one expression of emotional distress. The per-conversation frequency of expressions of emotional distress ranged from 1 to 10. Anxiety/fear were the most frequently encountered emotions (48.4%) followed by sadness (35.5%) and anger/frustration (16.1%). More than half of the emotions related to the patient's feelings (53.6%) and 41.9% were related to the loved ones' own emotions. The majority of emotions were moderate in intensity (65.8%) followed by strong (20.7%) and mild (13.5%). Clinicians responded to a majority of emotions with a compassionate response (75.7%) followed by those with medical content (21.9%) and very few were ignored (1.3%). CONCLUSIONS Expressions of emotional distress are common during PC consultations and are usually met with compassionate responses by the clinician.
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Alexander SC, Fortenberry JD, Pollak KI, Bravender T, Davis JK, Østbye T, Tulsky JA, Dolor RJ, Shields CG. Sexuality talk during adolescent health maintenance visits. JAMA Pediatr 2014; 168:163-9. [PMID: 24378686 PMCID: PMC4428666 DOI: 10.1001/jamapediatrics.2013.4338] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality. OBJECTIVE To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents. DESIGN, SETTING, AND PARTICIPANTS Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area. MAIN OUTCOMES AND MEASURES Total time per visit during which sexuality issues were discussed. RESULTS One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥ 36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥ 36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation. CONCLUSIONS AND RELEVANCE Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01040975.
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Bravender T, Tulsky JA, Farrell D, Alexander SC, Østbye T, Lyna P, Dolor RJ, Coffman CJ, Bilheimer A, Lin PH, Pollak KI. Teen CHAT: Development and utilization of a web-based intervention to improve physician communication with adolescents about healthy weight. PATIENT EDUCATION AND COUNSELING 2013; 93:525-31. [PMID: 24021419 PMCID: PMC3851886 DOI: 10.1016/j.pec.2013.08.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 07/29/2013] [Accepted: 08/12/2013] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To describe the theoretical basis, use, and satisfaction with Teen CHAT, an online educational intervention designed to improve physician-adolescent communication about healthy weight. METHODS Routine health maintenance encounters between pediatricians and family practitioners and their overweight adolescent patients were audio recorded, and content was coded to summarize adherence with motivational interviewing techniques. An online educational intervention was developed using constructs from social cognitive theory and using personalized audio recordings. Physicians were randomized to the online intervention or not, and completed post-intervention surveys. RESULTS Forty-six physicians were recruited, and 22 physicians were randomized to view the intervention website. The educational intervention took an average of 54min to complete, and most physicians thought it was useful, that they would use newly acquired skills with their patients, and would recommend it to others. Fewer physicians thought it helped them address confidentiality issues with their adolescent patients. CONCLUSION The Teen CHAT online intervention shows potential for enhancing physician motivational interviewing skills in an acceptable and time-efficient manner. PRACTICE IMPLICATIONS If found to be effective in enhancing motivational interviewing skills and changing adolescent weight-related behaviors, wide dissemination will be feasible and indicated.
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Bays AM, Engelberg RA, Back AL, Ford DW, Downey L, Shannon SE, Doorenbos AZ, Edlund B, Christianson P, Arnold RW, O'Connor K, Kross EK, Reinke LF, Cecere Feemster L, Fryer-Edwards K, Alexander SC, Tulsky JA, Curtis JR. Interprofessional communication skills training for serious illness: evaluation of a small-group, simulated patient intervention. J Palliat Med 2013; 17:159-66. [PMID: 24180700 DOI: 10.1089/jpm.2013.0318] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Communication with patients and families is an essential component of high-quality care in serious illness. Small-group skills training can result in new communication behaviors, but past studies have used facilitators with extensive experience, raising concerns this is not scalable. OBJECTIVE The objective was to investigate the effect of an experiential communication skills building workshop (Codetalk), led by newly trained facilitators, on internal medicine trainees' and nurse practitioner students' ability to communicate bad news and express empathy. DESIGN Trainees participated in Codetalk; skill improvement was evaluated through pre- and post- standardized patient (SP) encounters. SETTING AND SUBJECTS The subjects were internal medicine residents and nurse practitioner students at two universities. INTERVENTION AND MEASUREMENTS The study was carried out in anywhere from five to eight half-day sessions over a month. The first and last sessions included audiotaped trainee SP encounters coded for effective communication behaviors. The primary outcome was change in communication scores from pre-intervention to post-intervention. We also measured trainee characteristics to identify predictors of performance and change in performance over time. RESULTS We enrolled 145 trainees who completed pre- and post-intervention SP interviews-with participation rates of 52% for physicians and 14% for nurse practitioners. Trainees' scores improved in 8 of 11 coded behaviors (p<0.05). The only significant predictors of performance were having participated in the intervention (p<0.001) and study site (p<0.003). The only predictor of improvement in performance over time was participating in the intervention (p<0.001). CONCLUSIONS A communication skills intervention using newly trained facilitators was associated with improvement in trainees' skills in giving bad news and expressing empathy. Improvement in communication skills did not vary by trainee characteristics.
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Norton SA, Metzger M, DeLuca J, Alexander SC, Quill TE, Gramling R. Palliative care communication: linking patients' prognoses, values, and goals of care. Res Nurs Health 2013; 36:582-90. [PMID: 24114740 DOI: 10.1002/nur.21563] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2013] [Indexed: 11/08/2022]
Abstract
Prognostic communication is a primary component of goals of care conversations in palliative care (PC) practice. Little is known about these conversations in the natural setting. This study's aim was to describe the processes of prognostic communication in PC goals of care consultations. Using line-by-line qualitative analysis, we examined prognostic conversation in 66 audio-taped PC consultations. We identified five processes by which clinicians link prognoses, values, and goals of care: (1) signposting the crossroads; (2) closing off a goal; (3) clarifying current path; (4) linking paths and patients' values; and (5) choosing among paths. The findings add to our understanding of PC consultation by describing how prognoses link with patients' values and choices in goals of care conversations.
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Chang JC, Alexander SC, Holland CL, Arnold RM, Landsittel D, Tulsky JA, Pollak KI. Smoking is bad for babies: obstetric care providers' use of best practice smoking cessation counseling techniques. Am J Health Promot 2013; 27:170-6. [PMID: 23286593 PMCID: PMC3733346 DOI: 10.4278/ajhp.110624-qual-265] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To use direct observations of first prenatal visits to describe obstetric providers' adherence to the evidence-based clinical practice guideline for smoking cessation counseling recommended by the American College of Obstetricians and Gynecologists, the 5 A's (Ask, Advice, Assess, Assist, and Arrange). DESIGN Observational study using audio recordings of first obstetric visits. SETTING An urban academic hospital-based clinic. PARTICIPANTS Obstetric care providers and pregnant women attending their first obstetric visit. METHOD First obstetric visits were audio recorded. Visits were identified in which patients reported smoking, and discussions were analyzed for obstetric providers' use of the 5 A's in smoking cessation counseling. RESULTS Obstetric providers asked about smoking in 98% of the 116 visits analyzed, but used 3 or more of the 5 A's in only 21% (24) of visits. In no visits did providers use all 5 A's. In 54% of the visits, providers gave patients information about smoking, most commonly about risks associated with perinatal smoking. CONCLUSION Few obstetric care providers performed the recommended 5 A's smoking cessation counseling with their pregnant smokers. Effective and innovative methods are needed to improve obstetric providers' use of the 5 A's.
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Cousino MK, Zyzanski SJ, Yamokoski AD, Hazen RA, Baker JN, Noll RB, Rheingold SR, Geyer JR, Alexander SC, Drotar D, Kodish ED. Communicating and understanding the purpose of pediatric phase I cancer trials. J Clin Oncol 2012; 30:4367-72. [PMID: 23071225 DOI: 10.1200/jco.2012.42.3004] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Quality informed consent should provide a clear understanding of the purpose of the research. Given the ethical challenges of pediatric phase I cancer trials, it is important to investigate physician-parent communication during informed consent conferences (ICCs) and parental understanding of the purpose of these studies. METHODS In the multisite Informed Consent in Pediatric Phase I Cancer Trials study, 85 ICCs for phase I research between June 2008 and May 2011 were directly observed, and 60 parents were subsequently interviewed. The scientific purpose was defined as composite understanding of drug safety, dose finding, and dose escalation. We determined the frequency with which physicians explained these and other phase I-related concepts during the ICC. Parent interviews were analyzed to determine understanding. RESULTS The child was present at 83 of 85 ICCs. Only 32% of parents demonstrated substantial understanding of the scientific purpose of phase I cancer trials; 35% demonstrated little or no understanding. Parents of higher socioeconomic status and racial majority status were more likely to understand the scientific purpose. Factors associated with understanding included physician explanation of the goal of the applicable phase I protocol offered (explained in 85% of ICCs) and explanation of the dose cohorts (explained in 43% of ICCs). Physicians explained drug safety in 23% of ICCs, dose finding in 52% of ICCs, and dose escalation in 53% of ICCs. CONCLUSION Many parents of children participating in phase I trials do not understand the purpose of these trials. Physician-parent communication about the purpose of phase I research is lacking during ICCs.
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Pollak KI, Coffman CJ, Alexander SC, Tulsky JA, Lyna P, Dolor RJ, Cox ME, Brouwer RJN, Bodner ME, Østbye T. Can physicians accurately predict which patients will lose weight, improve nutrition and increase physical activity? Fam Pract 2012; 29:553-60. [PMID: 22315467 PMCID: PMC3450433 DOI: 10.1093/fampra/cms004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Physician counselling may help patients increase physical activity, improve nutrition and lose weight. However, physicians have low outcome expectations that patients will change. The aims are to describe the accuracy of physicians' outcome expectations about whether patients will follow weight loss, nutrition and physical activity recommendations. The relationships between physician outcome expectations and patient motivation and confidence also are assessed. METHODS This was an observational study that audio recorded encounters between 40 primary care physicians and 461 of their overweight or obese patients. We surveyed physicians to assess outcome expectations that patients will lose weight, improve nutrition and increase physical activity after counselling. We assessed actual patient change in behaviours from baseline to 3 months after the encounter and changes in motivation and confidence from baseline to immediately post-encounter. RESULTS Right after the visit, ~55% of the time physicians were optimistic that their individual patients would improve. Physicians were not very accurate about which patients actually would improve weight, nutrition and physical activity. More patients had higher confidence to lose weight when physicians thought that patients would be likely to follow their weight loss recommendations. CONCLUSIONS Physicians are moderately optimistic that patients will follow their weight loss, nutrition and physical activity recommendations. Patients might perceive physicians' confidence in them and thus feel more confident themselves. Physicians, however, are not very accurate in predicting which patients will or will not change behaviours. Their optimism, although helpful for patient confidence, might make physicians less receptive to learning effective counselling techniques.
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Gulbrandsen P, Østbye T, Lyna P, Dolor RJ, Tulsky JA, Alexander SC, Pollak KI. The influence of physician communication style on overweight patients' perceptions of length of encounter and physician being rushed. Fam Med 2012; 44:183-188. [PMID: 22399481 PMCID: PMC3363284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND OBJECTIVES Little is known about how patients and physicians perceive time and the extent to which they perceive the physician being rushed during encounters. One aim of this paper is to examine whether patient and physician characteristics and physician communication influence patient perception of the duration of the encounter and their perception of physicians being rushed. Another aim is to examine the relationship between patient and physician perceptions of physicians feeling rushed. METHODS We audiorecorded 461 encounters of overweight or obese patients with 40 primary care physicians and included 320 encounters in which weight was discussed. We calculated time spent with physician and coded all communication about weight using the Motivational Interview Treatment Integrity scale (MITI). Patients completed post-visit questionnaires in which they reported the estimated duration of the encounter and how rushed they thought the physician was during the encounter. Physicians reported how rushed they felt. RESULTS Patients estimated encounters to be longer than they actually were by an average of 2.6 minutes (SD=11.0). When physicians used reflective statements when discussing weight, patients estimated the encounter to be shorter than when physicians did not use reflective statements (1.17 versus 4.56 minutes more than actual duration). Whites perceived the encounter as shorter than African Americans (1.45 versus 4.28 minutes more than actual duration). Physicians felt rushed in 66% of visits; however, most patients did not perceive this. Internists were perceived to be more rushed than family physicians. CONCLUSIONS There is wide variation in patients' ability to estimate the length of time they spend with their physician. Some physician and patient characteristics were related to patient perceptions of the length of the encounter. Reflective statements might lead patients to perceive encounters as shorter. Physicians, especially family physicians, appear able to conceal that they are feeling rushed.
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Pollak KI, Coffman CJ, Alexander SC, Manusov JRE, Ostbye T, Tulsky JA, Lyna P, Esoimeme I, Brouwer RJN, Dolor RJ. Predictors of weight loss communication in primary care encounters. PATIENT EDUCATION AND COUNSELING 2011; 85:e175-e182. [PMID: 21474267 PMCID: PMC3154469 DOI: 10.1016/j.pec.2011.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 02/15/2011] [Accepted: 03/05/2011] [Indexed: 05/28/2023]
Abstract
OBJECTIVE Evidence suggests that physicians' use of motivational interviewing (MI) techniques helps patients lose weight. We assessed patient, physician, relationship, and systems predictors of length of weight-loss discussions and whether physicians' used MI techniques. METHODS Forty primary care physicians and 461 of their overweight or obese patients were audio recorded and surveyed. RESULTS Weight-related topics were commonly discussed (nutrition 78%, physical activity 82%, and BMI/weight 72%). Use of MI techniques was low. A multivariable linear mixed model was fit to time spent discussing weight, adjusting for patient clustering within physician. More time was spent with obese patients (p=.0002), by African American physicians (p=.03), family physicians (p=.02), and physicians who believed patients were embarrassed to discuss weight (p=.05). Female physicians were more likely to use MI techniques (p=.02); African American physicians were more likely to use MI-inconsistent techniques (p<.001). CONCLUSION Primary care physicians routinely counsel about weight and are likely to spend more time with obese than with overweight patients. Internists spend less time on weight. Patient and systems factors do not seem to influence physicians' use MI techniques. PRACTICE IMPLICATIONS All physicians, particularly, male and African American physicians, could increase their use of MI techniques to promote more weight loss among patients.
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Cox ME, Yancy WS, Coffman CJ, Ostbye T, Tulsky JA, Alexander SC, Brouwer RJN, Dolor RJ, Pollak KI. Effects of counseling techniques on patients' weight-related attitudes and behaviors in a primary care clinic. PATIENT EDUCATION AND COUNSELING 2011; 85:363-368. [PMID: 21316897 PMCID: PMC3368547 DOI: 10.1016/j.pec.2011.01.024] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 01/17/2011] [Accepted: 01/23/2011] [Indexed: 05/28/2023]
Abstract
OBJECTIVE Examine primary care physicians' use of counseling techniques when treating overweight and obese patients and the association with mediators of behavior change as well as change in nutrition, exercise, and weight loss attempts. METHODS We audio recorded office encounters between 40 physicians and 461 patients. Encounters were coded for physician use of selected counseling techniques using the Motivational Interviewing Treatment Integrity (MITI) scale. Patient motivation and confidence as well as Fat and Fiber Diet score (1-4), Framingham physical activity questionnaire (MET-minutes), and weight loss attempts (yes/no) were assessed by surveys. Generalized linear models were fit, including physician, patient, and visit level covariates. RESULTS Patients whose physicians were rated higher in empathy improved their Fat and Fiber intake 0.18 units (95% CI 0, 0.4). When physicians used "MI consistent" techniques, patients reported higher confidence to improve nutrition (OR 2.57, 95% CI 1.2, 5.7). CONCLUSION When physicians used counseling techniques consistent with MI principles, some of their patients' weight-related attitudes and behaviors improved. PRACTICE IMPLICATIONS Physicians may not be able to employ formal MI during a clinic visit. However, use of counseling techniques consistent with MI principles, such as expression of empathy, may improve patients' weight-related attitudes and behaviors.
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Tulsky JA, Arnold RM, Alexander SC, Olsen MK, Jeffreys AS, Rodriguez KL, Skinner CS, Farrell D, Abernethy AP, Pollak KI. Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial. Ann Intern Med 2011. [PMID: 22041948 PMCID: PMC3368370 DOI: 10.1059/0003-4819-155-9-201111010-00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Quality cancer care requires addressing patients' emotions, which oncologists infrequently do. Multiday courses can teach oncologists skills to handle emotion; however, such workshops are long and costly. OBJECTIVE To test whether a brief, computerized intervention improves oncologist responses to patient expressions of negative emotion. DESIGN Randomized, controlled, parallel-group trial stratified by site, sex, and oncologic specialty. Oncologists were randomly assigned to receive a communication lecture or the lecture plus a tailored CD-ROM. (ClinicalTrials.gov registration number: NCT00276627) SETTING Oncology clinics at a comprehensive cancer center and Veterans Affairs Medical Center in Durham, North Carolina, and a comprehensive cancer center in Pittsburgh, Pennsylvania. PARTICIPANTS 48 medical, gynecologic, and radiation oncologists and 264 patients with advanced cancer. INTERVENTION Oncologists were randomly assigned in a 1:1 ratio to receive an interactive CD-ROM about responding to patients' negative emotions. The CD-ROM included tailored feedback on the oncologists' own recorded conversations. MEASUREMENTS Postintervention audio recordings were used to identify the number of empathic statements and responses to patients' expressions of negative emotion. Surveys evaluated patients' trust in their oncologists and perceptions of their oncologists' communication skills. RESULTS Oncologists in the intervention group used more empathic statements (relative risk, 1.9 [95% CI, 1.1 to 3.3]; P = 0.024) and were more likely to respond to negative emotions empathically (odds ratio, 2.1 [CI, 1.1 to 4.2]; P = 0.028) than control oncologists. Patients of intervention oncologists reported greater trust in their oncologists than did patients of control oncologists (estimated mean difference, 0.1 [CI, 0.0 to 0.2]; P = 0.036). There was no significant difference in perceptions of communication skills. LIMITATIONS Long-term effects were not examined. The findings may not be generalizable outside of academic medical centers. CONCLUSION A brief computerized intervention improves how oncologists respond to patients' expressions of negative emotions. PRIMARY FUNDING SOURCE National Cancer Institute.
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Tulsky JA, Arnold RM, Alexander SC, Olsen MK, Jeffreys AS, Rodriguez KL, Skinner CS, Farrell D, Abernethy AP, Pollak KI. Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial. Ann Intern Med 2011; 155:593-601. [PMID: 22041948 PMCID: PMC3368370 DOI: 10.7326/0003-4819-155-9-201111010-00007] [Citation(s) in RCA: 190] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Quality cancer care requires addressing patients' emotions, which oncologists infrequently do. Multiday courses can teach oncologists skills to handle emotion; however, such workshops are long and costly. OBJECTIVE To test whether a brief, computerized intervention improves oncologist responses to patient expressions of negative emotion. DESIGN Randomized, controlled, parallel-group trial stratified by site, sex, and oncologic specialty. Oncologists were randomly assigned to receive a communication lecture or the lecture plus a tailored CD-ROM. (ClinicalTrials.gov registration number: NCT00276627) SETTING Oncology clinics at a comprehensive cancer center and Veterans Affairs Medical Center in Durham, North Carolina, and a comprehensive cancer center in Pittsburgh, Pennsylvania. PARTICIPANTS 48 medical, gynecologic, and radiation oncologists and 264 patients with advanced cancer. INTERVENTION Oncologists were randomly assigned in a 1:1 ratio to receive an interactive CD-ROM about responding to patients' negative emotions. The CD-ROM included tailored feedback on the oncologists' own recorded conversations. MEASUREMENTS Postintervention audio recordings were used to identify the number of empathic statements and responses to patients' expressions of negative emotion. Surveys evaluated patients' trust in their oncologists and perceptions of their oncologists' communication skills. RESULTS Oncologists in the intervention group used more empathic statements (relative risk, 1.9 [95% CI, 1.1 to 3.3]; P = 0.024) and were more likely to respond to negative emotions empathically (odds ratio, 2.1 [CI, 1.1 to 4.2]; P = 0.028) than control oncologists. Patients of intervention oncologists reported greater trust in their oncologists than did patients of control oncologists (estimated mean difference, 0.1 [CI, 0.0 to 0.2]; P = 0.036). There was no significant difference in perceptions of communication skills. LIMITATIONS Long-term effects were not examined. The findings may not be generalizable outside of academic medical centers. CONCLUSION A brief computerized intervention improves how oncologists respond to patients' expressions of negative emotions. PRIMARY FUNDING SOURCE National Cancer Institute.
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Alexander SC, Cox ME, Yancy WS, Boling Turer C, Lyna P, Østbye T, Dolor RJ, Tulsky JA, Pollak KI. Weight-loss talks: what works (and what doesn't). THE JOURNAL OF FAMILY PRACTICE 2011; 60:213-219. [PMID: 26048291 PMCID: PMC4478072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND In primary care encounters, it is unknown whether physician advice on weight-related matters leads to patient weight loss. To examine this issue, we analyzed physician weight loss advice and measured corresponding changes in patients' dietary intake, physical activity, and weight. METHODS Using audio-recorded primary care encounters between 40 physicians and 461 of their overweight or obese patients, we coded weight-related advice as nonspecific, specific nutritional, specific exercise, or specific weight. Physicians and patients were told the study was about preventive health, not weight. We used mixed models (SAS ProcMixed), controlled for physician clustering and baseline covariates, to assess changes in diet, exercise, and measured weight, both pre-encounter and 3 months post-encounter. RESULTS When discussing weight, physicians typically provided a combination of specific weight, nutrition, and physical activity advice to their patients (34%). Combined advice resulted in patients reducing their dietary fat intake (P=.02). However, when physicians provided physical activity advice only, patients were significantly (P=.02) more likely to gain weight (+1.41 kg) compared with those who received no advice. CONCLUSION When giving weight-related advice, most physicians provided a combination of lifestyle recommendations. Combining advice may help patients reduce their fat intake. Physical activity advice alone may not be particularly helpful.
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Alexander SC, Cox ME, Boling Turer CL, Lyna P, Østbye T, Tulsky JA, Dolor RJ, Pollak KI. Do the five A's work when physicians counsel about weight loss? Fam Med 2011; 43:179-184. [PMID: 21380950 PMCID: PMC3367376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND AND OBJECTIVES More than two thirds of Americans are overweight or obese. Physician counseling may help patients lose weight; however, physicians perceive these discussions as somewhat futile and time-consuming. An effective and efficient tool for smoking cessation is the Five A's (Ask, Advise, Assess, Assist, and Arrange). We studied the effectiveness of the Five A's in weight-loss counseling. METHODS We audiorecorded primary care encounters between 40 physicians and 461 of their overweight or obese patients. All were told the study was about preventive health, not weight specifically. Encounters were coded for physician use of the Five A's. Patients' motivation and confidence were assessed before and immediately after the encounter. Three months later, we assessed patient change in dietary fat intake, exercise, and weight. RESULTS Generalized linear models were fit adjusting for patient clustering within physician. Physicians used at least one of the Five A's often (83%). Physicians routinely Ask and Advise patients to lose weight; however, they rarely Assess, Assist, or Arrange. Assist and Arrange were related to diet improvement, whereas Advise was associated with increases in motivation and confidence to change dietary fat intake and confidence to lose weight. CONCLUSIONS Similar to smoking cessation counseling, physicians routinely Asked and Advised patients to lose weight; however, they rarely Assessed, Assisted, or Arranged. Given the potential impact of using all of these counseling tools on changing patient behavior, physicians should be encouraged to increase their use of the Five A's when counseling patients to lose weight.
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Alexander SC, Sullivan AM, Back AL, Tulsky JA, Goldman RE, Block SD, Stewart SK, Wilson-Genderson M, Lee SJ. Information giving and receiving in hematological malignancy consultations. Psychooncology 2011; 21:297-306. [PMID: 21294221 DOI: 10.1002/pon.1891] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 11/05/2010] [Accepted: 11/12/2010] [Indexed: 11/12/2022]
Abstract
PURPOSE Little is known about communication with patients suffering from hematologic malignancies, many of whom are seen by subspecialists in consultation at tertiary-care centers. These subspecialized consultations might provide the best examples of optimal physician-patient communication behaviors, given that these consultations tend to be lengthy, to occur between individuals who have not met before and may have no intention of an ongoing relationship, and which have a goal of providing treatment recommendations. The aim of this paper is to describe and quantify the content of the subspecialty consultation in regards to exchanging information and identify patient and provider characteristics associated with discussion elements. METHODS Audio-recorded consultations between 236 patients and 40 hematologists were coded for recommended communication practices. Multilevel models for dichotomous outcomes were created to test associations between patient, physician and consultation characteristics and key discussion elements. RESULTS Discussions about the purpose of the visit and patient's knowledge about their disease were common. Other elements such as patient's preference for his/her role in decision-making, preferences for information, or understanding of presented information were less common. Treatment recommendations were provided in 97% of the consultations and unambiguous presentations of prognosis occurred in 81% of the consultations. Unambiguous presentations of prognosis were associated with non-White patient race, lower educational status, greater number of questions asked, and specific physician provider. CONCLUSION Although some communication behaviors occur in most consultations, others are much less common and could help tailor the amount and type of information discussed. Approximately half of the patients are told unambiguous prognostic estimates for mortality or cure.
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