Communication Skills Training for Physicians Improves Patient Satisfaction

Assessing Communication Quality in the Intensive Care Unit

Introduction: Successful shared decision-making for critically ill intensive care unit (ICU) patients requires bidirectional communication. Through observation of ICU conversations, our study aimed to identify communication skill deficiencies in providers who care for patients in the ICU. Methods: This was an observational prospective study performed in a single urban academic medical center (671 beds) from June 2021 through August 2021. Twenty-three providers were recruited from medical and surgical ICU services (56 beds). Thirty-nine surrogate decision makers were identified. Provider skills were assessed using a customized observational tool that examined nonverbal communication, verbal communication, opening the discussion, gathering information, understanding the family's perspective, sharing information, reaching agreements on problems and plans, and providing closure. Results: Thirty-nine conversations were observed for six attending physicians, four fellow physicians, eight resident physicians, two nurse practitioners, and three physician assistants during the coronavirus 19 (COVID19) pandemic. A dedicated critical care provider engaged in 19 observed conversations; 20 discussions occurred with individuals rotating/consulting in the ICU. Communication skill did not depend on experience or area of expertise. Less than half of conversations achieved bidirectional communication proficiency. Scheduled conversations (n = 14) had significantly higher average communication scores than unscheduled encounters (n = 25). Conclusions: Superficial unidirectional communication with decision makers was commonly observed. Providers were less proficient at advanced communication skills needed for shared decision-making. We recommend that providers have more scheduled conversations, which were more productive in achieving bidirectional communication. A targeted simulation curriculum addressing these areas may improve patient, decision maker, and provider satisfaction, while promoting patient-centered care.

Teaching communication skills in medical education : Best practice example of an interdisciplinary seminar in radiation oncology

BACKGROUND

Communication with patients is challenging, especially in radiation oncology. Therefore, radiation oncology is particularly suited to sensitize medical students for this topic and to train them competently. We report on experiences with an innovative teaching project for fourth- and fifth-year medical students.

MATERIALS AND METHODS

The course, funded as an innovative teaching project by the medical faculty, was offered as an optional course for medical students in 2019 and again in 2022 after a pandemic-related break. The curriculum and evaluation form were developed through a two-stage Delphi process. The course consisted of, first, participation during counselling of patients prior to radiotherapy, mainly on topics with shared decision-making, and, second, a 1-week interdisciplinary block seminar with practical exercises. The topics covered a broad spectrum of the competence areas defined in the National Competence-Based Learning Objectives Catalog for Medicine (NKLM). The number of participants was limited to approximately 15 students because of the practical components.

RESULTS

So far, 30 students (all at least in the seventh semester or higher) have participated in the teaching project. The most frequent reasons for participation were the desire to acquire competence in breaking bad news and confidence in talking to patients. The overall evaluation of the course was very positive, with a grade of 1.08 + 0.28 (on a scale of 1 = totally agree to 5 = totally disagree) plus German grade 1 (very good) to 6 (very bad). Notably, participants' expectations regarding specific competencies (e.g., breaking bad news) were also met.

CONCLUSION

Although the evaluation results cannot be generalized to the entirety of medical students due to the limited number of voluntary participants, the very positive evaluation shows the need for such projects among students and can also be seen as an indication that radiation oncology as a patient-centered discipline is particularly well suited to teach medical communication.

When Musculoskeletal Clinicians Respond to Empathetic Opportunities, do Patients Perceive Greater Empathy?

BACKGROUND

Patient use of verbal and nonverbal communication to signal what is most important to them can be considered empathetic opportunities. Orthopaedic surgeons may have mixed feelings toward empathetic opportunities, on one hand wanting the patient to know that they care, and on the other hand fearing offense, prolonged visit duration, or discussions for which they feel ill prepared. Evidence that action about empathetic opportunities does not harm the patient's experience or appreciably prolong the visit could increase the use of these communication tactics with potential for improved experience and outcomes of care.

QUESTIONS/PURPOSES

Using transcripts from musculoskeletal specialty care visits in prior studies, we asked: (1) Are there factors, including clinician attentiveness to empathetic opportunities, associated with patient perception of clinician empathy? (2) Are there factors associated with the number of patient-initiated empathetic opportunities? (3) Are there factors associated with clinician acknowledgment of empathetic opportunities? (4) Are there factors associated with the frequency with which clinicians elicited empathetic opportunities?

METHODS

This study was a retrospective, secondary analysis of transcripts from prior studies of audio and video recordings of patient visits with musculoskeletal specialists. Three trained observers identified empathetic opportunities in 80% (209 of 261) of transcripts of adult patient musculoskeletal specialty care visits, with any uncertainties or disagreements resolved by discussion and a final decision by the senior author. Patient statements considered consistent with empathetic opportunities included relation of emotion, expression of worries or concerns, description of loss of valued activities or loss of important roles or identities, relation of a troubling psychologic or social event, and elaboration on daily life. Clinician-initiated empathetic opportunities were considered clinician inquiries about these factors. Clinician acknowledgment of empathetic opportunities included encouragement, affirmation or reassurance, or supportive statements. Participants completed post-visit surveys of perceived clinician empathy, symptoms of depression, and health anxiety. Factors associated with perceived clinician empathy, number of empathetic opportunities, clinician responses to these opportunities, and the frequency with which clinicians elicited empathetic opportunities were sought in bivariate and multivariable analyses.

RESULTS

After controlling for potentially confounding variables such as working status and pain self-efficacy scores in the multivariable analysis, no factors were associated with patient perception of clinician empathy, including attentiveness to empathetic opportunities. Patient-initiated empathetic opportunities were modestly associated with longer visit duration (correlation coefficient 0.037 [95% confidence interval 0.023 to 0.050]; p < 0.001). Clinician acknowledgment of empathetic opportunities was modestly associated with longer visit duration (correlation coefficient 0.06 [95% CI 0.03 to 0.09]; p < 0.001). Clinician-initiated empathetic opportunities were modestly associated with younger patient age (correlation coefficient -0.025 [95% CI -0.037 to -0.014]; p < 0.001) and strongly associated with one specific interviewing clinician as well as other clinicians (correlation coefficient -1.3 [95% CI -2.2 to -0.42]; p = 0.004 and -0.53 [95% CI -0.95 to -0.12]; p = 0.01).

CONCLUSION

Musculoskeletal specialists can respond to empathic opportunities without harming efficiency, throughput, or patient experience.

CLINICAL RELEVANCE

Given the evidence that patients prioritize feeling heard and understood, and evidence that a trusting patient-clinician relationship is protective and healthful, the results of this study can motivate specialists to train and practice effective communication tactics.

Empathy training for service employees: A mixed-methods systematic review

Following the surge for empathy training in service literature and its increasing demand in service industries, this study systematically reviews empirical papers implementing and testing empathy training programs in various service domains. A mixed-methods systematic review was performed to identify and describe empathy training programs and discuss their effectiveness in service quality, service employees' well-being, and service users' satisfaction. Included papers met those eligibility criteria: qualitative, quantitative, or mixed-methods study; one training in empathy is identifiable; described training(s) developed for or tested with service employees dealing with service users. We searched health, business, education, and psychology databases, such as CINAHL, Medline ABI/Inform Global, Business Source Premier, PsycINFO, and ERIC. We used the Mixed-Method Assessment Tool to appraise the quality of included papers. A data-based convergent synthesis design allowed for the analysis of the data. A total of 44 studies published between 2009 to 2022 were included. The narrative presentation of findings was regrouped into these six dimensions of empathy training programs: 1) why, 2) who, 3) what, 4) how, 5) where, and 6) when and how much. Close to 50% of studies did not include a definition of empathy. Four main empathic competencies developed through the training programs were identified: communication, relationship building, emotional resilience, and counseling skills. Face-to-face and group-setting interventions are widespread. Our systematic review shows that the 44 papers identified come only from health services with a predominant population of physicians and nurses. However, we show that the four empathic skills identified could be trained and developed in other sectors, such as business. This is the first mixed-methods, multi-disciplinary systematic review of empathy training programs in service research. The review integrates insights from health services, identifies research limitations and gaps in existing empirical research, and outlines a research agenda for future research and implications for service research.

Association of Job Characteristics and Burnout of Healthcare Workers in Different Positions in Rural China: A Cross-Sectional Study

Objectives: Health workers in rural primary care systems are at increased risk of job burnout, but their associations with different positions have received scant attention in the literature. Thus, this study aims to measure job burnout in different positions in rural China and to identify factors associated with it. Methods: A cross-sectional survey was conducted with a total of 15,627 participants from six provinces in China. And job burnout was measured using the Chinese version of the Maslach Burnout Inventory-General Scale (MBI-GS). Multilevel regression analyses were used in examining factors potentially associated with job burnout in different positions. Results: Overall, more than half of providers suffered from moderate burnout. The degree of job burnout varied among different positions. Middle managers showed higher levels personal stress, while general staff showed the lowest interpersonal and self-evaluation dimensions of burnout. Job duty, job capability, job treatment, and career advancement are potential factors affecting these results. Conclusion: Interventions aimed at providing appropriate training and development opportunities, developing relevant career planning and management strategies, and implementing reasonable staffing and job design may be promising strategies for alleviating burnout in different positions and improving health system performance.

Orthopedic Resident and Patient Perception of Electronic Medical Record Use During the Clinic Visit

Background The transition from paper charts to electronic medical records (EMRs) has resulted in greater efficiency and reduced medical errors. This study aimed to examine the perception of patients and orthopedic residents regarding computer use during the clinic visit. Methodology This study utilized a cross-sectional cluster design. Orthopedic resident physicians were given a one-time general pre-visit survey. Additional surveys were given to patients and resident physicians post-visit. Surveys included questions that assessed satisfaction and the perceived impact of computer usage on doctor-patient interactions. Logistic generalized estimating equations were run to determine if there was an association between patient response and clinician assessment, adjusting for repeated measures within clinicians. Results A total of 80 patients and 15 residents completed the surveys. Results from the physician pre-visit survey showed that more residents perceived the computer as having a "negative" (47%) than "positive" (26%) effect on their relationship with patients. According to the post-visit analysis, patients perceived the residents' use of the EMR as having an overall positive effect on their ability to establish a personal connection and having a positive effect on their ability to give them attention. Conclusions Overall, there was little correlation between patient and resident perception of the computer's effect on their relationship. Patients generally perceived the computer as having a positive effect on their interaction with the residents even when residents had a negative perception of the computer's effect on their interaction.

Improving serious illness communication: a qualitative study of clinical culture

OBJECTIVE

Communication about patients' values, goals, and prognosis in serious illness (serious illness communication) is a cornerstone of person-centered care yet difficult to implement in practice. As part of Serious Illness Care Program implementation in five health systems, we studied the clinical culture-related factors that supported or impeded improvement in serious illness conversations.

METHODS

Qualitative analysis of semi-structured interviews of clinical leaders, implementation teams, and frontline champions.

RESULTS

We completed 30 interviews across palliative care, oncology, primary care, and hospital medicine. Participants identified four culture-related domains that influenced serious illness communication improvement: (1) clinical paradigms; (2) interprofessional empowerment; (3) perceived conversation impact; (4) practice norms. Changes in clinicians' beliefs, attitudes, and behaviors in these domains supported values and goals conversations, including: shifting paradigms about serious illness communication from 'end-of-life planning' to 'knowing and honoring what matters most to patients;' improvements in psychological safety that empowered advanced practice clinicians, nurses and social workers to take expanded roles; experiencing benefits of earlier values and goals conversations; shifting from avoidant norms to integration norms in which earlier serious illness discussions became part of routine processes. Culture-related inhibitors included: beliefs that conversations are about dying or withdrawing care; attitudes that serious illness communication is the physician's job; discomfort managing emotions; lack of reliable processes.

CONCLUSIONS

Aspects of clinical culture, such as paradigms about serious illness communication and inter-professional empowerment, are linked to successful adoption of serious illness communication. Further research is warranted to identify effective strategies to enhance clinical culture and drive clinician practice change.

Clients' and genetic counselors' perceptions of empathy in Japan: A pilot study of simulated consultations of genetic counseling

The rapidly increasing availability of genetic testing is driving the acceleration of genetic counseling implementation. Empathy is important in medical encounters in general and forms a core component of a successful genetic counseling session; however, empirical evidence on empathy in genetic counseling is minimal. This study aimed to explore the perceptions of empathy in simulated genetic counseling consultations from the perspectives of clients and genetic counselors. Semi-structured interviews and interpersonal process recall were used with participants of simulated genetic counseling consultations to elicit their experiences of empathy. A constructivist grounded theory was used for data analysis. A total of 15 participants, including 10 clients and 5 genetic counselors, participated in 10 simulated counseling sessions. The genetic counselors attempted to demonstrate empathy and were sensitive toward detecting changes in clients. Meanwhile, the clients' perceptions represented their feelings and thoughts elicited through the counselors' empathic approaches. This was the first process study to examine empathy in simulated genetic counseling sessions. Our model of communication of empathy is a process in which counselors try to address implicit aspects of clients, and clients are provided with time and a safe place for introspection, which contributes to discussions on building good relationships with patients. There is also a suggestion of the utility of simulated consultations for healthcare providers to learn empathic communication.

Palliative care to support the needs of adults with neurological disease

Neurological diseases cause physical, psychosocial, and spiritual or existential suffering from the time of their diagnosis. Palliative care focuses on improving quality of life for people with serious illness and their families by addressing this multidimensional suffering. Evidence from clinical trials supports the ability of palliative care to improve patient and caregiver outcomes by the use of outpatient or home-based palliative care interventions for people with motor neuron disease, multiple sclerosis, or Parkinson's disease; inpatient palliative care consultations for people with advanced dementia; telephone-based case management for people with dementia in the community; and nurse-led discussions with decision aids for people with advanced dementia in long-term care. Unfortunately, most people with neurological diseases do not get the support that they need for their palliative care under current standards of healthcare. Improving this situation requires the deployment of routine screening to identify individual palliative care needs, the integration of palliative care approaches into routine neurological care, and collaboration between neurologists and palliative care specialists. Research, education, and advocacy are also needed to raise standards of care.

The Importance of Facilitating Goal-Concordant Care (GCC) in a Pandemic: The MD Anderson Experience with hospitalized COVID-19 positive patients

Purpose

Provider-patient communication (PPC) about goals of care (GOC) facilitates goal-concordant care (GCC) delivery. Hospital resource limitations imposed during the pandemic made it vital to deliver GCC to a patient cohort with COVID-19 and cancer. Our aim was to understand the population and adoption of GOC-PPC along with structured documentation in the form of an Advance Care Planning (ACP) note.

Methods

A multidisciplinary GOC task force developed processes for ease of conducting GOC-PPC and implemented structured documentation. Data were obtained from multiple electronic medical record elements, with each source identified, data integrated and analyzed. We looked at PPC and ACP documentation pre and post implementation alongside demographics, length of stay (LOS), 30-day readmission rate and mortality.

Results

494 unique patients were identified, 52% male, 63% Caucasian, 28% Hispanic, 16% African American and 3% Asian. Active cancer was identified in 81% patients, of which 64% were solid tumors and 36% hematologic malignancies. LOS was 9 days with a 30-day readmission rate of 15% and inpatient mortality of 14%. Inpatient ACP note documentation was significantly higher post-implementation as compared to pre-implementation (90% vs 8%, P < 0.05). We saw sustained ACP documentation throughout the pandemic suggesting effective processes.

Conclusions

The implementation of institutional structured processes for GOC-PPC resulted in rapid sustainable adoption of ACP documentation for COVID-19 positive cancer patients. This was highly beneficial for this population during the pandemic, as it demonstrated the role of agile processes in care delivery models, which will be beneficial in the future when rapid implementation is needed.

Validity and reliability of standardized instruments measuring physician communication and interpersonal skills in video-recorded medical consultations - A systematic review

OBJECTIVE

To identify standardized instruments measuring physician communication and interpersonal skills based on video-recorded consultations.

METHODS

We searched electronic databases for primary studies published from 1950 to 2022. Eligible studies had to report the validation of standardized instruments dedicated to the assessment of physician interpersonal skills based on video-recorded consultations with adult patients.

RESULTS

Of 7155 studies retrieved, 13 primary studies involving nine standardized instruments were included. The median number of physicians and participants was 23 (range, 1-200) and 71 (range, 1-950), respectively. Seven out of nine instruments were multidimensional and comprised a median number of 23 items (range, 7-95). The conceptual framework was reported for two instruments only. Content analysis identified 12 key behaviors with substantial overlap across instruments. The Four Habits Coding Scheme (4-HCS) yielded satisfactory validity and reliability while the evidence on psychometric properties was limited for other instruments.

CONCLUSION

Limited evidence supports the psychometric attributes for most of the published standardized instruments dedicated to assessing physician communication and interpersonal skills.

PRACTICE IMPLICATIONS

Although the decision to use a specific instrument depends on the study aims, the 4-HCS appears to be the most reliable instrument for assessing physician communication and interpersonal skills based on video-recorded consultations.

Effect of a Coaching Intervention to Improve Cardiologist Communication: A Randomized Clinical Trial

Importance

Communication between cardiologists and patients can significantly affect patient comprehension, adherence, and satisfaction. To our knowledge, a coaching intervention to improve cardiologist communication has not been tested.

Objective

To evaluate the effect of a communication coaching intervention to teach evidence-based communication skills to cardiologists.

Design, Setting, and Participants

This 2-arm randomized clinical trial was performed at outpatient cardiology clinics at an academic medical center and affiliated community clinics, and from February 2019 through March 2020 recruited 40 cardiologists and audio recorded 161 patients in the preintervention phase and 240 in the postintervention phase. Data analysis was performed from March 2022 to January 2023.

Interventions

Half of the cardiologists were randomized to receive a coaching intervention that involved three 1:1 sessions, 2 of which included feedback on their audio-recorded encounters. Communication coaches taught 5 skills derived from motivational interviewing: (1) sitting down and making eye contact with all in the room, (2) open-ended questions, (3) reflective statements, (4) empathic statements, and (5) "What questions do you have?"

Main Outcomes and Measures

Coders unaware of study arm coded these behaviors in the preintervention and postintervention audio-recorded encounters (objective communication). Patients completed a survey after the visit to report perceptions of communication quality (subjective communication).

Results

Analysis included 40 cardiologists (mean [SD] age, 47 [9] years; 7 female and 33 male) and 240 patients in the postintervention phase (mean [SD] age, 58 [15] years; 122 female, 118 male). When controlling for preintervention behaviors, cardiologists in the intervention vs control arm were more likely to make empathic statements (intervention: 52 of 117 [44%] vs control: 31 of 113 [27%]; P = .05); to ask, "What questions do you have?" (26 of 117 [22%] vs 6 of 113 [5%]; P = .002); and to respond with empathy when patients expressed negative emotions (mean ratio of empathic responses to empathic opportunities, 0.50 vs 0.20; P = .004). These effects did not vary based on patient or cardiologist race or sex. We found no arm differences for open-ended questions or reflective statements and were unable to assess differences in patient ratings due to ceiling effects.

Conclusions and Relevance

In this randomized clinical trial, a communication coaching intervention improved 2 key communication behaviors: expressing empathy and eliciting questions. Empathic communication is a harder-level skill that may improve the patient experience and information comprehension. Future work should explore how best to assess the effect of communication coaching on patient perceptions of care and clinical outcomes and determine its effectiveness in larger, more diverse samples of cardiologists.

Trial Registration

ClinicalTrials.gov Identifier: NCT03464110.

Rekindling Joy in Medicine Through Thoughtful Communication: A Practical Guide

Joy in medicine, or the loss of it, is a popular topic of conversation, even more so since the pandemic. Burnout in oncology is common and diminishes the satisfaction of practicing medicine. One of the challenges clinicians face is the way in which modern clinical practice takes us away from what we find most meaningful in our work: time with patients. Strategies like being kind, expressing gratitude, and using effective communication skills can establish more connection with our colleagues and our patients, and, in turn, result in a more joyful work environment. Creating space for more moments of feeling deep interconnectedness with patients and colleagues can rekindle feelings of joy in oncology practice. This article reviews the concepts of joy in medicine, the term sacred moments, and outlines practical strategies and communication skills that are effective in enhancing the patient-provider relationship.

Impact of Training in Serious Illness Communication and Work Life Balance on Physicians' Self-Efficacy, Clinical Practice and Perception of Roles

Purpose

Serious illness communication is a core task in hemato-oncology that require advanced communication skills and can be emotionally demanding. A 2-day course was implemented as a mandatory part of the 5-year hematology specialist training program in Denmark in 2021. The aim of this study was to assess the quantitative and qualitative effect of course participation on self-efficacy in serious illness communication and measure the prevalence of burnout among physicians in hematology specialist training.

Methods

For quantitative assessment course participants answered three questionnaires: Self-efficacy Advance care planning (ACP), Self-efficacy Existential communication (EC) and the Copenhagen Burnout Inventory at baseline, 4 and 12 weeks after the course. The control group answered the questionnaires once. Qualitative assessment was performed as structured group interviews with course participants 4 weeks after the course, transcribed, coded, and transformed into themes.

Results

All self-efficacy EC scores and 12 out of 17 self-efficacy ACP scores improved after the course, though mostly non-significant. Course participants reported altered clinical practice and perception of role as a physician. The physicians' confidence that they could find the time to discuss ACP were low and remained low. The prevalence of burnout was high. Burnout levels were non-significantly lower after the course.

Conclusion

A mandatory course of formal training can increase physician self-efficacy in serious illness communication and alter clinical practice and perception of roles. The high level of burnout among physicians in hemato-oncology calls for institutional interventions in addition to training.

Intervention to reduce age bias in medical students' decision making for the treatment of older women with breast cancer: A novel approach to bias training

Objectives: Despite NICE guidelines to 'treat people with invasive breast cancer, irrespective of age, with surgery and appropriate systemic therapy, rather than endocrine therapy alone', older patients receive differential treatment and experience worse outcomes. Research has evidenced the prevalence of ageism and identified the role of implicit bias in reflecting and potentially perpetuating disparities across society, including in healthcare. Yet age bias has rarely been considered as an explanatory factor in poorer outcomes for older breast cancer patients nor, consequentially, has removing age bias been considered as an approach to improving outcomes. Many organizations carry out bias training with the aim of reducing negative impacts from biased decision making, yet the few evaluations of these interventions have mostly seen small or negative effects. This study explores whether a novel intervention to address age bias leads to better quality decision making for the treatment of older women with breast cancer.Methods: An online study compared medical students' treatment recommendations for older breast cancer patients and the reasoning for their decision making before and after a novel bias training intervention. Thirty-one medical students participated in the study.Results: The results show that the bias training intervention led medical students to make better quality decisions for older breast cancer patients. The quality of decision making was measured by decreases in age-based decision making and increased efforts to include patients in decision making. These results suggest there is value in exploring whether if anti-bias training interventions could usefully be applied in other areas of practice where older patients experience poorer outcomes.Conclusions: This study evidences that bias training improves the quality of decision making by medical students in respect of older breast cancer patients. The study findings show promise that this novel approach to bias training might usefully be applied to all medical practitioners making treatment recommendations for older patients.

Considerations in the Management of Functional Neurological Disorders in Patients with Hearing Loss

CASE

Adam is a 14-year-old adolescent boy with hearing loss who presented to the pediatric neurology clinic accompanied by his father for evaluation of new-onset left hand tremor for a duration of 1 month. An American Sign Language interpreter was present and used throughout the visit.Adam has bilateral sensorineural hearing loss related to premature birth at 28 weeks' gestation. He uses sign language and attends a school for the hearing impaired. He has been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and a nonspecific learning disorder. His ADHD symptoms are well controlled with a stimulant medication. He is independent in activities of daily living, and there is no concern for intellectual disability. His father is concerned that Adam may have anxiety, but this has not been evaluated.After careful history, it is found that the tremor was first noted the day after burglars broke into his home and stole precious belongings. Current stressors include difficulties with schoolwork and a strained relationship with an extended family member. There is no family history of tremor.The tremor was intermittent initially, with episodes lasting around 30 minutes. Over time, the tremor became more persistent. Adam is left-handed, and the tremor is now interfering with handwriting, eating, and other fine motor skills. The tremor worsens when Adam is tired or stressed and improves with relaxation. No tremor has been noted in other body parts. Adam denies any other neurological symptoms, including headache, vision changes, or gait abnormalities.On examination, Adam seemed anxious but showed no significant distress and had normal vital signs. His general examination was unremarkable. His neurological examination showed intact cranial nerves, apart from the hearing impairment. He had normal muscle tone, intact strength and coordination, and a normal casual gait. Rhythmic shaking of the left upper extremity was present with action, while maintaining posture. Using specific examination techniques, the examiner was able to alter the rhythm of the tremor, and the tremor was noted to subside when the patient was engaged with the examiner. These findings in addition to signs of suggestibility and variable frequency/direction were consistent with a functional etiology.The diagnosis of a functional neurological disorder manifesting in the form of functional tremor was discussed with the patient and his father with assistance from the sign language interpreter. Counseling regarding management consisting mainly of cognitive behavioral therapy and evaluation of possible coexisting conditions, such as anxiety, was discussed.What factors would you consider in diagnosis and management of functional neurological disorder in a hearing-impaired child/adolescent?

There is Little or No Association Between Independently Assessed Communication Strategies and Patient Ratings of Clinician Empathy

BACKGROUND

Quality of care is increasingly assessed and incentivized using measures of patient-reported outcomes and experience. Little is known about the association between measurement of clinician communication strategies by trained observers and patient-rated clinician empathy (a patient-reported experience measure). An effective independent measure could help identify and promote clinician behaviors associated with good patient experience of care.

QUESTIONS/PURPOSES

(1) What is the association between independently assessed clinician communication effectiveness and patient-rated clinician empathy? (2) Which factors are associated with independently assessed communication effectiveness?

METHODS

One hundred twenty adult (age > 17 years) new or returning patients seeking musculoskeletal specialty care between September 2019 and January 2020 consented to video recording of their visit followed by completion of questionnaires rating their perceptions of providers' empathy levels in this prospective study. Patients who had operative treatment and those who had nonoperative treatment were included in our sample. We pooled new and returning patients because our prior studies of patient experience found no influence of visit type and because we were interested in the potential influences of familiarity with the clinician on empathy ratings. We did not record the number of patients or baseline data of patients who were approached, but most patients (> 80%) were willing to participate. For 7% (eight of 120 patients), there was a malfunction with the video equipment or files were misplaced, leaving 112 records available for analysis. Patients were seen by one provider among four attending physicians, four residents, or four physician assistants or nurse practitioners. The primary study question addressed the correlation between patient-rated clinician empathy using the Jefferson Scale of Patient Perceptions of Physician Empathy and clinician communication effectiveness, independently rated by two communication scholars using the Liverpool Communication Skills Assessment Scale. Based on a subset of 68 videos (61%), the interrater reliability was considered good for individual items on the Liverpool Communication Skills Assessment Scale (intraclass correlation coefficient [ICC] 0.78 [95% confidence interval (CI) 0.75 to 0.81]) and excellent for the sum of the items (that is, the total score) (ICC = 0.92 [95% CI 0.87 to 0.95]). To account for the potential association of personal factors with empathy ratings, patients completed measures of symptoms of depression (the Patient-Reported Outcome Measurement Information System depression computerized adaptive test), self-efficacy in response to pain (the two-item Pain Self-Efficacy Questionnaire), health anxiety (the five-item Short Health Anxiety Inventory), and basic demographics.

RESULTS

Accounting for potentially confounding variables, including specific clinicians, marital status, and work status in the multivariable analysis, we found higher independent ratings of communication effectiveness had a slight association (odds ratio [OR] 1.1 [95% CI 1.0 to 1.3]; p = 0.02) with higher (dichotomized) ratings of patient-rated clinician empathy, while being single was associated with lower ratings (OR 0.40 [95% CI 0.16 to 0.99]; p = 0.05). Independent ratings of communication effectiveness were slightly higher for women (regression coefficient 1.1 [95% CI 0.05 to 2.2]); in addition, two of the four attending physicians were rated notably higher than the other 10 participants after controlling for confounding variables (differences up to 5.8 points on average [95% CI 2.6 to 8.9] on a 36-point scale).

CONCLUSION

The observation that ratings of communication effectiveness by trained communication scholars have little or no association with patient-rated clinician empathy suggests that either effective communication is insufficient for good patient experience or that the existing measures are inadequate or inappropriate. This line of investigation might be enhanced by efforts to identify clinician behaviors associated with better patient experience, develop reliable and effective measures of clinician behaviors and patient experience, and use those measures to develop training approaches that improve patient experience.

LEVEL OF EVIDENCE

Level I, prognostic study .

An initial reliability analysis of a patient counseling rubric to objectively measure student pharmacist performance

Current literature outlines the documented need for improved communication during patient medication counseling. Although many tools exist, there needs to be a national standardized tool that complies with federal and state law, to objectively measure student pharmacist performance during patient counseling in the community pharmacy setting. The primary objective of this study is to perform an initial analysis of the internal consistency reliability of a patient medication counseling rubric designed with an Indian Health Services theoretical framework. Secondary objectives include measuring changes in student performance over the time of the study. The 18-item rubric was developed to objectively measure student pharmacist performance during patient medication counseling sessions in a 21-h Introductory Pharmacy Practice Experience (IPPE) course. The community-pharmacy-based IPPE patient counseling course evaluates students' communication skills and patient-centered counseling techniques in live and simulated patient counseling sessions. Three pharmacist evaluators assessed a total of 247 student counseling sessions. The rubric's internal consistency reliability was analyzed, and student performance improvement was observed within the course. Students' performance was evaluated as "meets expectations" in most live and simulated sessions. However, an independent groups t-test showed that the mean performance score for the live counseling sessions (2.59, SD = 0.29) was higher (p < 0.001) than that for the simulated counseling sessions (2.35, SD = 0.35). Students' performance in the course improved over three weeks [Week 1: mean (SD) = 2.29 (0.32), Week 2: mean (SD) = 2.44 (0.33), Week 3: mean (SD) = 2.62 (0.29); p < 0.001]. A Tukey-Kramer comparison post hoc test found a significant increase in the mean performance scores between weeks (p < 0.05). The overall internal consistency reliability of the counseling rubric was determined acceptable, with a Cronbach's alpha of 0.75. Further study is required, including the assessment of inter-rater reliability, factor analysis, variable analysis, and use in other states with patient confirmation testing necessary to validate the rubric for use with student pharmacists in the community pharmacy setting.

[Multimodal selection of medical students: The predictive power of individual process components in the two-stage selection process at Witten/Herdecke University (UW/H)]

OBJECTIVE

According to the legislator's ideas, the selection of medical students in Germany should no longer be based on the Abitur grade alone. This approach has already been implemented in the two-stage selection process at Witten/Herdecke University (UW/H) using several criteria. On the one hand, the present study aims to determine the prognostic value of the procedural components for the overall performance on the selection day. On the other hand, the different strategies of the applicants in processing the written task (phase 1) will be examined with regard to their application success.

METHODOLOGY

Data on applications for the summer semester 2020 (N = 819 phase 1; N = 233 phase 2) were available retrospectively. A stepwise regression analysis was conducted to determine the predictive power of each procedural component. Using a summary content analysis, the four essays from the applicants' motivation letters were structured and categories were identified, and an extreme group comparison (Group 1: Not invited; Group 2: University acceptance; N = 60 essays) was conducted.

RESULTS

As the stepwise regression analysis shows, the individual biographical interview emerged as the strongest predictor in terms of overall performance, followed by lecture, group interview, and multiple mini interviews. Content analysis extracted content and scaling categories for the individual essays, as well as an additional meta-category (Impression Management, IM). Successful applicants demonstrated, among other things, better judgment skills, more sophisticated reasoning skills, and an internalized role model as a physician. In addition, they used defensive IM strategies, e.g., subjectification and self-deprecation, more frequently.

CONCLUSION

Biographical interview is considered the strongest predictor of overall performance. The dimensions of impression management, reasoning quality and judgment proved to be reliable predictors of successful performance in the selection process. In addition, role image as a physician and professional commitment had a favorable effect on the selection decision.

Patients values regarding primary health care: a systematic review of qualitative and quantitative evidence

BACKGROUND

Accessible and high-quality primary health care (PHC) is fundamental to countries moving towards universal health coverage. In order to improve the quality of patient-centered care provided in PHC, a comprehensive understanding of patients' values is crucial to address any gaps in the health care system. This systematic review aimed to identify patients' values relevant to PHC.

METHODS

We searched primary qualitative and quantitative studies about patients' values related to primary care in PubMed and EMBASE (Ovid) from 2009 to 2020. The studies' quality was assessed using Joanna Briggs Institute (JBI) Critical Appraisal Checklist for both quantitative and qualitative studies and Consolidated Criteria for Reporting Qualitative Studies (COREQ) for qualitative studies. A thematic approach was used in the data synthesis.

OUTCOME

The database search resulted in 1,817 articles. A total of 68 articles were full-text screened. Data were extracted from nine quantitative and nine qualitative studies that met the inclusion criteria. The participants of the studies were mainly the general population in high-income countries. Four themes emerged from the analysis: patients' values related to privacy and autonomy; values associated with the general practitioners including virtuous characteristics, knowledge and competence; values involving patient-doctor interactions such as shared decision-making and empowerment; and core values related to the primary care system such as continuity, referral, and accessibility.

CONCLUSIONS

This review reveals that the doctor's personal characteristics and their interactions with the patients are critical considerations concerning the primary care services from the patients' point of view. The inclusion of these values is essential to improve the quality of primary care.

Evaluating patient recall following operative orthopaedic trauma

INTRODUCTION

Orthopedic trauma patients may have poor recall of their injuries and treatment. This may lead to poor adherence to instructions. The purposes of this project were to quantify recall about injury and treatment information, and to assess adherence to postoperative instructions and satisfaction with care.

METHODS

A prospective cohort of 110 consecutive adult orthopaedic trauma patients treated for acute injury at a Level 1 trauma center were included. All had undergone surgical treatment of fractures of the pelvis or lower extremity. A brief survey to assess patient recall about injury and treatment knowledge, adherence to weightbearing and DVT recommendations and to evaluate patient satisfaction was administered during the first post-hospital clinic visit.

RESULTS

Patients correctly answered 64% of recall-oriented questions. 82% and 83% of patients, respectively, reported adherence to their weightbearing restrictions and their DVT prophylaxis regimen, while 66% of patients reported adherence to both. Forty-two percent of non-adherent patients could not remember their weightbearing restrictions, while 78% of non-adherent patients could not remember their DVT prophylaxis regimen. Average patient satisfaction was 4.3 (range 1-5), with 15% of patients indicating neutral sentiment or dissatisfaction with their care.

CONCLUSION

Orthopaedic trauma patients have poor recall, which likely reduces postoperative adherence and may impair patient satisfaction. A postoperative educational protocol focused on improving patient recall may be useful.

LEVEL OF EVIDENCE

Level 4, prognostic.

Neurology faculty comfort and experience with communication skills

BACKGROUND

Neurology faculty care for complex patients, teach, and work within multidisciplinary teams. It is imperative for faculty to have strong communication skills.

METHODS

We surveyed NYU neurology teaching faculty to determine levels of comfort and experience over the past year with providing negative feedback to a trainee; debriefing after an adverse clinical outcome; and assisting a struggling colleague. We examined the relationship between levels of comfort and experience with 1) faculty self-identified sex and 2) number of years since completion of medical training.

RESULTS

The survey was completed by 36/83 teaching neurology faculty (43 %); 17 (47 %) respondents were female and 21 (58 %) were ≤10 years post-training. The proportions of faculty who reported feeling uncomfortable were 44 % (16/36) for assisting a struggling colleague, 28 % (10/36) for providing negative feedback, and 19 % (7/36) for debriefing an adverse outcome. Proportions of faculty who reported they had no experience were 75 % (27/36) for assisting a struggling colleague, 39 % (14/36) for debriefing an adverse clinical event, and 17 % (6/36) for providing negative feedback. Female respondents and faculty who were ≤10 years post-training were more likely to report feeling uncomfortable with assisting a struggling colleague and to have had no experience doing so in the past year. On multivariate analyses accounting for sex and experience, sex remained independently associated with feeling uncomfortable with assisting a struggling colleague (OR = 12.2, 95 % CI: 2.1-69.6, p = 0.005).

CONCLUSION

Faculty development may be needed to improve comfort and experience with challenging communication-based interactions. Female faculty and faculty early in their careers may benefit most.

The efficacy of applying the Interpersonal Effectiveness skills of dialectical behavior therapy into communication skills workshop for clinical nurses

Background

We designed this open-pilot study to investigate the efficacy and feasibility of incorporating the Interpersonal Effectiveness skills from Dialectical Behavior Therapy (DBT-IE) into a 3-h clinical communication workshop for registered nurses.

Method

A convenience sample of registered nurses were invited. The Professional Fulfillment Index, Perceived Stress Scale, Empathy Index, the Interpersonal Reactivity Index, and measures regarding quality of life, anxiety, depression, and insomnia were completed. A subgroup of participants received the Objective Structured Teaching Examinations (OSTE). Pre- and post-workshop assessments were conducted to identify the most empathetic or validated responses from case scenarios and to assess the self-rated levels of confidence regarding the capability to select the best answer. The satisfaction of the participants with respect to the workshop content, process, and the lecturer were also collected. Paired t-test was used for statistical analysis.

Results

Among the 164 participants of the clinical communication workshop, 72 consented and their pre- and post-results were analyzed. Post-workshop assessment revealed significant improvement in professional fulfillment (p = 0.014), interpersonal coping ability (p = 0.038), and decrease in dysfunctional coping style (p < 0.001). The overall satisfaction score of participants was 4.68 (5-point Likert scale). In the subgroup that underwent pre- and post-workshop OSTE (n = 28), there was a significant improvement in total scores, pass rates, ratings from observational supervisors, simulated students, and simulated patients after the workshop (p < 0.001).

Conclusion

Our results demonstrated the effectiveness, acceptance, and feasibility of incorporating the DBT-IE skills into a clinical medical communication workshop through a teaching style comprising of rigorous interactions and hands-on practices.

Developing an Inpatient Relationship Centered Communication Curriculum (I-RCCC) rounding framework for surgical teams

BACKGROUND

Morning rounds by an acute care surgery (ACS) service at a level one trauma center are uniquely demanding, given the fast pace, high acuity, and increased patient volume. These demands notwithstanding, communication remains integral to the success of surgical teams. Yet there are limited published curricula that address trauma inpatient communication needs. Observations at our institution confirmed that the surgical team lacked a shared mental model for communication. We hypothesized that creating a relationship-centered rounding conceptual framework model would enhance the provider-patient experience.

STUDY DESIGN

A mixed-methods approach was used for this study. A multi-pronged needs assessment was conducted. Provider communion items for Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to measure patients' expressed needs. Faculty with experience in relationship-centered communication observed morning rounds and documented demonstrated behaviors. A five-hour workshop was designed based on the identified needs. A pre-and post-course Assessment and course evaluation were conducted. Provider-related patient satisfaction items were measured six months before the course and six months after the workshop.

RESULTS

Needs assessment revealed a lack of a shared communication framework and a lack of leadership skills for senior trauma residents. Barriers included: time constraints, patient load, and interruptions during rounds. The curriculum was very well received. The self-reflected behaviors that demonstrated the most dramatic change between the pre and post-workshop surveys were: I listened without interrupting; I spoke clearly and at a moderate pace; I repeated key points; and I checked that the patient understood. All these changed from being performed by 50% of respondents "about half of the time" to 100% of them "always". Press Ganey top box likelihood to recommend (LTR) and provider-related top box items showed a trend towards improvement after implementing the training with a percentage difference of up to 20%.

CONCLUSION

The Inpatient Relationship Centered Communication Curriculum (I-RCCC) targeting senior residents and Nurse Practitioners (NP) was feasible, practical, and well-received by participants. There was a trend of an increase in LTRs and provider-specific patient satisfaction items. This curriculum will be refined based on the study results and potentially scalable to other surgical specialties.

Action Research on Applying Compound Stimulus Approach to Improve Empathetic Communication: The Case of Physical Therapy Students

(1) Background: Empathetic communicative skills are the first step in establishing a good therapeutic relationship. The purpose of this study is to understand the effectiveness of improving the empathetic communicative skills applied to obtain accurate and precise information from patients via compound stimulus-drama in education. (2) Methods: A cross-sectional, one-group, pre- and post-test design was used for this study. In the two-day workshop, four clinical physiotherapists acted as tutors for the "Compound Stimulus-Drama in Education" module and assessed students' performances. The Standard Patient Rating Scale (SPRS), Objective Structured Clinical Examination Scale (OSCES), Professional and Communication Self-Assessment Scale (PCSS), Patients' Information (PI), and the Jefferson Scale of Empathy (JSE) were used to assess the students' empathy scores and communication skills, before and after the course. (3) Results: Fifty-seven students participated in this study. The results showed that there were significant improvements in the SPRS, OSCES, PCSS, PI, and JSE (p < 0.05). Both the quantitative data and the participants' reflection feedback suggest that this novel module was more helpful than traditional clinical practice courses for improving clinical empathy communication skills. (4) Conclusions: This study provided an innovative teaching model and assessment tools for learning clinic empathetic communicative skills in future education training.

Communication Training Helps to Reduce Burnout During COVID-19 Pandemic

Objective

To determine the effectiveness of communication training and its impact on burnout among healthcare providers (physicians, physician assistants, nurse practitioners), in the setting of the COVID-19 pandemic.

Methods

To evaluate the effectiveness of communication training on burnout during the COVID-19 pandemic, healthcare providers participating in a Communication in Healthcare (CIH) module between October 31, 2019, through February 20, 2020, were identified using a scanned sign-in sheet. A 3-question online survey regarding the utilization of communication skills during the COVID-19 pandemic was sent via email. An ordinal scale was used to rate the effectiveness of the training on subsequent burnout and work satisfaction during the pandemic.

Results

Of the 98 surveys distributed via email, a total of 33 participants completed the survey. Seventy-three percent of respondents agreed that communication training helped prevent burnout, and 39% strongly agreed that the modules improved work satisfaction.

Conclusion

Our study found communication training was effective in reducing burnout in healthcare providers, in the setting of the COVID-19 pandemic. The participants felt the communication tools learned from the training modules were useful in improving work satisfaction and communication with patients during the pandemic.

The Impact of Dynamic Real-Time Feedback on Patient Satisfaction Scores

INTRODUCTION

Providers' communication skills have a significant impact on patients' satisfaction. Improved patients' satisfaction has been positively correlated with various healthcare and financial outcomes. Patients' satisfaction in the inpatient setting is measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. In this study, we evaluated the impact of dynamic real-time feedback to the providers on the HCAHPS scores.

METHODS

This was a randomized study conducted at our 550-bed level-1 tertiary care center. Twenty-six out of 27 hospitalists staffing our 12 medicine teams (including teams containing advanced practice providers (APPs) and house-staff teams) were randomized into intervention and control groups. Our research assistant interviewed 1110 patients over a period of 7 months and asked them the three provider communication-specific questions from the HCAHPS survey. Our intervention was a daily computer-generated email which alerted providers to their performance on HCAHPS questions (proportions of "always" responses) along with the performance of their peers and Medicare benchmarks.

RESULTS

The intervention and control groups were similar with regard to baseline HCAHPS scores and clinical experience. The proportion of "always" responses to the three questions related to provider communication was statistically significantly higher in the intervention group compared to the control group (86% vs 80.5%, p-value 0.00001). It was also noted that the HCAHPS scores were overall lower on the house-staff teams and higher on the teams with APPs.

CONCLUSION

Real-time patients' feedback to inpatient providers with peer comparison via email has a positive impact on the provider-specific HCAHPS scores.

The Gender of the Sender: Assessing Gender Biases of Greetings in Patient Portal Messages

Purpose: The purpose of the study was to determine if the use of professional titles in patient electronic health record (EHR) messages varied by gender of the physician receiving the message and gender of the patient sending the message. Methods: We conducted a retrospective observational study evaluating 285,744 messages for a patient's greeting to their physician. Logistic regression mixed effects models were fit to estimate the relationship between title use and gender. Results: Female physicians received 189,442 (66%), and female patients sent 183,579 (64%) messages. Female physicians received an average of 1754 messages each (sd = 1615, median [IQR] = 1624 [255-3040]), which was significantly more than the average 1235 messages for males (sd = 1527, median [IQR] = 385 [103-1857], Mann-Whitney-Wilcoxon p-value = 0.006). Female patients were more likely to send messages using professional titles (OR = 1.37, CI = 1.28-1.47, p < 0.001). Female physicians were no more likely than male physicians to receive professional titles (OR = 1.06, CI = 0.89-1.27, p = 0.500). Conclusions: Female physicians received significantly more EHR messages than men, and female patients were more likely to use a professional title when addressing their physician, regardless of gender. Across all patients, physician gender did not influence the rate of professional title used.

Design and Integration of a Texting Tool to Keep Patients' Family Members Updated During Hospitalization: Clinicians' Perspectives

An important gap in the literature is how clinicians feel about patient-centered technologies and how clinicians experience patient-centered technologies in their workflows. Our goal was to identify clinician users' perspectives on facilitators (pros) and barriers (cons) to using 1 digital texting innovation to promote family centered care during patients' hospitalizations. This qualitative study was conducted at a tertiary care center in Houston, consisting of 7 hospitals (1 academic hospital and 6 community hospitals), involving analyzation of 3 focus groups of 18 physicians, 5 advanced practice providers, and 10 nurse directors and managers, as well as a content analysis of 156 real-time alerts signaling family dissatisfaction on the nursing unit/floor. Thematic analysis methods were used. We selected these participants by attending their regularly scheduled service-line meetings. Clinician feedback from focus groups resulted in 3 themes as facilitators: (a) texting platforms must be integrated within the electronic medical record; (b) texting reduces outgoing phone calls; (c) texting reduces incoming family phone calls. Clinician feedback resulted in 3 themes as barriers: (a) best practice alerts can be disruptive; (b) real-time alerts can create hopelessness; and (c) scale-up is challenging. The analyzation of facilitators (pros) and barriers (cons) pertains only to the clinician's feedback. We also analyzed real-time alerts signaling family dissatisfaction (defined as "service recovery escalation" throughout this manuscript). The most common selection for the source of family dissatisfaction, as reflected through the real-time alerts was, "I haven't heard from physicians enough," appearing in 52 out of 156 alerts (33%). The second most common selection for the source of dissatisfaction was "perceived inconsistent or incomplete information provided by team members," which was selected in 48 cases (31%). Our findings indicate that clinicians value inpatient texting, not only for its ability to quickly relay updates to multiple family members with 1 click, but also because, when used intentionally and meaningfully, texting decreases family phone calls.

Serious Illness Communication Training Among Radiation Oncology Residents

PURPOSE

Education and specific training on serious illness communication skills for radiation oncology residents is lacking. The Accreditation Council for Graduate Medical Education requires radiation oncology residents to demonstrate interpersonal and communication skills; however, implementing specific training to address this poses an ongoing challenge. This study assesses the feasibility and effectiveness of a radiation oncology specific serious illness communication curriculum at a single radiation oncology residency program.

METHODS AND MATERIALS

The primary objectives were to assess observable communication skills among radiation oncology residents and their perceived level of preparedness and comfort with patient encounters surrounding serious illness. Each resident participated in a baseline simulated patient encounter. Two virtual half-day experience-based learning sessions led by faculty experts trained in teaching serious illness communication were held. The training consisted of brief didactic teaching, with the emphasis on small group guided practice with simulated patients in scenarios specific to radiation oncology. Each resident participated in a postcourse simulated patient encounter. Three blinded faculty trained in serious illness communication completed objective assessments of observable communication skills to compare pre- and postcourse performance.

RESULTS

A t test based on validated assessments reviewed by blinded faculty demonstrated significant improvement in overall observable communication skills among radiation oncology residents in the postcourse encounter compared with the precourse encounter (P = .0067). Overall, 8 of 9 (89%) residents felt more comfortable and prepared with radiation oncology-specific serious illness communication after the course compared with prior. The simulated patients rated the overall average resident performance higher on the postcourse assessment (Likert 4.89/5) compared with the precourse assessment (Likert 4.09/5), which trended toward a significant improvement (P = .0515).

CONCLUSIONS

Radiation oncology residents had a significant improvement in observable communication skills after participating in an experience-based training curriculum. This course can serve as an adaptable model that may be implemented by other radiation oncology residency programs.

Development and validation of conflict management attitude questionnaire for medical students

BACKGROUND

Medical students should effectively manage conflicts in teamwork and communication with other team members. This study aimed to develop and validate a tool to evaluate attitude of medical students and physicians toward conflict management.

METHOD

A multi-step process was employed to develop and validate a Conflict Management Attitude Questionnaire (CMAQ) based on the steps recommended in AMEE Guide No. 87. First, the initial items were obtained from the literature review and focus group. After cognitive interviews with the medical students and revision of the questionnaire, content validity was performed by experts. The construct validity and reliability of the questionnaire were assessed using exploratory Factor Analysis (EFA) and Cronbach's alpha coefficient, respectively.

RESULTS

This multi-step process resulted in a 12-item, five-point Likert-type questionnaire with satisfactory construct validity. Exploratory factor analysis revealed three factors, comprising the four items from the "perceived interactions in conflict management" subscale loading on the first factor, and five items from the "perceived value of learning conflict management" subscale loading on the second factor, along with three items from the "perceived application of conflict management" subscale loading on the third factor. All subscales described 56.48% of the variance. Validation results showed that Content Validity Index (CVI) and Content Validity Ratio (CVR) were greater than 0.75. Cronbach's alpha coefficient was 0.791.

CONCLUSION

This study showed that CMAQ has valid evidence for assessing the attitude of medical students toward conflict management with favorable psychometric properties and strong evidence of construct validity. However, due to the lack of evidence on any specific questionnaire to evaluate the attitude towards conflict management, future studies should conduct a confirmatory investigation regarding other aspects of medical students' attitudes toward conflict management.

Is there evidence of age bias in breast cancer health care professionals' treatment of older patients?

OBJECTIVES

Despite NICE (2009; 2018) guidelines to treat breast cancer patients 'irrespective of age', older women experience differential treatment and worse outcomes beyond that which can be explained by patient health or patient choice. Research has evidenced the prevalence of ageism and identified the role of implicit bias in reflecting and perhaps perpetuating disparities across society, including in healthcare. Yet age bias has rarely been considered as an explanatory factor in poorer outcomes for older breast cancer patients.

METHODS

This mixed methods study explored age bias amongst breast cancer HCPs through four components: 1) An implicit associations test (31 HCPs) 2) A treatment recommendations questionnaire (46 HCPs). 3) An attitudes about older patients questionnaire (31 HCPs). 4) A treatment recommendations interview (20 HCPs).

RESULTS

This study showed that breast cancer HCPs held negative implicit associations towards older women; HCPs were less likely to recommend surgery for older patients; some HCPs held assumptions that older patients are more afraid, less willing and able to be involved in decision-making, and are less willing and able to cope with being informed of a poor treatment prognosis; and conditions which disproportionately affect older patients, such as dementia, are not always well understood by breast cancer HCPs.

CONCLUSIONS

These results indicate that there are elements of age bias present amongst breast cancer HCPs. The study's findings of age-based assumptions and a poorer understanding of conditions which disproportionately affect older patients align with patterns of differential treatment towards older breast cancer patients suggesting that age bias may be, at least in part, driving differential treatment.

How health systems facilitate patient-centered care and care coordination: a case series analysis to identify best practices

Large- and small-scale transformation of healthcare delivery toward improved patient experience through promotion of patient-centered and coordinated care continues to be at the forefront of health system efforts in the United States. As part of a Quality Improvement (QI) project at a large, midwestern health system, a case series of high-performing organizations was explored with the goal of identifying best practices in patient-centered care and/or care coordination (PCC/CC). Identification of best practices was done through rapid realist review of peer-reviewed literature supporting three PCC/CC interventions per case. Mechanisms responsible for successful intervention outcomes and associated institutional-level facilitators were evaluated, and cross-case analysis produced high-level focus items for health system leadership, including (1) institutional values surrounding PCC/CC, (2) optimization of IT infrastructure to enhance performance and communication, (3) pay structures and employment models that enhance accountability, and (4) organizing bodies to support implementation efforts. Health systems may use this review to gain insight into how institutional-level factors may facilitate small-scale PCC/CC behaviors, or to conduct similar assessments in their own QI projects. Based on our analysis, we recommend health systems seeking to improve PCC/CC at any level or scale to evaluate how IT infrastructure affects provider-provider and provider-patient communication, and the extent to which institutional prioritization of PCC/CC is manifest and held accountable in performance feedback, incentivization, and values shared among departments and settings. Ideally, this evaluation work should be performed and/or supported by cross-department organizing bodies specifically devoted to PCC/CC implementation work.

The Patient's Voice in Assessing Resident Communication Skills

OBJECTIVE

To generate validity evidence for using patient-reported satisfaction ratings of residents' communication skills to determine progress along the Interpersonal and Communication Skills (ICS) Milestones.

DESIGN

A single-institution, retrospective study analyzed a CAHPS Clinician and Group Survey (CG-CAHPS) database which collects inpatients' ratings of residents' communication skills using 6 questions on a scale of 1 (very poor) to 5 (very good). CG-CAHPS results for each resident were averaged for each question as well as across the 6 questions. The averaged ratings were compared between low and high performer groups.

SETTING

A large, academic, mid-western General Surgery residency program.

PARTICIPANTS

General Surgery residents with 3 or more survey responses from July 2020 to June 2021 were included. Residents were dichotomized into low or high performer groups based on their end-of-year ICS1 sub-competency milestone within their post-graduate year (PGY) cohort.

RESULTS

543 CG-CAHPS responses across 44 residents were analyzed with a median of 9 (Interquartile range 6, 17) responses per resident. When residents were compared based on PGY, ratings for the question "resident's knowledge about your medical care of condition" demonstrated statistically significant differences with PGY5s receiving the lowest score (p = 0.05). PGY5s received the lowest averaged ratings across all questions (p = 0.08, η² = 0.10). When residents were dichotomized into low (n = 21) and high performer groups (n = 23) based on ICS1 milestones, statistically significant differences were noted in ratings for the questions "concern the resident showed for your questions or worries" (4.81 vs. 5, p = 0.047) and "courtesy and respect of the resident" (4.75 vs. 5, p = 0.046).

CONCLUSIONS

Analysis of patient ratings of surgery residents' communication skills demonstrated concordant findings between ICS1 milestone and 2 domains of CG-CAHPS responses. When low and high performer groups were compared, CG-CAHPS responses demonstrated a similar pattern. These findings provide validity evidence for CG-CAHPS data as a source of information for ICS1 sub-competency assessment.

Understanding the Professional Care Experience of Patients with Stroke: A Qualitative Study Using In-Depth Interviews

Background

Professional support and communication stimulates the professional-patient relationship and supports the recovery of stroke patients.

Objectives

To describe the perspectives of patients with stroke regarding communication, professional support, and their ability to participate in processes and integrated care with health providers.

Methods

A qualitative study was conducted. A purposeful sampling and snowball-technique were used. Patients diagnosed with moderate or severe stroke in the post-acute or chronic stage of the disease were included. Data collection consisted of in-depth interviews and researcher field notes. A thematic analysis was performed.

Results

Thirty-one patients were included. Three themes were identified: 1) Providing support, with four categories, professional behavior, personalized attention, the heart of the professional and building a bond with the patient; 2) Facilitating communication, with three categories, the patient as the recipient, the content of the message and the channel, and the professional as the person that conveys the message; and 3) Promoting participation, with two categories, barriers, and incentives to participate.

Conclusions

When providing support, professionals should consider communicating information and encouraging the participation of stroke patients for integrated care.

Disparities in Treatment Satisfaction and Supportive Care Receipt for Young Adult Oncology Patients on the Basis of Residential Location

PURPOSE:

Adolescent and young adult oncology programs are critical but exist primarily in academic centers, prompting potential disparities in care on the basis of patient residence. We studied the impact of residential location on supportive care receipt and treatment satisfaction in young adults (YAs) with cancer age 19-39 years treated at the University of Wisconsin Carbone Cancer Center (UWCCC).

METHODS:

YA patients with cancer age 19-39 years seen at UWCCC from March 30, 2019, to March 29, 2020, were sent a survey assessing supportive care receipt and satisfaction. Survey results were compared with retrospective chart review of YAs seen at UWCCC between April 1, 2011, and April 1, 2021. Data were categorized on the basis of residential location using distance from UWCCC and 2013 Rural-Urban Continuum Code (RUCC).

RESULTS:

Survey results were obtained for 145 YAs, including 29 from nonmetro RUCC (20.0%) and 81 living > 20 miles from UWCCC (55.9%). YAs from nonmetro locations had lower satisfaction with available treatments (79.3% v 91.4%, P = .005), and distant YAs living > 20 miles from UWCCC more frequently identified location as a barrier to supportive care receipt (35.6% v 15.8%, P = .02). Metro YAs more frequently listed fertility consultations as unavailable (38.0% v 16.0%, P = .04) in the survey despite chart review data showing higher rates of sexual health assessments (48.2% v 20.4%, P = .002) and fertility visits (29.6% v 18.5%, P = .18).

CONCLUSION:

We identified differences in both supportive care receipt and treatment satisfaction on the basis of residential location. These findings support the need for measures to successfully meet treatment and supportive care needs regardless of residential location.

Physician Communication Coaching: How Psychologists can Elevate Skills and Support Resident Education, Professionalism, and Well-being

Many factors influence resident physician communication, including rigorous training demands that can contribute to professionalism issues or burnout. The University of Rochester Physician Communication Coaching program launched for attendings in 2011, and expanded to residency programs within 11 clinical departments of our institution. In this model, psychologists serve as coaches, drawing on their expertise in communication skills, behavior change, and wellness promotion. These coaches conduct real-time observation of patient encounters, coding communication with an expanded Cambridge-Calgary Patient-Centered Observational Checklist. Residents receive a written report with individualized feedback. From 2013 to 2020, 279 residents were coached. Since 2018, residents have been formally surveyed for feedback (n = 70 surveys completed; 61% response rate), with 97% rating the experience Very Helpful or Helpful. Of the 70 completed surveys, 54 (77%) included qualitative feedback that has also been positive. Due to the feasibility and growing demand for communication coaching from other residency and fellowship programs, in 2018 two authors (SM and LD-R) developed a 2-year, part-time program to train communication coaches.

Training in communication and emotion handling skills for students attending medical school: Relationship with empathy, emotional intelligence, and attachment style

OBJECTIVE

To describe the Emoty-Com training, its impact on medical students' attitudes towards doctors' emotions and to explore the association between students' empathy, emotional intelligence (EI), and attachment style (AS) with post-training performance scores.

METHODS

The 16-hour Emoty-Com training was delivered to all second-year medical students of Verona and Milan (Italy) Universities. At pre-training, students filled out three questionnaires assessing empathy, AS and EI and responded to three questions on attitudes towards doctors' emotions in the doctor-patient encounter. The same three questions and a final evaluation test were proposed at post-training.

RESULTS

264 students participated in the study. The training reduced students' worry about managing emotions during doctor-patient relationships. Gender was associated with specific subscales of empathy, EI, and AS. Final performance scores were associated with students' attitudes towards emotions but not with empathy, EI, and AS.

CONCLUSION

The Emoty-Com training increased students' self-efficacy in handling their own emotions during consultations. Students' performance scores were related to their attitude towards doctors' emotions in clinical encounters.

PRACTICE IMPLICATIONS

The Emoty-Com training suggests ways to teach and evaluate emotion-handling skills for medical students. Possible links between empathy, EI, AS, and the attitudes towards doctors' emotions during the years of education are highlighted.

Provider Communication and Fever Protocol for Children With Sickle Cell Disease in the Emergency Department

OBJECTIVE

We assessed whether prior communication between pediatric hematologists and emergency department (ED) providers reduced time to administration of parenteral antibiotics for children with sickle cell disease presenting with fever.

METHODS

Patients 2 months to 21 years of age were retrospectively identified if they were followed up at our center's pediatric hematology clinic and presented to the pediatric ED with fever. Emergency department-hematology communication before patient arrival was ascertained by chart review. The primary outcome was time to administration of parenteral antibiotics after ED arrival, with 60 minutes being the recommended maximum.

RESULTS

Forty-nine patients were included in the analysis. Prior communication occurred in 43% of cases, with a median time to antibiotic administration of 79 minutes in this group (interquartile range, 59-142), compared with 136 minutes for patients without prior communication (interquartile range, 105-181 minutes; P = 0.012). The groups did not differ in hospital length of stay at the index visit.

CONCLUSIONS

Advance communication between the pediatric hematologist and ED physician was associated with reduced time to antibiotic administration for febrile children with sickle cell disease. Further interventions should be explored to achieve timely antibiotics administration within 60 minutes of ED arrival.

Implementing a telemedicine curriculum for internal medicine residents during a pandemic: the Cleveland Clinic experience

Telemedicine training was not a substantial element of most residency programmes prior to the COVID-19 pandemic. Social distancing measures changed this. The Cleveland Clinic Internal Medicine Residency Programme (IMRP) is one of the largest programmes in the USA, which made the task of implementing a telemedicine curriculum more complex. Here we describe our experience implementing an effective, expedited telemedicine curriculum for our ambulatory resident clinics. This study was started in April 2020 when we implemented a resident-led curriculum and training programme for providing ambulatory telemedicine care. The curriculum was finalised in less than 5 weeks. It entailed introducing a formal training programme for residents, creating a resource guide for different video communication tools and training preceptors to safely supervise care in this new paradigm. Residents were surveyed before the curriculum to assess prior experience with telemedicine, and then afterward to assess the curriculum's effectiveness. We also created a mini-CEX assessment for residents to solicit feedback on their performance during virtual appointments. Over 2000 virtual visits were performed by residents in a span of 10 weeks. Of 148 residents, 38% responded to the pre-participation survey. A majority had no prior telemedicine experience and expressed only slight comfort with the modality. Through collaboration with experienced residents and faculty, we expeditiously deployed an enhancement to our ambulatory care curriculum to teach residents how to provide virtual care and help faculty with supervision. We share our insights on this experience for other residency programmes to use.

Improving Communication Skills: A Roadmap for Humanistic Health Care

This article outlines frameworks that enable health care providers to take steps to improve their health care communication skills, including not only outward-facing conversational tools but also personal awareness. Such awareness includes recognition of bias and emotional reactions, their behavioral consequences, and how to intervene when necessary. The authors describe the intrinsic and extrinsic motivators to improving communication skills, followed by a review of foundational communication microskills and suggestions on how to improve them through the perspectives of the clinician as a self-learner, the clinician with external coaching, and the administrator/leader.

The effect of a relationship-centered communication program on patient experience and provider wellness

OBJECTIVES

Despite evidence of the central importance of communication to patient experience, health outcomes, and provider wellness, communication training for clinicians is not a standard part of clinical education. The study explores the impact of an 8-hour relationship-centered communication (RCC) training program on patient experience and provider wellness.

METHODS

636 healthcare providers participated in 48 workshops conducted January-August 2018. 481 (76%) agreed to participate in research. Participants completed a pre/post assessment that included a wellness survey, the Professional Fulfillment Index (PFI). We conducted chi-squared analyses comparing wellness data immediately prior to the course to 3 months following course participation. Patient experience, assessed using Press Ganey likelihood to recommend care provider (PG-LTR CP) scores, were examined prior to an individual's course participation and following participation up to September 2019.

RESULTS

104 participants completed the three-month PFI (22% response rate). Participants demonstrated marked improvements in professional wellness after 3 months. In bivariate analyses, PG-LTR CP significantly increased and persisted more than 7 months following program completion.

CONCLUSIONS

The RCC training program, a low-cost communication intervention, led to significant, beneficial changes in provider wellness and patient experience.

PRACTICE IMPLICATIONS

Implementing a RCC course for providers may improve patient experience and provider wellness.

“Acquiring the Skills Needed to Communicate What Is in Our Teams’ Heart: Love, Compassion and Partnership”: Qualitative Analysis of Intact Multidisciplinary Teams’ Experience of Relationship-Centered Communication Training

The Partnership Enhancement Program (PEP) is a 6-hour relationship-centered communication training for intact cystic fibrosis (CF) teams. The aim of this study was to analyze qualitative responses from survey participants regarding their takeaways from the training. A total of 210 professionals participated in 20 pilot workshops at 19 care centers in the United States from November 2018 to December 2019. After the workshop, qualitative feedback was captured by PEP facilitators during a feedback gathering session or submitted immediately in writing by participants. The manuscript team used grounded theory and qualitative methods of coding to identify recurring themes across participant responses. Thematic analysis revealed 5 primary themes and a web of interconnected subthemes. Primary themes include the acquisition of skills to improve communication, strengthened patient/provider connection, improved quality of communication, improved team building, and the ability to change and enhance practice. Participants who completed PEP training endorse acquiring communication skills that increase coproduction of care with patients and caregivers as well as improve relationships across the healthcare system.

Evaluation of the communication of nursing students in the simulated teleconsultation: A cross-sectional study

INTRODUCTION

The COVID-19 pandemic presented universities with the challenge of virtualizing the teaching-learning process. Simulated teleconsultation has been used in undergraduate training, which allows nursing students to interact with simulated patients remotely. Studies have identified that distance imposes communication barriers on all elements-sender, receiver and message-and in both forms of transmission: verbal and nonverbal.

OBJECTIVE

To describe the communication of nursing students in teleconsultation with simulated patients in the context of primary health care.

METHODS

This was a descriptive, cross-sectional study of 92 fifth-year nursing students. The communication variable was measured with the Connect Identify Understand Agree Help scale. In the data analysis, the mean and standard deviation of the scores on the 29 items of the scale were determined, as were the mean values for the total scale and for the 3 domains of the scale.

RESULTS

The items that presented an average of less than 1 were primarily those related to the Agree and Help to Act domain. The total mean was 1.15, and the means for the domains Connect, Identify and Understand Problems and Agree and Help to Act were 1.53, 0.90 and 1.28, respectively. A weakness in the exploration of the psychosocial context of the simulated patients was observed.

CONCLUSIONS

The results of this study, which evaluated communication in the context of distance care, corroborate the evidence regarding communication in real or simulated face-to-face situations. Studies that compare communication in various teaching-learning contexts, whether real or virtual, face-to-face or at a distance, are recommended.

Experiences of Families Caring for Children with Newborn Screening-Related Conditions: Implications for the Expansion of Genomics in Population-Based Neonatal Public Health Programs

With the expansion of newborn screening conditions globally and the increased use of genomic technologies for early detection, there is a need for ethically nuanced policies to guide the future integration of ever-more comprehensive genomics into population-based newborn screening programs. In the current paper, we consider the lived experiences of 169 family caregivers caring for 77 children with NBS-related conditions to identify lessons learned that can inform policy and practice related to population-based newborn screening using genomic technologies. Based on caregiver narratives obtained through in-depth interviews, we identify themes characterizing these families' diagnostic odyssey continuum, which fall within two domains: (1) medical management implications of a child diagnosed with an NBS-related condition and (2) psychological implications of a child diagnosed with an NBS-related condition. For Domain 1, family caregivers' experiences point to the need for educational resources for both health care professionals that serve children with NBS-related conditions and their families; empowerment programs for family caregivers; training for providers in patient-centered communication; and access to multi-disciplinary specialists. For Domain 2, caregivers' experiences suggest a need for access to continuous, long-term counseling resources; patient navigator resources; and peer support programs. These lessons learned can inform policy recommendations for the benefit of the child, the family, the healthcare system, and society.

Sense of Coherence as a Mediator in the Association Between Empathy and Moods in Healthcare Professionals: The Moderating Effect of Age

While empathy is considered a critical determinant of the quality of medical care, growing evidence suggests it may be associated with both one’s own positive and negative moods among healthcare professionals. Meanwhile, sense of coherence (SOC) plays an essential role in the improvement of both psychological and physical health. Reportedly, individual SOC reaches full stability after around age 30. The aim of this study was first to evaluate the mediatory role of SOC on the association between empathy and individual moods among 114 healthcare professionals in a general hospital, and then to examine the moderating effect of age on this association. Participants completed a range of self-report demographic questionnaires, Empathy Process Scale (EPS), the 13-item Antonovsky’s SOC, and Profile of Mood States (POMS). Findings showed that SOC mediated the relations between empathy (EPS) and both POMS-Vigor (POMS-V: self-vigor mood) and POMS-Depression (POMS-D: self-depression mood). Notably, moderated mediation analysis revealed that there was a significant interaction (age × SOC) on self-vigor mood (POMS-V) in healthcare professionals. The indirect effect of empathy (EPS) on self-vigor mood (POMS-V) through SOC was significant at over mean age “32.83.” Although there was no significant interaction with age regarding the indirect effect of empathy (EPS) on self-depression mood (POMS-D), in the sub-category level analysis of empathy (EPS), we found a significant interaction item [age × empathy for other’s negative affect (EPS-N)] on SOC. This indirect effect was also significant at over mean age “32.83.” Taken, together, the current study highlighted the significant mediator of SOC on that empathy amplifies self-vigor mood and attenuates self-depression mood as a protective factor among the Japanese healthcare professionals. Some components of these processes may depend on the moderating role of age, indicating that we may need to consider the SOC development with age for more effective empathy performance interventions among healthcare professionals.