Are physicians' attitudes of respect accurately perceived by patients and associated with more positive communication behaviors?

Respecting patients is associated with more patient-centered communication behaviors in clinical encounters

OBJECTIVE

Attitudes towards patients may influence how clinicians interact. We investigated whether respect for patients was associated with communication behaviors during HIV care encounters.

METHODS

We analyzed audio-recordings of visits between 413 adult HIV-infected patients and 45 primary HIV care providers. The independent variable was clinician-reported respect for the patient and outcomes were clinician and patient communication behaviors assessed by the Roter Interaction Analysis System (RIAS). We performed negative binomial regressions for counts outcomes and linear regressions for global outcomes.

RESULTS

When clinicians had higher respect for a patient, they engaged in more rapport-building, social chitchat, and positive talk. Patients of clinicians with higher respect for them engaged in more rapport-building, social chitchat, positive talk, and gave more psychosocial information. Encounters between patients and clinicians with higher respect for them had more positive clinician emotional tone [regression coefficient 2.97 (1.92-4.59)], more positive patient emotional tone [2.71 (1.75-4.21)], less clinician verbal dominance [0.81 (0.68-0.96)] and more patient-centeredness [1.28 (1.09-1.51)].

CONCLUSIONS

Respect is associated with positive and patient-centered communication behaviors during encounters.

PRACTICE IMPLICATIONS

Clinicians should be mindful of their respectful attitudes and work to foster positive regard for patients. Educators should consider methods to enhance trainees' respect in communication skills training.

How patients would like to improve medical consultations: Insights from a multicentre European study

OBJECTIVE

In a previous qualitative study (GULiVer-I), a series of lay-people derived recommendations ('tips') was listed for doctor and patient on 'How to make medical consultation more effective from the patient's perspective'. This work (GULiVer-II) aims to find evidence whether these tips can be generally applied, by using a quantitative approach, which is grounded in the previous qualitative study.

METHODS

The study design is based on a sequential mixed method approach. 798 patients, representing United Kingdom, Italy, Belgium and the Netherlands, were invited to assess on four point Likert scales the importance of the GULiVer-I tips listed in the 'Patient Consultation Values questionnaire'.

RESULTS

All tips for the doctor and the patient were considered as (very) important by the majority of the participants. Doctors' and patients' contributions to communicate honestly, treatment and time management were considered as equally important (65, 71 and 58% respectively); whereas the contribution of doctors to the course and content of the consultation was seen as more important than that of patients.

CONCLUSIONS

The relevance of GULiVer-I tips is confirmed, but tips for doctors were assessed as more important than those for patients.

PRACTICE IMPLICATIONS

Doctors and patients should pay attention to these "tips" in order to have an effective medical consultation.

The Association of Clinician Characteristics with their Attitudes Toward Patients with Sickle Cell Disease: Secondary Analyses of a Randomized Controlled Trial

BACKGROUND

A high level of evidence exists to suggest that negative attitudes held by clinicians toward persons with sickle cell disease serve as important barriers to the delivery of high quality care to this patient population. Little is known, though, about the characteristics of clinicians that may be predictive of these negative attitudes.

METHODS

During spring and summer 2009, we conducted a randomized controlled trial to test an intervention to improve clinician attitudes toward persons with sickle cell disease. Participating clinicians completed questionnaires regarding their demographic characteristics and their attitudes toward sickle cell patients. Principal clinician characteristics of interest included their race, professional discipline (nurse/physician), and the amount of their recent exposure to sickle cell patients in pain. Secondary analyses from this trial are presented here.

MAIN FINDINGS

Asian clinicians reported more negative attitudes towards these patients than did Black or White clinicians, nurses reported more negative attitudes than physicians, and clinicians with the greatest levels of recent exposure to sickle cell patients in pain reported more negative attitudes than did clinicians with lower levels of recent exposure.

CONCLUSIONS

Our findings could facilitate the development of tailored educational resources needed to improve the quality of care delivered to persons with sickle cell disease, a national priority for sickle cell efforts.

Improving Clinician Attitudes of Respect and Trust for Persons With Sickle Cell Disease

OBJECTIVE

To test the effect of 1 high-intensity, and 1 reduced-intensity, educational intervention designed to improve health care provider attitudes toward youth with sickle cell disease (SCD).

METHODS

We exposed a regional sample of pediatric health care providers to a 2.5-day high-intensity educational and experiential intervention using videos about the SCD patient experience. Additionally, we traveled to a different set of regional health care institutions and offered pediatric providers a reduced-intensity intervention, consisting of a 90-minute lunchtime in-service centered on our same set of videos about the patient's experience. We assessed the impact of both interventions by taking pre/post measurements of the negative and positive attitudes expressed by participating providers toward patients with SCD.

RESULTS

Both interventions tested elicited improvements in the SCD attitudes expressed by the pediatric providers as suggested through a reduction in measured negative attitude scores (20.0 vs 12.1, P < .001), and an improvement in positive attitude scores (67.1 vs 72.2, P < .001). Further testing suggested that the high-intensity intervention elicited a stronger effect than the reduced-intensity intervention across multiple attitudinal domains.

CONCLUSIONS

Video-based interventions can be used to improve the attitudes of pediatric providers toward patients with SCD. The availability of interventions of varying intensities provides greater flexibility in designing efforts to advance the quality of SCD care through the improvement of provider attitudes.

Communication between health professionals and patients: review of studies using the RIAS (Roter Interaction Analysis System) method

OBJECTIVE

Systematic review of studies that investigate the communication between patients and health professionals with the application of the RIAS methodology.

METHODS

Keyword Roter Interaction Analysis System was searched in the following bibliographic resources: Academic Search Complete, Current Contents, ISI Proceedings, PubMed, Elsevier, SpringerLink, Web of Science, RCAAP, Solo and the official RIAS site. Selection period: 2006 to 2011. Studies were selected using multicriteria dichotomous analysis and organized according to PRISMA.

RESULTS

Identification of 1,262 articles (455 unrepeated). 34 articles were selected for analysis, distributed by the following health professions: family medicine and general practitioners (14), pediatricians (5), nurses (4), geneticists (3), carers of patients with AIDS (2), oncologists (2), surgeons (2), anesthetists (1) and family planning specialists (1). The RIAS is scarcely used and publicized within the scope of healthcare in Portuguese speaking countries.

DISCUSSION

Main themes studied include the influence of tiredness, anxiety and professional burnout on communication and the impact of specific training actions on professional activities. The review enabled the identification of the main strengths and weaknesses of synchronous and dyadic verbal communication within the provision of healthcare.

CONCLUSION

Scientific investigation of the communication between health professionals and patients using RIAS has produced concrete results. An improvement is expected in health outcomes through the application of the RIAS.

A five-year follow-up of a patient with fulminant myocarditis who underwent a stepwise and goal-oriented individualized comprehensive cardiac rehabilitation program

A 39-year-old man developed fulminant myocarditis and was transferred on mechanical ventilation and a ventricular-assist device to our hospital. On Hospital Day 10, he was weaned from all medical engineering devices, and bedside rehabilitation was initiated. Although a multidisciplinary cardiac rehabilitation team had intervened since Hospital Day 3, he could not be encouraged to begin ambulation because of hypotension and tachycardia. Moreover, he complained of loss of self-confidence and anxiety regarding physical strength, and expansion of activities was difficult. Exercises reflecting his immediate desires and daily activities were used as activity goals, and we developed an individualized exercise program with stepwise increase in load to motivate him to perform rehabilitation. At the time of discharge, his cardiac function recovered to nearly normal levels; however, muscle strength and respiratory function had not recovered. While the intervention was continued at the cardiac rehabilitation outpatient unit, improvement was observed in physical health and mental health-related scale scores. The patient returned to work 4 months after onset of his myocarditis. Moreover, the cardiac rehabilitation team provided support to him for his long-term overseas assignment in the fifth year after myocarditis onset. Long-term comprehensive support by the cardiac rehabilitation team was feasible and useful. .

Impact of weight bias and stigma on quality of care and outcomes for patients with obesity

The objective of this study was to critically review the empirical evidence from all relevant disciplines regarding obesity stigma in order to (i) determine the implications of obesity stigma for healthcare providers and their patients with obesity and (ii) identify strategies to improve care for patients with obesity. We conducted a search of Medline and PsychInfo for all peer-reviewed papers presenting original empirical data relevant to stigma, bias, discrimination, prejudice and medical care. We then performed a narrative review of the existing empirical evidence regarding the impact of obesity stigma and weight bias for healthcare quality and outcomes. Many healthcare providers hold strong negative attitudes and stereotypes about people with obesity. There is considerable evidence that such attitudes influence person-perceptions, judgment, interpersonal behaviour and decision-making. These attitudes may impact the care they provide. Experiences of or expectations for poor treatment may cause stress and avoidance of care, mistrust of doctors and poor adherence among patients with obesity. Stigma can reduce the quality of care for patients with obesity despite the best intentions of healthcare providers to provide high-quality care. There are several potential intervention strategies that may reduce the impact of obesity stigma on quality of care.

Role of patient treatment beliefs and provider characteristics in establishing patient-provider relationships

BACKGROUND

Positive patient-provider relationships have been associated with improved depression treatment outcomes. Little is known about how patient treatment beliefs influence patient-provider relationships, specifically treatment alliance and shared decision making in primary care (PC).

OBJECTIVE

We evaluated the relationship between patient treatment beliefs and patient-provider relationships by gender, race and current depression.

METHODS

We used a deductive parallel convergent mixed method design with cross-sectional data. Participants were 227 Black and White patients presenting with depression symptoms in PC settings. Individuals were randomized into either a quantitative survey (n = 198) or qualitative interview (n = 29) group. We used multiple ordinary least squares regression to evaluate the association between patient beliefs, as measured by the Treatment Beliefs Scale and the Medication Beliefs Scale, and treatment alliance or shared decision making. We concurrently conducted thematic analyses of qualitative semistructured interview data to explicate the nature of patient-provider relationships.

RESULTS

We found that patients who believed their provider would respectfully facilitate depression treatment reported greater bond, openness and shared decision making with their provider. We also identified qualitative themes of physicians listening to, caring about and respecting patients. Empathy and emotive expression increased patient trust in PC providers as facilitators of depression treatment.

CONCLUSIONS

This work systematically demonstrated what many providers anecdotally believe: PC environments in which individuals feel safe sharing psychological distress are essential to early identification and treatment of depression. Interprofessional skills-based training in attentiveness and active listening may influence the effectiveness of depression intervention.

Provider communication quality: influence of patients' weight and race

OBJECTIVE

To examine the relationship between patient weight and provider communication quality and determine whether patient race/ethnicity modifies this association.

METHODS

We conducted a cross-sectional analysis with 2009-2010 medical expenditures panel survey-household component (N=25,971). Our dependent variables were patient report of providers explaining well, listening, showing respect, and spending time. Our independent variables were patient weight status and patient weight-race/ethnicity groups. Using survey weights, we performed multivariate logistic regression to examine the adjusted association between patient weight and patient-provider communication measures, and whether patient race/ethnicity modifies this relationship.

RESULTS

Compared to healthy weight whites, obese blacks were less likely to report that their providers explained things well (OR 0.78; p=0.02) or spent enough time with them (OR 0.81; p=0.04), and overweight blacks were also less likely to report that providers spent enough time with them (OR 0.78; p=0.02). Healthy weight Hispanics were also less likely to report adequate provider explanations (OR 0.74; p=0.04).

CONCLUSION

Our study provides preliminary evidence that overweight/obese black and healthy weight Hispanic patients experience disparities in provider communication quality.

PRACTICE IMPLICATION

Curricula on weight bias and cultural competency might improve communication between providers and their overweight/obese black and healthy weight Hispanic patients.

A Rasch analysis of patients' opinions of primary health care professionals' ethical behaviour with respect to communication issues

BACKGROUND

Patients' opinions are crucial in assessing the effectiveness of the ethical theories which underlie the care relationship between patients and primary health care professionals.

OBJECTIVES

To study the ethical behaviour of primary health care professionals with respect to communication issues according to patients' opinions.

METHODS

Cross-sectional study using a self-administered questionnaire in patients from a network of 15 urban primary health centres. Participants were patients attended at the centres when the study was conducted. We used a Rasch analysis to verify the structure of the 17 questionnaire items, and to calculate interval level measures for patients and items. We analysed differences according to patient subgroups using analysis of variance tests and differences between the endorsement of each item.

RESULTS

We analysed 1013 (70.34%) of questionnaires. Data fit to the Rasch model was achieved after collapsing two categories and eliminating five items. Items with the lowest degree of endorsement were related to the management of differences in conflictive situations between patients and health care professionals. We found significant differences (P < 0.001) in patients' opinions according to the degree of confidence in professionals and their educational level.

CONCLUSIONS

Patients opined that empathy and traditional communication skills were respected by family physicians and nurses. However, opinions on endorsement were lower when patients disagreed with health care professionals. The differences found between patient subgroups demonstrated the importance of trust and confidence between patients and professionals.

A mixed methods study of patient-provider communication about opioid analgesics

OBJECTIVE

To describe patient-provider communication about opioid pain medicine and explore how these discussions affect provider attitudes toward patients.

METHODS

We audio-recorded 45 HIV providers and 423 patients in routine outpatient encounters at four sites across the country. Providers completed post-visit questionnaires assessing their attitudes toward patients. We identified discussions about opioid pain management and analyzed them qualitatively. We used logistic regression to assess the association between opioid discussion and providers' attitudes toward patients.

RESULTS

48 encounters (11% of the total sample) contained substantive discussion of opioid-related pain management. Most conversations were initiated by patients (n=28, 58%) and ended by the providers (n=36, 75%). Twelve encounters (25%) contained dialog suggesting a difference of opinion or conflict. Providers more often agreed than disagreed to give the prescription (50% vs. 23%), sometimes reluctantly; in 27% (n=13) of encounters, no decision was made. Fewer than half of providers (n=20, 42%) acknowledged the patient's experience of pain. Providers had a lower odds of positive regard for the patient (adjusted OR=0.51, 95% CI: 0.27-0.95) when opioids were discussed.

CONCLUSIONS

Pain management discussions are common in routine outpatient HIV encounters and providers may regard patients less favorably if opioids are discussed during visits. The sometimes-adversarial nature of these discussions may negatively affect provider attitudes toward patients.

PRACTICE IMPLICATIONS

Empathy and pain acknowledgment are tools that clinicians can use to facilitate productive discussions of pain management.

Social work decision-making: need factors of older adults that affect outcomes of home- and community-based services

The purposes of this study were to examine social work decision-making outcomes of home- and community-based services (HCBS) referrals provided to older adults with unmet physical and psychosocial needs discharged from acute care to a community setting, and to understand older adults' (N=247) responses to receiving referrals for HCBS. Older adults with inadequately or marginally met basic needs was a statistically significant predictor of the number of HCBS referrals home health social workers provided to older adult clients (p < .01). The adapted three-step models were statistically significant: activities of daily living model [F(15) = 1.95, p < .05] and instrumental activities of daily living model [F(15) = 2.06, p < .05]. Most older adults accepted the HCBS referrals provided to them at the time of the social work home visit. Implications for practice were suggested for clinical social workers.and case managers providing HCBS referrals to older adults with unmet physical and psychosocial needs discharged from acute care or skilled care to community settings.

An observational study of social and emotional support in smoking cessation Twitter accounts: content analysis of tweets

Background

Smoking continues to be the number one preventable cause of premature death in the United States. While evidence for the effectiveness of smoking cessation interventions has increased rapidly, questions remain on how to effectively disseminate these findings. Twitter, the second largest online social network, provides a natural way of disseminating information. Health communicators can use Twitter to inform smokers, provide social support, and attract them to other interventions. A key challenge for health researchers is how to frame their communications to maximize the engagement of smokers.

Objective

Our aim was to examine current Twitter activity for smoking cessation.

Methods

Active smoking cessation related Twitter accounts (N=18) were identified. Their 50 most recent tweets were content coded using a schema adapted from the Roter Interaction Analysis System (RIAS), a theory-based, validated coding method. Using negative binomial regression, the association of number of followers and frequency of individual tweet content at baseline was assessed. The difference in followership at 6 months (compared to baseline) to the frequency of tweet content was compared using linear regression. Both analyses were adjusted by account type (organizational or not organizational).

Results

The 18 accounts had 60,609 followers at baseline and 68,167 at 6 months. A total of 24% of tweets were socioemotional support (mean 11.8, SD 9.8), 14% (mean 7, SD 8.4) were encouraging/engagement, and 62% (mean 31.2, SD 15.2) were informational. At baseline, higher frequency of socioemotional support and encouraging/engaging tweets was significantly associated with higher number of followers (socioemotional: incident rate ratio [IRR] 1.09, 95% CI 1.02-1.20; encouraging/engaging: IRR 1.06, 95% CI 1.00-1.12). Conversely, higher frequency of informational tweets was significantly associated with lower number of followers (IRR 0.95, 95% CI 0.92-0.98). At 6 months, for every increase by 1 in socioemotional tweets, the change in followership significantly increased by 43.94 (P=.027); the association was slightly attenuated after adjusting by account type and was not significant (P=.064).

Conclusions

Smoking cessation activity does exist on Twitter. Preliminary findings suggest that certain content strategies can be used to encourage followership, and this needs to be further investigated.

The Association of Patient Chronic Disease Burden and Self-Management Requirements With Shared Decision Making in Primary Care Visits

BACKGROUND

Shared decision making (SDM) is associated with positive health outcomes and may be particularly relevant for patients with chronic disease.

OBJECTIVES

To investigate whether (1) patients with chronic diseases, particularly those requiring self-management, are more likely to engage in SDM behaviors than patients without chronic diseases and (2) patients with chronic diseases are more likely to have their physicians engage them in SDM.

DESIGN

A cross-sectional study of patients who were enrolled in a randomized controlled trial to improve patient-physician communication.

PARTICIPANTS

Adult patients with hypertension at community health clinics in Baltimore, Maryland.

APPROACH

We used multivariable regression models to examine the associations of the following predictor variables: (1) chronic disease burden and (2) diseases requiring self-management with the following outcome variables measuring SDM components: (1) patient information sharing, (2) patient decision making, and (3) physician SDM facilitation.

KEY RESULTS

Patients with greater chronic disease burden and more diseases requiring self-management reported more information sharing (β = .07, P = .03 and β = .12, P = .046, respectively) and decision making (β = .06, P = .02 and β = .21, P < .001) as did patients who reported poor general health. Physician facilitation of SDM was not associated with chronic disease burden or with diseases requiring self-management but was associated with higher patient income.

CONCLUSIONS

Patients with chronic diseases, particularly those requiring self-management, may be more likely to engage in SDM behaviors, but physicians may not be more likely to engage such patients in SDM. Targeting patients with chronic disease for SDM may improve health outcomes among the chronically ill, particularly among vulnerable patients (eg, minorities, low-income patients) who suffer disproportionately from such conditions.

Implicit and explicit weight bias in a national sample of 4,732 medical students: the medical student CHANGES study

OBJECTIVE

To examine the magnitude of explicit and implicit weight biases compared to biases against other groups; and identify student factors predicting bias in a large national sample of medical students.

METHODS

A web-based survey was completed by 4,732 1st year medical students from 49 medical schools as part of a longitudinal study of medical education. The survey included a validated measure of implicit weight bias, the implicit association test, and 2 measures of explicit bias: a feeling thermometer and the anti-fat attitudes test.

RESULTS

A majority of students exhibited implicit (74%) and explicit (67%) weight bias. Implicit weight bias scores were comparable to reported bias against racial minorities. Explicit attitudes were more negative toward obese people than toward racial minorities, gays, lesbians, and poor people. In multivariate regression models, implicit and explicit weight bias was predicted by lower BMI, male sex, and non-Black race. Either implicit or explicit bias was also predicted by age, SES, country of birth, and specialty choice.

CONCLUSIONS

Implicit and explicit weight bias is common among 1st year medical students, and varies across student factors. Future research should assess implications of biases and test interventions to reduce their impact.

Student nurses' views on respect towards service users - an interpretative phenomenological study

AIM

To explore student nurses' understanding and behaviours of respect towards patients in order to inform educational strategies to optimise respectful care.

BACKGROUND

There is a causal relationship between the perception of being treated with respect and patient satisfaction. Concerns over standards of care prompted a commissioned report into the quality of nurse education in the United Kingdom.

DESIGN

A hermeneutic phenomenological interview study was used to identify and interpret student nurses' behaviours and understanding of respect towards patients.

SETTING

University health and social care faculty in the north-west of England, United Kingdom.

PARTICIPANTS

Eight third-year student nurses (adult branch), on different university sites, with practice placements across different healthcare trusts.

METHODS

Interviews about their understanding of respect and their behavioural intentions of respect towards patients were recorded and transcribed, then analysed using interpretative phenomenological analysis (IPA) to produce themes from the data.

FINDINGS

Three themes of relevance to nurse education were identified. Respect is a complex concept that is difficult to apply in practice. Students are not always aware of incongruence between their feelings of respect towards patients and their behaviours towards them. Role-modelling of respectful care is variable, and essential care is often learned from healthcare assistants.

DISCUSSION

Awareness of emotional responses and their relationship to patient perceptions of respect should be facilitated in theory and practice. Rehearsal of the application of respect involving emotional labour, and reflection in and on the practice of respectful care, are needed to address student learning needs. The theory-practice gap in relation to respect, variation in professional practice and the under-recognised importance of healthcare assistants in student nurse education, are barriers to the learning of respect to patients.

CONCLUSIONS

Interactive education experiences are important to develop self-awareness and insight into respectful care. Mentorship in practice should encourage reflection in and on the practice of respect towards patients.

Respect in final-year student nurse-patient encounters - an interpretative phenomenological analysis

Very little is known regarding health-care professionals' understanding and experiences of respect towards patients. The study aimed to explore student nurses' understanding and experiences of respect in their encounters with patients. Semi-structured interviews were conducted with eight final-year student nurses with practice placements across different health-care trusts in the UK. Transcripts were analysed using interpretative phenomenological analysis (IPA). Three super-ordinate themes were identified: understanding of what it means to show respect, negotiating role expectations and personal attitudes in practice, and barriers related to the performance of the nursing role. The factors identified should be investigated further and addressed as they are likely to influence patients' experiences of feeling respected in nurse–patient interactions and subsequently their well-being and health-related behaviours.

Association between perceived health care stigmatization and BMI change

BACKGROUND/AIMS

This study examined the association between experiences of health care stigmatization and BMI changes in men and women with normal weight and obesity in Sweden.

METHODS

The participants were drawn from a population-based survey in Sweden (1996-2006), and data on their perceived health care stigmatization were measured in 2008. They were categorized in individuals with normal weight (n = 1,064), moderate obesity (n = 1,273), and severe obesity (n = 291). The main outcome measure was change in BMI.

RESULTS

Individuals with severe obesity experiencing any health care stigmatization showed a BMI increase by 1.5 kg/m2 more than individuals with severe obesity with no such experience. For individuals with moderate obesity, insulting treatment by a physician and avoidance of health care were associated with a relative BMI increase of 0.40 and 0.75 kg/m2, respectively, compared with their counterparts who did not experience stigmatization in these areas. No difference in experience of any form of health care stigmatizing associated BMI change was observed for men and women with normal weight.

CONCLUSION

In this large, population-based study, perceived health care stigmatization was associated with an increased relative BMI in individuals with severe obesity. For moderate obesity, the evidence of an association was inconclusive.

(Re)Introducing communication competence to the health professions

Despite the central role that communication skills play in contemporary accounts of effective health care delivery in general, and the communication of medical error specifically, there is no common or consensual core in the health professions regarding the nature of such skills. This lack of consensus reflects, in part, the tendency for disciplines to reinvent concepts and measures without first situating such development in disciplines with more cognate specialization in such concepts. In this essay, an integrative model of communication competence is introduced, along with its theoretical background and rationale. Communication competence is defined as an impression of appropriateness and effectiveness, which is functionally related to individual motivation, knowledge, skills, and contextual facilitators and constraints. Within this conceptualization, error disclosure contexts are utilized to illustrate the heuristic value of the theory, and implications for assessment are suggested. Significance for public healthModels matter, as do the presuppositions that underlie their architecture. Research indicates that judgments of competence moderate outcomes such as satisfaction, trust, understanding, and power-sharing in relationships and in individual encounters. If the outcomes of health care encounters depend on the impression of competence that patients or their family members have of health care professionals, then knowing which specific communicative behaviors contribute to such impressions is not merely important - it is essential. To pursue such a research agenda requires that competence assessment and operationalization becomes better aligned with conceptual assumptions that separate behavioral performance from the judgments of the competence of that performance.

Physicians build less rapport with obese patients

OBJECTIVE

Physicians' negative attitudes toward patients with obesity are well documented. Whether or how these beliefs may affect patient-physician communication is unknown. To describe the relationship between patient body mass index (BMI) and physician communication behaviors (biomedical, psychosocial/lifestyle, and rapport building) during typical outpatient primary care visits was aimed.

DESIGN AND METHODS

Using audio-recorded outpatient encounters from 39 urban primary care physicians (PCPs) and 208 of their patients, the frequency of communication behaviors using the Roter Interaction Analysis System was examined. The independent variable was measured; patient BMI and dependent variables were communication behaviors by the PCP within the biomedical, psychosocial/lifestyle, and rapport building domains. A cross-sectional analysis using multilevel Poisson regression models to evaluate the association between BMI and physician communication was performed.

RESULTS

PCPs demonstrated less emotional rapport with overweight and obese patients (incidence rate ratio, IRR, 0.65, 95%CI 0.48-0.88, P = 0.01; IRR 0.69, 95%CI 0.58-0.82, P < 0.01, respectively) than for normal weight patients. No differences in PCPs' biomedical or psychosocial/lifestyle communication by patient BMI were found.

CONCLUSIONS

Our findings raise the concern that low levels of emotional rapport in primary care visits with overweight and obese patients may weaken the patient-physician relationship, diminish patients' adherence to recommendations, and decrease the effectiveness of behavior change counseling.

The person in the room: how relating holistically contributes to an effective patient-care provider alliance

The purpose of this paper is to explore how relating to the 'whole' person--both the physical body and the invisible aspects of the 'self'--is essential in the establishment of a strong therapeutic alliance between patients and health care providers. Our work is based on interviews conducted with individuals affected by neurological illnesses (patients and family care providers). Hsieh and Shannon's (2005) conventional content analysis was used to analyze the data. Under the broad theme of 'maintaining a coherent sense of self' we identified four distinct sub-themes related to interactions with health care providers. The results elucidate the more complex and deep needs of patients who must access care on an ongoing basis, and highlight the important role that care providers play in supporting individuals who are experiencing physical, spiritual and social losses. Care must attend to the deep needs of these individuals by communicating in a style that addresses both emotional and cognitive needs of patients, by thorough and holistic assessment and by appropriate referrals.

Doctors' self-reported physical activity, their counselling practices and their correlates in urban Trivandrum, South India: should a full-service doctor be a physically active doctor?

BACKGROUND

Doctors' self-reported physical activity (PA) is associated with their propensity for prescribing PA.

METHODS

We surveyed 146 doctors (median age 42 years; men 58.9%), selected by multistage random sampling. Information on demographic details, self-reported PA and counselling offered to their patients was collected using a pretested, structured, self-administered questionnaire. Multivariate logistic regression analysis was carried out to find the predictors of PA and PA counselling offered to the patients.

RESULTS

Moderate PA was reported by 37.7% (95% CI 29.8 to 45.5) of the doctors and the remaining 62.3%reported being inactive. Doctors who were motivated to perform PA (OR 4.01, 95% CI 1.82 to 8.86), who used exercise equipment at home (OR 3.97, CI 1.68 to 9.36) and who used a neighbourhood facility for PA (OR 2.36, CI 1.11 to 5.02) were more likely to perform moderate PA compared with their counterparts. 25% of the doctors always asked and advised their patients on PA. Doctors who believed that their own healthy lifestyle influenced advice practices (OR 9.13, CI 2.49 to 33.41), who consulted less than 30 patients/day (OR 5.35, CI 1.41 to 20.25) and who reported previous participation in sports activities (OR 4.22, CI 1.77 to 10.04) were more likely to always ask and advise their patients on PA compared with their counterparts.

CONCLUSIONS

A majority of the doctors in our study were inactive and did not ask or advise their patients on PA. Measures are warranted to enhance doctors' own PA and their counselling practices.

Problems and processes in medical encounters: the cases method of dialogue analysis

OBJECTIVE

To develop methods to reliably capture structural and dynamic temporal features of clinical interactions.

METHODS

Observational study of 50 audio-recorded routine outpatient visits to HIV specialty clinics, using innovative analytic methods. The comprehensive analysis of the structure of encounters system (CASES) uses transcripts coded for speech acts, then imposes larger-scale structural elements: threads--the problems or issues addressed; and processes within threads--basic tasks of clinical care labeled presentation, information, resolution (decision making) and Engagement (interpersonal exchange). Threads are also coded for the nature of resolution.

RESULTS

61% of utterances are in presentation processes. Provider verbal dominance is greatest in information and resolution processes, which also contain a high proportion of provider directives. About half of threads result in no action or decision. Information flows predominantly from patient to provider in presentation processes, and from provider to patient in information processes. Engagement is rare.

CONCLUSIONS

In this data, resolution is provider centered; more time for patient participation in resolution, or interpersonal engagement, would have to come from presentation.

PRACTICE IMPLICATIONS

Awareness of the use of time in clinical encounters, and the interaction processes associated with various tasks, may help make clinical communication more efficient and effective.

A qualitative study of experiences with and perceptions regarding long-acting injectable antipsychotics: part II-physician perspectives

OBJECTIVE

In many countries, including Canada, a small proportion of people with psychotic disorders receive long-acting injectable (LAI) antipsychotics (APs), despite their demonstrated effectiveness and possible advantages for improving adherence rates. Attitudes regarding LAIs among physicians may influence their prescribing practices and thereby contribute to the underuse of LAIs. Here, we report on a qualitative study of perceptions and attitudes toward LAIs among psychiatrists in Canada.

METHOD

Focus groups were conducted with 24 psychiatrists in 4 Canadian provinces. The focus groups inquired about experiences with and attitudes toward LAI APs. The sessions were audiotaped and transcribed verbatim, and transcripts were coded using a hybrid process of deductive and inductive methods. A brief pre-focus group questionnaire was administered.

RESULTS

The pre-focus group questionnaires indicated that psychiatrists in our study prescribed the oral formulation of APs most of the time and had limited experience with LAIs. The focus groups yielded 4 main themes: limited knowledge about and experience with LAIs; attitudes toward LAIs (beliefs about negative perceptions of patients regarding LAIs, personal bias against needles, and consensus about some advantages of LAIs); prescribing practices around LAIs (generally seen as a last-resort option for patients with a history of nonadherence); and pragmatic barriers to using LAIs (for example, cost, storage, and staffing).

CONCLUSION

Several factors may be contributing to the underuse of LAIs and the continuing stigmatized and coercive image of LAIs. Psychiatrists may benefit from better education about LAIs, and from self-examination of their attitudes to LAIs and their prescribing practices.

Interactions between patients and dental care providers: does gender matter?

Research findings concerning the role of gender in patient-physician interactions can inform considerations about the role of gender in patient-dental care provider interactions. Medical research showed that gender differences in verbal and nonverbal communication in medical settings exist and that they affect the outcomes of these interactions. The process of communication is shaped by gender identities, gender stereotypes, and attitudes. Future research needs to consider the cultural complexity and diversity in which gender issues are embedded and the degree to which ongoing value change will shape gender roles and in turn interactions between dental patients and their providers.

Is perceived social distance between the patient and the general practitioner related to their disagreement on patient's health status?

OBJECTIVE

To ascertain whether disagreement between patients and general practitioners (GP) on the patient's health status varies according to their respective perceived social distance (PSD).

METHODS

The analysis used the Intermede project's quantitative data collected from 585 patients and 27 doctors via mirrored questionnaires. GPs and patients ranked their own perceived social position (PSP) in society, and their patients' and their GP respectively. PSD was calculated as the PSP's subtraction from the patients' and GPs' assessments.

RESULTS

Disagreement between GPs and patients regarding the patient's health status was associated with PSD by the GP whereas it was not associated with PSD by the patient. In the multilevel analysis, disagreement whereby GPs overestimate patient's health status increased within PSD by the GP: OR:2.9 (95%CI = 1.0-8.6, p = 0.055) for low PSD, OR:3.4 (95%CI = 1.1-10.2, p < 0.05) for moderate PSD and OR:3.8 (95%CI = 1.1-13.1, p < 0.05) for high PSD (reference: no distance).

CONCLUSIONS

Patients perceived with a lower social position by their GP and who consider themselves to have poor health are less likely to be identified in the primary care system.

PRACTICE IMPLICATIONS

Physicians need to be conscious that their own perception influences the quality of the interaction with their patients, potentially resulting in unequal health care trajectories.

Providers' HIV-related avoidance attitude and patient satisfaction

OBJECTIVES

This article explores the associations between medical care providers' attitudes towards patients living with HIV (PLH) and the service satisfaction reported from general patients.

METHODS

Data were collected from 40 county-level hospitals in China, including 1760 service providers and 1000 patients receiving medical services from the hospitals. Provider and patient assessments were conducted by self-administered questionnaires and face-to-face interviews, respectively. Random-effect regression models were used to examine relationships between the providers' avoidance attitudes and patient satisfaction at the hospital level while taking into account variations in demographics and professional experience within each hospital.

RESULTS AND CONCLUSIONS

Service providers' avoidance attitudes towards PLH were negatively associated with general patients' satisfaction with service providers at the hospital level. The relationship was strong and significant whether or not adjustments were made for background characteristics. Medical care providers' stigmatizing attitudes towards PLH could be a reflection of the providers' general outlook with all patients. This study underscores a broader focus for HIV-related stigma reduction interventions in medical settings at both individual and institutional levels, targeting attitudes towards both patients with HIV/AIDS and the general patient population.

Learning in context: identifying gaps in research on the transfer of medical communication skills to the clinical workplace

OBJECTIVE

In order to reduce the inconsistencies of findings and the apparent low transfer of communication skills from training to medical practice, this narrative review identifies some main gaps in research on medical communication skills training and presents insights from theories on learning and transfer to broaden the view for future research.

METHODS

Relevant literature was identified using Pubmed, GoogleScholar, Cochrane database, and Web of Science; and analyzed using an iterative procedure.

RESULTS

Research findings on the effectiveness of medical communication training still show inconsistencies and variability. Contemporary theories on learning based on a constructivist paradigm offer the following insights: acquisition of knowledge and skills should be viewed as an ongoing process of exchange between the learner and his environment, so called lifelong learning. This process can neither be atomized nor separated from the context in which it occurs. Four contemporary approaches are presented as examples.

CONCLUSION

The following shift in focus for future research is proposed: beyond isolated single factor effectiveness studies toward constructivist, non-reductionistic studies integrating the context.

PRACTICE IMPLICATIONS

Future research should investigate how constructivist approaches can be used in the medical context to increase effective learning and transition of communication skills.

Preventive evidence into practice (PEP) study: implementation of guidelines to prevent primary vascular disease in general practice protocol for a cluster randomised controlled trial

BACKGROUND

There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession.

METHODS

We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%); and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews.

DISCUSSION

We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations.

The impact of depressive symptoms on patient-provider communication in HIV care

Persons with HIV who develop depression have worse medical adherence and outcomes. Poor patient-provider communication may play a role in these outcomes. This cross-sectional study evaluated the influence of patient depression on the quality of patient-provider communication. Patient-provider visits (n=406) at four HIV care sites were audio-recorded and coded with the Roter Interaction Analysis System (RIAS). Negative binomial and linear regressions using generalized estimating equations tested the association of depressive symptoms, as measured by the Center for Epidemiology Studies Depression scale (CES-D), with RIAS measures and postvisit patient-rated quality of care and provider-reported regard for his or her patient. The patients, averaged 45 years of age (range =20-77), were predominately male (n=286, 68.5%), of black race (n=250, 60%), and on antiretroviral medications (n=334, 80%). Women had greater mean CES-D depression scores (12.0) than men (10.6; p=0.03). There were no age, race, or education differences in depression scores. Visits with patients reporting severe depressive symptoms compared to those reporting none/mild depressive symptoms were longer and speech speed was slower. Patients with severe depressive symptoms did more emotional rapport building but less social rapport building, and their providers did more data gathering/counseling (ps<0.05). In postvisit questionnaires, providers reported lower levels of positive regard for, and rated more negatively patients reporting more depressive symptoms (p<0.01). In turn, patients reporting more depressive symptoms felt less respected and were less likely to report that their provider knows them as a person than none/mild depressive symptoms patients (ps<0.05). Greater psychosocial needs of patients presenting with depressive symptoms and limited time/resources to address these needs may partially contribute to providers' negative attitudes regarding their patients with depressive symptoms. These negative attitudes may ultimately serve to adversely impact patient-provider communication and quality of HIV care.

Comparison of expectations of physicians and patients with rheumatoid arthritis for rheumatology clinic visits: a pilot, multicenter, international study

AIM

To describe and compare expectations of patients with rheumatoid arthritis (RA) and their physicians with regard to what is most important to achieve during a rheumatology clinic visit.

METHODS

Subjects were RA patients enrolled in four centers from China, one from Japan and one from the USA, and rheumatologists at those centers. The questionnaires were provided at clinics and patients were asked to list their three top priorities for the rheumatology clinic visit. Physicians were contacted separately and asked to give three general expectations, not for specific visits. We classified clinical expectations into a series of 24 terms for patients and 17 for physicians. We compared physicians' to patients' responses, compared expectations among centers in China, Japan and the USA, and evaluated relationships between patients' responses and age, gender, nationality, disease duration and DAS-28 (Disease Activity Score-28).

RESULTS

Patients' clinical expectations for visits focused primarily on control of pain (63.7%), improvement of function (49.3%) and discussion of effects of medication (38.1%). Physicians also included control of pain (59.5%), but also emphasized inquiry about drug side-effects (47.8%) and objective assessment of disease activity (41.4%). We found no differences related to patients' gender, disease duration and DAS-28, but there were some differences related to age and nationality.

CONCLUSION

We found some agreement and some discordance of clinical expectations between RA patients and physicians. There appear to be some different expectations in different countries. Findings from this pilot survey may help physicians consider patients' expectations in planning rheumatology clinic visits and may lead to further hypothesis-driven studies.

Clinician stress and patient-clinician communication in HIV care

BACKGROUND

Clinician stress is common, but few studies have examined its relationship with communication behaviors.

OBJECTIVE

To investigate associations between clinician stress and patient-clinician communication in primary HIV care.

DESIGN

Observational study.

PARTICIPANTS

Thirty-three primary HIV clinicians and 350 HIV-infected adult, English-speaking patients at three U.S. HIV specialty clinic sites.

MAIN MEASURES

Clinicians completed the Perceived Stress Scale, and we categorized scores in tertiles. Audio-recordings of patient-clinician encounters were coded using the Roter Interaction Analysis System. Patients rated the quality of their clinician's communication and overall quality of medical care. We used regression with generalized estimating equations to examine associations between clinician stress and communication outcomes, controlling for clinician gender, clinic site, and visit length.

KEY RESULTS

Among the 33 clinicians, 70 % were physicians, 64 % were women, 67 % were non-Hispanic white, and the mean stress score was 3.9 (SD 2.4, range 0-8). Among the 350 patients, 34 % were women, 55 % were African American, 23 % were non-Hispanic white, 16 % were Hispanic, and 30 % had been with their clinicians >5 years. Verbal dominance was higher for moderate-stress clinicians (ratio=1.93, p<0.01) and high-stress clinicians (ratio=1.76, p=0.01), compared with low-stress clinicians (ratio 1.45). More medical information was offered by moderate-stress clinicians (145.5 statements, p <0.01) and high-stress clinicians (125.9 statements, p=0.02), compared with low-stress clinicians (97.8 statements). High-stress clinicians offered less psychosocial information (17.1 vs. 19.3, p=0.02), and patients of high-stress clinicians rated their quality of care as excellent less frequently than patients of low-stress clinicians (49.5 % vs. 66.9 %, p<0.01). However, moderate-stress clinicians offered more partnering statements (27.7 vs. 18.2, p=0.04) and positive affect (3.88 vs. 3.78 score, p=0.02) than low-stress clinicians, and their patients' ratings did not differ.

CONCLUSIONS

Although higher stress was associated with verbal dominance and lower patient ratings, moderate stress was associated with some positive communication behaviors. Prospective mixed methods studies should examine the complex relationships across the continuum of clinician well-being and health communication.

HIV providers' perceptions of and attitudes toward female versus male patients

As a first step in understanding the role that health care providers may play in observed gender disparities in HIV care in the United States, we sought to examine whether HIV providers' perceptions of and attitudes toward female and male patients differ. We used data from the Enhancing Communication to Improve HIV Outcomes (ECHO) study, a multisite, cross-sectional study focused on the role of the patient-provider relationship in disparities in HIV care conducted from October 2006 to June 2007. Using separate scales, we assessed HIV providers' perceptions about their patients (e.g., intelligence, compliance, responsibility) as well as providers' attitudes toward their patients (e.g., like, respect, frustrate). We used multivariable linear regression with generalized estimating equations to compare provider scores for female and male patients. Our sample comprised 37 HIV providers and 317 patients. Compared with male patients, HIV-infected females were less likely to be highly educated or employed, and more likely to report nonadherence to antiretroviral medications and depressive symptoms. In unadjusted and adjusted analyses, there was a significant difference in providers' perceptions of female and male patients, with providers having more negative perceptions of female patients. However, there was no significant difference in HIV providers' attitudes toward female and male patients in unadjusted or adjusted analyses. Further study is needed to elucidate the role of providers' perceptions and attitudes about female and male patients in observed gender disparities in HIV care.

Emergency department team communication with the patient: the patient's perspective

BACKGROUND

Effective communication is important for the delivery of quality care. The Emergency Department (ED) environment poses significant challenges to effective communication.

OBJECTIVES

The objective of this study was to determine patients' perceptions of their ED team's communication skills.

METHODS

This was a cross-sectional study in an urban, academic ED. Patients completed the Communication Assessment Tool for Teams (CAT-T) survey upon ED exit. The CAT-T was adapted from the psychometrically validated Communication Assessment Tool (CAT) to measure patient perceptions of communication with a medical team. The 14 core CAT-T items are associated with a 5-point scale (5 = excellent); results are reported as the percent of participants who responded "excellent." Responses were analyzed for differences based on age, sex, race, and operational metrics (wait time, ED daily census).

RESULTS

There were 346 patients identified; the final sample for analysis was 226 patients (53.5% female, 48.2% Caucasian), representing a response rate of 65.3%. The scores on CAT-T items (reported as % "excellent") ranged from 50.0% to 76.1%. The highest-scoring items were "let me talk without interruptions" (76.1%), "talked in terms I could understand" (75.2%), and "treated me with respect" (74.3%). The lowest-scoring item was "encouraged me to ask questions" (50.0%). No differences were noted based on patient sex, race, age, wait time, or daily census of the ED.

CONCLUSIONS

The patients in this study perceived that the ED teams were respectful and allowed them to talk without interruptions; however, lower ratings were given for items related to actively engaging the patient in decision-making and asking questions.

Kosovo-Serbs' experiences of seeking healthcare in a post-conflict and ethnically segregated health system

OBJECTIVE

To examine the experiences of Kosovo-Serbs who seek healthcare in the formal Kosovo health system.

METHODS

Eleven semi-structured interviews were carried out with Kosovo-Serbs who live in one of the following mono-ethnic enclaves: Gorazhdevc/Goraždevac, Videje/Vidanje, Klinë/Klina and Viti/Vitina. A phenomenological approach was used to collect and analyze data.

RESULTS

The analysis shows the critical role of the depth of the relationship with Kosovo-Albanian doctors in the Kosovo-Serbs' experience of seeking care in the formal sector. The patient-doctor relationship is the result of two processes-longitudinal care and consultation experiences. Four elements, i.e., knowledge, trust, closeness and regard were identified as key aspects contributing to the depth of the relationship between Kosovo-Serb patients and Kosovo-Albanian doctors.

CONCLUSIONS

Fear, anxiety and language differences are still important barriers to Kosovo-Serbs' access to formal health care. These barriers are partly overcome as interviewees establish and develop relationships to Kosovo-Albanian doctors based on reciprocal knowledge, trust, closeness, and regard. Hereby, Kosovo-Serb patients and Kosovo-Albanian doctors contribute to blur the lines the ethnically divided health system and transcend the legacy of war.

Affective interactions in medical visits: ethnic differences among American Indian older adults

OBJECTIVE

Investigate influence of ethnicity on older American Indian patients' interpretations of providers' affective behaviors.

METHOD

Using data from 115 older American Indian patients, random effects ordered logit models related patient ratings of providers' respect, empathy, and rapport first to separate measures of American Indian and White American ethnicity, then to "ethnic discordance," or difference between providers' and patients' cultural characteristics.

RESULTS

In models accounting for patients' ethnicity only, high scores for American Indian ethnicity were linked to reduced evaluations for providers' respect; high scores on White ethnicity were associated with elevated ratings for empathy and rapport. In models accounting for provider-patient ethnic discordance, high discordance on either ethnicity scale was associated with reduced ratings for the same behaviors.

DISCUSSION

Findings support "orthogonal ethnic identity" theory and extend "cultural health capital" theory, suggesting a pathway by which ethnicity becomes relevant to experience of health care among older adults.

Patients' views on changes in doctor-patient communication between 1982 and 2001: a mixed-methods study

BACKGROUND

Doctor-patient communication has been influenced over time by factors such as the rise of evidence-based medicine and a growing emphasis on patient-centred care. Despite disputes in the literature on the tension between evidence-based medicine and patient-centered medicine, patients' views on what constitutes high quality of doctor-patient communication are seldom an explicit topic for research. The aim of this study is to examine whether analogue patients (lay people judging videotaped consultations) perceive shifts in the quality of doctor-patient communication over a twenty-year period.

METHODS

Analogue patients (N = 108) assessed 189 videotaped general practice consultations from two periods (1982-1984 and 2000-2001). They provided ratings on three dimensions (scale 1-10) and gave written feedback. With a mixed-methods research design, we examined these assessments quantitatively (in relation to observed communication coded with RIAS) and qualitatively.

RESULTS

1) The quantitative analyses showed that biomedical communication and rapport building were positively associated with the quality assessments of videotaped consultations from the first period, but not from the second. Psychosocial communication and personal remarks were related to positive quality assessments of both periods; 2) the qualitative analyses showed that in both periods, participants provided the same balance between positive and negative comments. Listening, giving support, and showing respect were considered equally important in both periods. We identified shifts in the participants' observations on how GPs explained things to the patient, the division of roles and responsibilities, and the emphasis on problem-focused communication (first period) versus solution-focused communication (last period).

CONCLUSION

Analogue patients recognize shifts in the quality of doctor-patient communication from two different periods, including a shift from problem-focused communication to solution-focused communication, and they value an egalitarian doctor-patient relationship. The two research methods were complementary; based on the quantitative analyses we found shifts in communication, which we confirmed and specified in our qualitative analyses.

Obese patients overestimate physicians' attitudes of respect

OBJECTIVE

To evaluate whether obese patients overestimate or underestimate the level of respect that their physicians hold toward them.

METHODS

We performed a cross-sectional analysis of data from questionnaires and audio-recordings of visits between primary care physicians and their patients. Using multilevel logistic regression, we evaluated the association between patient BMI and accurate estimation of physician respect. Physician respectfulness was also rated independently by assessing the visit audiotapes.

RESULTS

Thirty-nine primary care physicians and 199 of their patients were included in the analysis. The mean patient BMI was 32.8 kg/m2 (SD 8.2). For each 5 kg/m2 increase in BMI, the odds of overestimating physician respect significantly increased [OR 1.32, 95% CI 1.04-1.68, p=0.02]. Few patients underestimated physician respect. There were no differences in ratings of physician respectfulness by independent evaluators of the audiotapes.

CONCLUSION

We consider our results preliminary. Patients were significantly more likely to overestimate physician respect as BMI increased, which was not accounted for by increased respectful treatment by the physician.

PRACTICE IMPLICATIONS

Among patients who overestimate physician respect, the authenticity of the patient-physician relationship should be questioned.

[Definition of medical competence. The point of view of chronically-ill patients in the Andalusian public healthcare system (Spain)]

OBJECTIVE

To identify the attributes used by chronically-ill patients to describe physicians' competence in the public healthcare system in Andalucia.

METHODS

A total of 147 chronically-ill patients and their relatives were included in this qualitative study. Focal groups and in-depth interviews were performed in health centers and outpatient centers in Granada, Malaga, Seville, Cadiz and Cordoba between 2007 and 2008. Content analysis was carried out using Nudist Vivo.

RESULTS

The participants defined medical competence as combining elements of technical ability and knowledge (awareness of and interest in the disease, continuity of follow-up and requesting specific tests) with interpersonal skills related to communication, information (informing, listening, trust, prompting questions) and attention (courtesy, cordiality, respect, interest and approachability). Primary care was expected to provide a close relationship, personalized treatment, information, drug prescription, and referral to specialized care. Specialized care was expected to provide an accurate diagnosis and appropriate treatment, information and follow-up. Highly valued aspects of emergency care were symptom relief, accurate diagnosis, referral to specialists and courtesy.

CONCLUSIONS

Chronically-ill patients based their evaluation of medical competence on technical and interpersonal skills.

An exercise programme for community-dwelling, mobility-restricted and chronically ill older adults with structured support by the general practitioner's practice (HOMEfit). From feasibility to evaluation

Programmes containing health-enhancing physical exercise should be evaluated using standards that are just as rigorous as those required for drug development. In contrast to new medicines, exercise programmes are highly complex. This has to be taken into account when designing the research plan. In order to illustrate the development process of a "complex intervention", we use the example of an exercise programme for community-dwelling, mobility-restricted and chronically ill older adults. Based on a framework for evaluation of complex interventions (Medical Research Council [MRC], UK), a research plan was set up containing the phases: development, feasibility, evaluation, implementation. The development phase resulted in the design of a home-based exercise programme in which the target group is approached and supported via their general practitioner and an exercise therapist. A feasibility study was performed. Three quantitative criteria for feasibility (adoption, safety, continuing participation) were statistically confirmed which permitted the decision to proceed with the research plan. So far, the MRC framework has proved to be valuable for the development of the new programme.

The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care

OBJECTIVES

We examined the associations of clinicians' implicit attitudes about race with visit communication and patient ratings of care.

METHODS

In a cross-sectional study of 40 primary care clinicians and 269 patients in urban community-based practices, we measured clinicians' implicit general race bias and race and compliance stereotyping with 2 implicit association tests and related them to audiotape measures of visit communication and patient ratings.

RESULTS

Among Black patients, general race bias was associated with more clinician verbal dominance, lower patient positive affect, and poorer ratings of interpersonal care; race and compliance stereotyping was associated with longer visits, slower speech, less patient centeredness, and poorer ratings of interpersonal care. Among White patients, bias was associated with more verbal dominance and better ratings of interpersonal care; race and compliance stereotyping was associated with less verbal dominance, shorter visits, faster speech, more patient centeredness, higher clinician positive affect, and lower ratings of some aspects of interpersonal care.

CONCLUSIONS

Clinician implicit race bias and race and compliance stereotyping are associated with markers of poor visit communication and poor ratings of care, particularly among Black patients.

The social gradient in doctor-patient communication

OBJECTIVE

In recent years, the importance of social differences in the physician-patient relationship has frequently been the subject of research. A 2002 review synthesised the evidence on this topic. Considering the increasing importance of social inequalities in health care, an actualization of this review seemed appropriate.

METHODS

A systematic search of literature published between 1965 and 2011 on the social gradient in doctor-patient communication. In this review social class was determined by patient's income, education or occupation.

RESULTS

Twenty original research papers and meta-analyses were included. Social differences in doctor-patient communication were described according to the following classification: verbal behaviour including instrumental and affective behaviour, non-verbal behaviour and patient-centred behaviour.

CONCLUSION

This review indicates that the literature on the social gradient in doctor-patient communication that was published in the last decade, addresses new issues and themes. Firstly, most of the found studies emphasize the importance of the reciprocity of communication.Secondly, there seems to be a growing interest in patient's perception of doctor-patient communication.

PRACTICE IMPLICATIONS

By increasing the doctors' awareness of the communicative differences and by empowering patients to express concerns and preferences, a more effective communication could be established.

Gianotti-Crosti syndrome, pityriasis rosea, asymmetrical periflexural exanthem, unilateral mediothoracic exanthem, eruptive pseudoangiomatosis, and papular-purpuric gloves and socks syndrome: a brief review and arguments for diagnostic criteria

Several exanthems including Gianotti-Crosti syndrome, pityriasis rosea, asymmetrical periflexural exanthem, eruptive pseudoangiomatosis, and papular-purpuric gloves and socks syndrome are suspected to be caused by viruses. These viruses are potentially dangerous. Gianotti-Crosti syndrome is related to hepatitis B virus infection which is the commonest cause of hepatocellular carcinoma, and Epstein-Barr virus infection which is related to nasopharyngeal carcinoma. Pityriasis rosea has been suspected to be related to human herpesvirus 7 and 8 infections, with the significance of the former still largely unknown, and the latter being a known cause of Kaposi's sarcoma. Papular-purpuric gloves and socks syndrome is significantly associated with human B19 erythrovirus infection which can lead to aplastic anemia in individuals with congenital hemoglobinopathies, and when transmitted to pregnant women, can cause spontaneous abortions and congenital anomalies. With viral DNA sequence detection technologies, false positive results are common. We can no longer apply Koch's postulates to establish cause-effect relationships. Biological properties of some viruses including lifelong latent infection, asymptomatic shedding, and endogenous reactivation render virological results on various body tissues difficult to interpret. We might not be able to confirm or refute viral causes for these rashes in the near future. Owing to the relatively small number of patients, virological and epidemiology studies, and treatment trials usually recruit few study and control subjects. This leads to low statistical powers and thus results have little clinical significance. Moreover, studies with few patients are less likely to be accepted by mainstream dermatology journals, leading to publication bias. Aggregation of data by meta-analyses on many studies each with a small number of patients can theoretically elevate the power of the results. Techniques are also in place to compensate for publication bias. However, these are not currently feasible owing to different inclusion and exclusion criteria in clinical studies and treatment trials. The diagnoses of these rashes are based on clinical assessment. Investigations only serve to exclude important differential diagnoses. A wide spectrum of clinical features is seen, and clinical features can vary across different populations. The terminologies used to define these rashes are confusing, and even more so are the atypical forms and variants. Previously reported virological and epidemiological results for these rashes are conflicting in many aspects. The cause of such incongruence is unknown, but low homogeneity during diagnosis and subject recruitment might be one of the factors leading to these incongruent results. The establishment and proper validation of diagnostic criteria will facilitate clinical diagnosis, hasten recruitment into clinical studies, and allow results of different studies to be directly compared with each another. Meta-analyses and systematic reviews would be more valid. Diagnostic criteria also streamline clinical audits and surveillance of these diseases from community perspectives. However, over-dependence on diagnostic criteria in the face of conflicting clinical features is a potential pitfall. Clinical acumen and the experience of the clinicians cannot be replaced by diagnostic criteria. Diagnostic criteria should be validated and re-validated in response to the ever-changing manifestations of these intriguing rashes. We advocate the establishment and validation of diagnostic criteria of these rashes. We also encourage the ongoing conduction of studies with a small number of patients. However, for a wider purpose, these studies should recruit homogenous patient groups with a view towards future data aggregation.

A study of patients' perceptions of diabetes care delivery and diabetes: propositional analysis in people with type 1 and 2 diabetes managed by group or usual care

OBJECTIVE

We investigated the perceptions of diabetes care and diabetes in patients followed long-term by group or usual care.

RESEARCH DESIGN AND METHODS

Three open questions were administered to 120 patients (43 with T1DM and 77 with T2DM) who had been randomized at least 2 years before to be followed by group care and 121 (41 T1DM and 80 T2DM) who had always been on usual care. The responses were analyzed by propositional analysis, by identifying the focal nuclei, i.e., the terms around which all sentences are organized, and then other predicates, according to their hierarchical relationship to the nuclear proposition. Specific communicative units were arbitrarily classified into three categories: attitudes, empowerment, and locus of control.

RESULTS

Patients on group care showed more positive attitudes, higher sense of empowerment, and more internal locus of control than those on usual care. In addition, they expressed a wider and more articulated range of concepts associated with the care received and made less use of medical terminology (P < 0.001, all). Higher HbA(1c) was associated with negative attitudes (P = 0.025) and negative empowerment (P = 0.055).

CONCLUSIONS

Group treatment reinforces communication and peer identification and may achieve its clinical results by promoting awareness, self-efficacy, positive attitudes toward diabetes and the setting of care, an internal locus of control, and, ultimately, empowerment in the patients.