Patient participation in the medical specialist encounter: does physicians' patient-centred communication matter?

E-mail in patient-provider communication: a systematic review

OBJECTIVE

To review systematically the role of e-mails in patient-provider communication in terms of e-mail content, and perspectives of providers and patients on e-mail communication in health care.

METHODS

A systematic review of studies on e-mail communication between patients and health providers in regular health care published from 2000 to 2008.

RESULTS

A total of 24 studies were included in the review. Among these studies, 21 studies examined e-mail communication between patients and providers, and three studies examined the e-mail communication between parents of patients in pediatric primary care and pediatricians. In the content analyses of e-mail messages, topics well represented were medical information exchange, medical condition or update, medication information, and subspecialty evaluation. A number of personal and institutional features were associated with the likelihood of e-mail use between patients and providers. While benefits of e-mails in enhancing communication were recognized by both patients and providers, concerns about confidentiality and security were also expressed.

CONCLUSION

The e-mail is transforming the relationship between patients and providers. The rigorous exploration of pros and cons of electronic interaction in health care settings will help make e-mail communication a more powerful, mutually beneficial health care provision tool.

PRACTICE IMPLICATIONS

It is important to develop an electronic communication system for the clinical practice that can address a range of concerns. More efforts need to be made to educate patients and providers to appropriately and effectively use e-mail for communication.

Improving physician-patient communication about cancer pain with a tailored education-coaching intervention

OBJECTIVE

This study examined the effect of a theoretically grounded, tailored education-coaching intervention to help patients more effectively discuss their pain-related questions, concerns, and preferences with physicians.

METHODS

Grounded in social-cognitive and communication theory, a tailored education-coaching (TEC) intervention was developed to help patients learn pain management and communication skills. In a RCT, 148 cancer patients agreed to have their consultations audio-recorded and were assigned to the intervention or a control group. The recordings were used to code for patients' questions, acts of assertiveness, and expressed concerns and to rate the quality of physicians' communication.

RESULTS

Patients in the TEC group discussed their pain concerns more than did patients in the control group. More active patients also had more baseline pain and interacted with physicians using participatory decision-making. Ratings of physicians' information about pain were higher when patients talked more about their pain concerns.

CONCLUSIONS

The study demonstrates the efficacy of a theoretically grounded, coaching intervention to help cancer patients talk about pain control.

PRACTICE IMPLICATIONS

Coaching interventions can be effective resources for helping cancer patients communicate about their pain concerns if they are theoretically grounded, can be integrated within clinical routines, and lead to improve health outcomes.

Is patient involvement during hospitalization for acute myocardial infarction associated with post-discharge treatment outcome? An exploratory study

OBJECTIVE

To investigate whether patient involvement during hospitalization for acute myocardial infarction (MI) was associated with health and behavioural outcomes 6-10 weeks after hospital discharge.

BACKGROUND

Patient involvement has been associated with improved health outcomes in chronic disease, but less research has focused on the effects of patient involvement in acute conditions, such as MI.

DESIGN

Self-administered questionnaire study. Questionnaire results were run against medical outcome data in a national database of cardiac patients.

SETTING AND PARTICIPANTS

Cardiac patients (n = 591) on their first follow-up visit after hospitalization for MI at 11 Swedish hospitals.

MAIN OUTCOME MEASURES

Patient ratings of three questionnaire scales related to involvement; cardiovascular symptoms, medication compliance, participation in cardiac rehabilitation, and achievement of secondary preventive goals.

RESULTS

More positive patient ratings of involvement were significantly associated with fewer cardiovascular symptoms 6-10 weeks after hospital discharge. In contrast, patients who attended cardiac rehabilitation and achieved the goals for smoking cessation and systolic blood pressure were significantly less satisfied with their involvement. No association was found between involvement ratings and medication compliance.

CONCLUSION

This study represents a first attempt to examine associations between patient involvement in the acute phase of illness and short-term health outcomes. Some significant associations between involvement and health and behavioural outcomes after acute MI were found. However, higher involvement ratings were not consistently associated with more desirable outcomes, and involvement during hospitalization was not associated with MI patient health and behaviour 6-10 weeks after hospital discharge to the extent hypothesized.

The relation between patient-centeredness and patient empowerment: a discussion on concepts

OBJECTIVE

The concepts of patient-centeredness and patient empowerment offer opportunities for patients to increase their autonomy and involvement in their care and treatment. However, these concepts appear to be understood in different ways by professional groups involved in healthcare and research. To optimize understanding there is a need to create a common language. To explore and compare the concepts of patient-centeredness and patient empowerment, and clarify a possible relationship between the two from the perspective of the encounter between patients and their healthcare providers.

METHODS

Concept analysis approach in which the concepts are compared based on literature review.

RESULTS

Patient-centeredness can be the goal of an encounter between patient and caregiver. As a process, it is of great value in the process of patient empowerment. Patient empowerment appears to be broader than patient-centeredness, and may place greater demands on caregivers and the organisation of healthcare.

CONCLUSION

Patient-centeredness and patient empowerment are complementary concepts which do not oppose one-another. Patient empowerment can be achieved by patient-centeredness, but patients can also empower themselves.

PRACTICE IMPLICATIONS

Clarification of patient-centeredness and patient empowerment can facilitate their use by those involved in healthcare, improve the quality of healthcare, and aid future research.

Fatigue communication at the out-patient clinic of Rheumatology

OBJECTIVE

To describe nurse-patient and rheumatologist-patient interaction in fatigue communication at the rheumatology out-patient clinic.

METHODS

Consultations of 20 rheumatoid arthritis (RA) patients with the nurse specialist and the rheumatologist were videotaped and analysed using the Medical Interview Aural Rating Scale (MIARS). Subsequently, patients were asked to fill out a concern questionnaire asking how worried they felt and how satisfied they were with attention given by both healthcare professionals. Finally, patients were interviewed on reasons for being not or not completely satisfied with the care received.

RESULTS

Fatigue was discussed in 42% of the rheumatologists' consultations and 83% of the nurse specialists' consultations. RA patients more often used implicit cues instead of explicit concerns related to fatigue. Almost 72% of the patients felt worried about fatigue and in general they were more satisfied with the nurse specialist's attention to fatigue than with the attention from the rheumatologist.

CONCLUSION

Fatigue is not structurally communicated at the rheumatology out-patient clinic and exploring and acknowledging communication techniques can help patients to express their concerns about fatigue.

PRACTICE IMPLICATIONS

Healthcare professionals must recognise fatigue as a severe problem for RA patients and start the conversation on fatigue instead of waiting for the patient to mention fatigue spontaneously.

Patients' reflections on communication in the second-opinion hematology-oncology consultation

OBJECTIVE

The nature of communication between patients and their second-opinion hematology consultants may be very different in these one-time consultations than for those that are within long-term relationships. This study explored patients' perceptions of their second-opinion hematology-oncology consultation to investigate physician-patient communication in malignant disease at a critical juncture in cancer patients' care and decision-making.

METHODS

In-depth telephone interviews with a subset of 20 patients from a larger study, following their subspecialty hematology consultations.

RESULTS

Most patients wanted to contribute to the consultation agenda, but were unable to do so. Patients sought expert and honest advice delivered with empathy, though most did not expect the consultant to directly address their emotions. They wanted the physician to apply his/her knowledge to the specifics of their individual cases, and were disappointed and distrustful when physicians cited only general prognostic statistics. In contrast, physicians' consideration of the unique elements of patients' cases, and demonstrations of empathy and respect made patients' feel positively about the encounter, regardless of the prognosis.

CONCLUSIONS

Patients provided concrete recommendations for physician and patient behaviors to enhance the consultation.

PRACTICE IMPLICATIONS

Consideration of these recommendations may result in more effective communication and increased patient satisfaction with medical visits.

General beliefs about medicines among doctors and nurses in out-patient care: a cross-sectional study

Background

Doctors and nurses are two natural partners in the healthcare team, but they usually differ in their perspectives on how to work for increased health. These professions may also have different beliefs about medicines, a factor important for adherence to medicines. The aim was to explore general beliefs about medicines among doctors and nurses.

Methods

Questionnaires were sent to 306 private practitioners (PPs), 298 general practitioners (GPs) and 303 nurses in the county of Västra Götaland, Sweden. The questionnaire included sociodemographic questions and the general part of the Beliefs about Medicines Questionnaire (BMQ), which measures the beliefs people have about medicines in general. General beliefs about medicines in relation to background variables were explored with independent t-tests and ANOVA analyses. Differences between occupations and influences of interaction variables were analysed with multiple linear regression models for general beliefs about medicines.

Results

The data collection resulted in 616 questionnaires (62.1% PPs; 61.6% GPs; 80.5% nurses). The majority of the PPs and 40% of the GPs were male but most of the nurses were female. The GPs' mean age was 47 years, PPs' 60 years and nurses' 52 years. Few nurses originated from non-Nordic countries while 15% of the PPs and 25% of the GPs did. Nurses saw medicines as more harmful and less beneficial than did PPs and GPs. These differences could not be explained by the included interaction variables. GPs with a Nordic background saw medicines as more beneficial and less harmful than did GPs with a non-Nordic background.

Furthermore, GPs of non-Nordic origin were most likely to believe that medicines were overprescribed by doctors.

Conclusion

Doctors were more positive about medicines than nurses. The differences in beliefs about medicines found between doctors and nurses could not be explained by any of the included interaction variables. These differences in beliefs may be useful in discussions among future and practising doctors and nurses to enhance understanding of each other's profession and teamwork.

Measuring patients' experiences with individual specialist physicians and their practices

This study assesses the reliability of patient-reported information about care received by individual specialist physicians. A patient questionnaire that included core composites from the Consumer Assessment of Healthcare Providers and Systems Clinician & Group survey was administered to random samples of patients visiting 1315 physicians from 14 specialties in California during 2005-2006 (n = 68 406 respondents). The quality of specialist-patient interaction and organizational access composites achieved adequate physician-level reliability (alpha(MD) = 0.70) with 30 or fewer patients per specialist, but the care coordination and health promotion support composites were generally less reliable. Patients reporting consult-based relationships with specialists reported worse care experiences across measures (P < .001). The results indicate that reliable patient-reported information can be obtained about specialist physicians with patient sample size requirements comparable to primary care physicians. In order to promote equitable performance measurement in specialty care, future research should clarify the contribution of consult-based specialist-patient relationships to performance differences.

Gender differences in patient perceptions of involvement in myocardial infarction care

BACKGROUND

Gender differences in the clinical presentation, treatment and outcomes of myocardial infarction (MI) have been demonstrated. However, few studies have examined gender differences in patients' perceptions of involvement in MI care, and whether differing levels of involvement might be associated with gender differences in treatment and outcome.

AIM

To examine possible gender differences in MI patients' perceptions of their involvement during hospitalization.

METHODS

Questionnaire study conducted in 2005-2006 among MI patients under the age of 75 at eleven hospitals. Patient ratings of their involvement during hospitalization were analyzed for age-stratified gender differences.

RESULTS

Younger (<70 years of age) female MI patients placed significantly more value on shared decision-making than younger (<70) men. More than one third of patients would have liked to be more involved in their care during hospitalization and discharge planning, with women significantly more dissatisfied than men. Significantly fewer younger female patients discussed secondary preventive lifestyle changes with cardiology staff prior to hospital discharge.

CONCLUSION

Significant age-specific gender differences exist in MI patient ratings of, and satisfaction with, involvement during hospitalization. Further study is needed regarding the possible role of involvement in the recognized gender differences in the treatment and outcomes of MI.

Nurse training of a patient-centered information procedure for CABG patients

OBJECTIVE

At the study hospital, all elective coronary artery bypass graft (CABG) surgery patients were given similar, standardized information by the nurses. The nurses reported problems in establishing contact and interacting with patients when using this approach. To help remedy communication problems between nurses and CABG patients, a programme training nurses in a patient-centred information procedure was developed and implemented. This article describes how challenging interactions were recorded and analysed for training nurses in the patient-centred approach.

METHOD

In group training for patient-centeredness, nurses presented audio-recordings of nurse-patient interactions they found problematic. These were used as a basis for discussions and training in the patient-centered approach. A set of cases was developed using a qualitative phenomenological approach, illustrating how the patient-centered approach could be applied to the difficult situations.

RESULTS

The nurses found the patient-centered approach particularly useful in situations when patients frequently asked questions, seemed to have difficulties expressing their worries, frequently complained, or when spouses expressed worries.

CONCLUSION

Nurses found the patient-centered approach and the training procedure used in this study useful in their clinical work with CABG patients.

PRACTICE IMPLICATIONS

This training which requires minimal resources and can be easily implemented, may guide the nurses in their interaction with patients. Providing a patient-centered approach to the CABG patients may enhance the nurse-patient contact and improve patients' hospital experience and subjective health.

Comparing genetic counseling with non-genetic health care interactions: two of a kind?

OBJECTIVE

Increasingly clinicians other than genetic counselors will advise people with genetic risks. Although some express concerns about this development because of the need for non-genetic clinicians to have additional training, we argue that genetic counseling has more in common with other health care interactions than is generally assumed.

METHODS

In this narrative review we investigate the health communication literature taking the perspective that all provider-patient/client interactions share the following goals: forming a relationship, the exchange of information, decision making, promoting health-related behavior and providing support.

RESULTS

We found that both non-genetic and genetic 'disciplines' endorse an egalitarian relationship, based on a patient-centered approach and both have difficulties with attuning to the patients' agendas and enhancing patient understanding. Shared decision making is increasingly the preferred model for geneticists and non-geneticists alike, and both need skills to constructively discuss patients' risk-reducing behavior and provide emotional support.

CONCLUSION

Rather than developing separate vocabularies and research traditions, the discipline of genetic counseling may benefit by drawing on non-genetic patient-provider interaction research.

PRACTICE IMPLICATIONS

Since geneticists face the same challenges as non-geneticists, medical training should continue to improve basic consultation skills, regardless of whether the consultation involves genetic information.

Beyond content analysis and non-verbal behaviour - what about atmosphere? A phenomenological approach

OBJECTIVE

Basic research and careful observation of clinical practice have yielded a vast amount of empirical data on communication in health care. This research has been guided by the assumption that good communication will be better understood and easier to teach when its single constituents are identified. This paper points to the limitation of this approach.

METHODS

Based upon the terminology of phenomenological thinking grounded in neo-phenomenology (Hermann Schmitz) contradictory findings from the literature on patient-centred communication in Internal Medicine and Oncology are used as a starting point to elucidate different paradigms in conducting research in clinical communication.

RESULTS

The phenomenological approach of the German philosopher Hermann Schmitz (*1928) is briefly presented. It is based upon experiences that 'on the average everybody can vividly access or retrieve from his memory'. Empirical research does not provide unequivocal advice how to communicate with an individual patient. Likewise, researchers note unexpected reactions from real patients-they do not behave as the expert would assume. The inclusion of the phenomenon of a certain atmosphere is proposed referring to the impression of 'something in the air' that sometimes can be identified during communication or upon entering a room. Even though it can be sensed with high evidence, it cannot be deduced from particular observations. Instead, the atmosphere is part of a situation in which meaning is dissolved in chaotic manifoldness. Sensing an atmosphere is a function of the lived body (Leib) as opposed to phenomena that are mediated by the senses.

CONCLUSION

Current research and teaching models cover only part of the phenomenology of professional communication. How research and education might profit from the addition of Schmitz' philosophical approach will be outlined in this article.

PRACTICE IMPLICATIONS

Including perceptions of the lived body (Leib) should improve research in clinical communication and teaching courses.

Medical specialists' patient-centered communication and patient-reported outcomes

BACKGROUND

Physicians' patient-centered communication in the medical consultation is generally expected to improve patient outcomes. However, empirical evidence is contradictory so far, and most studies were done in primary care.

OBJECTIVE

We sought to determine the association of specialists' patient-centered communication with patient satisfaction, adherence, and health status.

METHODS

Residents and specialists in internal medicine (n = 30) and their patients (n = 323) completed a questionnaire before a (videotaped) follow-up encounter. Patients' satisfaction was assessed immediately after the consultation and their self-reported treatment adherence, symptoms, and distress 2 weeks later. Specialists' patient-centered communication was assessed by coding behaviors that facilitate or rather inhibit patients to express their perspective. Patient participation was assessed by determining their relative contribution to the conversation and their active participation behavior. Outcomes were assessed using standard questionnaires. Analyses accounted for relevant patient, visit and physician characteristics.

RESULTS AND CONCLUSIONS

Medical specialists' facilitating behavior was associated with greater satisfaction in patients who were less confident in communicating with their doctor. Patient-centered communication was not associated with patients' health status or adherence in general, but facilitating behavior was positively related to the adherence of patients with a foreign primary language. In general, patients appeared to be more satisfied after an encounter with a more-facilitating and a less-inhibiting physician, but these associations diminished when controlling for background characteristics. We conclude that the absence of strong associations between patient-centered communication and patient-reported outcomes may be explained by medical specialists being responsive to patients' characteristics.