The effect of physician solicitation approaches on ability to identify patient concerns

Elements of effective communication--rediscoveries from homeopathy

OBJECTIVE

Patients are increasingly attracted to homeopathy despite the unproven effectiveness of homeopathic remedies. Clinical benefit of homeopathy may be due to communication. This review aims to identify and assess effective communication patterns in homeopathy.

METHODS

Narrative review and synthesis of published communication patterns, patient narratives and the author's professional experience as a homeopathic practitioner.

RESULTS

In the biomedical model, where the focus is on disease, communication is physician-centered with early redirection of patients' concerns, and associated with reduced compliance, increasing risk of malpractice claims and low professional fulfillment. The biopsychosocial and the developing integrative medicine models are based on biomedicine but aim to include the whole person. Patient-centeredness is a behavior that elicits, respects and incorporates patients' wishes, allows active patient participation and is related to improved outcomes. The homeopathic model is based on holism and comprehension of the totality of the patient and uses patient-centered communication with a high degree of physician co-operation, empathy, hopefulness, enablement and narrative competence, all of which can improve outcomes.

CONCLUSION

Both biopsychosocial and homeopathic models rely on patient-centered communication. Regardless of conceptual differences, they overlap in their common respect for the totality and individuality of the patient. The study of the homeopathic model shows that respect for the whole person is a basic requirement to entrench patient-centeredness more firmly in medicine.

PRACTICE IMPLICATIONS

Medical education should include values such as individual coping strategies, the benefits of a sound and healthy life-style and the necessity of hope and enablement. Health care should be redesigned to honor physicians who practice these values.

Patient-centered interviewing and student performance in a comprehensive clinical skills examination: is there an association?

OBJECTIVE

Communication skills, including patient-centered interviewing (PCI), have become a major priority for educational and licensing organizations in the United States. While patient-centered interviewing is associated with positive patient outcomes and improved diagnostic accuracy, it is unknown if an association exists between patient-centered interviewing and student performance in high-stakes clinical skills assessment (CSA) examinations. The purpose of this study was to determine if generic communication skills and patient-centered interviewing skills were associated with students' overall student performance on a multi-station clinical skills assessment (CSA) examination.

METHODS

This was a cross-sectional study to assess student performance with standardized patients (SPs). We conducted a retrospective review of 30 videotaped SP encounters of Third year medical students (class of 2006) at the University of Kansas School of Medicine. We measured correlations between observed PCI scores, overall CSA scores and CSA interpersonal and communication (ICS) skills scores of student-SP encounters.

RESULTS

PCI scores, as measured with the Four Habits Coding Scheme, a measurement tool of patient-centered communication, were not correlated with either overall CSA scores or ICS scores. Students' PCI scores were lower than the ICS scores (57% vs. 85% of correct items). The students performed poorly (30% mean score of correct items) in eliciting patient perspectives, compared to three other domains (Invest in the beginning, Demonstrate empathy, and Invest in end) of patient-centered interviewing.

CONCLUSIONS

Our study failed to demonstrate any association between student performance and patient-centered interviewing skills (PCI) in the setting of a comprehensive in-house CSA examination. Third-year medical students in our study did not practice some elements of patient-centered interviewing.

PRACTICE IMPLICATIONS

Given the increasing importance of patient-centered communication, the high-stakes in-house clinical skills examinations may consider assessing patient-centered interviewing using a more comprehensive and valid checklist.

In-office discussions of migraine: results from the American Migraine Communication Study

BACKGROUND

Research indicates that successful migraine assessment and treatment depends on information obtained during patient and healthcare professional (HCP) discussions. However, no studies outline how migraine is actually discussed during clinical encounters.

OBJECTIVE

Record naturally occurring HCP-migraineur interactions, analyzing frequency and impairment assessment, and preventive treatment discussions.

DESIGN

HCPs seeing high volumes of migraineurs were recruited for a communication study. Patients likely to discuss migraine were recruited immediately before their normally scheduled appointment and, once consented, were audio- and video-recorded without a researcher present. Separate post-visit interviews were conducted with patients and HCPs. All interactions were transcribed.

PARTICIPANTS

Sixty patients (83% female; mean age 41.7) were analyzed. Patients were diagnosed with migraine 14 years and experienced 5 per month, on average.

APPROACH

Transcripts were analyzed using sociolinguistic techniques such as number and type of questions asked and post-visit alignment on migraine frequency and impairment. American Migraine Prevalence and Prevention Study guidelines were utilized.

RESULTS

Ninety-one percent of HCP-initiated, migraine-specific questions were closed-ended/short answer; assessments focused on frequency and did not focus on attention on impairment. Open-ended questions in patient post-visit interviews yielded robust impairment-related information. Post-visit, 55% of HCP-patient pairs were misaligned regarding frequency; 51% on impairment. Of the 20 (33%) patients who were preventive medication candidates, 80% did not receive it and 50% of their visits lacked discussion of prevention.

CONCLUSIONS

Sociolinguistic analysis revealed that HCPs often used narrowly focused, closed-ended questions and were often unaware of how migraine affected patients' lives as a result. It is recommended that HCPs assess impairment using open-ended questions in combination with the ask-tell-ask technique.

Risk factors of symptom underestimation by physicians

OBJECTIVE

The aims of this study were to characterize patient-physician agreement on various psychological and somatic symptoms in internal medicine inpatients and to identify predictors of symptom severity underestimation by physicians.

METHODS

Consecutive adult inpatients of two internal medicine wards of a university hospital completed visual analogue scales (VASs) for severity of disability, anxiety, depression, somatic symptoms, and pain at the time of admission (n=639, participation rate=70%) and 5 days thereafter (n=401, participation rate=82%). In addition, the Patient Health Questionnaire 9 (PHQ-9) depression scale and the Clinical Global Impression Scale--Revised were used. At the same time, the six treating physicians independently rated the complaints of their patients using the same VAS. Rates of overestimation, concordance, and underestimation of symptom severity were analyzed. Logistic regression analyses were used to identify predictors of symptom underestimation by physicians.

RESULTS

Concordance between patients and physicians regarding disability, anxiety, depression, somatic symptom severity, and pain reached 50-60%. Symptom severity of patients suffering from major depressive episode was significantly more often underestimated than that of nondepressed patients (all P<.01). Of all the variables, greater depression on the PHQ depression score was the most important risk factor for symptom underestimation by physicians (OR ranging from 1.29 to 1.57; all P<.05, except underestimation of disability). Symptom underestimation of pain severity was also associated with panic disorder symptoms (odds ratio, 2.44; P=.01).

CONCLUSION

Depressed patients seem to be at greater risk of symptom underestimation by their physicians--a finding bearing implications for avoidance of underdiagnosis and insufficient treatment. Mutual understanding could be improved by better doctor-patient communication skills. Brief self-report depression screeners might help to reliably identify patients at risk for symptom underestimation by physicians.

Improving in-office discussion of chronic obstructive pulmonary disease: results and recommendations from an in-office linguistic study in chronic obstructive pulmonary disease

Effective management of chronic obstructive pulmonary disease (COPD) requires successful physician-patient communication. Unfortunately, however, both parties often report problematic communication. Accommodating patients' desire for more information and an increased role in decision-making can increase their satisfaction surrounding the dialogue. This study analyzed naturally occurring interactions to assess in-office COPD discussions, identifying best practices and gaps in communication. In-office discussions of a study population of 17 community-based physicians and 32 outpatients with COPD (59% women; mean age, 69.5 years) were recorded during regularly scheduled visits. Individual postvisit interviews were conducted to clarify health history and perceptions of the office visit. Recordings were transcribed and analyzed using validated sociolinguistic techniques. Physicians initiated discussions of COPD with the term "breathing" in 56% of visits; these discussions focused on the acute nature of the disease, including an average of 6.4 physician-initiated, symptom-related questions. In postvisit interviews, participants (patients versus physicians) were frequently misaligned about the severity of, as well as the patient's level of concern about, the disease. Quality-of-life discussions were largely absent from visits, although patients offered emotionally charged responses postvisit about the impact of COPD in their lives. Despite accepted guidelines, discussions on smoking cessation, spirometry, and inhaler technique were underused. To reduce observed gaps in communication, physicians can focus on 4 topic areas: (1) communicating COPD diagnosis and test results, (2) optimizing disease education, (3) prioritizing smoking cessation, and (4) demonstrating correct inhaler use. Simple communication techniques, including consistent vocabulary, perspective display series, the 5 As of smoking cessation (ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in quit attempt, arrange follow-up), and inhaler training, can maximize in-office efficiency. Combining these topic areas and communication techniques could result in higher levels of physician and patient satisfaction.

Interpersonal skill in medicine: the essential partner of verbal communication

Medical educators have promoted skillful communication as a means for doctors to develop positive relationships with their patients. In practice, communication tends to be defined primarily as what doctors say, with less attention to how, when, and to whom they say it. These latter elements of communication, which often carry the emotional content of the discourse, are usually referred to as interpersonal skills. Although recognized as important by some educators, interpersonal skills have received much less attention than task-oriented, verbal aspects. Moreover, the field lacks a common language and conceptualization for discussing them. This paper offers a framework for describing interpersonal skills and understanding their relationship to verbal communication and describes an interpersonal skill-set comprised of Understanding, Empathy, and Relational Versatility.

The predictive ability of self-assessed health for mortality in different educational groups

BACKGROUND

The purpose of this study was to assess potential differences in the predictive ability of self-assessed health for mortality between educational groups, and to find explanations for any of these educational differences.

METHODS

We used data from the longitudinal GLOBE study, with a 13-year mortality follow-up. Analyses were performed for people aged between 25-74 years at baseline (n = 16,722). The associations of self-assessed health with mortality were estimated with Cox regression analyses, and the resulting hazard ratios were used as indicators of the 'predictive ability' of self-assessed health for mortality. Differences between educational levels were estimated by including an interaction term of education with self-assessed health in regression models with mortality as the outcome. The analyses were subsequently adjusted for: life threatening chronic conditions, non-life threatening conditions, stressors and health behaviour, to test the contribution of these factors to the predictive ability of self-assessed health.

RESULTS

Results indicated that the predictive ability of self-assessed health for mortality was greater in men with tertiary education as compared with the lowest educated men. No differences were observed in women. None of the four health aspects accounted for the educational difference in men.

CONCLUSIONS

Because differences in the predictive ability for mortality were limited to the extreme educational groups in men, educational differences in self-assessed health that are reported in numerous studies should not be expected to seriously overestimate educational differences in 'objective' health status.

Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management

OBJECTIVE

Clinical inertia has been identified as a critical barrier to glycemic control in type 2 diabetes. We assessed the relationship between patients' initial medication adherence and subsequent regimen intensification among patients with persistently elevated A1C levels.

RESEARCH DESIGN AND METHODS

We analyzed an inception cohort of 2,065 insured patients with type 2 diabetes who were newly started on hypoglycemic therapy and were followed for at least 3 years between 1992 and 2001. Medication adherence was assessed by taking the ratio of medication days dispensed (from pharmacy records) to medication days prescribed (as documented in the medical record) for the first prescribed hypoglycemic drug. Adherence was measured for the period between medication initiation and the next elevated A1C result measured at least 3 months later; intensification was defined as a dose increase or the addition of a second hypoglycemic agent.

RESULTS

Patients were aged (mean +/- SD) 55.4 +/- 12.2 years; 53% were men, and 19% were black. Baseline medication adherence was 79.8 +/- 19.3%. Patients in the lowest quartile of adherence were significantly less likely to have their regimens increased within 12 months of their first elevated A1C compared with patients in the highest quartile (27 vs. 37%, respectively, with increased regimens if A1C is elevated, P < 0.001). In multivariate models adjusting for patient demographic and treatment factors, patients in the highest adherence quartile had 53% greater odds of medication intensification after an elevated A1C (95% CI 1.11-1.93, P = 0.01).

CONCLUSIONS

Among insured diabetic patients with elevated A1C, level of medication adherence predicted subsequent medication intensification. Poor patient self-management behavior increases therapeutic clinical inertia.