Physician Empathy as a Driver of Hand Surgery Patient Satisfaction

Patients With Limited Health Literacy Ask Fewer Questions During Office Visits With Hand Surgeons

BACKGROUND

In the midst of rapid expansion of medical knowledge and decision-support tools intended to benefit diverse patients, patients with limited health literacy (the ability to obtain, process, and understand information and services to make health decisions) will benefit from asking questions and engaging actively in their own care. But little is known regarding the relationship between health literacy and question-asking behavior during outpatient office visits.

QUESTIONS/PURPOSES

(1) Do patients with lower levels of health literacy ask fewer questions in general, and as stratified by types of questions? (2) What other patient characteristics are associated with the number of questions asked? (3) How often do surgeons prompt patients to ask questions during an office visit?

METHODS

We audio-recorded office visits of 84 patients visiting one of three orthopaedic hand surgeons for the first time. Patient questions were counted and coded using an adaptation of the Roter Interaction Analysis System in 11 categories: (1) therapeutic regimen; (2) medical condition; (3) lifestyle; (4) requests for services or medications; (5) psychosocial/feelings; (6) nonmedical/procedural; (7) asks for understanding; (8) asks for reassurance; (9) paraphrase/checks for understanding; (10) bid for repetition; and (11) personal remarks/social conversation. Directly after the visit, patients completed the Newest Vital Sign (NVS) health literacy test, a sociodemographic survey (including age, sex, race, work status, marital status, insurance status), and three Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper-Extremity Function, Pain Interference, and Depression. The NVS scores were divided into limited (0-3) and adequate (4-6) health literacy as done by the tool's creators. We also assessed whether the surgeons prompted patients to ask questions during the encounter.

RESULTS

Patients with limited health literacy asked fewer questions than patients with adequate health literacy (5 ± 4 versus 9 ± 7; mean difference, -4; 95% CI, -7 to -1; p = 0.002). More specifically, patients with limited health literacy asked fewer questions regarding medical-care issues such as their therapeutic regimen (1 ± 2 versus 3 ± 4; mean difference, -2; 95% CI, -4 to -1]; p < 0.001) and condition (2 ± 2 versus 3 ± 3; mean difference, -1; 95% CI, -3 to 0; p = 0.022). Nonwhite patients asked fewer questions than did white patients (5 ± 4 versus 9 ± 7; mean difference, -4; 95% CI, -7 to 0; p = 0.032). No other patient characteristics were associated with the number of questions asked. Surgeons only occasionally (29%; 24/84) asked patients if they had questions during the encounter, but when they did, most patients (79%; 19/24) asked questions.

CONCLUSIONS

Limited health literacy is a barrier to effective patient engagement in hand surgery care. In the increasingly tangled health-information environment, it is important to actively involve patients with limited health literacy in the decision-making process by encouraging question-asking, particularly in practice settings where most decisions are preference-sensitive. Instead of assuming that patients understand what they are told, orthopaedic surgeons may take "universal precautions" by assuming that patients do not understand unless proved otherwise.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Client and practitioner perspectives on the screening mammography experience

Mammography can be painful and unpleasant, but effective interventions to improve the experience remain scarce. As a first step towards more effective interventions, we aimed to achieve a thorough, contemporary understanding of thoughts, feelings and behaviours which affect and arise from mammography experiences. Research and professional experience suggest that the interaction between client and practitioner may be paramount in determining the quality of a client's experience. Therefore, this study aimed to capture the perspectives of clients and mammography staff from UK breast screening programmes. Thematic analysis of semi-structured qualitative in-depth interviews with 22 clients and 18 staff revealed that clients had positive attitudes to breast screening and mostly low knowledge about potential harms. Staff data indicated that some women attend for breast screening under pressure from others. Pain and coping with it were prominent themes, with wide variations in pain experiences. Clients recognised differences in mammographers' abilities to put them at ease. Staff difficulties included empowering clients within the confines of a taxing technique, and maintaining compassionate care when under strain. Future intervention development should focus on the information and support needs of women prior to the appointment and on effectively training and supporting mammographers to deal with challenging encounters.

Coaching of patients with an isolated minimally displaced fracture of the radial head immediately increases range of motion

STUDY DESIGN

Prospective cohort.

INTRODUCTION

Elbow stiffness is the most common adverse event after isolated radial head fractures.

PURPOSE OF THE STUDY

To assess the effect of coaching on elbow motion during the same office visit in patients with such fractures.

METHODS

We enrolled 49 adult patients with minimally displaced radial head fractures, within 14 days of injury. After diagnosis, we measured demographics, catastrophic thinking, health anxiety, symptoms of depression, upper extremity-specific symptoms and disability, pain, and elbow and wrist motion. The patient was taught to apply an effective stretch in spite of the pain to limit stiffness, and elbow motion was measured again.

RESULTS

With the exception of radial deviation and pronation, motion measures improved slightly but significantly on average immediately after coaching. Elbow flexion improved from 79% (110° ± 22°) of the uninjured side to 88% (122° ± 18°) after coaching (P < .001); elbow extension improved from 71% (29° ± 14°) to 78% (22° ± 15°) (P = .0012).

DISCUSSION

Instruction that stretching exercises are healthy even when painful resulted in immediate improvements in motion. Prospective studies comparing different strategies for coaching patients regarding painful stretches might help clarify the optimal approach.

LEVEL OF EVIDENCE

Therapeutic level 4.

Living With Chronic Pain After Spinal Cord Injury: A Mixed-Methods Study

OBJECTIVE

To identify the relative importance of positive (facilitators) and negative (barriers) contributors to living with chronic pain after spinal cord injury (SCI).

DESIGN

Mixed-methods: (1) Qualitative (n=35): individual, semistructured, open-ended interviews identifying facilitator/barrier themes; (2) Quantitative (n=491): converting the most common themes into statements and quantifying agreement with these in an online survey to determine relative importance, underlying dimensions, and their associations with perceived difficulty in dealing with pain.

SETTING

University-based research setting and general community.

PARTICIPANTS

Volunteers (N=526) with SCI experiencing moderate to severe chronic pain.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Interview guides, facilitator/barrier statements, and pain inventories.

RESULTS

Exploratory factor analyses reduced agreement ratings into 4 facilitators (information regarding pain and treatments, resilience, coping, medication use) and 5 barriers (poor health care communication, pain impact and limitations, poor communication about pain, difficult nature of pain, treatment concerns). Greater "pain impact and limitations," "difficult nature of pain," "poor communication from provider," lower "resilience," greater "medication use," and younger age predicted greater difficulty in dealing with pain (r=.75; F=69.02; P<.001).

CONCLUSIONS

This study revealed multiple facilitators and barriers to living with chronic pain after SCI. The principal barrier, "poor health care communication," indicated that consumers do not receive adequate information from their health care providers regarding pain. "Information regarding pain and treatments" had greater agreement scores and factor loadings than all other facilitators, indicating that most participants view provider-patient communication and educational efforts regarding pain and pain management as priorities and critical needs. Further initiatives in these areas are important for improving pain management post-SCI.

The Perception of Physician Empathy by Patients with Inflammatory Bowel Disease

Background and Aims

This study focused on the difference between perceived and desired physician empathy (pPE and dPE) in the eye of patients with inflammatory bowel disease (IBD). It was investigated if a discrepancy (ΔPE) correlates with trust and satisfaction of patients. At the same time the aim was to gain detailed information about the subjective burden of disease and the resources of IBD patients, in order to better understand them.

Methods

A modified version of the German Version of the Consultation and Relational Empathy (CARE) measure was completed as a paper-and-pencil questionnaire by IBD patients attending our facility (n = 32) and as an online survey by IBD patients at other locations throughout Germany (n = 89). Patients were in average 36.3±12 years old.

Results

The mean (SD) rating of pPE was 3.93 (0.96) on a scale of 1 to 5 (“poor” to “excellent”); however, the mean (SD) dPE was 4.38 (0.48) on the same scale. ΔPE correlated with perceived empathy and with patients’ satisfaction with treatment and trust in their health care providers. Patients reported quite a high subjective burden (mean [SD]: 2.93 [.63]) and named family, friends, and support groups as resources.

Conclusions

Rather than assessing patient satisfaction with treatment and trust in their physician only with perceived PE, we suggest ΔPE as a useful additional parameter.

Impact of Perceived Weight Stigma among Underserved Women on Doctor-Patient Relationships

Objective

The aim of this study was to evaluate how perception of weight stigma among underserved women with obesity impacts doctor–patient relationships.

Methods

This study consisted of an interviewer‐administered survey of 149 women with obesity (body mass index (BMI) > 30 kg m⁻²) immediately after their physician visit at four Federally Qualified Health Centers. Perceptions of weight stigma and physician empathy were measured using the Stigma Situations in Health Care instrument and Consultation and Relational Empathy (CARE) measure, respectively. Associations of CARE and Stigma scores with BMI and patient characteristics were analysed using Mantel–Haenszel chi‐squared test and ordinal logistic regression.

Results

The mean CARE score was 42.1 (standard deviation 8.4; range 11.0–50.0), and mean stigma score was 4.6 (standard deviation 7.6; range 0–43.0). Each increase in BMI category was associated with almost twofold increased odds of higher perception of stigma (odds ratio, 1.90, 95% confidence interval 1.30–2.78, P = 0.001). BMI was not associated with CARE. However, for each increase in stigma category, the odds of lower CARE score doubled (odds ratio, 0.52, 95% confidence interval 0.36–0.75, P = 0.0005).

Conclusions

While BMI was not associated with perception of physician empathy, higher frequency of weight stigmatizing situations was negatively associated with perception of physician empathy. Reducing weight stigma in primary care could improve doctor–patient relationships and quality of care in patients with obesity.

Health Literacy and Time Spent With a Hand Surgeon

PURPOSE

To characterize the relationship between health literacy and duration of new hand surgery office visits.

METHODS

Using a stopwatch from outside the room, we measured the duration of the visit (minutes of face-to-face contact between attending surgeon and patient) for 224 new patients presenting to 1 of 5 orthopedic hand surgeons (D.R.). Directly after the visit, patients were asked to complete the Newest Vital Sign (NVS) health literacy test, a sociodemographic survey, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Pain Interference, Upper Extremity Function, and Depression. The Newest Vital Sign scores were divided into limited (0-3) and adequate (4-6) health literacy. Medical records were reviewed to collect data on diagnosis, visit type, management, and whether patients were first seen by a resident/fellow. Multiple linear regression modeling was used to characterize the association between health literacy and duration of visit while controlling for the effect of other patient and visit characteristics.

RESULTS

The unadjusted mean visit duration was 1.9 minutes shorter in patients with limited health literacy (9.4 minutes) than in patients with adequate health literacy (11.3 minutes), and this difference persisted after adjustment for a broad range of patient and visit characteristics. Greater magnitude of disability was associated with longer visits, as were second-opinion appointments, a diagnosis of nonspecific arm pain or compression neuropathy, and appointments in which operative management was chosen. Visits in which a resident/fellow saw the patient first were shorter than visits without resident/fellow assistance.

CONCLUSIONS

The finding that limited health literacy correlated with shorter visits may suggest that patients who may stand to benefit the most from detailed health education and counseling received less.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Patient Satisfaction and its Relation to Perceived Visit Duration With a Hand Surgeon

PURPOSE

To determine whether patient perception of time spent with a hand surgeon relates to patient satisfaction after a single new-patient office visit.

METHODS

Prior to each visit, 112 consecutive new patients predicted how much time they expected to spend with the surgeon. Following the visit, patients were asked to estimate the time spent with the surgeon, indicate whether the surgeon appeared rushed, and rate their overall satisfaction with the surgeon. Wait time and actual visit duration were measured. Patients also completed a sociodemographic survey, the Consultation and Relational Empathy Measure, the Newest Vital Sign Health Literacy test, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper Extremity Function, Pain Interference, and Depression. Multivariable logistic and linear regression models were used to determine predictors of patient satisfaction, patient-perceived surgeon rush, and high previsit expectations of visit duration.

RESULTS

Patient satisfaction was not associated with perceived visit duration but did correlate strongly with patient-rated surgeon empathy and symptoms of depression. Neither visit duration nor previsit expectations of visit length were determinants of patient-perceived surgeon rush. Only surgeon empathy was associated. Less-educated patients anticipated needing more time with the surgeon.

CONCLUSIONS

Patient satisfaction with the surgeon and with the time spent during the office visit was primarily linked to surgeon empathy rather than to visit duration or previsit expectation of visit length. Efforts to make hand surgery office visits more patient-centered should focus on improving dialogue quality, and not necessarily on making visits longer.

Pain, Functional Scores, and Radiographic Severity of Illness Influence the Perception of Time Spent With the Physician by Patients Presenting for Initial Evaluation of Knee Osteoarthritis

BACKGROUND

Patient satisfaction has become a significant factor in reimbursement schedules for physicians. A matter of debate is whether the patient's perception of time spent with the physician improves patient satisfaction. We sought to determine whether patient-physican time correlates with patient satisfaction and which factors are associated with patient perception of time.

METHODS

A total of 73 patients who presented for an initial evaluation of knee osteoarthritis were evaluated by the same orthopedic surgeon at an outpatient clinic in New Orleans, LA. Each encounter was timed with a stopwatch. After the physician encounter, patients were asked to fill out a questionnaire assessing their perception of time spent with the physician, subjective pain, satisfaction with the visit, and understanding of the diagnosis and treatment plan. Patients were also asked to complete 4 functionality surveys. Radiographs of the patients' knees were taken and quantified using Kellgren-Lawrence and Ahlbäck grading scales.

RESULTS

We noted no relationship between patient satisfaction and patients' perception of time spent with the physician. Patients perceived their time with the physician to be an average of 6.5 minutes more than the actual time. However, patients who reported higher subjective pain scores (>7 on a 10-point scale) misestimated their time with the physician by nearly 96%, while patients with lower subjective pain scores (<7 on a 10-point scale) misestimated their time with the physician by only 54% (P<0.007). We discovered similar findings in patients with worse Kellgren-Lawrence radiographic scores as well as worse Oxford Knee Scores and Knee injury and Osteoarthritis Outcome Scores. The actual time spent was not different among patients.

CONCLUSION

Patients with greater subjective pain and worse functional status and patients with worse radiographic severity of knee osteoarthritis perceived greater time spent with the physician. However, no relationship between these variables and patient satisfaction scores was seen.