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

Same description, different values. How service users and providers define patient and public involvement in health care

BACKGROUND

Patient and public involvement in health care is important, but the existing definitions of the concept do not integrate the stakeholders' own perceptions.

OBJECTIVE

To investigate and compare service users' and service providers' own definitions of patient and public involvement and their implications.

DESIGN, SETTING AND PARTICIPANTS

Qualitative study with mainly individual in-depth semi-structured interviews conducted between June 2007 and June 2009. Data were analysed using a grounded theory approach.

RESULTS

A total of 20 patients, 13 public representatives and 44 health service providers/managers in both somatic and mental health care were interviewed. A common definition of patient and public involvement emerged: It is founded on mutual respect, carried out through dialogue aiming at achieving shared decision making. Nevertheless, users and providers assigned different values to the core aspects: Respect was imperative for service users and implied for providers, dialogue was a way to gain respect for service users and to achieve good outcome for providers, and both worried that the other party wanted to make sole decisions.

CONCLUSIONS

Users and providers need to consider that although they have a common definition of involvement in health care, they assign different values to its aspects. Increasing and improving patient and public involvement therefore requires knowledge on and dialogue between the parties about these differences.

Respect, trust, and the management of sickle cell disease pain in hospital: comparative analysis of concern-raising behaviors, preliminary model, and agenda for international collaborative research to inform practice

BACKGROUND/OBJECTIVES

Qualitative interview studies suggest that adult patients' experiences of hospital treatment for sickle cell disease (SCD) pain reflect an absence of respect by providers for patients, and an absence or breakdown of trust. Systematic comparisons between treatment settings could help identify contextual influences on respect and trust.

DESIGN

Quantitative comparison of concern-raising behaviors (pain treatment outcomes indicating breakdowns of trust) among adult SCD patients in Baltimore, Maryland, USA, and London, UK, followed by analysis of potential explanations for differences, including socio-cultural and behavioral factors, with a preliminary model of the processes leading to concern-raising behaviors.

RESULTS

Rates of concern-raising behaviors were significantly higher in Baltimore than London. The model identifies respect and trust as key factors which could be targeted in efforts to improve the quality of SCD pain management in hospital.

CONCLUSION

An agenda for international, interdisciplinary research to improve the treatment of SCD pain in hospital should include: comparative analyses between countries and treatment settings of factors that could influence respect and trust; research to test hypotheses derived from models about the roles of respect and trust in the treatment of pain; studies of the impact of healthcare structures and policy on patients' experiences of care; research focusing on developmental and interpersonal processes related to respect and trust; applications of attribution and other social psychology theories; and development and evaluation of interventions to improve the hospital treatment of SCD pain by increasing respect and trust.

Impact of genetic causal information on medical students' clinical encounters with an obese virtual patient: health promotion and social stigma

BACKGROUND

Health care providers will increasingly encounter information about the genetics of obesity as genetics research progresses.

PURPOSE

This study explores whether information about the genetics of obesity reduces medical student stigmatization of obese patients, and how it affects rates of health behavior-related referral.

METHODS

One hundred and ten third and fourth year medical students were randomly assigned to read about genetic or behavioral mechanisms of obesity, or a control topic. Students interacted with an obese virtual patient in a virtual clinic and completed a battery of measures.

RESULTS

Rates of most health behavior screening recommendations (weight loss, exercise, and diet consultations) were lower among participants exposed to genetic causal information than control. The genetic causal information group exhibited less negative stereotyping of the patient than control, F(1,105) = 5.00, p = 0.028, but did not differ in anticipated patient adherence, F(1,105) = 3.18, p = 0.077.

CONCLUSIONS

Information highlighting genetic contributions to obesity may lead to both positive and negative outcomes. Communication about the genetics of obesity should discuss the multi-factorial and non-deterministic nature of genetic risk.

General practitioner advice on physical activity: analyses in a cohort of older primary health care patients (getABI)

Background

Although the benefits of physical activity for health and functioning are recognized to extend throughout life, the physical activity level of most older people is insufficient with respect to current guidelines. The primary health care setting may offer an opportunity to influence and to support older people to become physically active on a regular basis. Currently, there is a lack of data concerning general practitioner (GP) advice on physical activity in Germany. Therefore, the aim of this study was to evaluate the rate and characteristics of older patients receiving advice on physical activity from their GP.

Methods

This is a cross-sectional study using data collected at 7 years of follow-up of a prospective cohort study (German epidemiological trial on ankle brachial index, getABI). 6,880 unselected patients aged 65 years and above in the primary health care setting in Germany were followed up since October 2001. During the 7-year follow-up telephone interview, 1,937 patients were asked whether their GP had advised them to get regular physical activity within the preceding 12 months. The interview also included questions on socio-demographic and lifestyle variables, medical conditions, and physical activity. Logistic regression analysis (unadjusted and adjusted for all covariables) was used to examine factors associated with receiving advice. Analyses comprised only complete cases with regard to the analysed variables. Results are expressed as odds ratios (ORs) with 95% confidence intervals (95% CI).

Results

Of the 1,627 analysed patients (median age 77; range 72-93 years; 52.5% women), 534 (32.8%) stated that they had been advised to get regular physical activity. In the adjusted model, those more likely to receive GP advice on physical activity were men (OR [95% CI] 1.34 [1.06-1.70]), patients suffering from pain (1.43 [1.13-1.81]), coronary heart disease and/or myocardial infarction (1.56 [1.21-2.01]), diabetes mellitus (1.79 [1.39-2.30]) or arthritis (1.37 [1.08-1.73]), and patients taking a high (> 5) number of medications (1.41 [1.11-1.80]).

Conclusions

The study revealed a relatively low rate of older primary health care patients receiving GP advice on physical activity. GPs appeared to focus their advice on patients with chronic medical conditions. However, there are likely to be many more patients who would benefit from advice.

Patient reactions to personalized medicine vignettes: an experimental design

PURPOSE

Translational investigation on personalized medicine is in its infancy. Exploratory studies reveal attitudinal barriers to "race-based medicine" and cautious optimism regarding genetically personalized medicine. This study describes patient responses to hypothetical conventional, race-based, or genetically personalized medicine prescriptions.

METHODS

Three hundred eighty-seven participants (mean age = 47 years; 46% white) recruited from a Baltimore outpatient center were randomized to this vignette-based experimental study. They were asked to imagine a doctor diagnosing a condition and prescribing them one of three medications. The outcomes are emotional response to vignette, belief in vignette medication efficacy, experience of respect, trust in the vignette physician, and adherence intention.

RESULTS

Race-based medicine vignettes were appraised more negatively than conventional vignettes across the board (Cohen's d = -0.51-0.57-0.64, P < 0.001). Participants rated genetically personalized comparably with conventional medicine (-0.14-0.15-0.17, P = 0.47), with the exception of reduced adherence intention to genetically personalized medicine (Cohen's d = -0.38-0.41-0.44, P = 0.009). This relative reluctance to take genetically personalized medicine was pronounced for racial minorities (Cohen's d = -0.38-0.31-0.25, P = 0.02) and was related to trust in the vignette physician (change in R = 0.23, P < 0.001).

CONCLUSIONS

This study demonstrates a relative reluctance to embrace personalized medicine technology, especially among racial minorities, and highlights enhancement of adherence through improved doctor- patient relationships.

A video-intervention to improve clinician attitudes toward patients with sickle cell disease: the results of a randomized experiment

BACKGROUND

Clinician attitudes toward patients are associated with variability in the quality of health care. Attitudes are typically considered difficult to change, and few interventions have attempted to do so. Negative attitudes toward adults with sickle cell disease have been identified as an important barrier to the receipt of appropriate pain management for this patient population.

OBJECTIVE

To test the effect of a video-intervention designed to improve clinician attitudes toward adults with sickle cell disease.

INTERVENTIONS

An 8-minute video depicting a clinician expert and patients discussing challenges in seeking treatment for sickle cell pain.

DESIGN AND PARTICIPANTS

A randomized post-test only control group design was used to assess the impact of the intervention on the attitudes of 276 nurses and housestaff working at a large, urban, academic medical center.

MAIN MEASURES

Attitudes toward adult sickle cell patients assessed using 5- and 6-point Likert-scale items. Exploratory factor analysis was used to identify underlying attitudinal domains and develop scales. Examples of the negative and positive attitudes assessed include clinician estimates of the percentage of SCD patients that exaggerate pain (negative) or make clinicians glad they went into medicine (positive).

KEY RESULTS

Compared to the control group, the intervention group exhibited decreased negative attitudes (Difference in means = -8.9, 95%CI [-14.2, -3.6]; Cohen's d = 0.41), decreased endorsement of certain patient behaviors as "concern-raising" (Difference in means = -7.8, 95%CI [-13.1, -2.5]; Cohen's d = 0.36), and increased positive attitudes toward sickle cell patients (Difference in means = 6.6, 95% CI [0.6, 12.6]; Cohen's d = 0.27).

CONCLUSIONS

Our results suggest that the attitudes of clinicians toward sickle cell patients may be improved through a short and relatively easy to implement intervention. Whether the attitudinal differences associated with our intervention are sustainable or are linked to clinical outcomes remains to be seen.

Medical student bias and care recommendations for an obese versus non-obese virtual patient

OBJECTIVE

This study examined the independent effect of a patient's weight on medical students' attitudes, beliefs and interpersonal behavior toward the patient, in addition to the clinical recommendations they make for her care.

DESIGN

A total of 76 clinical-level medical students were randomly assigned to interact with a digital, virtual female patient who was visibly either obese or non-obese.

METHODS

Interactions with the patient took place in an immersive virtual (virtual reality) clinical environment that allowed standardization of all patient behaviors and characteristics except for weight. Visual contact behavior was automatically recorded during the interaction. Afterward, participants filled out a battery of self-report questionnaires.

RESULTS

Analyses revealed more negative stereotyping, less anticipated patient adherence, worse perceived health, more responsibility attributed for potentially weight-related presenting complaints and less visual contact directed toward the obese version of a virtual patient than the non-obese version of the patient. In contrast, there was no clear evidence of bias in clinical recommendations made for the patient's care.

CONCLUSION

Biases in attitudes, beliefs and interpersonal behavior have important implications because they can influence the tone of clinical encounters and rapport in the patient-provider relationship, which can have important downstream consequences. Gaining a clear understanding of the nature and source of weight bias in the clinical encounter is an important first step toward the development of strategies to address it.

"I wouldn't be this firm if I didn't care": preventive clinical counseling for reproductive health

OBJECTIVE

This qualitative study of health care clinicians serving women at heightened risk of sexually transmitted infections and unintended pregnancy was undertaken to explore concepts underlying reproductive health counseling messages in clinical encounters.

METHODS

In-depth interviews were conducted with 31 clinicians, including physicians and advanced practice nurses serving primarily low-income patients in high-risk communities throughout the U.S.

RESULTS

Most of the clinicians describe their influence on patients and protective behaviors as derived from medical authority and the presentation of information. The use of a parental style of authority, particularly for young or vulnerable patients, and emotional appeals to evoke negative emotions, such as fear, were also used to motivate protective behaviors. Many clinicians highlighted the importance of empathy, and understanding the cultural and social context of health behaviors. A few clinicians described innovative efforts to empower women to protect themselves and exert more control in relationships.

CONCLUSION

Some of the reproductive health counseling approaches described by clinicians are not consistent with leading health behavior change theories or patient-centered counseling.

PRACTICAL IMPLICATIONS

To improve counseling, these messages and concepts need to be evaluated for effectiveness, and possibly used to inform the development of novel theories for use in reproductive health counseling.

Fast healthcare: brief communication, traps and opportunities

Resource considerations have meant that brevity in health care interventions is a high priority, and have led to a constant striving after ever more impressive time efficiency. The UK's National Health Service may be described as a kind of 'fast healthcare', where everyone is task busy, time is money, bed spaces are frenetically shuffled so as to accommodate the most needy and there appears to be 'no time to talk'. Indeed, a great many health care encounters are taking place in short 'blips' often of 5min or less across a range of sites and involving a vast number of practitioners. In this paper we explore how brief communication can both alienate and be therapeutic for patients. We theorise brief interactions by considering a number of traditions of work in anthropology, linguistics and sociology and conclude that health care providers need to invest much more in the skills and strategies for how best to communicate briefly if it to retain its core tradition of caring for others.

How well do doctors know their patients? Factors affecting physician understanding of patients' health beliefs

BACKGROUND

An important feature of patient-centered care is physician understanding of their patients' health beliefs and values.

OBJECTIVE

Determine physicians' awareness of patients' health beliefs as well as communication, relationship, and demographic factors associated with better physician understanding of patients' illness perspectives.

DESIGN

Cross-sectional, observational study. RESEARCH PARTICIPANTS: A convenience sample of 207 patients and 29 primary care physicians from 10 outpatient clinics. APPROACH AND MEASURES: After their consultation, patients and physicians independently completed the CONNECT instrument, a measure that assesses beliefs about the degree to which the patient's condition has a biological cause, is the patient's fault, is one the patient can control, has meaning for the patient, can be treated with natural remedies, and patient preferences for a partnership with the physician. Physicians completed the measure again on how they thought the patient responded. Active patient participation (frequency of questions, concerns, acts of assertiveness) was coded from audio-recordings of the consultations. Physicians' answers for how they thought the patient responded to the health belief measure were compared to their patients' actual responses. Degree of physician understanding of patients' health beliefs was computed as the absolute difference between patients' health beliefs and physicians' perception of patients' health beliefs.

KEY RESULTS

Physicians' perceptions of their patients' health beliefs differed significantly (P<0.001) from patients' actual beliefs. Physicians also thought patients' beliefs were more aligned with their own. Physicians had a better understanding of the degree to which patients believed their health conditions had personal meaning (p=0.001), would benefit from natural remedies (p=0.049), were conditions the patient could control (p=0.001), and wanted a partnership with the doctor (p=0.014) when patients more often asked questions, expressed concerns, and stated their opinions. Physicians were poorer judges of patients' beliefs when patients were African-American (desire for partnership) (p=0.013), Hispanic (meaning) (p=0.075), or of a different race (sense of control) (p=0.024).

CONCLUSIONS

Physicians were not good judges of patient's health beliefs, but had a substantially better understanding when patients more actively participated in the consultation. Strategies for increasing physicians' awareness of patients' health beliefs include preconsultation assessment of patients' beliefs, implementing culturally appropriate patient activation programs, and greater use of partnership-building to encourage active patient participation.

Exploring the meaning of respect in medical student education: an analysis of student narratives

BACKGROUND

Respect for others is recognized in the medical literature and society as an essential attribute of the good medical professional. However, the specific meaning of respect varies widely and is underexplored as a lived experience of physicians-in-training.

OBJECTIVE

To describe third-year medical students' narratives of respect and disrespect [(dis)respect] during their internal medicine clerkship.

DESIGN

Qualitative thematic analysis of 152 third-year student narratives that 'taught them something about professionalism,' focusing on (dis)respect.

APPROACH

Immersion/crystallization narrative analysis.

RESULTS

We reviewed 595 professionalism narratives and found that one in four narratives involved (dis)respect. We then found that 2/3 of these narratives were negative (describing instances of disrespect rather than respect). In the other coded categories, the proportion of negative narratives was significantly lower. In order to better understand these results, we analyzed the content of the (dis)respect narratives and identified six primary themes: (1) content and manner of communication (including, appreciating or belittling, being sensitive or blunt and respecting privacy); (2) conduct: behaviors expressing (dis)respect; (3) patient centeredness: honoring others' preferences, decisions and needs; (4) treating others as equals; (5) valuing the other and their experience and/or problem; and (6) nurturing students' learning.

CONCLUSIONS

Focusing on the lived experience of (dis)respect on wards broadens the concept of respect beyond any one type of act, behavior or attitude. Students perceive respect as a way of being that applies in all settings (private and public), with all participants (patients, family members, nurses, colleagues and students) and under all circumstances (valuing others' time, needs, preferences, choices, opinions and privacy). Respect seems to entail responding to a need, while disrespect involves ignoring the need or bluntly violating it.

The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: the DISTANCE study

OBJECTIVE

To assess the association of limited English proficiency (LEP) and physician language concordance with patient reports of clinical interactions.

METHODS

Cross-sectional survey of 8638 Kaiser Permanente Northern California patients with diabetes. Patient responses were used to define English proficiency and physician language concordance. Quality of clinical interactions was based on 5 questions drawn from validated scales on communication, 2 on trust, and 3 on discrimination.

RESULTS

Respondents included 8116 English-proficient and 522 LEP patients. Among LEP patients, 210 were language concordant and 153 were language discordant. In fully adjusted models, LEP patients were more likely than English-proficient patients to report suboptimal interactions on 3 out of 10 outcomes, including 1 communication and 2 discrimination items. In separate analyses, LEP-discordant patients were more likely than English-proficient patients to report suboptimal clinician-patient interactions on 7 out of 10 outcomes, including 2 communication, 2 trust, and 3 discrimination items. In contrast, LEP-concordant patients reported similar interactions to English-proficient patients.

CONCLUSIONS

Reports of suboptimal interactions among patients with LEP were more common among those with language-discordant physicians.

PRACTICE IMPLICATIONS

Expanding access to language concordant physicians may improve clinical interactions among patients with LEP. Quality and performance assessments should consider physician-patient language concordance.

Determinants of physicians' communication behaviour in disability assessments

PURPOSE

Knowledge about the determinants of communication behaviour of physicians during face-to-face consultations with patients might increase our understanding of communication behaviour, and provide insight into how training might be able to change their communication behaviour. For physicians who conduct work disability assessment interviews, referred to as 'social insurance physicians', communication with patients is their most important instrument. Therefore, the aim of this study was to understand the determinants of communication behaviour of social insurance physicians, by modelling the following constructs of the Theory of Planned Behaviour: attitudes, social influence, self-efficacy, skills, barriers and intentions concerning their communication with claimants in medical disability assessments.

METHOD

Cross-sectional data were collected by means of questionnaires. Analyses were performed with the LISREL maximum likelihood estimation procedure.

RESULTS

The results showed a well-fitting model in which attitudes had a significant and substantial direct effect on two intentions. Self-efficacy had a significant, but smaller direct effect on one intention.

CONCLUSIONS

Empirical support was found for a model that describes intentions of social insurance physicians, especially intentions to give information and to consider personal aspects. Attitudes were the main determinants of physicians' intentions and therefore these may be a promising focus of communication skills training.

What does care mean? Perceptions of people approaching the end of life

Objective:

This project sought to better understand the nature of medical care from the perspective of people approaching the end of life.

Method:

We asked 13 people who were dying (and a family member for each) to describe their care and the ways in which doctors' behavior fosters or inhibits the feeling that they were cared for as individuals. Interviews took a phenomenological approach. Data analysis was thematic.

Results:

Examples used by participants as evidence of care varied widely and showed the potentially complex nature of quality care. Participants' descriptions reflect the many ways people can impart and experience care as unique individuals in the medical context. They also provide clear examples of what uncaring behaviour looks and feels like.

Significance of results:

The importance of care was clearly illustrated through descriptions of the benefits of caring behavior and the negative consequences of uncaring behavior. In order to demonstrate the empathy and compassion expected and assumed of medical graduates and engender a feeling of being cared for among their patients, doctors need to invite and develop a relationship with those they are caring for. There needs to be a focus on each member of the caring relationship primarily as individual human beings.

Communication skills education onsite in a veterinary practice

OBJECTIVE

To provide communication skills education to veterinary professionals in the practice setting and evaluate the training by measuring veterinarian communication pre- and post-intervention.

METHODS

This is a case-based pre-test/post-test intervention study of a veterinary practice in Denver, CO. Four veterinarians from a single practice and 48 clients (selected to represent wellness and problem visits) were recruited to the study. The veterinarians took part in a training intervention consisting of a year-long curriculum, including interactive communication modules, individual coaching and communication laboratories. Six visit interactions were measured for each of the 4 veterinarians pre- and post-skill training. The Roter interaction analysis system (RIAS) was used to analyze the study's 48 videotapes.

RESULTS

Compared to the pre-training visits, veterinarians gathered twice as much lifestyle-social data (p<0.02), and used 1.5 times more partnership building (p<0.03) and positive rapport-building (p<0.01) communication. Clients provided 1.4 times more lifestyle/social information (p<0.02) and expressed 1.7 times more emotional statements (p<0.01) in post-training visits.

CONCLUSION

The training intervention promoted a more client-centered approach to veterinarian-client communication.

PRACTICE IMPLICATIONS

Practice-based communication training is novel to veterinary practice. As a case study, generalization of the findings are limited, however the findings support the efficacy of the communication intervention and enhanced utilization of veterinarian-client communication skills by these veterinarians.

Patient-centered communication during the disclosure of a dementia diagnosis

This study examined physician use of patient-centered communication during disclosure of a dementia diagnosis. Fifty-four patients (mean age = 74.13) and companions (mean age = 65.67; n = 34 spouses/partners, 12 adult children, 8 other) were diagnosed with very mild (n = 36) or mild (n = 18) dementia at an Alzheimer's Disease Research Center. Audio recordings of these triadic encounters were evaluated with the Roter Interaction Analysis System. Physicians utilized moderate but variable amounts of patient-centered behaviors including positive rapport building, facilitation, and patient activation (P < .001). Physicians far less frequently used emotional rapport building (P < 0.001). Physicians who demonstrated more patient-centered communication also exhibited greater positive affect (P < 0.05). The use of patient-centered behaviors and positive affect was more variable between physicians than within physicians and may be more dependent on individual physician characteristics than dementia severity or age and gender of patients and companions.

Impact of student ethnicity and patient-centredness on communication skills performance

OBJECTIVES

The development of patient-centred attitudes by health care providers is critical to improving health care quality. A prior study showed that medical students with more patient-centred attitudes scored higher in communication skills as judged by standardised patients (SPs) than students with less patient-centred attitudes. We designed this multicentre study to examine the relationships among students' demographic characteristics, patient-centredness and communication scores on an SP examination.

METHODS

Early Year 4 medical students at three US schools completed a 12-item survey during an SP examination. Survey items addressed demographics (gender, ethnicity, primary childhood language) and patient-centredness. Factor analysis on the patient-centredness items defined specific patient-centred attitudes. We used multiple regression analysis incorporating demographic characteristics, school and patient-centredness items and examined the effect of these variables on the outcome variable of communication score.

RESULTS

A total of 351 students took the SP examination and 329 (94%) completed the patient-centredness questionnaire. Responses indicated generally high patient-centredness. Student ethnicity and medical school were significantly associated with communication scores; gender and primary childhood language were not. Two attitudinal factors were identified: patient perspective and impersonal attitude. Multiple regression analysis revealed that school and scores on the impersonal factor were associated with communication scores. The effect size was modest.

CONCLUSIONS

In a medical student SP examination, modest differences in communication scores based on ethnicity were observed and can be partially explained by student attitudes regarding patient-centredness. Curricular interventions to enhance clinical experiences, teaching and feedback are needed to address key elements of a patient-centred approach to care.

Patient use of weight-management activities: a comparison of patient and physician assessments

OBJECTIVE

Examine concordance between patient and physician assessments of patient self-reported use of weight-management activities.

METHODS

Analysis of baseline data from a randomized controlled trial of patient and physician interventions to improve patient-physician communication (41 physicians and 274 of their patients).

RESULTS

A majority of patients reported regular exercise (55.6%) and efforts to lose weight, such as eating less (63.1%) while physicians only perceived one-third of patients as engaging in those activities (exercise, 36.6%; weight loss, 33.3%). Kappa scores indicated small agreement between patient and physician assessments of patient self-reported use of exercise, mean kappa 0.28 (range 0.15 to 0.40) and no agreement between patient and physician assessments of patient self-reported efforts to lose weight, mean kappa -0.14 (range -0.26 to -0.01). Obese patients were more likely than non-obese patients to report trying to lose weight or exercising regularly (p<0.05), but physicians were less likely to perceive obese patients as engaging in those activities (p<0.05).

CONCLUSIONS

Primary care physicians differed considerably from their patients, especially obese patients, in their assessments of patient use of weight-management activities.

PRACTICE IMPLICATIONS

These results highlight the importance of improving patient-provider communication about weight-management activities, particularly among obese patients.

Quality of internal communication in health care and the professional-patient relationship

A study was undertaken for the purpose of describing internal communication and the professional-patient relationship and to establish a descriptive model of the interaction between these 2 variables. A nationwide survey was carried out in primary care and specialist care centers in Spain. A simple random sampling method was used with 1183 health care professionals. The data collection instrument was a Likert questionnaire that recorded information on the perceived quality of internal communication (0-100 scale), professional-patient relationships (0-100 scale), and sociodemographic variables. The results were analyzed using SPSS 15.0, performing mean comparisons and a suitable linear regression model.The total average of the quality of internal communication was 53.79 points, and that of the professional-patient relationships was 74.17 points. Sex made no statistically significant difference. Age shows that the older the participant, the better his/her opinion of internal communication and professional-patient relationships. Nursing staff had the highest opinion of internal communication and professional-patient relationships. The association between internal communication and professional-patient relationship was positive (R = 0.45).It was concluded that continuous exchange of information among health care professionals, together with learning and shared decision making or a positive emotional climate, is an element that will consolidate good professional-patient relationships and ensure patient satisfaction.

Medical care of hepatitis B among Asian American populations: perspectives from three provider groups

BACKGROUND

Physicians can play a significant role in helping to decrease the hepatitis B virus (HBV) burden among Asian Americans. Few studies have described knowledge and practice patterns in the medical community among different provider types regarding HBV and liver cancer.

OBJECTIVE

Our study explores the HBV beliefs, attitudes and practice patterns of medical providers serving Asian American communities.

DESIGN

We conducted three focus groups with primary care providers, liver specialists, and other providers predominantly serving Asian American community. We asked about practices and barriers to appropriate medical care and outreach.

PARTICIPANTS

We moderated three focus groups with 23 participants, 18 of whom completed and returned demographic surveys. Twelve were of Asian ethnicity and 13 spoke English as a second language. Only eight screened at least half of their patients, most (72%) using the hepatitis B surface antigen test.

APPROACH

We used grounded theory methods to analyze focus group transcripts.

RESULTS

Participants frequently discussed cultural and financial barriers to hepatitis care. They admitted reluctance to screen for HBV because patients might be unwilling or unable to afford treatment. Cultural differences were discussed most by primary care providers; best methods of outreach were discussed most by liver specialists; and alternative medicine was discussed most by acupuncturists and other providers.

CONCLUSIONS

More resources are needed to lower financial barriers complicating HBV care and encourage providing guideline-recommended screenings. Other providers can help promote HBV screening and increase community and cultural awareness.

Pain in youths with neuromuscular disease

To examine the prevalence and characteristics of pain in children with neuromuscular disease (NMD), 42 youths with NMD underwent a comprehensive evaluation including a detailed intake interview and structured questionnaire that included demographic and functional data. Youths who reported chronic pain were further queried about pain characteristics, locations, and intensity using an 11-point numerical rating scale and a modified Brief Pain Inventory (BPI). The sample consisted of 24 males (57%) and 18 females (43%), ages ranging from 9 to 20 years (M = 14.8, SD = 2.96). Participants included 14 (37%) with Duchenne muscular dystrophy, 6 (14%) with myotonic dystrophy, 2 (5%) with Becker dystrophy, 2 (5%) with limb-girdle dystrophy, 2 (5%) with congenital muscular dystrophy, 1 (2%) facioscapulohumeral, and 15 (36%) were classified as ''other NMD.'' Twenty-one (50%) were ambulatory; 26 (62%) used power wheelchairs/scooters, 9 (2%) used manual wheelchairs, 3 (.07%) used crutches/canes, and 1 (2%) used a walker. A total of 23 (55%) of the youths reported having chronic pain. Current pain intensity was 1.30 (range = 0-6), mean pain intensity over the past week was 2.39 (range = 0-7), mean pain duration was 8.75 hours (SD = 12.84). Pain in the legs was most commonly reported and 83% reported using pain medications. This study indicates that chronic pain is a significant problem in youths with NMD. These data strongly support making comprehensive pain assessment and management an integral part of the standard of care for youths with NMD.

The future of critical care

PURPOSE OF REVIEW

This review will examine the current scenario of critical care medicine and describe trends for the future.

RECENT FINDINGS

Critical care is facing increasing demands due to an aging population and the relative lack of intensivists. Quality and healthcare costs are becoming day-to-day issues. The future will see an increasing use of protocols, virtual consultations, and regionalized care for more complex and common diseases such as trauma and acute lung injury. Intensivists will be skeptical due to difficulties in demonstrating benefits of any new drug, ventilator, monitor, or laboratory test, when added to basic, life-saving treatments. We do not believe that a 'magic bullet' is soon to come, and emphasis will be placed on cost restraining. Computers will have an increasing presence in critical care, now eased by a user group that is increasingly adept at using them. However, ICUs will still rely on human resource, making the myth of a fully automated ICU bed unlikely.

SUMMARY

The future of ICU will rely on management and teamwork. The costs of critical care will be restrained through the use of better management, guidelines, and skepticism regarding new technologies and drugs. Policy makers will help society build better strategies for critical care services.

Physician respect for patients with obesity

INTRODUCTION

Obesity stigma is common in our society, and a general stigma towards obesity has also been documented in physicians. We hypothesized that physician respect for patients would be lower in patients with higher body mass index (BMI).

METHODS

We analyzed data from the baseline visit of 40 physicians and 238 patients enrolled in a randomized controlled trial of patient-physician communication. The independent variable was BMI, and the outcome was physician respect for the patient. We performed Poisson regression analyses with robust variance estimates, accounting for clustering of patients within physicians, to examine the association between BMI and physician ratings of respect for particular patients.

RESULTS

The mean (SD) BMI of the patients was 32.9(8.1) kg/m(2). Physicians had low respect for 39% of the participants. Higher BMI was significantly and negatively associated with respect [prevalence ratio (PrR) 0.83, 95% CI: 0.73-0.95; p = 0.006; per 10 kg/m(2) increase in BMI]. BMI remained significantly associated with respect after adjustment for patient age and gender (PrR 0.86, 95%CI: 0.74-1.00; p = 0.049).

CONCLUSION

We found that higher patient BMI was associated with lower physician respect. Further research is needed to understand if lower physician respect for patients with higher BMI adversely affects the quality of care.

A theoretical framework to describe communication processes during medical disability assessment interviews

BACKGROUND

Research in different fields of medicine suggests that communication is important in physician-patient encounters and influences satisfaction with these encounters. It is argued that this also applies to the non-curative tasks that physicians perform, such as sickness certification and medical disability assessments. However, there is no conceptualised theoretical framework that can be used to describe intentions with regard to communication behaviour, communication behaviour itself, and satisfaction with communication behaviour in a medical disability assessment context.

OBJECTIVE

The objective of this paper is to describe the conceptualization of a model for the communication behaviour of physicians performing medical disability assessments in a social insurance context and of their claimants, in face-to-face encounters during medical disability assessment interviews and the preparation thereof. CONCEPTUALIzATION: The behavioural model, based on the Theory of Planned Behaviour (TPB), is conceptualised for the communication behaviour of social insurance physicians and claimants separately, but also combined during the assessment interview. Other important concepts in the model are the evaluation of communication behaviour (satisfaction), intentions, attitudes, skills, and barriers for communication.

CONCLUSION

The conceptualization of the TPB-based behavioural model will help to provide insight into the communication behaviour of social insurance physicians and claimants during disability assessment interviews. After empirical testing of the relationships in the model, it can be used in other studies to obtain more insight into communication behaviour in non-curative medicine, and it could help social insurance physicians to adapt their communication behaviour to their task when performing disability assessments.

Health care provider attitudes toward patients with acute vaso-occlusive crisis due to sickle cell disease: development of a scale

OBJECTIVE

Patients with sickle cell disease (SCD) often perceive negative provider attitudes, which may affect the quality of patient-provider communication and care during vaso-occlusive crises (VOCs). This study investigated the validity and reliability of a scale to measure provider attitudes toward patients with acute VOC.

METHODS

Using a cohort of adults with VOC (September 2006 to June 2007), we administered a 10-item provider questionnaire within 72 h of patient encounters. After factor analysis, we created a 7-item Positive Provider Attitudes toward Sickle Cell Patients Scale (PASS); higher scores indicate more positive attitudes. We assessed internal consistency and evidence of construct validity, exploring bivariate relationships between provider or patient characteristics and the PASS score using multilevel modeling.

RESULTS

We collected 121 surveys from 84 health care providers for 47 patients. Patients averaged 30.3 years in age, and 60% were women. Among providers, 79% were nurses, and 70% worked in inpatient settings. PASS scores averaged 24.1 (S.D. 6.7), ranged 7-35, and had high internal consistency (Cronbach's alpha=0.91). As hypothesized, inpatient vs. emergency department providers (Delta=4.65, p<0.001) and nurses vs. other providers (Delta=0.95, p<0.001) had higher PASS scores. Higher patient educational attainment (Delta per year=2.74, p<0.001) and employment (Delta=5.62, p=0.001) were associated with higher PASS scores. More frequent hospitalizations (Delta per episode=-0.52, p<0.001) and prior disputes with staff (Delta=-7.53, p=0.002) were associated with lower PASS scores.

CONCLUSION

Our findings provide preliminary evidence for the reliability and construct validity of the PASS score in measuring provider attitudes toward patients with VOC.

PRACTICE IMPLICATIONS

Future studies should examine the validity of PASS in other cohorts of patients with SCD and their providers. With further evidence, PASS may prove useful for investigating the impact of provider attitudes on the quality of communication and care provided to these patients.

Measuring patients' perceptions of communication with healthcare providers: do differences in demographic and socioeconomic characteristics matter?

BACKGROUND

National governments across the globe have set goals to improve healthcare delivery. Understanding patient-provider communication is essential for the development of policies that measure how well a healthcare system delivers care.

OBJECTIVES

This study was designed to determine which, if any, demographic factors were independently associated with how US patients perceive various aspects of communication with their healthcare providers.

DESIGN AND METHODS

The study was a secondary, cross-sectional analysis of nationally representative data from the 2002 Medical Expenditure Panel Survey (MEPS). Among US adults with a healthcare visit in the past year (n = approximately 16,700), we assessed the association between several covariate demographic and socioeconomic factors and four dependent measures of patient perceptions of communication with their healthcare providers.

RESULTS

Across all four measures of communication, older patients were more likely to report positively. Having health insurance and a usual source of care were consistent predictors of positive perceptions of communication. Hispanic patients also reported better perceptions of communication across all four measures. The most economically disadvantaged patients were less likely to report that providers always explained things so that they understood. Male patients were more likely to report that providers always spent enough time with them.

CONCLUSIONS

This study suggests that patient perceptions of communication in healthcare settings vary widely by demographics and other individual patient characteristics. In this paper, we discuss the relevance of these communication disparities to design policies to improve healthcare systems, both at the individual practice level and the national level.

Discrepancy between physicians' perceptions and practices during pelvic examinations in Taiwan

OBJECTIVE

This study explored (1) physicians' perceptions of pelvic examination (PE) procedures and (2) the discrepancy between physicians' perceptions and their practices as observed by their attending nurses.

METHOD

Data were collected from 20 physician-completed questionnaires on the perceived importance of 23 PE procedures. Each physician's practice of the same 23 PE procedures was assessed by 4-6 attending nurses (100 nurse observations). Physicians and nurses were sampled by convenience from the obstetrics/gynecology outpatient departments of 3 teaching hospitals in central Taiwan. Discrepancies between physicians' perceptions and their practices as assessed by attending nurses were examined by the Mann-Whitney U test.

RESULTS

Physicians' mean scores ranged from 3.15 to 4.00, indicating that PE procedures were generally perceived as important. The procedures were rank ordered according to the mean scores from highest to lowest. Physicians' 5 top-ranking procedures were wearing gloves during the PE, asking agreement for the examination, paying attention to privacy during the PE, protecting the woman's personal information, and protecting the woman's medical records. Physicians' 5 lowest ranking procedures were telling the woman before inserting the speculum that she will feel some pressure, explaining the procedure before the PE, proactively providing information, asking the woman how she feels during the PE, asking a woman's permission to examine prior to commencing the PE, and describing observations to the woman during the PE (the last two procedures were tied for 5th rank). For 15 of the 23 PE procedures, physicians' perceptions did not differ significantly from their practices as assessed by attending nurses. The remaining 8 procedures were statistically significant between physicians' perception and their practices, and were rated higher by physicians (perception) than by attending nurses (practice).

CONCLUSION

The 5 top-ranking PE procedures in terms of perceived importance were related to procedural behaviors, whereas the 5 lowest ranking procedures were verbal statements with explicit affective content. During nurse-observed PEs, Taiwanese physicians consistently practiced the procedural aspects of PEs they perceived as important (e.g., communication and consultation, protection and skilled technique, and confidentiality). However, physicians' practices were less consistent in affective aspects (e.g., explanation and consent, information and instruction, and sensitivity).

PRACTICE IMPLICATIONS

Our results suggest that physicians should concentrate not only on procedural behaviors, but also on affective behaviors. These findings could be incorporated in medical education, particularly for medical students training to become obstetric and gynecological physicians.

Encounters with medical professionals: a crisis of trust or matter of respect?

In this paper I shed light on the connection between respect, trust and patients' satisfaction with their medical care. Using data collected in interviews with 49 women who had managed, or were in the process of managing, their risk of ovarian cancer using prophylactic surgery or ovarian screening, I examine their reported dissatisfaction with medical encounters. I argue that although many study participants appeared to mistrust their healthcare professionals' (HCPs) motives or knowledge base, their dissatisfaction arose not from a lack of trust, but from HCPs' failure to treat them as persons or take their concerns seriously. I conclude by describing how respect, as evidenced by "being taken seriously", is important for the development of trusting Patient-HCP relationships.

Physician burnout and patient-physician communication during primary care encounters

BACKGROUND

Although previous studies suggest an association between provider burnout and suboptimal self-reported communication, no studies relate physician burnout to observed patient-physician communication behaviors.

OBJECTIVE

To investigate the relationship between physician burnout and observed patient-physician communication outcomes in patient-physician encounters.

DESIGN

Longitudinal study of enrollment data from a trial of interventions to improve patient adherence to hypertension treatment.

SETTING

Fifteen urban community-based clinics in Baltimore, MD.

PARTICIPANTS

Forty physicians and 235 of their adult hypertensive patients, with oversampling of ethnic minorities and poor persons. Fifty-three percent of physicians were women, and the average practice experience was 11.2 years. Among the 235 patients, 66% were women, 60% were African-American, and 90% were insured.

MEASUREMENTS

Audiotape analysis of communication during outpatient encounters (one per patient) using the Roter Interaction Analysis System and patients' ratings of satisfaction with and trust and confidence in the physician.

RESULTS

The median time between the physician burnout assessment and the patient encounter was 15.1 months (range 5.6-30). Multivariate analyses revealed no significant differences in physician communication based on physician burnout. However, compared with patients of low-burnout physicians, patients of high-burnout physicians gave twice as many negative rapport-building statements (incident risk ratio 2.06, 95% CI 1.58-2.86, p < 0.001). Physician burnout was not significantly associated with physician or patient affect, patient-centeredness, verbal dominance, or length of the encounter. Physician burnout was also not significantly associated with patients' ratings of their satisfaction, confidence, or trust.

CONCLUSIONS

Physician burnout was not associated with physician communication behaviors nor with most measures of patient-centered communication. However, patients engaged in more rapport-building behaviors. These findings suggest a complex relationship between physician burnout and patient-physician communication, which should be investigated and linked to patient outcomes in future research.

Comprehending care in a medical home: a usual source of care and patient perceptions about healthcare communication

OBJECTIVE

To examine whether having a usual source of care (USC) is associated with positive patient perceptions of health care communication and to identify demographic factors among patients with a USC that are independently associated with differing reports of how patients perceive their involvement in health care decision making.

METHODS

Cross-sectional analyses of nationally representative data from the 2002 Medical Expenditure Panel Survey. Among adults with a health care visit in the past year (n = approximately 16,700), we measured independent associations between having a USC and patient perceptions of health care communication. Second, among respondents with a USC (n = approximately 18,000), we assessed the independent association between various demographic factors and indicators of patients' perceptions of their autonomy in making health care decisions.

RESULTS

Approximately 78% of adults in the United States reported having a USC. Those with a USC were more likely to report that providers always listened to them, always explained things clearly, always showed respect, and always spent enough time with them. Patients who perceived higher levels of decision-making autonomy were non-Hispanic, had health insurance coverage, lived in rural areas, and had higher incomes.

CONCLUSIONS

Patients with a USC were more likely to perceive positive health care interactions. Certain demographic factors among the subgroups of Medical Expenditure Panel Survey respondents with a USC were associated with patient perceptions of greater decision-making autonomy. Efforts to ensure universal access to a USC must be partnered with broader awareness and training of USC providers to engage patients from various demographic backgrounds equally when making health care decisions at the point of care.

Audio-visual recording of patient-GP consultations for research purposes: a literature review on recruiting rates and strategies

OBJECTIVE

To identify ethical processes and recruitment strategies, participation rates of studies using audio or video recording of primary health care consultations for research purposes, and the effect of recording on the behaviour, attitudes and feelings of participants.

METHODS

A structured literature review using Medline, Embase, Cochrane Library, and Psychinfo. This was followed by extensive hand search.

RESULTS

Recording consultations were regarded as ethically acceptable with some additional safeguards recommended. A range of sampling and recruitment strategies were identified although specific detail was often lacking. Non-participation rates in audio-recording studies ranged from 3 to 83% for patients and 7 to 84% for GPs; in video-recording studies they ranged from 0 to 83% for patients and 0 to 93% for GPs. There was little evidence to suggest that recording significantly affects patient or practitioner behaviour.

CONCLUSIONS

Research involving audio or video recording of consultations is both feasible and acceptable. More detailed reporting of the methodical characteristics of recruitment in the published literature is needed.

PRACTICE IMPLICATIONS

Researchers should consider the impact of diverse sampling and recruitment strategies on participation levels. Participants should be informed that there is little evidence that recording consultations negatively affects their content or the decisions made. Researchers should increase reporting of ethical and recruitment processes in order to facilitate future reviews and meta-analyses.

Understanding concordance in patient-physician relationships: personal and ethnic dimensions of shared identity

PURPOSE

Although concordance by race and sex in physician-patient relationships has been associated with patient ratings of better care, mechanisms through which concordance leads to better outcomes remains unknown. This investigation examined (1) whether patients' perceptions of similarity to their physicians predicted their ratings of quality of care and (2) whether perceived similarity was influenced by racial and sexual concordance and the physician's communication.

METHODS

The research design was a cross-sectional study with 214 patients and 29 primary care physicians from 10 private and public outpatient clinics. Measures included postvisit patient ratings of similarity to the physician; satisfaction, trust, and intent to adhere; and audiotape analysis of patient involvement and physicians' patient-centered communication.

RESULTS

Factor analysis revealed 2 dimensions of similarity, personal (in beliefs, values) and ethnic (in race, community). Black and white patients in racially concordant interactions reported more personal and ethnic similarity (mean score, 87.6 and 78.8, respectively, on a 100-point scale) to their physicians than did minority patients (mean score, 81.4 and 41.2, respectively) and white patients (mean score, 84.4 and 41.9, respectively) in racially discordant encounters. In multivariable models, perceived personal similarity was predicted by the patient's age, education, and physicians' patient-centered communication, but not by racial or sexual concordance. Perceived personal similarity and physicians' patient-centered communication predicted patients' trust, satisfaction, and intent to adhere.

CONCLUSIONS

The physician-patient relationship is strengthened when patients see themselves as similar to their physicians in personal beliefs, values, and communication. Perceived personal similarity is associated with higher ratings of trust, satisfaction, and intention to adhere. Race concordance is the primary predictor of perceived ethnic similarity, but several factors affect perceived personal similarity, including physicians' use of patient-centered communication.

Validation of the Health Care Communication Questionnaire (HCCQ) to measure outpatients' experience of communication with hospital staff

OBJECTIVE

All healthcare workers' communication skills are recognised as valuable indicators of quality of care from the patient's perspective. Most of the studies measure doctor-patient communication, giving scarce attention to other professionals. This study is aimed at developing and providing preliminary validation of a questionnaire to measure outpatients' experience of communication with hospital personnel other than doctors.

METHODS

Small groups of outpatients and hospital staffs were involved in identifying the domains and generating the items. A quantitative validation phase involving 401 outpatients followed in order to verify the hypothesised dimensionality of selected items and to measure reliability.

RESULTS

A 13-item questionnaire emerged, comprising four components of outpatients' experience in the healthcare communication domain: problem solving, respect, lack of hostility, and nonverbal immediacy. Psychometric tests were promising as regards factorial validity, evaluated with confirmatory factor analysis, and scales reliability. Factor scores were independent of patients' gender, age, and education.

CONCLUSION

The developed Health Care Communication Questionnaire (HCCQ) is a self-administered brief measure with good psychometric properties.

PRACTICE IMPLICATIONS

The HCCQ gives information that could be taken as an indirect and subjective indicator of the quality of hospital services as provided by non-medical staff. This aspect may have a role in local quality improvement initiatives.

The therapeutic effects of the physician-older patient relationship: effective communication with vulnerable older patients

There is growing evidence that the outcomes of health care for seniors are dependent not only upon patients' physical health status and the administration of care for their biomedical needs, but also upon care for patients' psychosocial needs and attention to their social, economic, cultural, and psychological vulnerabilities. Even when older patients have appropriate access to medical services, they also need effective and empathic communication as an essential part of their treatment. Older patients who are socially isolated, emotionally vulnerable, and economically disadvantaged are particularly in need of the social, emotional, and practical support that sensitive provider-patient communication can provide. In this review paper, we examine the complexities of communication between physicians and their older patients, and consider some of the particular challenges that manifest in providers' interactions with their older patients, particularly those who are socially isolated, suffering from depression, or of minority status or low income. This review offers guidelines for improved physician-older patient communication in medical practice, and examines interventions to coordinate care for older patients on multiple dimensions of a biopsychosocial model of health care.

Physicians' communication and perceptions of patients: is it how they look, how they talk, or is it just the doctor?

Although physicians' communication style and perceptions affect outcomes, few studies have examined how these perceptions relate to the way physicians communicate with patients. Moreover, while any number of factors may affect the communication process, few studies have analyzed these effects collectively in order to identify the most powerful influences on physician communication and perceptions. Adopting an ecological approach, this investigation examined: (a) the relationships of physicians' patient-centered communication (informative, supportive, partnership-building) and affect (positive, contentious) on their perceptions of the patient, and (b) the degree to which communication and perceptions were affected by the physicians' characteristics, patients' demographic characteristics, physician-patient concordance, and the patient's communication. Physicians (N=29) and patients (N=207) from 10 outpatient settings in the United States participated in the study. From audio-recordings of these visits, coders rated the physicians' communication and affect as well as the patients' participation and affect. Doctors were more patient-centered with patients they perceived as better communicators, more satisfied, and more likely to adhere. Physicians displayed more patient-centered communication and more favorably perceived patients who expressed positive affect, were more involved, and who were less contentious. Physicians were more contentious with black patients, whom they also perceived as less effective communicators and less satisfied. Finally, physicians who reported a patient-centered orientation to the doctor-patient relationship also were more patient-centered in their communication. The results suggest that reciprocity and mutual influence have a strong effect on these interactions in that more positive (or negative) communication from one participant leads to similar responses from the other. Physicians' encounters with black patients revealed communicative difficulties that may lower quality of care for these patients.