The practice orientations of physicians and patients: the effect of doctor-patient congruence on satisfaction

Physician gender and patient centered communication: the moderating effect of psychosocial and biomedical case characteristics

OBJECTIVE

Female physicians have a more patient-centered communication style than their male counterparts; however, few studies have investigated how the biomedical or psychosocial nature of a patient diagnosis might moderate this relationship.

METHODS

Seventy six 3rd year residents (50 male and 26 females) seeking board certification from the Korean Academy of Family Medicine participated in the 2013 Clinical Practice Examination by conducting two simulated patient (SP) interviews, one presenting a largely psychosocial case and the other largely biomedical. The interview recordings were coded with the Roter Interaction Analysis System (RIAS).

RESULTS

Female physicians and their SPs engaged in more dialog than male physicians in both cases. Female physicians were more patient-centered than males for the psychosocial case (t = -3.24, P < 0.05), however, their scores did not differ for the biomedical case. In multivariate analysis, a significant interaction between physician gender and case (z = -3.90, P < 0.001) similarly demonstrated greater female patient-centeredness only for the predominantly psychosocial case.

CONCLUSION

Case characteristics moderated the association between physician gender and patient-centeredness.

PRACTICE IMPLICATIONS

Case characteristics need to be considered in future research on the association of physician gender and the patient-centered communication, as well as in the tailoring of physician communication training.

Medication decision making and patient outcomes in GP, nurse and pharmacist prescriber consultations

Aim The aims of this study were twofold: (a) to explore whether specific components of shared decision making were present in consultations involving nurse prescribers (NPs), pharmacist prescribers (PPs) and general practitioners (GPs) and (b) to relate these to self-reported patient outcomes including satisfaction, adherence and patient perceptions of practitioner empathy.

BACKGROUND

There are a range of ways for defining and measuring the process of concordance, or shared decision making as it relates to decisions about medicines. As a result, demonstrating a convincing link between shared decision making and patient benefit is challenging. In the United Kingdom, nurses and pharmacists can now take on a prescribing role, engaging in shared decision making. Given the different professional backgrounds of GPs, NPs and PPs, this study sought to explore the process of shared decision making across these three prescriber groups.

METHODS

Analysis of audio-recordings of consultations in primary care in South England between patients and GPs, NPs and PPs. Analysis of patient questionnaires completed post consultation. Findings A total of 532 consultations were audio-recorded with 20 GPs, 19 NPs and 12 PPs. Prescribing decisions occurred in 421 (79%). Patients were given treatment options in 21% (102/482) of decisions, the prescriber elicited the patient's treatment preference in 18% (88/482) and the patient expressed a treatment preference in 24% (118/482) of decisions. PPs were more likely to ask for the patient's preference about their treatment regimen (χ 2=6.6, P=0.036, Cramer's V=0.12) than either NPs or GPs. Of the 275 patient questionnaires, 192(70%) could be matched with a prescribing decision. NP patients had higher satisfaction levels than patients of GPs or PPs. More time describing treatment options was associated with increased satisfaction, adherence and greater perceived practitioner empathy. While defining, measuring and enabling the process of shared decision making remains challenging, it may have patient benefit.

Determinants of patients' attitudes toward patient-centered care: a cross-sectional study in Greece

OBJECTIVE

The aim of this study was to investigate - for the first time in Greece - patients' attitudes toward patient-centered care, by identifying the impact of socio-demographic factors, health condition, social support and religious beliefs.

METHODS

454 Hospitalized patients were interviewed on the first day of their scheduled admission, answering demographic questions and the following questionnaires: Patient-Practitioner Orientation Scale (PPOS), Autonomy Preference Index (API), Short Form SF-12v2 Health Survey, God Locus of Health Control (GLHC) and Perceived Available Support (PAS).

RESULTS

Mean PPOS and API scores were: PPOS Sharing 3.4 (sd=0.69), Caring 3.99 (sd=0.76), API Information-Seeking 88.32 (sd=9.35) and Decision-Making 51.19 (sd=9.27). Higher desire for information was associated with younger age, more years of education, weaker spiritual faith in healing and worse subjective health status. Higher expectations for caring physicians were correlated with older age, more years of education, higher perceived social support and weaker spiritual faith in healing.

CONCLUSION

Age, years of education, health status, social support and religious beliefs are determinants of patient-centered attitudes.

PRACTICE IMPLICATIONS

Patients expect to be informed, although they do not equally want to be involved in decision-making. Religious faith and perceived social support should be taken into consideration to further understand patients' needs.

Associations between patient-provider communication and socio-cultural factors in prostate cancer patients: a cross-sectional evaluation of racial differences

OBJECTIVE

To examine the association between socio-cultural factors and patient-provider communication and related racial differences.

METHODS

Data analysis included 1854 men with prostate cancer from a population-based study. Participants completed an assessment of communication variables, physician trust, perceived racism, religious beliefs, traditional health beliefs, and health literacy. A multi-group structural equation modeling approach was used to address the research aims.

RESULTS

Compared with African Americans, Caucasian Americans had significantly greater mean scores of interpersonal treatment (p<0.01), prostate cancer communication (p<0.001), and physician trust (p<0.001), but lower mean scores of religious beliefs, traditional health beliefs, and perceived racism (all p values <0.001). For both African and Caucasian Americans, better patient-provider communication was associated with more physician trust, less perceived racism, greater religious beliefs (all p-values <0.01), and at least high school education (p<0.05).

CONCLUSION

Socio-cultural factors are associated with patient-provider communication among men with cancer. No evidence supported associations differed by race.

PRACTICE IMPLICATION

To facilitate patient-provider communication during prostate cancer care, providers need to be aware of patient education levels, engage in behaviors that enhance trust, treat patients equally, respect religious beliefs, and reduce the difficulty level of the information.

Effective Factors on Patients' Satisfaction with Emergency Care Services using Factor Analysis: A Cross Sectional Study

INTRODUCTION

Due to certain physical and psychological conditions of patients in emergency wards, pay attention to the effective factors on Patients' satisfaction is an essential issue in modern medicine. The aim of the present study was to investigate the effective factors on Patients' satisfaction with emergency medical services.

MATERIALS AND METHODS

A cross-sectional survey was carried out from November to December 2010. The study sample consisted of 100 patients hospitalized in the emergency wards of Imam and Mustafa Hospitals in Ilam- Iran. Subjects were selected through simple random sampling method. Data gathered using questioner. The questioner validity was obtained using the content validity. Reliability of questionnaire was checked using Cronbach α coefficient. To find the most important factors affecting patient satisfaction, factorial analysis technique was used.

RESULT

Exploratory factor analysis showed that the Patients' satisfaction is composed of six factors, including: satisfaction of physicians, nursing staff, the presence of students, the method of reception and discharge, deciding to cure and knowing the position of the therapist. Base on the results of the factorial analysis, the most important aspect of satisfaction was the satisfaction of physicians. The results revealed significant relationships between the occurrence time and the satisfaction of physician (r = 0.23, p=0.027), the number of visits and the satisfaction of physician (r =0.27, p=0.01), the time of visits and the satisfaction of physician (p= 0.016), also between occurrence time and the number of visit (r = 0.36, p=0.001).

CONCLUSION

Physicians and nurses actions and decision making are the major affecting factors satisfaction in emergency patients. Thus improving the quality of these factors will improve the quality of emergency services for patients.

Patient satisfaction and GP trustworthiness, practice orientation and performance: implications for selection, training and revalidation

PURPOSE

The purpose of this paper is to examine the doctor-patient relationship from the patients' perspective. It tests a number of hypothesized relationships with respect to the interaction inside the doctor-patient relationship including the continuity of care, doctors' practice orientation and performance, which help enhance the understanding of patient trust and satisfaction.

DESIGN/METHODOLOGY/APPROACH

A quantitative survey using a closed-ended questionnaire provided a useable sample of 372 respondents.

FINDINGS

There was an overall high level of patient trust in and satisfaction with GPs as well as good patient rapport with their GPs. Patients who were most satisfied with their doctor perceived them to be more trustworthy, were more satisfied with their performance and perceived them to have greater preference for a sharing orientation than those patients who were least satisfied.

PRACTICAL IMPLICATIONS

The research findings suggest ways of maintaining and enhancing trust through training, continuing professional development, appraisals and assessments and revalidation of doctors. The skill sets and competencies related to trust and practice are presented in light of current practice trends and changing health care agendas, including the recent Department of Health White Paper, "Liberating the NHS" (2010). Since the questionnaire was able to discriminate between those patients who were most and least satisfied with their doctors, it identified what patients appreciate and are concerned about with respect to GPs and their practice.

ORIGINALITY/VALUE

The research provides new insights and understanding of how patient satisfaction in the GP-patient relationship is influenced by GPs' trustworthiness, practice orientation and performance, for academic and practitioner communities.

Audiologists' preferences for patient-centredness: a cross-sectional questionnaire study of cross-cultural differences and similarities among professionals in Portugal, India and Iran

OBJECTIVE

Patient-centredness has become an important aspect of health service delivery; however, there are a limited number of studies that focus on this concept in the domain of hearing healthcare. The objective of this study was to examine and compare audiologists' preferences for patient-centredness in Portugal, India and Iran.

DESIGN

The study used a cross-sectional survey design with audiologists recruited from three different countries.

PARTICIPANTS

A total of 191 fully-completed responses were included in the analysis (55 from Portugal, 78 from India and 58 from Iran).

MAIN OUTCOME MEASURE

The Patient-Practitioner Orientation Scale (PPOS).

RESULTS

PPOS mean scores suggest that audiologists have a preference for patient-centredness (ie, mean of 3.6 in a 5-point scale). However, marked differences were observed between specific PPOS items suggesting these preferences vary across clinical situations. A significant level of difference (p<0.001) was found between audiologists' preferences for patient-centredness in three countries. Audiologists in Portugal had a greater preference for patient-centredness when compared to audiologists in India and Iran, although no significant differences were found in terms of age and duration of experience among these sample populations.

CONCLUSIONS

There are differences and similarities in audiologists' preferences for patient-centredness among countries. These findings may have implications for the training of professionals and also for clinical practice in terms of optimising hearing healthcare across countries.

Resident physicians' attitudes and confidence in communicating with patients: a pilot study at a Japanese university hospital

OBJECTIVE

This study aimed to explore the relationships among physicians' confidence in conducting medical interviews, their attitudes toward the patient-physician relationship, and undergraduate training in communication skills among resident physicians in Japan.

METHODS

Participants were 63 first-year resident physicians at a university hospital in Tokyo. The Physician Confidence in the Medical Interview scale (PCMI) was constructed based on the framework of the Calgary-Cambridge Guide. Additionally, participants' attitudes toward the patient-physician relationship (Patient-Practitioner Orientation Scale; PPOS), undergraduate experience of communication skills training, and demographic characteristics were assessed through a self-reported questionnaire.

RESULTS

The internal consistency of the PCMI and PPOS scales were adequate. As expected from the undergraduate curriculum for medical interviews in Japan, residents had relatively higher confidence in their communication skills with respect to gathering information and building the relationship, whereas less confident about sharing information and planning treatment. The PCMI was associated with a more patient-centered attitude as measured by the PPOS.

CONCLUSION

These scales could be useful tools to measure physicians' confidence and attitudes in communicating with patients and to explore their changes through medical education.

PRACTICE IMPLICATIONS

Residency programs should consider including systematic training and assessment in communication skills related to sharing information and planning treatment.

How patient-centered do female physicians need to be? Analogue patients' satisfaction with male and female physicians' identical behaviors

Previous research suggests that female physicians may not receive appropriate credit in patients' eyes for their patient-centered skills compared to their male counterparts. An experiment was conducted to determine whether a performance of higher (versus lower) verbal patient-centeredness would result in a greater difference in analogue patient satisfaction for male than female physicians. Two male and two female actors portrayed physicians speaking to a patient using high or low patient-centered scripts while not varying their nonverbal cues. One hundred ninety-two students served as analogue patients by assuming the patient role while watching one of the videos and rating their satisfaction and other evaluative responses to the physician. Greater verbal patient-centeredness had a stronger positive effect on satisfaction and evaluations for male than for female physicians. This pattern is consistent with the hypothesis that the different associations between patient-centeredness and patients' satisfaction for male versus female physicians occur because of the overlap between stereotypical female behavior and behaviors that comprise patient-centered medical care. If this is the case, high verbal patient-centered behavior by female physicians is not recognized as a marker of clinical competence, as it is for male physicians, but is rather seen as expected female behavior.

Patient-centered care in medicine and surgery: guidelines for achieving patient-centered subspecialty care

Patient-centered care is based on the principle that equality between physician and patient is mutually advantageous. This model of care recently has largely supplanted the historical paternalistic model of the physician-patient relationship. Patient-centered care differs from the disease-centered model of evidence-based medicine, but the two are not mutually exclusive. Patient-centered care has 5 core components: the biopsychosocial perspective, the patient as person, sharing power and responsibility, the therapeutic alliance, and the doctor as person. This article explores these components, explains the differences between patient-centered care and evidence-based medicine, and offers guidelines for achieving patient-centered subspecialty care in hand surgery.

Considering the issue of dual use in veterans affairs patients: implications & opportunities for improved communication & counseling

This study sought to ascertain perceptions of communication responsibility in veterans identified as using more than one health care system, otherwise known as dual users. Three hundred and fifteen veterans identified as dual users completed a telephone-based survey including questions about their perspectives regarding communication in the context of dual use. Nearly half (47.3%) indicated that that they believed it was primarily their responsibility to either directly communicate or facilitate communication between their Veterans Affairs (VA) and non-VA providers. Only 11.3% reported that it should be the responsibility of their VA provider, 19.6% believed that their non-VA provider should be responsible, and 7.3% believed both should be involved. Finally, 14.4% believed another person was responsible, such as a system administrator or patient representative. Of those patients indicating that it was their responsibility, a majority (61.7%) indicated that they preferred active involvement in their health care. Patient-centered care allows patients the opportunity to help facilitate communication between multiple health care systems, such as when using VA and non-VA providers, if they so choose. However, given that patient preferences for involvement vary considerably, it is likely that a multifaceted approach to this problem is necessary, involving patients, providers, and other system-level stakeholders. These data suggest a need to inquire about preferred patient roles and counsel patients regarding methods of communication that may serve to decrease fragmentation of care.

Clinically relevant correlates of accurate perception of patients' thoughts and feelings

The goal was to explore the clinical relevance of accurate understanding of patients' thoughts and feelings. Between 2010 and 2012, four groups of participants (nursing students, medical students, internal medicine residents, and undergraduate students) took a test of accuracy in understanding the thoughts and feelings of patients who were videorecorded during their actual medical visits and who afterward reviewed their video to identify their thoughts and feelings as they occurred (Test of Accurate Perception of Patients' Affect, or TAPPA). Participants' accuracy scores were then correlated with participants' attitudes toward patient-centered care, clinical course background, recall of clinical conversation, evaluations of clinical performance made by preceptors, evaluations of interpersonal skill made by standardized patients in clinical encounters, and independent coding of behavior in a clinical encounter. Accuracy in understanding patients' thoughts and feelings was significantly correlated with nursing students' clinical course experience, clinicians' favorable attitudes to psychosocial discussion, standardized patients' evaluations of medical students' interpersonal skill, independent coding of medical students' patient-centered behavior while taking a social history, and undergraduates' more accurate recall of what an actor-physician said on video. Accuracy in perceiving patients' thoughts and feelings can be objectively measured and is a skill relevant to clinical performance.

Brief training of student clinicians in shared decision making: a single-blind randomized controlled trial

BACKGROUND

Shared decision making is a crucial component of evidence-based practice, but a lack of training in the "how to" of it is a major barrier to its uptake.

OBJECTIVE

To evaluate the effectiveness of a brief intervention for facilitating shared decision making skills in clinicians and student clinicians.

DESIGN

Multi-centre randomized controlled trial.

PARTICIPANTS

One hundred and seven medical students, physiotherapy or occupational therapy students undertaking a compulsory course in evidence-based practice as part of their undergraduate or postgraduate degree from two Australian universities.

INTERVENTION

The 1-h small-group intervention consisted of facilitated critique of five-step framework, strategies, and pre-recorded modelled role-play. Both groups were provided with a chapter about shared decision making skills.

MAIN MEASURES

The primary outcome was skills in shared decision making and communicating evidence [Observing Patient Involvement (OPTION) scale, items from the Assessing Communication about Evidence and Patient Preferences (ACEPP) Tool], rated by a blinded assessor from videorecorded role-plays.

SECONDARY OUTCOMES

confidence in these skills and attitudes towards patient-centred communication (Patient Practitioner Orientation Scale (PPOS)).

KEY RESULTS

Of participants, 95 % (102) completed the primary outcome measures. Two weeks post-intervention, intervention group participants scored significantly higher on the OPTION scale (adjusted group difference = 18.9, 95 % CI 12.4 to 25.4), ACEPP items (difference = 0.9, 95 % CI 0.5 to 1.3), confidence measure (difference = 13.1, 95 % CI 8.5 to 17.7), and the PPOS sharing subscale (difference = 0.2, 95 % CI 0.1 to 0.5). There was no significant difference for the PPOS caring subscale.

CONCLUSIONS

This brief intervention was effective in improving student clinicians' ability, attitude towards, and confidence in shared decision making facilitation. Following further testing of the longer-term effects of this intervention, incorporation of this brief intervention into evidence-based practice courses and workshops should be considered, so that student clinicians graduate with these important skills, which are typically neglected in clinician training.

Physician gender, physician patient-centered behavior, and patient satisfaction: a study in three practice settings within a hospital

OBJECTIVE

To compare male and female physicians on patient-centeredness and patients' satisfaction in three practice settings within a hospital; to test whether satisfaction is more strongly predicted by patient-centeredness in male than female physicians.

METHODS

Encounters between physicians (N=71) and patients (N=497) in a hospital were videotaped and patients' satisfaction was measured. Patient-centeredness was measured by trained coders.

RESULTS

In the outpatient setting, female physicians were somewhat more patient-centered than male physicians; patient satisfaction did not differ. In the inpatient and emergency room settings, female physicians were notably more patient-centered than male physicians; satisfaction paralleled these differences. Nevertheless, there was some, though mixed, evidence that patient-centeredness predicted satisfaction more strongly in male than female physicians, suggesting that patients valued patient-centered behavior more in male than female physicians.

CONCLUSION

Even though satisfaction mirrored the different behavior styles of male and female physicians in the inpatient and emergency room settings, in all settings male physicians got somewhat more credit for being patient-centered than female physicians did.

PRACTICE IMPLICATIONS

If female physicians do not consistently receive credit for high patient-centeredness in the eyes of patients, this could lead female physicians to reduce their patient-centered behavior.

Changes in medical students' patient-centeredness attitudes by implementation of clinical performance examination

PURPOSE

From 2009, the Korean Medical Licensure Exam implemented a clinical performance examination (CPX) that highlighted the importance of good patient-physician relationships in medical education. This study aimed to examine changes in medical students' attitudes before and after implementation of the CPX in their medical education curriculum.

METHODS

In 2006 and 2009, 236 fourth-year medial students of C College of Medicine took the Patient Practitioner Orientation Scale (PPOS) by Krupet et al. (2000), which measures patient-centered attitudes in patient-physician relationships. The data were analyzed by independent t-test and two-way analysis of variance using SPSS 21.0.

RESULTS

The PPOS scores of year 2006 students were 3.88±0.25 for males and 3.98±0.38 for females. For year 2009 students, males scored 3.81±0.42 and females scored 4.01±0.48. All students had higher Care scores than Share scores (2006: Share, 3.67±0.47 vs. Care, 4.19±0.51; 2009: Share, 3.56±0.34 vs. Care, 4.18±0.53). There were significant differences in PPOS and Share scores by gender before and after the CPX. With regard to Care scores, female students' scores tended to rise and males' scores declined over time.

CONCLUSION

An educational program is needed for students to foster patient-centered attitudes, but gender differences should be taken into account.

Communication needs of medical tourists: an exploratory study in Thailand

Purpose

– The aim of this paper is to contribute a conceptualization of the information and communication needs of medical tourists from Western countries in an Asian health care context.

Design/methodology/approach

– Multi-phase, semi-structured, in-depth interviews and observations were conducted with 27 multi-source informants who have communication experience in the international healthcare setting.

Findings

– Multi-level information provision should be used to address communicative incongruence in Asian healthcare provider – Western patient encounters as was self-reported by the participants and observed by authors. The use of an informative communication model is proposed in order to facilitate interaction and the effective transfer of information with Western patients to overcome negative, underlying emotions and enable autonomous decision making by the patients.

Research limitations/implications

– This exploratory study is focused on Western patients and Asian practitioners in Thailand. Future research in other countries and with patients from other geographical areas could expand to generalize findings.

Practical implications

– Fostering information sharing with Western patients by using an integrative communication model can improve patient satisfaction and health outcomes. The need for developing and implementing these improved practices for communicating with Western patients is reflected by the healthcare industry's current developmental trends helping to lead to a future of health service internationalization.

Originality/value

– This is the first empirical study to provide insights concerning the communication needs and coping strategies of Western patients with Asian doctors in developing countries.

Investigating conflict in ICUs-is the clinicians' perspective enough?

OBJECTIVE

Most studies have assessed conflict between clinicians and surrogate decision makers in ICUs from only clinicians' perspectives. It is unknown if surrogates' perceptions differ from clinicians'. We sought to determine the degree of agreement between physicians and surrogates about conflict and to identify predictors of physician-surrogate conflict.

DESIGN

Prospective cohort study.

SETTING

Four ICUs of two hospitals in San Francisco, California.

PATIENTS

Two hundred and thirty surrogate decision makers and 100 physicians of 175 critically ill patients.

MEASUREMENTS

Questionnaires addressing participants' perceptions of whether there was physician-surrogate conflict, as well as attitudes and preferences about clinician-surrogate communication; κ scores to quantify physician-surrogate concordance about the presence of conflict; and hierarchical multivariate modeling to determine predictors of conflict.

MAIN RESULTS

Either the physician or surrogate identified conflict in 63% of cases. Physicians were less likely to perceive conflict than surrogates (27.8% vs 42.3%; p = 0.007). Agreement between physicians and surrogates about conflict was poor (κ = 0.14). Multivariable analysis with surrogate-assessed conflict as the outcome revealed that higher levels of surrogates' satisfaction with physicians' bedside manner were associated with lower odds of conflict (odds ratio, 0.75 per 1 point increase in satisfaction; 95% CI, 0.59-0.96). Multivariable analysis with physician-assessed conflict as the outcome revealed that the surrogate having felt discriminated against in the healthcare setting was associated with higher odds of conflict (odds ratio, 17.5; 95% CI, 1.6-190.1) while surrogates' satisfaction with physicians' bedside manner was associated with lower odds of conflict (0-10 scale; odds ratio, 0.76 per 1 point increase; 95% CI, 0.58-0.99).

CONCLUSIONS

Conflict between physicians and surrogates is common in ICUs. There is little agreement between physicians and surrogates about whether physician-surrogate conflict has occurred. Further work is needed to develop reliable and valid methods to assess conflict. In the interim, future studies should assess conflict from the perspective of both clinicians and surrogates.

Interventions for improving patients' trust in doctors and groups of doctors

BACKGROUND

Trust is a fundamental component of the patient-doctor relationship and is associated with increased satisfaction, adherence to treatment, and continuity of care. Our 2006 review found little evidence that interventions improve patients' trust in their doctor; therefore an updated search was required to find out if there is further evidence of the effects of interventions that may improve trust in doctors or groups of doctors.

OBJECTIVES

To update our earlier review assessing the effects of interventions intended to improve patients' trust in doctors or a group of doctors.

SEARCH METHODS

In 2003 we searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, EMBASE, Health Star, PsycINFO, CINAHL, LILACS, African Trials Register, African Health Anthology, Dissertation Abstracts International and the bibliographies of studies selected for inclusion. We also contacted researchers active in the field. We updated and re-ran the searches on available original databases (Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library issue 2, 2013), MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), CINAHL (Ebsco)) as well as Proquest Dissertations and Current Contents for the period 2003 to 18 March 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-randomised controlled trials, controlled before and after studies, and interrupted time series of interventions (informative, educational, behavioural, organisational) directed at doctors or patients (or carers) where trust was assessed as a primary or secondary outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies. Where mentioned, we extracted data on adverse effects. We synthesised data narratively.

MAIN RESULTS

We included 10 randomised controlled trials (including 7 new trials) involving 11,063 patients. These studies were all undertaken in North America, and all but two involved primary care.  As expected, there was considerable heterogeneity between the studies.  Interventions were of three main types; three employed additional physician training, four were education for patients and three provided additional information about doctors in terms of financial incentives or consulting style. Additionally, several different measures of trust were employed.The studies gave conflicting results. Trials showing a small but statistically-significant increase in trust included: a trial of physician disclosure of financial incentives; a trial of providing choice of physician based on concordance between patient and physician beliefs about care; a trial of group visits for new inductees into a Health Maintenance Organisation; a trial of training oncologists in communication skills; and a trial of group visits for diabetic patients. However, trust was not affected in a subsequent larger trial of group visits for uninsured people with diabetes, nor with a decision aid for helping choose statins, another trial of disclosure of financial incentives or specifically training doctors to increase trust or cultural competence. There was no evidence of harm from any of the studies.

AUTHORS' CONCLUSIONS

Overall, there remains insufficient evidence to conclude that any intervention may increase or decrease trust in doctors. This may be due in part to the sensitivity of trust instruments, and a ceiling effect, as trust in doctors is generally high. It may be that current measures of trust are insufficiently sensitive. Further trials are required to explore the impact of doctors' specific training or the use of a patient-centred or decision-sharing approach on patients' trust, especially in the areas of healthcare provider choice, and induction into healthcare organisation. International trials would be of particular benefit. The review was constrained by the lack of consistency between trust measurements, timeframes and populations.

Supporting self-management of obesity using a novel game architecture

Obesity has commonly been addressed using a 'one size fits all' approach centred on a combination of diet and exercise. This has not succeeded in halting the obesity epidemic, as two-thirds of American adults are now obese or overweight. Practitioners are increasingly highlighting that one's weight is shaped by myriad factors, suggesting that interventions should be tailored to the specific needs of individuals. Health games have potential to provide such tailored approach. However, they currently tend to focus on communicating and/or reinforcing knowledge, in order to suscitate learning in the participants. We argue that it would be equally, if not more valuable, that games learn from participants using recommender systems. This would allow treatments to be comprehensive, as games can deduce from the participants' behaviour which factors seem to be most relevant to his or her weight and focus on them. We introduce a novel game architecture and discuss its implications on facilitating the self-management of obesity.

Education and decision making at the time of triptan prescribing: patient expectations vs actual practice

BACKGROUND

Optimizing patient satisfaction with their medical care and maximizing patient adherence with treatment plans requires an understanding of patient preferences regarding education and their role in decision making when treatments are prescribed.

OBJECTIVE

To assess the congruence between patient expectations and actual practice regarding education and decision making at the time a triptan is prescribed.

METHODS

This multicenter cross-sectional survey was performed by headache fellow members of the American Headache Society Headache Fellows Research Consortium at their respective tertiary care headache clinics. Migraine patients who were new patients to the headache clinic and who were current triptan users (use within prior 3 months and for ≥1 year) or past triptan users (no use within 6 months; prior use within 2 years) completed questionnaires that assessed the education they received and their role in decision making at the time a triptan was first prescribed as well as their desire for education and participation in decision making when a triptan is prescribed.

RESULTS

Consistent with patient preference, most participants received the majority of their education about the triptan from the prescriber's office (70.2%). In descending rank order, participants most desired to be informed about how to decide if a triptan should be taken, when during the course of migraine a triptan should be taken, possible side effects, cost, and how to obtain refills. Regarding side effects, most participants preferred to receive education about the most common side effects of a triptan rather than addressing all possible side effects. Regarding triptan dosing, participants desired to be informed in descending order of importance about taking other medications with triptans, how many doses can be taken for each migraine, how many doses can be taken each week/month, what to do if the triptan does not work, and the triptan mechanism of action. The vast majority of participants (92%) preferred that the decision to prescribe a triptan be a joint decision between the patient and the provider. In actual practice, participants were not as involved in decision making as they would like to be, with patients reporting that the prescriber was the sole decision maker 55.1% of the time. Participants had confidence in their providers (87.7%) and generally felt they did a good job educating them about the triptan (71.1%).

CONCLUSIONS

Based on this study, it is clear that patients prefer the shared model approach to medical decision making in regards to the prescription of triptans. The majority of patients received education that was generally consistent with their desires. Patients preferred that the prescribing provider be the primary source of information. The most desired educational topics included when/if a triptan should be taken, the number of times a triptan can be taken for a single migraine, co-administration with other acute medications, and the most common side effects. Focusing on these topics should enhance patient satisfaction and may improve compliance.

An Australian survey of audiologists' preferences for patient-centredness

OBJECTIVE

Patient-centredness is becoming a core value of health services worldwide, however it remains largely unexplored in audiology. This study investigated audiologists' preferences for patient-centredness and identified factors that explain audiologists' preferences for patient-centredness.

DESIGN

All members of the Audiological Society of Australia received two questionnaires: (1) a descriptive questionnaire (e.g. age, gender, place of residence, years in practice, employment characteristics), and (2) a modified patient-practitioner orientation scale (PPOS; Krupat et al, 2000) which measures preferences for two aspects of patient-centredness, sharing and caring.

STUDY SAMPLE

In total 663 (46%) audiologists returned both questionnaires fully completed.

RESULTS

Mean PPOS scores indicated that audiologists prefer patient-centredness. Linear regression modelling identified that older audiologists, that had practiced longer, and who worked in community education, industrial audiology, or teaching had a significantly greater preference for patient-centredness than their peers. In contrast, audiologists who practiced in a private environment and who worked in the area of assessment of adults had a significantly lesser preference for patient-centredness than their peers.

CONCLUSIONS

Audiologists prefer client-centredness and age, years of experience, and employment characteristics can partly explain preferences for patient-centredness. Future research should explore the relationships between patient-centredness and intervention outcomes in audiology.

Scaling up family medicine training in Gezira, Sudan - a 2-year in-service master programme using modern information and communication technology: a survey study

BACKGROUND

In 2010 the Gezira Family Medicine Project (GFMP) was initiated in Gezira state, Sudan, designed as an in-service training model. The project is a collaboration project between the University of Gezira, which aims to provide a 2-year master's programme in family medicine for practicing doctors, and the Ministry of Health, which facilitates service provision and funds the training programme. This paper presents the programme, the teaching environment, and the first batch of candidates enrolled.

METHODS

In this study a self-administered questionnaire was used to collect baseline data at the start of the project from doctors who joined the programme. A checklist was also used to assess the health centres where they work. A total of 188 out of 207 doctors responded (91%), while data were gathered from all 158 health centres (100%) staffed by the programme candidates.

RESULTS

The Gezira model of in-service family medicine training has succeeded in recruiting 207 candidates in its first batch, providing health services in 158 centres, of which 84 had never been served by a doctor before. The curriculum is community oriented. The mean age of doctors was 32.5 years, 57% were males, and 32% were graduates from the University of Gezira. Respondents stated high confidence in practicing some skills such as asthma management and post-abortion uterine evacuation. They were least confident in other skills such as managing depression or inserting an intrauterine device. The majority of health centres was poorly equipped for management of noncommunicable diseases, as only 10% had an electrocardiography machine (ECG), 5% had spirometer, and 1% had a defibrillator.

CONCLUSIONS

The Gezira model has responded to local health system needs. Use of modern information and communication technology is used to facilitate both health service provision and training. The GFMP represents an example of a large-volume scaling-up programme of family medicine in Africa.

Assessment of nursing students and nurses' orientation towards patient-centeredness

BACKGROUND

Being patient centered is a core value for nursing. Patient centered-care has been related to patient and health provider satisfaction, better health outcomes, higher quality of care and more efficient health care delivery.

OBJECTIVES

The purpose was to assess the orientation adopted by nurses and students in patient care, using The Patient-Practitioner Orientation Scale, as well as to compare the results between resident nurses and students from different academic years.

SETTINGS

Public School of Nursing and a Central Hospital, in Lisbon (Portugal).

PARTICIPANTS

Students in the first, second and fourth year of nursing school and nurses participated in the study.

METHODS

For data collection, we used The Patient-Practitioner Orientation Scale (European Portuguese version), an instrument designed to measure individual preferences toward the dimension of caring a sharing in health professional-patient relationship. Students and nurses also filled out two additional questions about their perception of competence in technical and communication skills. Additional demographic information was also collected, including gender, age, academic year and length of professional experience.

RESULTS

A total of 525 students (84.7% female) and 108 nurses (77.8% female) participated in this study. In general, caring sub-scores, measuring the preference of about attending to patient emotional aspects, were higher than sharing sub-scores, measuring beliefs about giving information and perceiving patient as a member of the health team. Students were significantly more patient-centered throughout their nursing education (p<0.001). Comparing to students in the second and fourth academic years (p<0.001) nurses' scores were significantly lower both in total PPOS and in caring and sharing subscales.

CONCLUSIONS

These results reinforce the idea that patient centeredness may be developed in academic context. The scores obtained highlight the importance of studies that aim to identify factors that may explain the decrease of patient centeredness in professional practice.

Satisfaction with pain treatment in older cancer patients: Identifying variants of discrimination, trust, communication, and self-efficacy

How satisfied a patient is with their medical treatment may influence compliance and adherence to medical regimens. While a number of studies have examined patient satisfaction among younger populations, few have determined the impact social factors have on satisfaction with pain treatment among older adults. This study aimed to determine the influence discrimination, trust, communication, and other health characteristics have on satisfaction with pain treatment among older adults receiving outpatient services from a comprehensive cancer center. Participants were surveyed on questions assessing pain symptomatology, and identified social (discrimination, trust, and communication), physical (comorbidities, pain interference), behavioral (self-efficacy), and demographic characteristics. Analyses were calculated to determine the total and indirect effects of trust, communication, and self-efficacy as mediators on the perceived discrimination-patient satisfaction with pain treatment relationship. Data showed a significant relationship of communication and discrimination on patient satisfaction. However, none of the mediating effects were significant. It must be recognized that patient satisfaction is contingent upon a myriad of social factors that are not exclusive, but rather coexisting determinants of health. Particularly among the elderly, perceived discrimination and incidences of poor communication may be significant influences on health and the lived day-to-day experiences of this adult population.

Patients' preferences for patient-centered communication: a survey from an outpatient department in rural Sierra Leone

OBJECTIVES

To investigate patients' preferences for patient-centered communication (PCC) in the encounter with healthcare professionals in an outpatient department in rural Sierra Leone.

METHODS

A survey was conducted using an adapted version of the Patient-Practitioner Orientation Scale (PPOS) as a structured interview guide. The study population was drawn from the population of all adults attending for treatment or treatment for their children.

RESULTS

144 patients were included in the analysis. Factors, such as doctor's friendly approach, the interpersonal relationship and information-sharing were all scored high (patient-centered) on the PPOS. Factors associated with shared-decision making had a lower (doctor-centered) score. A high educational level was associated with a more patient-centered scoring, an association that was most pronounced in the female population.

CONCLUSION

The results provide an insight into the patients' preferences for PCC. Patients expressed a patient-centered attitude toward certain areas of PCC, while other areas were less expressed. More research is needed in order to fully qualify the applicability of PCC in resource-poor settings.

PRACTICE IMPLICATIONS

Stakeholders and healthcare professionals should aim to strengthen healthcare practice by focusing on PCC in the medical encounter while taking into considerations the patients' awareness and preferences for PCC.

Psychosomatics in obstetrics and gynecology - evaluation of a compulsory standardized teaching program

OBJECTIVE

This observational study was aimed at assessing the effect of case supervision in small groups over a two-year period as part of a standardized psychosomatic basic training for future obstetrician-gynecologists from the physicians' perspective.

METHODS

The supervised groups were evaluated by questionnaires distributed to all 128 candidates at the beginning (T1), at half time (T2) and at the end of the course (T3). Aside from a validated battery of questions on self-efficacy, items included self-estimated psychosomatic competence, professional satisfaction as well as a validation of the training program.

RESULTS

The training program was associated with a significant increase of self-reported psychosomatic competence (55.0/68.9, p = 0.000) and self-efficacy (2.4/2.8, p = 0.0011). While major changes occurred at the end of the first year of the supervised groups, no further enhancement could be demonstrated throughout the second year. A total of 44 (88%) study participants who answered at T3 considered the training program as helpful.

CONCLUSIONS

The presented teaching program - more precisely the supervised groups - seemed to be effective in increasing self-estimated psychosomatic competence and self-efficacy in future specialists for obstetrics and gynecology. It may serve as a model for the systematic integration of standardized psychosomatic basic training into the education of obstetrician-gynecologists.

Patients' and professionals' evaluations of quality of care in oncology outpatient clinics

PURPOSE

The purpose of this study is to compare patients' and professionals' evaluations of the quality of care in oncology outpatient clinics.

METHODS

The data were drawn from a 2011 survey of 1,379 patients and 155 professionals conducted in 15 % of oncology outpatient clinics in Quebec, Canada. Respondents completed self-administered questionnaires that addressed the aspects of timeliness (TIM), patient-centred care (PCC), communication (COM), quality of the physical environment (QPE), and continuity (CONT). Patients' and professionals' mean scores (maximum = 4) for each aspect were compared using mixed model analysis.

RESULTS

Patients' and professionals' perceptions of quality of care were largely positive, with mean scores for all items of 3.66 and 3.37, respectively. However, for the majority of aspects of quality, the professionals' scores were lower than those of patients. The aspects rated most positively by both groups were PCC, COM and CONT. Timeliness was the least positively evaluated, with mean scores of 3.34 for patients and 3.16 for professionals.

CONCLUSIONS

In many respects, cancer patients and professionals share relatively common views about the most and least positive aspects of the quality of care, although professionals tend to be more critical. Aspects evaluated less favourably by both groups and those on which opinions differ are good candidates for improvements. Some ideas for solutions are proposed. Positive patient feedback is especially important in cancer care, where attraction and retention of professionals is a key concern.

[Patient-centeredness of medical students during a real patient encounter and a standardized patient encounter on the clinical performance examination]

PURPOSE

Patient-centered care is one of the most important factors of high-quality medical care. Medical educators have been increasingly interested in education for patient-centered care. This study was conducted to guide such education by assessing the patient-centeredness of medical students in a real patient encounter and a standardized patient encounter on the clinical performance examination (CPX).

METHODS

During the first semester of 2010 and 2011, fourth-year medical students in a clinical clerkship interviewed outpatients who visited the Department of Family Medicine. The interviews were videotaped, 25 of which were selected for study. We searched the 25 students' CPX videotapes that were recorded in the same year for comparison. The patient-centeredness of the students was assessed by measure of patient-centered communication (MPCC).

RESULTS

The inter-rater reliability of the MPCC was 0.89 when measuring real patient encounters. MPCC scores of 25 students were very low for both real patients (mean, 28.8; range, 8.2~53.1) and for standardized patients (mean, 27.5; range, 8.2~52.7), and there was no significant difference between two groups. The component 1 MPCC scores were significantly higher for real patient encounters compared with those of CPX encounters (0.28 vs 0.18, p=0.0001). The component 2, 3 MPCC scores of two groups were not different each other.

CONCLUSION

Medical educators must emphasize the importance of exploring a patient's illness and social background and involving them in making a diagnosis and treatment plan for patient-centered care. They should give students more opportunities to interview real patients and diversify scenarios for standardized patients.

[Differences in attitude toward patient-centeredness in patients and physicians]

PURPOSE

There have been studies on the patient-centeredness of medical students and physicians in South Korea, but no result has presented the patient-centered attitude of patients and doctors. So, this study intended to compare the attitudes of patients and doctors toward the roles that patients and physicians should play in the health care process.

METHODS

One hundred and fifteen doctors and 264 patients participated in this survey using a structured questionnaire, including sociodemographic data and Patient Practitioner Orientation Scale (PPOS). The PPOS comprises sharing (sharing information, take part in decision making) and caring (respecting one's feelings, interpersonal relationships) subscales.

RESULTS

The PPOS scores of the doctors and patient were 3.02 and 3.20. In detail, the doctors' sharing and caring scores were and 3.02 and 3.48, and the those of patients were 3.14 and 3.12, respectively. This results are enough to demonstrate that patients are likely to be patient-centered with regard to sharing and that doctors tend to be patient-centered in terms of caring.

CONCLUSION

The patients' desire to obtain medical information and take part in decision making (sharing) are greater than those of doctors. Doctors had more patient-centered attitude than patients in terms of respects for one's feelings and interpersonal relationships (caring).

Cross-cultural validation of the Patient-Practitioner Orientation Scale (PPOS)

OBJECTIVES

Translate, adapt and validate the Patient-Practitioner Orientation Scale (PPOS) for use in Brazil.

METHODS

The PPOS was translated to Portuguese using a modified Delphi technique. The final version was applied to 360 participants. Reliability (test-retest and internal consistency) and construct validity (explanatory and confirmatory factor analysis) were assessed.

RESULTS

Only two items did not reach pre-established criteria agreement in Delphi technique. In pre-testing, seven items were modified. Internal consistency (Cronbach's alpha=0.605) and test-retest reliability (intraclass correlation coefficient=0.670) were adequate. In explanatory factor analysis, one item did not achieve a loading factor, one item was considered factorially complex and two items were inconsistent with a priori factors. Confirmatory factor analysis provided an acceptable adjustment for the observed variables (χ(2)/df=2.33; GFI=0.91; AGFI=0.89; CFI=0.84; NFI=0.75; NNFI=0.81; RMSEA=0.062 (p=0.016) and SRMR=0.065).

CONCLUSIONS

The Brazilian version PPOS (B-PPOS) showed acceptable validity and adequate reliability.

PRACTICE IMPLICATIONS

The use of the B-PPOS in national and cross-cultural studies may contribute to the evaluation and monitoring of the attitudes of doctors, medical students and patients toward their professional relationships in research and practice.

Patient-health care provider communication among patients with newly diagnosed prostate cancer: findings from a population-based survey

OBJECTIVE

To examine the multidimensional concept of patient-health care provider (HCP) communication, its effects on patient satisfaction with oncology care services, and related racial differences.

METHODS

The current analysis draws from a population-based survey sample of 1011 African American and 1034 Caucasian American men with newly diagnosed prostate cancer. The variables of satisfaction with health care services, interpersonal treatment, contextual knowledge of the patient, and prostate cancer communication were analyzed using multiple-group structural equation modeling.

RESULTS

Regardless of race, patient-HCP communication was related positively to interpersonal treatment by the HCP, HCP's contextual knowledge of the patient, and prostate cancer communication. More positive patient-HCP communication was related to more satisfaction with health care services. Racial differences were significant in the relationships between patient-HCP communication and prostate cancer communication.

CONCLUSION

Content and interpersonal relationships are important aspects of patient-HCP communication and affect patient satisfaction with oncologic care for prostate cancer.

PRACTICE IMPLICATIONS

HCPs need to integrate the transfer of information with emotional support and interpersonal connection when they communicate with men with newly diagnosed prostate cancer.

The importance of patient-centered care for various patient groups

OBJECTIVES

To assess differences in the importance ascribed to patient-centered care between various patient groups and demographic groups.

METHODS

Survey data collected using questionnaires were analyzed for patients that underwent hip or knee surgery (n=214), patients suffering from rheumatoid arthritis (n=343), spinal disk herniation (n=145), breast abnormalities (n=596) or congestive heart failure (n=118). A composite for patient-centered care priorities was constructed (α=0.82) and compared to the average importance over all healthcare aspects in the surveys.

RESULTS

All patient groups considered patient-centered care to be of above-average importance (p's<0.001). Small but significant differences were observed: patient-centered care was more important for patients suffering from congestive heart failure (p<0.001) and patients who were younger, female, well-educated and healthier (p's<0.05). Patients who had undergone hip or knee surgery considered patient-centered care more important than patients with spinal disk herniation did (p<0.05).

CONCLUSION

Patient-centered care is important to all patient groups. Differential policies regarding patient-centered care for patient subgroups do not seem required.

PRACTICAL IMPLICATIONS

Given the importance attributed to patient-centered care, it is essential that elements of patient-centered care are included in surveys, indicators of quality of care, and the training of doctors and nurses.

What circumstances prompt a workplace discussion in medical evaluations for back pain?

PURPOSE

To determine how frequently workplace topics emerge in the interactions between patients and providers in an evaluation for low back pain (LBP) and to determine its association with patient and provider characteristics.

METHODS

Adults with work-related LBP (N = 97; 64 % male; median age = 38) completed a demographic questionnaire and a survey of disability risk factors, then agreed to audio-taping of their visits with a participating occupational healthcare provider (n = 14). Utterance-level verbal exchanges were categorized by trained coders using the Roter interaction analysis system. In addition, coders flagged any instance of workplace discussion between patients and providers.

RESULTS

Workplace discussions occurred in 51 % of visits, and the most frequent topic was physical job demands. Workplace discussions were more frequent among the oldest and youngest patients and when patients were seen by providers who were more patient-centered and made more efforts to establish patient rapport and engagement. However, patients reporting numerous disability risk factors and workplace concerns in the pre-visit questionnaire were no more likely to discuss workplace topics with their providers (p > 0.05). Only the patient-centered orientations of providers and patients remained statistically significant predictors in multivariate modeling (p < 0.05).

CONCLUSIONS

Workplace discussions are facilitated by a patient-centered orientation and by efforts to establish patient engagement and rapport, but workplace discussions are no more frequent among patients with the most significant workplace concerns. Screening questionnaires and other assessment tools may be helpful to foster workplace discussions to overcome possible barriers for returning to work.

The effect of a patient- and family-centered care curriculum on pediatrics residents' patient-centeredness

BACKGROUND

Patient- and family-centered care (PFCC) approaches to care are important in enhancing the patient-centeredness of the health care experience, yet little is known about the effectiveness of formal approaches for teaching patient-centeredness in residency.

INTERVENTION

We developed and implemented a PFCC curriculum and assessed its impact on residents' self-perceptions of patient-centered behavior and practices.

METHODS

We used a quasi-experimental, nonrandomized approach with a pretest-posttest design. An experimental group of 24 interns filled out the Patient Practitioner Orientation Scale (PPOS) before residency, and a control group of 18 graduating residents who had not been exposed to a PFCC curriculum also completed the PPOS. After 2 years of residency and exposure to a PFCC curriculum, interns in the experimental group repeated the PPOS. We compared mean total and subscale PPOS scores.

RESULTS

There was no difference in baseline total or subscale PPOS scores between the experimental and control group. The mean total PPOS score for the experimental group after exposure to the curriculum was 4.55 (P  =  .45), reflecting no change in patient-centeredness. The 17 female interns in the intervention group were more patient centered (4.8 ± 0.36) than the 6 male interns (4.2 ± 0.38) (P  =  .005), scoring significantly higher (4.6 ± 0.39 versus 4.0 ± 0.38) in the sharing domain (P  =  .001).

CONCLUSION

Interns' exposure to a PFCC curriculum did not result in a change in their perceived patient-centeredness. Most pediatrics residents at our children's hospital perceive themselves as patient and family centered at the start of residency and remain so throughout.

Are physicians and patients in agreement? Exploring dyadic concordance

Dyadic concordance in physician-patient interactions can be defined as the extent of agreement between physicians and patients in their perceptions of the clinical encounter. The current research specifically examined two types of concordance: informational concordance-the extent of agreement in physician and patient responses regarding patient information (education, self-rated health, pain); and interactional concordance-the extent of physician-patient agreement regarding the patient's level of confidence and trust in the physician and the perceived quality of explanations concerning diagnosis and treatment. Using a convenience sample of physicians and patients (N = 50 dyads), a paired survey method was tested, which measured and compared physician and patient reports to identify informational and interactional concordances. Factors potentially related to dyadic concordance were also measured, including demographic characteristics (patient race, gender, age, and education) and clinical factors (whether this was a first visit and physician specialty in family medicine or oncology). The paired survey showed informational discordances, as physicians tended to underestimate patients' pain and overestimate patient education. Interactional discordances included overestimating patients' understanding of diagnosis and treatment explanations and patients' level of confidence and trust. Discordances were linked to patient dissatisfaction with physician listening, having unanswered questions, and feeling the physician had not spent enough time. The paired survey method effectively identified physician-patient discordances that may interfere with effective medical practice; this method may be used in various settings to identify potential areas of improvement in health communication and education.

Predictors of communication preferences in patients with chronic low back pain

BACKGROUND

The objective of this exploratory study was to identify patient-related predictors of communication preferences in patients with chronic low back pain for various dimensions of patient-physician communication (patient participation and orientation, effective and open communication, emotionally supportive communication, communication about personal circumstances).

METHODS

Eleven rehabilitation centers from various parts of Germany participated in collection of data between 2009 and 2011. A total of 701 patients with chronic low back pain were surveyed at the start of rehabilitation. The patient questionnaire captured communication preferences, pain impact, pain intensity, and psychologic variables (fear avoidance beliefs, illness coherence, control beliefs, communication self-efficacy, and personality characteristics). The rehabilitation physicians filled out a documentation sheet containing information on diagnosis, inability to work, duration of the illness, and comorbidity at the beginning and end of rehabilitation. Hierarchical regression analyses were performed.

RESULTS

On average, effective, open, and patient-centered communication was very important for patients with back pain, emotionally supportive communication was important, and communication about personal circumstances was somewhat important. The variance in communication preferences explained by the predictors studied here was 8%-19%. Older patients showed a lower preference for patient-centered and open communication, but a higher preference for communication about personal circumstances. Patients with psychologic risk factors (eg, fear avoidance beliefs), extroverted patients, and patients with high self-efficacy in patient-physician interaction generally had higher expectations of the physician's communicative behavior.

CONCLUSION

Providers should take into consideration the fact that patients with back pain have a strong need for effective, open, and patient-centered communication. A flexible approach to communication needs appears to be especially important for communication about emotional and personal circumstances, because the patients differ most clearly in this respect. Personal characteristics provided only initial clues to possible preferences; for more precision, an individual assessment (by means of questionnaires or discussion) is needed.

The validity of using analogue patients in practitioner-patient communication research: systematic review and meta-analysis

When studying the patient perspective on communication, some studies rely on analogue patients (patients and healthy subjects) who rate videotaped medical consultations while putting themselves in the shoes of the video-patient. To describe the rationales, methodology, and outcomes of studies using video-vignette designs in which videotaped medical consultations are watched and judged by analogue patients. Pubmed, Embase, Psychinfo and CINAHL databases were systematically searched up to February 2012. Data was extracted on: study characteristics and quality, design, rationales, internal and external validity, limitations and analogue patients' perceptions of studied communication. A meta-analysis was conducted on the distribution of analogue patients' evaluations of communication. Thirty-four studies were included, comprising both scripted and clinical studies, of average-to-superior quality. Studies provided unspecific, ethical as well as methodological rationales for conducting video-vignette studies with analogue patients. Scripted studies provided the most specific methodological rationales and tried the most to increase and test internal validity (e.g. by performing manipulation checks) and external validity (e.g. by determining identification with video-patient). Analogue patients' perceptions of communication largely overlap with clinical patients' perceptions. The meta-analysis revealed that analogue patients' evaluations of practitioners' communication are not subject to ceiling effects. Analogue patients' evaluations of communication equaled clinical patients' perceptions, while overcoming ceiling effects. This implies that analogue patients can be included as proxies for clinical patients in studies on communication, taken some described precautions into account. Insights from this review may ease decisions about including analogue patients in video-vignette studies, improve the quality of these studies and increase knowledge on communication from the patient perspective.

Further validation of the Patient-Practitioner Orientation Scale (PPOS) from recorded visits for back pain

OBJECTIVE

More patient-centered communication is associated with improved patient satisfaction and health status, fewer malpractice complaints, and increased adherence. In a study of medical encounters for acute low back pain (LBP), we conducted a secondary analysis to assess the validity of the Patient Practitioner Orientation Scale (PPOS), a measure of patient-centeredness.

METHODS

Fourteen clinicians and 89 of their patients with acute LBP completed the PPOS and agreed to have verbal exchanges recorded and coded using the Roter Interaction Analysis System (RIAS). We examined correlations between the PPOS and counts of patient and provider utterances within 8 RIAS verbal exchange categories.

RESULTS

Providers with a more patient-centered orientation asked fewer biomedical questions, posed more lifestyle questions, gave more lifestyle advice, and did more rapport-building. Their patients shared more lifestyle information and made more attempts at rapport building and provider engagement. In contrast, the patient-centered orientation of patients showed no effect on communication.

CONCLUSION

The PPOS scores of providers, but not patients, predicted significant and meaningful differences in the verbal exchanges of patients and providers.

PRACTICE IMPLICATIONS

The results support the validity of the PPOS measure and provide further evidence of the extent to which provider orientation influences patient communication and exchange.

Physician styles of patient management as a potential source of disparities: cluster analysis from a factorial experiment

OBJECTIVE

To identify styles of physician decision making (as opposed to singular clinical actions) and to analyze their association with variations in the management of a vignette presentation of coronary heart disease (CHD).

DATA SOURCE

Primary data were collected from primary care physicians in North and South Carolina.

STUDY DESIGN

In a balanced factorial experimental design, primary care physicians viewed one of 16 (2(4)) video vignette presentations of CHD and provided detailed information about how they would manage the case.

DATA COLLECTION METHOD

256 MD primary care physicians were interviewed face-to-face in North and South Carolina.

PRINCIPAL FINDINGS

We identify three clusters depicting unique styles of CHD management that are robust to controls for physician (gender and level of experience) and patient characteristics (age, gender, socioeconomic status, and race) as well as key organizational features of physicians' work settings. Physicians in Cluster 1 "Cardiac" (N = 92) were more likely to focus on cardiac issues compared with their counterparts; physicians in Cluster 2 "Talkers" (N = 93) were more likely to give advice and take additional medical history; whereas physicians in Cluster 3 "Minimalists" (N = 71) were less likely than their counterparts to take action on any of the types of management behavior.

CONCLUSIONS

Variations in styles of decision making, which encompass multiple outcome variables and extend beyond individual-level demographic predictors, may add to our understanding of disparities in health quality and outcomes.

Identifying family members who may struggle in the role of surrogate decision maker

Although acting as a surrogate decision maker can be highly distressing for some family members of intensive care unit patients, little is known about whether there are modifiable risk factors for the occurrence of such difficulties.

OBJECTIVES

To identify: 1) factors associated with lower levels of confidence among family members to function as surrogates and 2) whether the quality of clinician-family communication is associated with the timing of decisions to forego life support.

METHODS

We conducted a prospective study of 230 surrogate decision makers for incapacitated, mechanically ventilated patients at high risk of death in four intensive care units at University of California San Francisco Medical Center from 2006 to 2007. Surrogates completed a questionnaire addressing their perceived ability to act as a surrogate and the quality of their communication with physicians. We used clustered multivariate logistic regression to identify predictors of low levels of perceived ability to act as a surrogate and a Cox proportional hazard model to determine whether quality of communication was associated with the timing of decisions to withdraw life support.

RESULTS

There was substantial variability in family members' confidence to act as surrogate decision makers, with 27% rating their perceived ability as 7 or lower on a 10-point scale. Independent predictors of lower role confidence were the lack of prior experience as a surrogate (odds ratio 2.2, 95% confidence interval [1.04-4.46], p=.04), no prior discussions with the patient about treatment preferences (odds ratio 3.7, 95% confidence interval [1.79-7.76], p<.001), and poor quality of communication with the ICU physician (odds ratio 1.2, 95% confidence interval [1.09-1.35] p<.001). Higher quality physician-family communication was associated with a significantly shorter duration of life-sustaining treatment among patients who died (β=0.11, p=.001).

CONCLUSIONS

Family members without prior experience as a surrogate and those who had not engaged in advanced discussions with the patient about treatment preferences were at higher risk to report less confidence in carrying out the surrogate role. Better-quality clinician-family communication was associated with both more confidence among family members to act as surrogates and a shorter duration of use of life support among patients who died.

When you can't have the cake and eat it too: a study of medical doctors' priorities in complex choice situations

Available literature provides little insight into medical doctors' prescription choices when they are required to make complex trade-offs between different concerns such as treatment effect, costs, and patient preferences simultaneously. This study investigates this issue. It is based on a Discrete Choice Experiment (DCE) conducted with 571 Norwegian doctors, where the DCE captures preferences for medications described along five dimensions important for both clinical decision-making and prioritisation in the health sector. Although effectiveness is the most important determinant of choice in our study, doctors also put considerable weight on patients' preferences and on avoiding high total costs. The probability of choosing a particular medication increases when doctors have a positive experience with the medication. GPs value high clinical effectiveness less than hospital consultants do. They are also less concerned with patient preferences. For both groups of doctors it turns out that they are willing to make difficult trade-offs between attributes they are often assumed not to be willing to compromise on, like effectiveness or patient preferences, and cost measures - given that they have proper information about these attributes.

Patient preferences and healthcare outcomes: an ecological perspective

This article examines the nature of patients' preferences for healthcare and whether clinician accommodation of patient preferences influences health outcomes. First, we provide a conceptualization of patient preferences along with their key attributes. Second, we review research on the relationship between health outcomes and patient preferences for treatments and for the process of care (e.g., preferred involvement in decision-making). Third, following a critique of this literature, we present an ecological model of patient preferences that, while acknowledging that patient preferences may emerge from various contexts (e.g., family or media exposure), we focus on the important role that clinical encounters and patients' health-related experiences play in the elicitation and construction of patient preferences. Fourth, we propose two pathways, one behavioral (adherence) and the other psychological (sense of autonomy or satisfaction with decision), through which meeting patient preferences could lead to better health outcomes. Fifth, we discuss how preferences can be elicited and clarified through patient-centered conversations. We conclude with implications for future research and clinical practice.

Concordance between physician communication style and patient attitudes predicts patient satisfaction

OBJECTIVE

This study tested whether the impact of the physician's communication style on patient satisfaction differs depending on patients' attitudes toward caring and sharing. We predicted that the impact of physician caring on patient satisfaction depends on patient attitudes toward caring, and that the impact of physician sharing on patient satisfaction depends on patient attitudes toward sharing.

METHODS

Participants (N=167) were asked to imagine that they were consulting for recurrent headaches. They interacted on a computer with a virtual physician that communicated either in a low or high caring way and either in a low or high sharing way (2 × 2 design). Then, participants answered questions about their attitudes toward caring and sharing and about their satisfaction with the physician.

RESULTS

Hypotheses were confirmed. Furthermore, a high caring physician communication style led to higher satisfaction than a low caring one, regardless of participants' attitudes toward caring, while satisfaction with physicians' level of sharing was dependent on the participants' attitude toward sharing.

CONCLUSION AND PRACTICE IMPLICATIONS

Physicians may adopt a high caring style with confidence that all patients will benefit. Adoption of a sharing style should be more carefully adjusted to patient attitudes.

Patient-centered care: the influence of patient and resident physician gender and gender concordance in primary care

BACKGROUND

Patient-centered care (PCC) is thought to significantly influence the process of care and its outcomes and has been identified as part of a comprehensive strategy for improving our nation's healthcare delivery system. Patient and physician gender, as well as gender concordance, may influence the provision of PCC.

METHODS

Patients (315 women, 194 men) were randomized to care by primary care resident physicians (48 women, 57 men). Sociodemographic information, history of health risk behaviors (tobacco use, alcoholism, and obesity), and self-reported global pain and health status were collected before the first visit. That visit and subsequent patient visits to the primary care physician (PCP) were videotaped during the year-long study period. PCC was measured by coding all videotapes using a modified version of the Davis Observation Code.

RESULTS

No significant gender differences in PCC were found between the male and female patients; however, female physicians provided increased PCC to their patients. The greatest amount of PCC was seen in the female patient-female physician gender dyad. Regression analyses, controlling for other patient variables, confirmed that female concordant dyads were associated with a greater amount of PCC. There was no significant relationship for the male patient-male physician concordance (vs. disconcordance).

CONCLUSIONS

These findings highlight the influence of gender in the process of care and provision of PCC. Gender concordance in female patient-female physician dyads demonstrated significantly more PCC. Further research in other clinical settings using other measures of PCC is needed. A public mandate to provide care that is patient-centered has implications for medical education.