Doctor-patient communication: the Toronto consensus statement

Readability and content of postoperative tonsillectomy instructions given to patients in Scotland, a completed audit cycle

The aim of this study was to assess the impact of the recommendations and interventions of the 2003 audit of 'readability and content of postoperative tonsillectomy instructions, given to patients in Scotland'. A two-cycle audit of readability and content of postoperative tonsillectomy instructions was undertaken. All National Health Service (NHS) hospital wards and associated Otolaryngology Departments in Scotland where tonsillectomies were being performed were contacted. Interventions following the first cycle included the mailing copies of original audit results and conclusions to all ear, nose and throat wards in Scotland, presentation at a National Meeting and publication of results in a peer reviewed journal. While changes had occurred in 61% of the information sheets, and with six of the 31 (19%) postoperative information sheets now being written at or below the recommended reading level, the average reading grade/age required to understand these information sheets still remains above those recommended by patient education experts. In conclusion, the majority of postoperative tonsillectomy information sheets in Scotland remain written at a level above those recommended by patient education experts. The interventions undertaken in this audit were of limited success. The ENT-UK Tonsillectomy Information sheets (2006) are written at reasonable reading levels, have good content levels and we continue to recommend these information sheets.

Third year medical students perceptions towards learning communication skills: implications for medical education

OBJECTIVE

To analyze students' perceptions towards learning communication skills pre-and-post training in a Communication and Clinical Skills Course (CCSC) at a Portuguese Medical School.

METHODS

Content analysis was used to describe and systematically analyze the content written by students (n=215 from a total of 229) in an open-ended survey. In addition, content analysis association rules were used to identify meaning units.

RESULTS

Students' pre-training definitions of communication skills were not specific; their post-training definitions were more precise and elaborated. Students perceived communications skills in Medicine as important (61%), but recommended that teaching methodologies (52%) be restructured. There appeared to be no connection between criticism of teaching skills performance and perceptions of the other aspects of the course.

CONCLUSION

Students' experiences at CCSC are associated with their perceptions of communications skills learning. Content analysis associations indicated that these perceptions are influenced by context.

PRACTICE IMPLICATIONS

Improvement of curricula, teaching and assessment methods, and investment in faculty development are likely to foster positive perceptions towards learning communication skills in these students.

The importance of good communication between patient and health professionals

This article emphasizes the importance of a good communication between patients and health professionals. It focuses on how patients feels during the cancer journey and how professionals should behave to them. It also go through the different dilemmas and conflicts health professionals may come across in their interaction with patients and it suggests different ways about how those dilemmas can be resolved. The main idea of this article is the fact that health professionals-whether physicians, nurses or psychologists-need to focus on and improve, if necessary, their communication with patients; basically, learn how to unite the humanistic side of care with the technical side; how to be professionals without losing their humanistic identity.

Benefits of knowledge-based interprofessional communication skills training in medical undergraduate education

OBJECTIVES

Good interprofessional communication is fundamental to effective teamworking in medicine. Finalmed is a private course that teaches the principles and methods of clinical presenting as an iterative technique of reasoning though clinical data. We have tested the efficacy of this technique using a questionnaire-based study.

DESIGN

An anonymized 10-point Likert scale questionnaire was designed.

SETTING

Questionnaires were distributed at five UK courses and two UAE courses.

PARTICIPANTS

Questionnaires were given to all students attending these courses.

MAIN OUTCOME MEASURES

The questionnaire included pre- and post-course questions addressing self-reported confidence in clinical presenting (CCP) and effectiveness in clinical presenting (ECP). We also asked whether attendees felt that clinical presenting should be integrated formally into medical school curricula.

RESULTS

A total of 331/395 questionnaires were returned. Median improvement in CCP was 50% (P < 0.0001) and in ECP was 40% (P < 0.0001), irrespective of country of study, graduate entry status and whether the student felt that they had been exposed to these techniques previously. Students recorded a strong opinion in favour of integrating the content and style of the Finalmed course into their medical school curriculum, with 286 students (86%) recording a score of ≥8.

CONCLUSION

Our study suggests that after a two- or three-day dedicated course, both self-reported confidence and effectiveness in clinical presenting significantly improve. Furthermore, students in the UK and the UAE returned a desire for integration into medical school curricula of IPC through the teaching of clinical presenting.

Empathy decline and its reasons: a systematic review of studies with medical students and residents

PURPOSE

Empathy is a key element of patient-physician communication; it is relevant to and positively influences patients' health. The authors systematically reviewed the literature to investigate changes in trainee empathy and reasons for those changes during medical school and residency.

METHOD

The authors conducted a systematic search of studies concerning trainee empathy published from January 1990 to January 2010, using manual methods and the PubMed, EMBASE, and PsycINFO databases. They independently reviewed and selected quantitative and qualitative studies for inclusion. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and those with a sample size <30 were excluded.

RESULTS

Eighteen studies met the inclusion criteria: 11 on medical students and 7 on residents. Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the "hidden," "formal," and "informal" curricula as main reasons for empathy decline.

CONCLUSIONS

The results of the reviewed studies, especially those with longitudinal data, suggest that empathy decline during medical school and residency compromises striving toward professionalism and may threaten health care quality. Theory-based investigations of the factors that contribute to empathy decline among trainees and improvement of the validity of self-assessment methods are necessary for further research.

Effectiveness of communication skills training on perceptions and practice of pediatric residents

OBJECTIVE

To assess the effectiveness of a structured communication skills training workshop on the perceptions and practice of pediatric residents.

METHODS

The perceptions and practice of pediatric residents with regard to doctor- patient (parent) communication were evaluated before and 6 weeks after a communication skills training workshop, using a structured questionnaire.

RESULTS

Twenty pediatric residents participated in the study. They included nine residents who had completed 1 year of pediatric training and 11 residents who had completed 2 years or more of pediatric training. 9 were female residents and 11 were males. Before the intervention, majority of the residents rated themselves poorly on assessment of their perceptions and practice of communication skills. After the workshop there was overall improvement in the communication skills of the residents.

CONCLUSIONS

Communication skills of pediatric residents are generally inadequate. Structured training programs will help to improve their communication skills. There is a need to incorporate communication skills training in the pediatric postgraduate curriculum.

Effectiveness of a short course in clinical communication skills for hospital doctors: results of a crossover randomized controlled trial (ISRCTN22153332)

OBJECTIVE

To test the hypothesis that a 20-h communication skills course based on the Four Habits model can improve doctor-patient communication among hospital employed doctors across specialties.

METHODS

Crossover randomized controlled trial in a 500-bed hospital with interventions at different time points in the two arms. Assessments were video-based and blinded. Intervention consisted of 20 h of communication training, containing alternating plenary with theory/debriefs and practical group sessions with role-plays tailored to each doctor.

RESULTS

Of 103 doctors asked to participate, 72 were included, 62 received the intervention, 51 were included in the main analysis, and another six were included in the intention-to-treat analysis. We found an increase in the Four Habits Coding Scheme of 7.5 points (p = 0.01, 95% confidence interval 1.6-13.3), fairly evenly distributed on subgroups. Baseline score (SD) was 60.3 (9.9). Global patient satisfaction did not change, neither did average encounter duration.

CONCLUSION

Utilizing an outpatient-clinic training model developed in the US, we demonstrated that a 20-h course could be generalized across medical and national cultures, indicating improvement of communication skills among hospital doctors.

PRACTICE IMPLICATIONS

The Four Habits model is suitable for communication-training courses in hospital settings. Doctors across specialties can attend the same course.

Effective training strategies for teaching communication skills to physicians: an overview of systematic reviews

OBJECTIVE

Physicians need good communication skills to communicate effectively with patients. The objective of this review was to identify effective training strategies for teaching communication skills to qualified physicians.

METHODS

PubMED, PsycINFO, CINAHL, and COCHRANE were searched in October 2008 and in March 2009. Two authors independently selected relevant reviews and assessed their methodological quality with AMSTAR. Summary tables were constructed for data-synthesis, and results were linked to outcome measures. As a result, conclusions about the effectiveness of communication skills training strategies for physicians could be drawn.

RESULTS

Twelve systematic reviews on communication skills training programmes for physicians were identified. Some focused on specific training strategies, whereas others emphasized a more general approach with mixed strategies. Training programmes were effective if they lasted for at least one day, were learner-centred, and focused on practising skills. The best training strategies within the programmes included role-play, feedback, and small group discussions.

CONCLUSION

Training programmes should include active, practice-oriented strategies. Oral presentations on communication skills, modelling, and written information should only be used as supportive strategies.

PRACTICE IMPLICATIONS

To be able to compare the effectiveness of training programmes more easily in the future, general agreement on outcome measures has to be established.

Clinician-patient communication: evidence-based recommendations to guide practice in cancer

Goals of Work

To develop recommendations for effective communication between cancer health care providers and patients based on a systematic review of methods of clinician–patient communication that may affect patient outcomes associated with distress at critical points in the course of cancer care.

Materials and Methods

A systematic review of the literature was conducted, and evidence-based recommendations were formulated to guide clinician–patient communication in cancer care. A formal external review was conducted to validate the relevance of these recommendations.

Main Results

Recommendations for communication in cancer care are presented, based on

guidelines from the Australian National Breast Cancer Centre and the Australian National Cancer Control Initiative,

an updated systematic review of the research evidence, and

a consensus by the Clinician–Patient Communications Working Panel of the Program in Evidence-Based Care of Cancer Care Ontario.

The recommendations were sent to 110 Ontario practitioners for external review: 33 responded (30% response rate). Most of these respondents (87%) agreed with the draft recommendations and approved of their use as a practice guideline (90%). A condensed version of the recommendations, including 10 key points, was also created.

Conclusions

There is evidence to support general clinician–patient communication approaches, although the preferences of cancer patients regarding such communication exhibit individual and cultural variability. Recommendations are provided, based on evidence, the consensus of an expert panel, and feedback from a survey of external practitioners. Evidence evaluating the role of decision aids and strategies to facilitate better communication is inconsistent, although such tools may be of value for some patients.

What should psychiatric trainees in years 1–3 gain from CBT training? Implications from a Royal College Divisional Workshop

Competencies for psychiatric training have been developed that reflect what psychiatrists have to be able to do in order to function in their role. Although the need for a formally delivered psychotherapy experience is assumed and associated competencies are represented in the curriculum, it is not clear which competencies thereby achieved can be translated into generic practice. This paper reports the outcomes of a workshop held at an academic regional meeting of the Royal College of Psychiatrists. Potential competencies to be achieved following training and experience in CBT were presented. Small group review of the frameworks and subsequent feedback demonstrated broad support for requirements of CBT knowledge and attitudinal competencies that could inform day-to-day practice, within a generic psychotherapeutic skills framework. New competencies that were related to CBT and considered meaningful in daily psychiatric practice emerged. Further development of these ideas from the workshop in this paper leads to a set of coherent competencies that would be helpful in non-CBT specialist practice and are congruent with the context of generic psychiatric practice. These enable models of training other than the delivery of a single ‘brief’ psychotherapy case to be considered.

Good communication in psychiatry--a conceptual review

BACKGROUND

The communication between clinician and patient is the basis of psychiatric treatment. However, there has been little practical attention to training in it, and no specific theory of what constitutes good communication in psychiatry has been developed. This review aims to identify principles that guide good communication.

METHODS

A conceptual review of guiding principles for how clinicians should communicate with patients to achieve clinical objectives in psychiatry.

RESULTS

Five guiding principles for clinicians were identified: a focus on the patient's concerns; positive regard and personal respect; appropriate involvement of patients in decision making; genuineness with a personal touch; and the use of a psychological treatment model.

CONCLUSIONS

The principles are mostly generic, but their implementation can be particularly challenging in psychiatry. They may guide further empirical research on effective communication in psychiatry and be utilised using different personal skills of clinicians.

Crossing the patient-centered divide: transforming health care quality through enhanced faculty development

In the report "Crossing the Quality Chasm," the Institute of Medicine asserted that patient-centered care is one of the six domains of quality. In this article, the authors consider how the patient- and relationship-centered components of quality can be achieved in all aspects of medical care. They suggest that faculty development in three key areas-mindful practice, formation, and training in communication skills-is necessary to achieve patient- and relationship-centeredness.The authors first review the philosophical and scientific foundations of patient-centered and relationship-centered care. They next describe and provide concrete examples to illustrate the underlying theory and practices associated with each of the three faculty development areas. They then propose five key areas for faculty development in patient- and relationship-centered care: (1) making it a central competency in all health care interactions, (2) developing a national curriculum framework, (3) requiring performance metrics for professional development, (4) partnering with national health care organizations to disseminate the curriculum framework, and (5) preserving face-to-face educational methods for delivering key elements of the curriculum. Finally, the authors consider the issues faced in faculty development today in light of the medical education issues Abraham Flexner identified more than a century ago.

Progress in teaching physician-patient communication in medical school; personal observations and experience of a medical educator

In spite of the enormous progress of Western medicine during the past century there has not be a concomitant rise in the public's satisfaction with the medical profession. Much of the discontent relates to problems in physician-patient communication. The multiple advantages of good communication have been clearly demonstrated by numerous careful studies. While the past few decades have witnessed much more attention given to teaching communication skills in medical schools, there are a number of factors that create new problems in physician-patient communication and counteract the positive teaching efforts. The "hidden curriculum", the increased emphasis on technology, the greater time pressures, and the introduction of the computer in the interface between physician and patient present new challenges for the teaching of physician-patient communication.

Perceptions of health care communication: examining the role of patients' psychological distress

OBJECTIVE

We sought to gain a better understanding of the relationship between patients' serious psychological distress (SPD) and their perception of interactions with health care providers and their ratings of the health care quality.

METHODS

We analyzed data from 6286 adult respondents to the 2007 Health Information National Trends Survey. We conducted cross-tabulations to compare sociodemographic characteristics between those with SPD and those without SPD. Using odds ratios and 95% confidence intervals from logistic regression models, we assessed the association between psychological status and indicators of perceived health care communication and the overall health care quality after controlling for sociodemographic variables.

RESULTS

Patients with SPD were less likely to report that their provider "always" paid attention to their feelings and emotions, "always" ensured their understanding of the needed care, and "always" assisted them dealing with uncertain feelings. These distressed patients were also less satisfied with the overall health care quality.

CONCLUSIONS

Patients' psychological distress is negatively associated with their perceived quality of communication with health providers. Further knowledge on the health care need of patients with SPD would be important in improving health service delivery and optimizing the psychological care of medical patients.

Creativity in clinical communication: from communication skills to skilled communication

Medical Education 2011: 45: 217-226 Objectives  The view that training in communication skills produces skilled communication is sometimes criticised by those who argue that communication is individual and intuitive. We therefore examine the validity of the concept of communication as a skill and identify alternative principles to underpin future development of this field. Methods  We critically examine research evidence about the nature of clinical communication, and draw from theory and evidence concerning education and evaluation, particularly in creative disciplines. Results  Skilled communication cannot be fully described using the concept of communication skills. Attempts to do so risk constraining and distorting pedagogical development in communication. Current education practice often masks the difficulties with the concept by introducing subjectivity into the definition and assessment of skills. As all clinical situations differ to some extent, clinical communication is inherently creative. Because it is rarely possible to attribute specific effects to specific elements of communication, communication needs to be taught and evaluated holistically. Conclusions  For communication teaching to be pedagogically and clinically valid in supporting the inherent creativity of clinical communication, it will need to draw from education theory and practice that have been developed in explicitly creative disciplines.

[Satisfied companion, a quality indicator in emergencies]

OBJECTIVES

To determine the level of satisfaction of the accompanying person in the Emergency Department and to identify main factors that could influence satisfaction and to establish areas of improvement.

METHODOLOGY

A retrospective descriptive study of family or companion of patients seen in the Emergency Department. A randomised telephone questionnaire was used. The statistics used were chi-squared for categorical variables and variance analysis for those showing a normal distribution. The analysis was made with the SPSS 16.0 programme.

RESULTS

A total of 117 responses were received, from a minimum sample size of 90. The demographic characteristics of the accompanying person did not influence the evaluation of the satisfaction, unlike of other studies. The fact of accompanying the patient and receiving periodic information showed differences in overall satisfaction of the accompanying person, as well as the waiting time. A long waiting time and the lack of company were the most frequent reasons for dissatisfaction. The accompanying person emphasised the feeling of isolation of the patient, the lack of health personnel, the long wait for assistance and the location of facilities.

CONCLUSIONS

Rapid assistance, facilities for the accompanying person, information, empathy and friendliness are the factors which are the most appreciated when they come to Emergency Department.

The patient and the computer in the primary care consultation

OBJECTIVE

Studies of the doctor-patient relationship have focused on the elaboration of power and/or authority using a range of techniques to study the encounter between doctor and patient. The widespread adoption of computers by doctors brings a third party into the consultation. While there has been some research into the way doctors view and manage this new relationship, the behavior of patients in response to the computer is rarely studied. In this paper, the authors use Goffman's dramaturgy to explore patients' approaches to the doctor's computer in the consultation, and its influence on the patient-doctor relationship.

DESIGN

Observational study of Australian general practice. 141 consultations from 20 general practitioners were videotaped and analyzed using a hermeneutic framework.

RESULTS

Patients negotiated the relationship between themselves, the doctor, and the computer demonstrating two themes: dyadic (dealing primarily with the doctor) or triadic (dealing with both computer and doctor). Patients used three signaling behaviors in relation to the computer on the doctor's desk (screen watching, screen ignoring, and screen excluding) to influence the behavior of the doctor. Patients were able to draw the doctor to the computer, and used the computer to challenge doctor's statements.

CONCLUSION

This study demonstrates that in consultations where doctors use computers, the computer can legitimately be regarded as part of a triadic relationship. Routine use of computers in the consultation changes the doctor-patient relationship, and is altering the distribution of power and authority between doctor and patient.

Teaching communication and compassionate care skills: an innovative curriculum for pre-clerkship medical students

BACKGROUND

Physicians require communications training to improve effective and compassionate care. Clinicians discuss challenging communication issues in existing hospital "Schwartz Rounds."

AIMS

To improve communication skills, the Warren Alpert Medical School of Brown University designed "Schwartz Communication Sessions" for the mandatory 2-year pre-clerkship Doctoring course. Alongside learning interviewing, physical examination, and professionalism skills, the new Schwartz curriculum provides medical students with the rationale and proficiency for effective communication with patients, families and the healthcare team.

METHODS

First-year students experience a graduated curriculum of three sessions on themes such as empathy and professionalism using innovative methods. Sessions highlight cases and videos depicting successful and ineffective interactions, large and small group discussions, role play and skills practice, guest patient presentations, and multi-disciplinary panels. The second-year students' session focuses on communications with challenging patients.

RESULTS

Students and faculty rate the sessions highly on effectiveness of enhancing communication skills, gaining perspective in healthcare communication, and appreciating the complexities of healthcare situations. Expansion of the program using case-based sessions for clerkship students is planned for a continuous and graduated experience.

CONCLUSIONS

Integrating a pre-clerkship communications curriculum may help improve future physicians' interactions with patients and families. Implications of this curriculum for medical education are discussed.

A course for nurses to handle difficult communication situations. A randomized controlled trial of impact on self-efficacy and performance

OBJECTIVE

to evaluate the impact of a communication skills course for nurses on how to handle difficult communication situations in their daily work.

METHODS

a 7-h course was developed using a construct of "Awareness, Feelings, Listen, Solve" (AFLS). A pedagogy of experiential, learner-centered learning was adopted. The course evaluation used a randomized controlled design with pre- and post-measures of self-efficacy and performance.

RESULTS

forty-one nurses volunteered and thirty-three nurses completed all assigned parts of the study. On self-assessment, there was significant improvement for self-efficacy (F=24.43, p<0.001), but not for emotional awareness. On performance, there was no significant improvement between intervention and control groups (F=3.46, p=0.073).

CONCLUSION

a short course for nurses on handling difficult communication situations achieved significant improvements in self-efficacy but not in performance.

PRACTICE IMPLICATIONS

teaching communication skills in community-based settings is important for the safety and effectiveness of patient care. Sponsoring organizations should weigh trade-offs between feasibility and achievement of measurable improvements in performance. One possible approach is to focus on specific communication skills rather than a full suite of skills.

Twelve tips for implementing tools for direct observation of medical trainees' clinical skills during patient encounters

BACKGROUND

Direct observation of medical trainees by their supervisors with actual patients is essential for trainees to develop clinical skills competence. Despite the many available tools for direct observation of trainees by supervisors, it is unclear how educators should identify an appropriate tool for a particular clinical setting and implement the tool to maximize educational benefits for trainees in a manner that is feasible for faculty.

AIMS AND METHODS

Based on our previous systematic review of the literature, we provide 12 tips for selecting and incorporating a tool for direct observation into a medical training program. We focus specifically on direct observation that occurs in clinical settings with actual patients.

RESULTS

Educators should focus on the existing tools for direct observation that have evidence of validity. Tool implementation must be a component of an educational program that includes faculty development about rating performance, providing meaningful feedback, and developing action plans collaboratively with learners.

CONCLUSIONS

Educators can enhance clinical skills education with strategic incorporation of tools for direct observation into medical training programs. Identification of a psychometrically sound instrument and attention to faculty development and the feedback process are critical to the success of a program of direct observation.

Communication and social competencies in medical education in German-speaking countries: the Basel consensus statement. Results of a Delphi survey

OBJECTIVE

To propose a comprehensive set of competencies and educational objectives for communication and social competencies in undergraduate medical education and to support the nationwide implementation of these issues in all medical schools.

METHODS

Thirty experts from different medical and psychosocial disciplines participated in a 2-day workshop using the Nominal Group Technique (NGT) to develop an initial set of educational objectives. These were refined, structured, and rated according to their importance by means of a two-step Delphi Survey involving additional experts in medical education.

RESULTS

The initial workshop resulted in 188 educational objectives assigned to 26 different topics. After the Delphi Survey, 131 objectives remained, assigned to 19 different topics. Some objectives that could be assigned to more than one topic were subsumed under a new more general category.

CONCLUSION

The described consensus process proved successful as one method to develop a set of educational objectives.

PRACTICAL IMPLICATIONS

The Basel consensus statement can be used to orientate curriculum reform and development in medical education.

Health care providers underestimate symptom intensities of cancer patients: a multicenter European study

Background

Many patients with advanced cancer depend upon health care providers for symptom assessment. The extent of agreement between patient and provider symptom assessments and the association of agreement with demographic- and disease-related factors was examined.

Methods

This cross-sectional study included 1933 patient-health care provider dyads, from 11 European countries. Patients reported symptoms by using the four-point scales of the European Organization of Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) version 3, and providers used corresponding four-point categorical scales. Level of agreement was addressed at the group level (Wilcoxon Signed-Rank test), by difference scores (provider score minus patient score), at the individual level (Intraclass Correlation Coefficients, ICCs) and visually by Bland-Altman plots. Absolute numbers and chi-square tests were used to investigate the relationship between agreement and demographic-, as well as disease-related factors.

Results

The prevalence of symptoms assessed as moderate or severe by patients and providers, respectively, were for pain (67 vs.47%), fatigue (71 vs. 54%), generalized weakness (65 vs. 47%), anorexia (47 vs. 25%), depression (31 vs. 17%), constipation (45 vs. 30%), poor sleep (32 vs. 21%), dyspnea (30 vs. 16%), nausea (27 vs. 14%), vomiting (14 vs. 6%) and diarrhea (14 vs. 6%). Symptom scores were identical or differed by only one response category in the majority of patient-provider assessment pairs (79-93%). Providers underestimated the symptom in approximately one of ten patients and overestimated in 1% of patients. Agreement at the individual level was moderate (ICC 0.38 to 0.59). Patients with low Karnofsky Performance Status, high Mini Mental State-score, hospitalized, recently diagnosed or undergoing opioid titration were at increased risk of symptom underestimation by providers (all p < 0.001). Also, the agreement was significantly associated with drug abuse (p = 0.024), provider profession (p < 0.001), cancer diagnosis (p < 0.001) and country (p < 0.001).

Conclusions

Considerable numbers of health care providers underestimated symptom intensities. Clinicians in cancer care should be aware of the factors characterizing patients at risk of symptom underestimation.

Reactions to cancer: communicating with patients, family and carers

Effective communication has benefits for both patients and members of the health care team. Five main communication tasks in head and neck cancer are identified: Screening for head and neck cancer and communicating risk; Communicating the diagnosis of head and neck cancer; Providing information about treatment and pre-treatment; Communicating following treatment and dealing with fear of recurrence; Discussing the end of life. For each specific aspects of the communication situation are discussed. Underpinning each is the use of core communication skills.

Patient-clinician communication: associations with important health outcomes among veterans with COPD

BACKGROUND

High quality patient-clinician communication is widely advocated, but little is known about which health outcomes are associated with communication for patients with COPD.

METHODS

Using a cross-sectional study of 342 veterans enrolled in a randomized controlled trial, we evaluated the association of communication, measured with the quality of communication (QOC) instrument, with subject-reported quality of clinician care, breathing problem confidence, and general self-rated health. We measured these associations using general estimating equations and adjusted odds ratios (OR) of patient-reported outcomes associated with one-point changes in QOC scores.

RESULTS

Nearly one-half of the subjects reported receiving the best imaginable care (47%), whereas fewer reported being confident with their breathing problems all the time (29%) or in very good or excellent health (15%). General communication was associated with best-imagined quality of care (OR, 4.29; 95% CI, 2.84-6.48; P < .001) and confidence in dealing with breathing problems all the time (OR, 1.74; 95% CI, 1.34-2.25; P < .001) but not general self-rated health (OR, 1.19; 95% CI, 0.92-1.55; P = .19). Specific clinician behaviors with larger associations with higher quality care included listening, caring, and attentiveness. The associations between general communication and quality care increased over time (P for interaction .03).

CONCLUSIONS

Communication between patients and clinicians is associated with quality of care and confidence in dealing with breathing problems, and this association may change over time. Attention to specific communication strategies may lead to improvements in the care of patients with COPD.

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.

Mid-level providers in gastroenterology

One response to the challenges of modern day clinical practice has been to employ "mid-level providers" (MLPs), such as physician assistants and nurse practitioners. MLPs may complement physicians by supporting patient self-management and performing routine, protocol-guided management. In turn, MLPs may improve health outcomes and simultaneously lower costs. Within gastroenterology, the prevalence of MLPs remains unknown, though it appears to be significant and increasing. Additionally, professional organizations predict that in the future, MLPs will play a central role in digestive disease care. Although incorporating MLPs into gastroenterology has great potential, numerous challenges exist, and their specific roles must first be defined and evaluated.

[Information or confusion. A formal quantitative analysis of ophthalmology ward rounds]

BACKGROUND

The daily ward round is the main opportunity for communicative interaction between physician and patient during a patient's hospital stay. We analysed to what extent the round was capable of fulfilling the patients' needs for information and emotional support, using the ophthalmologic ward of a university hospital as an example.

MATERIAL AND METHODS

For a period of 4 months in 2006, doctor-patient-interactions in an ophthalmologic ward round were recorded with a dictating machine. Fifty physician-patient interactions between 50 patients and five different physicians were selected according to uniform criteria. After the recordings were transcribed, the interactions were evaluated using formal quantitative speech analysis. We examined the patients' subjective perceptions by means of a standardised questionnaire.

RESULTS

The average doctor-patient interaction lasted just under 4 min. The formal quantitative analysis of the effective verbal communication between physician and patient indicated an asymmetry to the advantage of the physician, who spoke 73% of the words (Chi 245.48 words). The patient remained rather incommunicative during the course of the conversation. Medical terms were used in only 0.53% of the direct doctor-patient dialogue. The ward round conversation was characterised by numerous personnel internal dialogues. During much of the rounds (46% of the time), the patients were unable to participate actively in the conversations. As a result, information could not reach the patients. Requests to speak were initiated 83% of the time by the physicians and only 33% of the time by the patients. Nevertheless, the patients indicated high (22%) and very high (66%) satisfaction with the ward rounds.

CONCLUSIONS

In the future, the ophthalmologic ward round should satisfy the criteria of patient-centric conversation. Therefore, the informational value of the daily ward round must be increased, and organisational and structural changes must be made to promote direct conversation between the patient and the eye specialist. A team conference before and after the physician-patient interaction would allow a focus on team-referred and patient-referred interests within the ward round.

Patient-centred attitudes among medical students: gender and work experience in health care make a difference

BACKGROUND

Previous studies of medical students' patient-centred attitudes show a decline across undergraduate education and overall higher scores for female students.

AIM

To assess undergraduate students' patient-centred attitudes at various stages of education and to explore possible associations between attitudes and age, gender and work experience in health care.

METHODS

In autumn 2005, medical students in Gothenburg (n = 797) were asked to answer Patient-Practitioner Orientation Scale (PPOS), a validated instrument exploring attitudes towards the doctor-patient relationship. Data including gender, age, current term and students' work experience in health care were collected.

RESULTS

Of 797 students 600 (75%) answered the questionnaire. No decrease of students' PPOS score across the curriculum was observed. PPOS scores from female students were higher compared to males (p < 0.0001) and female scores were significantly higher in the later terms compared with earlier (p = 0.0011). Female students had more experience from working in health care (p = 0.0023). Extended work experience was associated with higher PPOS only among females (p = 0.0031).

CONCLUSION

No decline of students' patient-centred attitudes may indicate an ongoing shift. Gender differences in patient-centred attitudes were reproduced. Work experience in health care presents a new gender difference. These gender differences should be considered when training patient-centred attitudes and skills.

Communication matters: the impact of communication and participation in decision making on breast cancer patients' depression and quality of life

OBJECTIVE

This study explored the impact of breast cancer patients' experiences of physician-patient communication and participation in decision making on patient depression and quality of life three and six months after primary treatment.

METHODS

Participants were 135 German breast cancer patients, recruited within a week after the beginning of treatment. Women were asked to complete a self-administered questionnaire at baseline and three and six months later.

RESULTS

Patients who rated their level of information at baseline as high were less depressed after three (p=.010) and six months (p<.001) and experienced higher quality of life after three (p<.001) and six months (p=.049). Patients who participated as much as they had wanted were more satisfied with the decision making process (p<.001) and had lower depression scores three months later (p=.005). The level of participation itself (passive, collaborative, active) and the treatment type had no impact.

CONCLUSION

The findings reveal the significance of physician-patient communication and stress the meaning of baseline depression for later adjustment.

PRACTICE IMPLICATIONS

A high level of information and tailoring the involvement in decision making to patients' desired level can help patients to better cope with their illness. Physicians should assess and treat depression early in cancer treatment.

Doctors' stress responses and poor communication performance in simulated bad-news consultations

PURPOSE

No studies have previously evaluated factors associated with high stress levels and poor communication performance in breaking bad news (BBN) consultations. This study determined factors that were most strongly related to doctors' stress responses and poor communication performance during a simulated BBN task.

METHOD

In 2007, the authors recruited 24 doctors comprising 12 novices (i.e., interns/residents with 1-3 years' experience) and 12 experts (i.e., registrars, medical/radiation oncologists, or cancer surgeons, with more than 4 years' experience). Doctors participated in simulated BBN consultations and a number of control tasks. Five-minute-epoch heart rate (HR), HR variability, and communication performance were assessed in all participants. Subjects also completed a short questionnaire asking about their prior experience BBN, perceived stress, psychological distress (i.e., anxiety, depression), fatigue, and burnout.

RESULTS

High stress responses were related to inexperience with BBN, fatigue, and giving bad versus good news. Poor communication performance in the consultation was related to high burnout and fatigue scores.

CONCLUSIONS

These results suggest that BBN was a stressful experience for doctors even in a simulated encounter, especially for those who were inexperienced and/or fatigued. Poor communication performance was related to burnout and fatigue, but not inexperience with BBN. These results likely indicate that burnout and fatigue contributed to stress and poor work performance in some doctors during the simulated BBN task.

Facilitating communication with patients for improved migraine outcomes

Effective communication is integral to good medical care. Medical professional groups, regulatory agencies, educators, researchers, and patients recognize its importance. Quality of medical communication is directly related to patient satisfaction, improvement in medication adherence, treatment compliance, other outcomes, decreased risk of malpractice, and increase in health care providers' levels of satisfaction. However, skill level and training remain problematic in this area. Fortunately, research has shown that medical communication skills can be successfully taught and acquired, and that improvement in communication skills improves outcomes. The American Migraine Communication Studies I and II evaluated the current state of health care provider-patient communication in headache care and tested a simple educational intervention. They found problematic issues but demonstrated that these areas could be improved. We review theoretical models of effective communication and discuss strategies for improving communication, including active listening, interviewing strategies, and methods for gathering information about headache-related impairment, mood, and quality of life.

Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life

Migraine can be characterized as a chronic disorder with episodic attacks and the potential for progression to chronic migraine. We conducted a PubMed literature search (January 1, 1970 through May 31, 2008) for studies on the impact of migraine, including disability, health-related quality of life (HRQoL), comorbidities, and instruments used by health care professionals to treat patients with migraine. Numerous studies have shown that migraine substantially impairs a person's functions during attacks and diminishes HRQoL during and between attacks. Despite its impact, migraine remains underestimated, underdiagnosed, and undertreated. Several tools are available to help physicians assess the impact of migraine on the daily activities and HRQoL of their patients, such as the 36-Item Short-Form Health Survey and the Headache Impact Test. Improving communication during the office visit through active listening, use of open-ended questions, and use of the "ask-tell-ask" strategy can also help in assessing migraine-related impairment. Together, these tools and communication techniques can lead to a more complete assessment of how migraine affects patients' lives and can aid in the development of the optimal treatment plan for each patient. Both pharmacotherapy (acute and preventive treatment strategies) and nonpharmacological therapies play important roles in the management of migraine.

Assessment of communication skills and self-appraisal in the simulated environment: feasibility of multirater feedback with gap analysis

INTRODUCTION

Multirater assessment is a powerful means of measuring communication skills. The use of gap analysis to assess self-appraisal is a strength of this technique. On the basis of Kalamazoo Consensus Statement framework and 360-degree assessment models, we developed a multirater instrument with gap analysis, with the goals of examining both communication skills and situational self-appraisal, and assessing the feasibility of the combined approach.

METHODS

The multirater communication skills instrument was used to assess Pediatric and Neonatal Intensive Care fellows after participation in seven simulated family meetings. Instrument reliability was determined using Cronbach's Alpha and Factorial Analysis. Correlations between rater groups were examined with Spearman's Rank Coefficient. Gap analyses and rater perceptions of the instruments were analyzed using descriptive statistics.

RESULTS

Seven pediatric intensive care unit and neonatal intensive care fellows were each assessed by 11 to 18 raters (108 total assessments). Correlations were identified between disciplinary groups within each encounter. Among the 7 fellows, 30 communication strengths or areas needing improvement and 24 significant gaps were identified, indicating self under-appraisals, 9 (38%) of which overlapped. The instrument was logistically feasible and well received.

CONCLUSIONS

Our multirater communication skills instrument with gap analysis proved useful in identifying areas of strength and areas needing improvement, and in highlighting areas of self over- and under-appraisal that require focused feedback. The use of multirater assessment with gap analysis, in a simulated and "safe" environment, may assist in the delivery of feedback to trainees.

Clinician-patient communication: a systematic review

GOAL OF WORK

The goal of this work was to identify methods of clinician-patient cancer-related communication that may impact patient outcomes associated with distress at critical points in the course of cancer care.

MATERIALS AND METHODS

A systematic review of practice guidelines, systematic reviews, or randomized trials on this topic was conducted. Guidelines for quality was evaluated using the Appraisal of Guidelines for Research and Evaluation Instrument, and the contributive value for recommendations was assessed. Systematic reviews and randomized trials were also evaluated for methodological rigor.

RESULTS

Four existing guidelines, eight systematic reviews and nine randomized trials were identified. Two of the guidelines were of high quality, and all systematic reviews reported clear search criteria and support for their conclusions; the randomized trials were of modest or low quality. For all situations and disease stages, guidelines consistently identified open, honest, and timely communication as important; specifically, there was evidence for a reduction in anxiety when discussions of life expectancy and prognosis were included in consultations. Techniques to increase patient participation in decision-making were associated with greater satisfaction but did not necessarily decrease distress. Few studies took cultural and religious diversity into account.

CONCLUSIONS

There is little definitive evidence supporting the superiority of one specific method for communicating information compared to another. Evidence regarding the benefit of decision aids or other strategies to facilitate better communication is inconsistent. Since patients vary in their communication preferences and desire for active participation in decision making, there is a need to individualize communication style.

The psychosocial transition associated with spontaneous 46,XX primary ovarian insufficiency: illness uncertainty, stigma, goal flexibility, and purpose in life as factors in emotional health

OBJECTIVE

To examine factors associated with emotional well-being in women with spontaneous primary ovarian insufficiency.

DESIGN

Cross-sectional and case-control study.

SETTING

Clinical research center, national U.S. health research facility.

PATIENT(S)

Women diagnosed with spontaneous 46,XX primary ovarian insufficiency (n = 100) at a mean age of 32.4 years and healthy control women of similar age (n = 60).

INTERVENTION(S)

Administration of validated self-reporting instruments.

MAIN OUTCOME MEASURE(S)

Illness uncertainty, stigma, goal disengagement/re-engagement, purpose in life, Positive and Negative Affect Schedule, Center of Epidemiologic Studies Depression Scale, State-Trait Anxiety Inventory.

RESULT(S)

Compared with controls, women with spontaneous primary ovarian insufficiency scored adversely on all measures of affect. Illness uncertainty and purpose in life were significant independent factors associated with anxiety (R(2) = 0.47), stigma and purpose in life were the significant independent factors associated with depression (R(2) = 0.51), and goal re-engagement and purpose in life were significantly and independently associated with positive affect (R(2) = 0.43).

CONCLUSION(S)

This evidence supports the need for prospective studies. Our findings are consistent with the hypothesis that clinicians could improve the emotional well-being of their patients with primary ovarian insufficiency by [1] informing them better about their condition, [2] helping them to feel less stigmatized by the disorder, and [3] assisting them in developing alternative goals with regard to family planning as well as other goals.

Using television shows to teach communication skills in internal medicine residency

BACKGROUND

To address evidence-based effective communication skills in the formal academic half day curriculum of our core internal medicine residency program, we designed and delivered an interactive session using excerpts taken from medically-themed television shows.

METHODS

We selected two excerpts from the television show House, and one from Gray's Anatomy and featured them in conjunction with a brief didactic presentation of the Kalamazoo consensus statement on doctor-patient communication. To assess the efficacy of this approach a set of standardized questions were given to our residents once at the beginning and once at the completion of the session.

RESULTS

Our residents indicated that their understanding of an evidence-based model of effective communication such as the Kalamazoo model, and their comfort levels in applying such model in clinical practice increased significantly. Furthermore, residents' understanding levels of the seven essential competencies listed in the Kalamazoo model also improved significantly. Finally, the residents reported that their comfort levels in three challenging clinical scenarios presented to them improved significantly.

CONCLUSION

We used popular television shows to teach residents in our core internal medicine residency program about effective communication skills with a focus on the Kalamazoo's model. The results of the subjective assessment of this approach indicated that it was successful in accomplishing our objectives.

Assessing students' communication skills: validation of a global rating

Communication skills training is an accepted part of undergraduate medical programs nowadays. In addition to learning experiences its importance should be emphasised by performance-based assessment. As detailed checklists have been shown to be not well suited for the assessment of communication skills for different reasons, this study aimed to validate a global rating scale. A Canadian instrument was translated to German and adapted to assess students' communication skills during an end-of-semester-OSCE. Subjects were second and third year medical students at the reformed track of the Charité-Universitaetsmedizin Berlin. Different groups of raters were trained to assess students' communication skills using the global rating scale. Validity testing included concurrent validity and construct validity: Judgements of different groups of raters were compared to expert ratings as a defined gold standard. Furthermore, the amount of agreement between scores obtained with this global rating scale and a different instrument for assessing communication skills was determined. Results show that communication skills can be validly assessed by trained non-expert raters as well as standardised patients using this instrument.

The effect of undergraduate education in communication skills: a randomised controlled clinical trial

PURPOSE

To determine whether students improve their communication skills as a result of supervised patient care and whether a newly implemented communication course could further improve these skills.

METHOD

We conducted a randomised, controlled trial including all participants of the first clinical treatment course (n = 26) between October 2006 and February 2007. Randomisation was balanced by gender and basic communication skills. The test group practised dentist-patient communication skills in small groups with role-plays and videotaped real patient interviews, whereas the control group learned in problem-based workshops both on a weekly basis. Before and after the interventions (two group pre- and post-design) all students conducted two interviews with simulated patients. The encounters were rated using a 10-item checklist derived from the Calgary-Cambridge Observation Guide I.

RESULTS

Repeated measures ANOVA (alpha = 0.05) showed a significant difference of the sum scores of the ratings between test and control group (P = 0.004). The participants educated in communication skills improved significantly (Delta = +14.9; P = 0.004), whereas in the control group no accretion of practical communication competence was observed (Delta = -3.9; P = 0.23).

CONCLUSION

It could be demonstrated that solely interacting with patients during a clinical treatment course did not inevitably improve professional communication skills. In contrast, implementation of a course in communication skills improved the practical competence in dentist-patient interaction.