Patient and visit characteristics related to physicians' participatory decision-making style. Results from the Medical Outcomes Study

Direct marketing of pharmaceuticals to consumers

Revised FDA regulations governing pharmaceutical companies' broadcast advertisements directed to consumers produced substantial increases in direct-to-consumer advertising (DTCA) expenditures. Proponents of DTCA claim it supports patient autonomy in the patient-physician relationship and has motivated some consumers to seek a physician's care for conditions they previously had not discussed with a doctor. However, DTCA's blend of promotion and information has produced more prescription drug awareness than knowledge--it has been largely ineffective in educating patients with medical conditions about the medications for those conditions. The evidence for DTCA's increase in pharmaceutical sales is as impressive as is the lack of evidence concerning its impact on the health of the public. Broadcast advertisements are too brief to include extensive technical information; consequently, the impact of FDA regulations to assure a fair balance of risk and benefit in DTCA is still being assessed.

Is GP-patient communication related to their perceptions of illness severity, coping and social support?

The aim of the study was to explore the relationship between the communicative behaviour of general practitioner and patient on the one hand and the perception of the coping behaviour of the patient, the severity of the complaint and the presence of social support on the other hand. From 20 general practitioners (GP), 15 consultations per GP were videotaped and analysed using the Roter Interaction Analysis System. Doctors and patients rated their perceptions on questionnaires. The finding was that doctors and patients used predominantly task-oriented (instrumental) behaviour, with some exceptions. With older patients and patients with low social support the GPs used more affective communication, mainly consisting of social talk and mutual agreement. In the case of complex problems, the GP paid special attention to the relationship with the patient. Within the domain of instrumental communication, some differences between doctor and patient were observed. Although doctors and patients exchanged a lot of information about medical issues, patients gave information about their lifestyle and emotions, which the doctors did not verbally explore. In consultations where the patient perceived the complaint as severe, he or she was more focussed on the medical content. When the GP considered psychosocial issues important, doctor and patient communicated about lifestyle, emotions and social relations. This doctor-patient correlation was not found when patients perceived their problem as psychosocial.

Psychosocial treatment research with ethnic minority populations: ethical considerations in conducting clinical trials

Because of historical mistreatment of ethnic minorities by research and medical institutions, it is particularly important for researchers to be mindful of ethical issues that arise when conducting research with ethnic minority populations. In this article, we focus on the ethical issues related to the inclusion of ethnic minorities in clinical trials of psychosocial treatments. We highlight 2 factors, skepticism and mistrust by ethnic minorities about research and current inequities in the mental health care system, that researchers should consider when developing psychosocial interventions studies that include ethnic minorities.

Implementation of consultative geriatric recommendations: the role of patient-primary care physician concordance

OBJECTIVES

To examine the effect on primary care physicians' implementation and their patients' adherence behaviors of patient-physician concordance about recommended geriatric health care.

DESIGN

Case-series, independent interviews of patients and their physicians about their perceptions of the patients' health and the comprehensive geriatric assessment (CGA).

SETTING

Community.

PARTICIPANTS

Community-dwelling older patients (n = 111) who received consultative outpatient CGA and their primary care physicians.

MEASUREMENTS

Concordance variables were generated using physician and patient responses to 10 questions on health- and CGA-related perceptions. An overall concordance score was generated by summing the total number of items on which patients and physicians agreed. Measures of the two dependent variables (physician implementation of and patient adherence to CGA recommendations) were by self-report.

RESULTS

In multiple logistic regression analyses, overall concordance between patient and physician proved to be a significant and powerful predictor of physician implementation of (adjusted odds ratio (OR) = 2.7, 95% confidence interval (CI) = 1.6-4.6, P <.001) and patient adherence to (OR = 2.7, 95% CI = 1.7-4.2, P <.001) CGA recommendations, controlling for patient and physician gender and age, patients' functional status, duration of the patient-physician relationship, and frequency of visits in the previous year. Further analysis revealed that mutual patient-physician concordance on health-related perceptions was a significant predictor of these outcomes, whereas individual patient or physician perceptions were not.

CONCLUSION

Concordance between older patients and their primary care physicians is a powerful predictor of physician implementation of and patient adherence to outpatient consultative CGA recommendations. Future research should focus on ways physicians can assess and negotiate patient-physician agreement on geriatric healthcare recommendations.

Measuring health care quality: comparing and contrasting the medical and the marketing approaches

Health care quality, a key concept for medical practice and research, is also a widely used construct in health care administration and marketing research. We explored discipline-specific differences in the definition of quality, with the intent of finding a more unified approach. We summarized definitions and basic conceptual approaches to quality in both disciplines and then compared them on several attributes: basic goals, sources of measurement, role of patient perceptions, role of health care personnel, and need for risk adjustment. We developed a conceptual model combining the 2 approaches. Both disciplines could benefit from broadening their outcome measures. Patient satisfaction deserves more attention from medical researchers, whereas marketing approaches should go beyond using patient satisfaction as the only outcome of interest. It is conceptually feasible to integrate medical and marketing approaches to quality, with important insights resulting from this integration.

Designing and evaluating interventions to eliminate racial and ethnic disparities in health care

A large number of factors contribute to racial and ethnic disparities in health status. Health care professionals, researchers, and policymakers have believed for some time that access to care is the centerpiece in the elimination of these health disparities. The Institute of Medicine's (IOM) model of access to health services includes personal, financial, and structural barriers, health service utilization, and mediators of care. This model can be used to describe the interactions among these factors and their impact on health outcomes and equity of services among racial and ethnic groups. We present a modified version of the IOM model that incorporates the features of other access models and highlights barriers and mediators that are relevant for interventions designed to eliminate disparities in U.S. health care. We also suggest that interventions to eliminate disparities and achieve equity in health care services be considered within the broader context of improving quality of care. Some health service intervention studies have shown improvements in the health of disadvantaged groups. If properly designed and implemented, these interventions could be used to reduce health disparities. Successful features of interventions include the use of multifaceted, intense approaches, culturally and linguistically appropriate methods, improved access to care, tailoring, the establishment of partnerships with stakeholders, and community involvement. However, in order to be effective in reducing disparities in health care and health status, important limitations of previous studies need to be addressed, including the lack of control groups, nonrandom assignment of subjects to experimental interventions, and use of health outcome measures that are not validated. Interventions might be improved by targeting high-risk populations, focusing on the most important contributing factors, including measures of appropriateness and quality of care and health outcomes, and prioritizing dissemination efforts.

The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management

OBJECTIVE

Patients' self-management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient-physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient-physician interaction styles on patients' diabetes self-management. This study assessed the influence of patients' evaluation of their physicians' participatory decision-making style, rating of physician communication, and reported understanding of diabetes self-care on their self-reported diabetes management.

DESIGN

We surveyed 2,000 patients receiving diabetes care across 25 Veterans' Affairs facilities. We measured patients' evaluation of provider participatory decision making with a 4-item scale (Provider Participatory Decision-making Style [PDMstyle]; alpha = 0.96), rating of providers' communication with a 5-item scale (Provider Communication [PCOM]; alpha = 0.93), understanding of diabetes self-care with an 8-item scale (alpha = 0.90), and patients' completion of diabetes self-care activities (self-management) in 5 domains (alpha = 0.68). Using multivariable linear regression, we examined self-management with the independent associations of PDMstyle, PCOM, and Understanding.

RESULTS

Sixty-six percent of the sample completed the surveys (N = 1,314). Higher ratings in PDMstyle and PCOM were each associated with higher self-management assessments (P < .01 in all models). When modeled together, PCOM remained a significant independent predictor of self-management (standardized beta: 0.18; P < .001), but PDMstyle became nonsignificant. Adding Understanding to the model diminished the unique effect of PCOM in predicting self-management (standardized beta: 0.10; P =.004). Understanding was strongly and independently associated with self-management (standardized beta: 0.25; P < .001).

CONCLUSION

For these patients, ratings of providers' communication effectiveness were more important than a participatory decision-making style in predicting diabetes self-management. Reported understanding of self-care behaviors was highly predictive of and attenuated the effect of both PDMstyle and PCOM on self-management, raising the possibility that both provider styles enhance self-management through increased patient understanding or self-confidence.

Deconstructing patient centred communication and uncovering shared decision making: an observational study

BACKGROUND

Patient centred communication (PCC) has been described as a method for doctor-patient communication. The principles of shared decision making (SDM) have been proposed more recently.

AIMS

This study aimed to examine PCC and SDM empirically with respect to their mutual association, the variation in practitioners' working styles, and the associations with patient characteristics.

METHODS

Sixty general practitioners recruited 596 adult patients who gave written consent to have their consultations videotaped. The tapes were assessed by two researchers, using a standardised instrument for global communication. For the purpose of this exploratory study, scales for PCC and SDM were based on subsamples of items in the MAAS.

RESULTS

The scales for PCC and SDM were weakly associated (Pearson correlation: 0.25). Physicians varied more on SDM than on PCC. The intracluster correlation of the PCC and SDM scales were, respectively, 0.34 and 0.19. However, hypotheses regarding associations with patient characteristics were not confirmed. Neither PCC nor SDM scores were related to patient gender, education, age, functional health status or existence of chronic conditions.

CONCLUSION

The study provides evidence that PCC and SDM can be differentiated and comprise approaches to communication between clinicians and patients which may be more clearly distinguished by further focused research and training developments.

Physician gender effects on preventive screening and counseling: an analysis of male and female patients' health care experiences

BACKGROUND

Studies have documented that patients of female physicians receive higher levels of preventive services. However, most studies include patients of only one gender, examine mainly gender-specific screening services, and do not examine patient education and counseling.

OBJECTIVES

This study tests both physician- and patient-gender effects on screening and counseling services received in the past year and considers effects of gender-matched patient-physician pairs.

RESEARCH DESIGN

Multivariate analyses are conducted to assess direct and interactive (physician x patient) gender effects and to control for important covariates.

SUBJECTS

Data are from the 1998 Commonwealth Fund Survey of Women's Health, a nationally representative sample of U.S. adults. The analytic sample includes 1,661 men and 1,288 women ages 18 and over.

MEASURES

Dependent variables are measures of patient-reported screening and counseling services received, including gender-specific and gender-nonspecific services and counseling on general health habits and sensitive topics.

RESULTS

Female physician gender is associated with a greater likelihood of receiving preventive counseling for both male and female patients. For female patients, there is an increased likelihood of receiving more gender-specific screening (OR = 1.36, P <0.05) and counseling (OR = 1.40, P <0.05). These analyses provide no evidence that gender-matched physician-patient pairs provide an additional preventive care benefit beyond the main effect of female physician gender.

CONCLUSIONS

Female physician gender influences the provision of both screening and counseling services. These influences may reflect physicians' practice and communication styles as well as patients' preferences and expectations.

The effects of patient communication skills training on the discourse of older patients during a primary care interview

OBJECTIVES

To test the effects of a communication skills training intervention on older patients' discourse during a primary care interview.

DESIGN

A quasi-experimental design involving two intervention conditions.

SETTING

The Family Practice Center of a university-based clinic.

PARTICIPANTS

Thirty-three patients averaging age 72 and 9 family practice physicians.

INTERVENTION

A communication skills training booklet received approximately 3 days before the scheduled appointment and a 30-minute face-to-face follow-up session before seeing the physician.

MEASUREMENTS

Patients' seeking, providing, and verifying of information were coded from transcripts of the 33 interviews.

RESULTS

Trained patients engaged in significantly more seeking and providing of information than untrained patients. Additionally, trained patients obtained significantly more information from physicians than did untrained patients, both in terms of the number of total information units and the number of units per question asked.

CONCLUSION

Patient communication skills training appears to be an effective means of enhancing patients' participation in the medical interview without increasing the overall length of the interview.

Relationship of disability prevention to patient health status and satisfaction with primary care provider

A sample of 625 patients aged 18 to 65 with primary care visits was used to explore the relationship of disability prevention to patient health status and satisfaction with health care provider. Disability prevention and the patient-provider relationship, the latter a potential mediating factor, were measured using reliable and valid scales. The joint effects of disability prevention and a strong patient-provider relationship were associated with decreased risks for poor physical health, as measured by the Medical Outcomes Study 12-item short-form health survey, decreased restricted activity days, and overall satisfaction with their primary care provider. Patient-provider relationship was independently associated with increased patient satisfaction with the provider overall and endorsement of the provider to family or friends. The evidence questions the conventional wisdom among some primary care providers that incorporating disability prevention principles into their daily practice jeopardizes patient satisfaction. These results suggest that primary care providers with strong patient-provider relationships can successfully add disability prevention to their practice.

Panel-based pain management in primary care. a pilot study

Although pain is an extremely common symptom presenting to primary care physicians, it frequently is not optimally managed. The purpose of this feasibility study was to develop and pilot-test an efficient, rapid assessment and management approach for pain in busy community practices. The intervention utilized the Dartmouth COOP Clinical Improvement System (DCCIS) and a telephone-based, nurse-educator intervention. Patients from four primary care practices in rural New Hampshire and Vermont were screened by mail for the presence of persistent pain. Patients with mild to severe pain were randomized to either the usual care control group (n = 383) or the intervention group (n = 320). Patients who reported pain but no psychosocial problems received a summary of identified problems and targeted educational material via mail (DCCIS). Patients who reported pain and psychosocial problems received the DCCIS intervention and calls from a nurse-educator who provided pain self-management strategies and a problem-solving approach for psychosocial problems. Post-treatment evaluation revealed that patients in the intervention group scored significantly better on the Pain, Physical, Emotional, and Social subscales of the SF-36 and on the total score of the Functional Interference Scale, as compared to a usual care control group. Feasibility and acceptability of the approach were demonstrated; however, the conclusions based on analyses of the post-treatment outcomes were tempered by baseline imbalances across groups.

What do women want? Women's experiences of infertility treatment

Finnish women's experiences of infertility treatment were investigated by examining their satisfaction and dissatisfaction, and their most positive and negative experiences with the treatment. Three hundred and forty four (16%) out of the 2,189 women respondents to a 1994 postal survey (response rate 74%) had experienced difficulties in having a baby. Two-thirds had sought medical help, generally from private gynaecologists. Less than half of the women were satisfied with the infertility treatment, expressing less satisfaction than is generally found among health care clients. Dissatisfied women were more often 35-39 years of age, in treatment during the study period, in treatment in public clinics and not successful in having a baby. However, about one-third of the women were unsure about or did not give their opinion in regard to satisfaction. The subsequent birth of a baby was the most common reason for satisfaction. The most positive treatment experience was respectful, empathic and personal care from the doctor. Unsatisfactory encounters with health care personnel were the main reasons for dissatisfaction and were most often cited as the most negative treatment experience. This dissatisfaction could reflect relatively young and healthy women's assertive attitudes toward infertility care services in the context of the intimacy and vulnerability of childlessness.

Current perspectives on patient education in the US

Patient education has evolved from its medically-dominated and narrow origin in patient teaching to support of patient empowerment in interpersonal, organizational, and policy domains relevant to health. This essay reflects on both the historical and contemporary context of patient education in the US and explores implications of the empowerment movement on new initiatives and directions in patient education. By using diabetes education as an exemplar, innovations in patient activation and empowerment are explored and future directions and challenges to the field are considered.

Essential elements of communication in medical encounters: the Kalamazoo consensus statement

In May 1999, 21 leaders and representatives from major medical education and professional organizations attended an invitational conference jointly sponsored by the Bayer Institute for Health Care Communication and the Fetzer INSTITUTE: The participants focused on delineating a coherent set of essential elements in physician-patient communication to: (1) facilitate the development, implementation, and evaluation of communication-oriented curricula in medical education and (2) inform the development of specific standards in this domain. Since the group included architects and representatives of five currently used models of doctor-patient communication, participants agreed that the goals might best be achieved through review and synthesis of the models. Presentations about the five models encompassed their research base, overarching views of the medical encounter, and current applications. All attendees participated in discussion of the models and common elements. Written proceedings generated during the conference were posted on an electronic listserv for review and comment by the entire group. A three-person writing committee synthesized suggestions, resolved questions, and posted a succession of drafts on a listserv. The current document was circulated to the entire group for final approval before it was submitted for publication. The group identified seven essential sets of communication tasks: (1) build the doctor-patient relationship; (2) open the discussion; (3) gather information; (4) understand the patient's perspective; (5) share information; (6) reach agreement on problems and plans; and (7) provide closure. These broadly supported elements provide a useful framework for communication-oriented curricula and standards.

Measuring the involvement of patients in shared decision-making: a systematic review of instruments

We wanted to determine whether research instruments exist which focus on measuring to what extent health professionals involve patients in treatment and management decisions. A systematic search and appraisal of the relevant literature was conducted by electronic searching techniques, snowball sampling and correspondence with field specialists. The instruments had to concentrate on assessing patient involvement in decision-making by observation techniques (either direct or using audio or videotaped data) and contain assessments of the core aspects of 'involvement', namely evidence of patients being involved (explicitly or implicitly) in decision-making processes, a portrayal of options and a decision-making or deferring stage. Eight instruments met the inclusion criteria. But we did not find any instruments that had been specifically designed to measure the concept of 'involving patients' in decisions. The results reveal that little attention has been given to a detailed assessment of the processes of patient involvement in decision-making. The existing instrumentation only includes these concepts as sub-units within broader assessments, and does not allow the construct of patient involvement to be measured accurately. Instruments developed to measure 'patient-centeredness' are unable to provide enough focus on 'involvement' because of their attempt to cover so many dimensions. The concept of patient involvement (shared decision-making; informed collaborative choice) is emerging in the literature and requires an accurate method of assessment.

Does physician gender affect satisfaction of men and women visiting the emergency department?

OBJECTIVE

To assess the association of physician gender with patient ratings of physician care.

DESIGN

Interviewer-administered survey and follow-up interviews 1 week after emergency department (ED) visit.

SETTING

Public hospital ED.

PATIENTS/PARTICIPANTS

English- and Spanish-speaking adults presenting for care of nonemergent problems; of 852 patients interviewed in the ED who were eligible for follow-up, 727 (85%) completed a second interview.

MEASUREMENTS AND MAIN RESULTS

We conducted separate ordered logistic regressions for women and men to determine the unique association of physician gender with patient ratings of 5 interpersonal aspects of care, their trust of the physician, and their overall ratings of the physician, controlling for patient age, health status, language and interpreter status, literacy level, and expected satisfaction. Female patients trusted female physicians more (P =.003) than male physicians and rated female physicians more positively on the amount of time spent (P =.01), on concern shown (P =.04), and overall (P =.03). Differences in ratings by female patients of male and female physicians in terms of friendliness (P =.13), respect shown (P =.74), and the extent to which the physician made them feel comfortable (P =.10) did not differ significantly. Male patients rated male and female physicians similarly on all dimensions of care (overall, P =.74; friendliness, P =.75; time spent, P =.30; concern shown, P =.62; making them feel comfortable, P =.75; respect shown, P =.13; trust, P =.92).

CONCLUSIONS

Having a female physician was positively associated with women's satisfaction, but physician gender was not associated with men's satisfaction. Further studies are needed to identify reasons for physician gender differences in interpersonal care delivered to women.

Physicians' assessments of their ability to provide high-quality care in a changing health care system

BACKGROUND

With the growth of managed care, there are increasing concerns but inconclusive evidence regarding deterioration in the quality of medical care.

OBJECTIVES

To assess physicians' perceptions of their ability to provide high-quality care and explore what factors, including managed care, affect these perceptions.

RESEARCH DESIGN

Bivariate and multivariate analyses of the Community Tracking Study Physician Survey, a cross-sectional, nationally representative telephone survey of 12,385 patient-care physicians conducted in 1996/1997. The response rate was 65%.

PARTICIPANTS

Physicians who provide direct patient care for > or =20 h/wk, excluding federal employees and those in selected specialties.

MEASURES

Level of agreement with 4 statements: 1 regarding overall ability to provide high-quality care and 3 regarding aspects of care delivery associated with quality.

RESULTS

Between 21% and 31% of physicians disagreed with the quality statements. Specialists were generally 50% more likely than primary care physicians to express concerns about their ability to provide quality care. Generally, the number of managed care contracts, but not the percent of practice revenue from managed care, was negatively associated with perceived quality. Market-level managed care penetration independently affected physicians' perceptions. Practice setting affected perceptions of quality, with physicians in group settings less likely to express concerns than physicians in solo and 2-physician practices. Specific financial incentives and care management tools had limited positive or negative associations with perceived quality.

CONCLUSIONS

Managed care involvement is only modestly associated with reduced perceptions of quality among physicians, with some specific tools enhancing perceived quality. Physicians may be able to moderate some negative effects of managed care by altering their practice arrangements.

Impact of the physician's participatory style in asthma outcomes and patient satisfaction

OBJECTIVES

To identify factors associated with asthma patients' perceptions of the propensity of pulmonologists to involve them in treatment decision-making, and its association with asthma outcomes.

DESIGN

Cross-sectional observational study performed from June 1995 to December 1997.

SETTING

Pulmonary unit of a university teaching hospital.

PATIENTS

Adult patients with asthma (n = 128).

MEASUREMENTS AND RESULTS

By patient self-report, mean physician's participatory decision-making (PDM) style score was 72 (maximum 100, 95% CI 65, 79). PDM scores were significantly correlated (P < .0001) with the duration of clinic visits (r = .63), patient satisfaction (r = .53), duration of tenure of doctor-patient relationship (r = .37), and formal education (r = .22, P = .023). Significantly higher PDM style scores were reported when visits lasted longer than 20 minutes and when a patient had a >6-month relationship with a particular doctor. PDM scores were also significantly correlated with possession of a written asthma action plan (r = .54, P < .0001), days affected by asthma (r = .36, P = .0001), asthma symptoms (r = .23, P = .017), and preferences for autonomy in asthma management decisions (r = .28, P = .0035). Those with PDM scores <50 reported significantly lower quality of life for all domains of a disease-specific instrument and the Short-Form 36 health survey version 1.0. In multiple regression analysis, PDM style was associated with the length of the office visit and the duration of tenure of the physician-patient relationship (R2 = 0.47, P = .0009). The adjusted odds ratio, per standard deviation decrease in PDM scores, for an asthma hospitalization was 2.0 (95% CI 1.2, 3.2) and for rehospitalization was 2.5 (95% CI 1.2, 4.2).

CONCLUSIONS

Patients' report of their physician's PDM style is significantly associated with health-related quality of life, work disability, and recent need for acute health services. Organizational factors, specifically longer visits and more time seeing a particular physician, are independently associated with more participatory visits. This has significant policy implications for asthma management.

Patient preferences for autonomy in decision making in asthma management

BACKGROUND

Lower patient preferences for autonomy in management decision making during asthma exacerbations have been associated with an increased risk for future hospital admissions. We sought to examine patient preferences for asthma self-management autonomy, and the clinical and psychosocial factors associated with autonomy preferences.

METHODS

A cross sectional observational study was performed with data collected between June 1995 and December 1997 of 212 adult patients with moderate to severe asthma managed, at least in part, at two teaching hospitals. Subjects completed a survey of autonomy preferences, quality of life, clinical morbidity and health service use, asthma knowledge, self-efficacy, coping styles, and psychosocial measures.

RESULTS

Patients preferred clinicians to assume the major role in most decision making about their management. However, patients wished to remain in control in choosing when to seek care and wanted to share decisions regarding initiating changes in medications during a moderate exacerbation. Multiple regression analysis showed that concerns about adverse effects of medications, education level, an active coping style, perceptions of the propensity of physicians to involve them in treatment decision making, and concerns about costs causing delays in seeking medical care were associated with preferences for autonomy in decision making. Autonomy preferences were not related to measures of concurrent clinical asthma control or health related quality of life.

CONCLUSIONS

In a group of patients with moderate to severe asthma, a high proportion of whom were from socioeconomically disadvantaged backgrounds, education level, perceived physician behaviour, cost barriers to care, and psychosocial factors (but not clinical asthma control or management) were related to patient preferences for autonomy in management decision making during asthma exacerbations. This has implications for asthma action plans and design of self-management programmes.

Loyalty to the regular care provider: patients' and physicians' views

BACKGROUND

Changes in the organization of primary care practices are likely to have repercussions on the manner in which patients and physicians perceive loyalty to a regular source of care. A better understanding of their views will contribute to conceptual reflections on this poorly documented topic and, where needed, will reinforce efforts to adapt services to patient expectations.

OBJECTIVES

The aims of this study are to document and compare the views that patients and GPs have of loyalty to the regular care provider.

METHODS

This exploratory study uses the focus group technique. In 1997, we set up three groups of patients and three groups of physicians practising in Montreal. A total of 23 patients and 14 physicians participated in the study. The meetings investigated the participants' points of view on various aspects of the notion of loyalty. Analysis was based on transcripts of the meetings. The emerging themes were identified and the viewpoints were coded independently and then revised (when necessary) in order to obtain a consensus.

RESULTS

Patients and physicians have a relatively congruent vision of the notion of loyalty. This tendency to use the regular source of care over time appears to be rooted in a formal or informal contract between patients and their physicians and implies a sustained partnership and a strong interpersonal relationship. The relationship established is neither exclusive nor permanent. Patients periodically reconsider it by evaluating their physician's technical and interpersonal skills.

CONCLUSIONS

This study highlights the dynamic and multidimensional nature of the notion of loyalty. It shows that patients clearly identify with a particular physician rather than a clinic. The results challenge the prevailing methods of assessing longitudinality of care.

Physician-patient communication in HIV disease: the importance of patient, physician, and visit characteristics

BACKGROUND

Although previous work that considered a variety of chronic conditions has shown that higher quality physician-patient communication care is related to better health outcomes, the quality of physician-patient communication itself for patients with HIV disease has not been well studied.

OBJECTIVE

To determine the relationship of patient, visit, physician, and physician practice characteristics to two measures of physician-patient communication for patients with HIV disease.

DESIGN

Cross-sectional survey of physicians and patients.

SETTING

Cohort study enrolling patients from throughout eastern Massachusetts.

STUDY SUBJECTS

264 patients with HIV disease and their their primary HIV physicians (n = 69).

MEASUREMENTS

Two measures of physician-patient communication were used, a five-item general communication measure (Cronbach's alpha = 0.93), and a four-item HIV-specific communication measure that included items about alcohol, drug use, and sexual behaviors (Cronbach's alpha = 0.92).

RESULTS

The mean age of patients was 39. 5 years, 24% patients were women, 31.1% were nonwhite, and 52% indicated same-sex contact as their principal HIV risk factor. The mean age of physicians was 39.1 years, 33.3% were female, 39.7% were specialists, and 25.0% self-identified as gay, lesbian, or bisexual. In multivariable models relating patient and visit characteristics to general communication, longer reported visit length (p<.0001), longer duration of the physician-patient relationship (p =.02), and female gender (p =.04) were significantly associated with better communication. The interaction of patient gender and visit length was also significant (p =.02); longer visit length was more strongly associated with better general communication for male than female patients. In similar models relating patient and visit characteristics to HIV-specific communication, longer visit length (p <.0001) and less advanced disease stage (p =.009) were associated with better communication. In multivariable models relating physician and practice characteristics to general communication no variables were significant. However, both female physician gender (p =.002) and gay/lesbian/bisexual sexual preference (p =.003) were significantly associated with better HIV-specific communication.

CONCLUSIONS

In this study, female and homosexual physicians provided higher quality HIV-specific communication than male and heterosexual physicians. Better understanding the processes by which female and homosexual physicians achieve higher quality communication may help other physicians communicate more effectively. Health care providers and third-party payers should be aware that shorter visits may compromise physician-patient communication, and that this effect may be more consequential for male patients.

Facilitating participatory decision-making: what happens in real-world community practice?

BACKGROUND

Participatory decision-making (PDM), a widely held ideal, depends on physician facilitation of patient participation. However, little is known about how PDM facilitation is actualized in outpatient primary care.

OBJECTIVES

The objective of this study was to describe the prevalence of physician facilitation of PDM in community family practices and associated physician, patient, and visit characteristics.

RESEARCH DESIGN

This was a cross-sectional observational study.

SUBJECTS

The study included 3,453 patients seen by 138 family physicians in 84 community practices.

MAIN OUTCOME MEASURES

Research nurses directly observed PDM facilitation in consecutive adult outpatient visits. The association between PDM facilitation and patient, physician, and visit characteristics was assessed with multilevel multivariable regression.

RESULTS

PDM facilitation occurred during 25% of observed patient visits. Rates varied considerably among physicians, from 0% to 79% of visits. Patient satisfaction was not associated with PDM facilitation. In multivariable analyses, employed physicians, chronic illness visits, longer visit duration, and visits involving referral were independently associated with PDM facilitation. Visits in which greater time was spent planning treatment and conducting health education were also more likely to involve facilitation of PDM.

CONCLUSIONS

Community family physicians facilitate PDM at highly variable rates but focus it on patients with the greatest medical needs and most complex levels of decision making. This selective approach appears to meet patient expectations, because PDM facilitation and patient satisfaction are not associated. If patient participation is to be more widely incorporated into outpatient primary care, it must be addressed within the complexity and multiple demands of community practice.

Contract medicine arrangements in Hong Kong: an example of risk-bearing provider networks in an unregulated environment

It is increasingly common in Hong Kong and elsewhere for employers to contract directly with physician networks to provide medical services to employees. These contracts are known in Hong Kong as contract medicine arrangements. In other countries and areas, managed care organizations are generally required by regulation or legislation to ensure that services of adequate quality are provided to patients who are locked in to network providers. There are no such requirements in Hong Kong and concerns have been raised about potential quality and cost trade-offs in contract medicine arrangements. Satisfaction surveys were sent to contract medicine enrollees in one large company in Hong Kong. The response rate was 30% and analysis of non-respondent data shows that respondents were representative of their group. Comparison of satisfaction using logistic regression showed that risk-bearing networks paid by capitation had consistently lower satisfaction ratings across all major dimensions including access, interpersonal care, communication with the doctor, choice of doctor, and outcomes. These findings suggest that quality, at least as perceived by the patient, may be lower in these networks. The issue is of concern in Asia where infrastructures and data systems are not well developed to adequately monitor quality of care or protect patient interests. This study highlights the need to structure pre-paid provider networks and managed care organizations so that quality of care is not compromised. At a time when managed care concepts are being applied throughout Asia, we believe attention needs to be drawn to this problem.

The work lives of women physicians results from the physician work life study. The SGIM Career Satisfaction Study Group

OBJECTIVE

To describe gender differences in job satisfaction, work life issues, and burnout of U.S. physicians.

DESIGN/PARTICIPANTS

The Physician Work life Study, a nationally representative random stratified sample of 5,704 physicians in primary and specialty nonsurgical care (N = 2,326 respondents; 32% female, adjusted response rate = 52%). Survey contained 150 items assessing career satisfaction and multiple aspects of work life.

MEASUREMENTS AND MAIN RESULTS

Odds of being satisfied with facets of work life and odds of reporting burnout were modeled with survey-weighted logistic regression controlling for demographic variables and practice characteristics. Multiple linear regression was performed to model dependent variables of global, career, and specialty satisfaction with independent variables of income, time pressure, and items measuring control over medical and workplace issues. Compared with male physicians, female physicians were more likely to report satisfaction with their specialty and with patient and colleague relationships (P <.05), but less likely to be satisfied with autonomy, relationships with community, pay, and resources (P <.05). Female physicians reported more female patients and more patients with complex psychosocial problems, but the same numbers of complex medical patients, compared with their male colleagues. Time pressure in ambulatory settings was greater for women, who on average reported needing 36% more time than allotted to provide quality care for new patients or consultations, compared with 21% more time needed by men (P <.01). Female physicians reported significantly less work control than male physicians regarding day-to-day aspects of practice including volume of patient load, selecting physicians for referrals, and details of office scheduling (P <.01). When controlling for multiple factors, mean income for women was approximately $22,000 less than that of men. Women had 1.6 times the odds of reporting burnout compared with men (P <.05), with the odds of burnout by women increasing by 12% to 15% for each additional 5 hours worked per week over 40 hours (P <.05). Lack of workplace control predicted burnout in women but not in men. For those women with young children, odds of burnout were 40% less when support of colleagues, spouse, or significant other for balancing work and home issues was present.

CONCLUSIONS

Gender differences exist in both the experience of and satisfaction with medical practice. Addressing these gender differences will optimize the participation of female physicians within the medical workforce.

Relation of gender and health insurance to cardiovascular procedure use in persons with progression of chronic renal disease

BACKGROUND

Women often are less likely than men to receive diagnostic and therapeutic invasive procedures for coronary disease.

OBJECTIVE

To examine the relation between gender, health insurance, and access to cardiovascular procedures over time in persons with chronic illness.

RESEARCH DESIGN

Seven-year longitudinal analyses in a cohort from the United States Renal Data System.

SUBJECTS

National random sample of women and men who progressed to end-stage renal disease (ESRD) in 1986 to 1987 and were treated at 303 dialysis facilities (n = 4,987).

MEASURES

Medical history and utilization records, physical examination, and laboratory data.

MAIN OUTCOME MEASURES

Receipt of a coronary catheterization or revascularization procedure before (baseline) and after (follow-up) the development of ESRD and acquisition of Medicare, adjusted for clinical and socioeconomic variables.

RESULTS

At baseline, 5.2% of women and 9.2% of men had undergone a cardiac procedure; the odds of women receiving a procedure were one third lower than for men (adjusted odds ratio 0.66 [95% CI 0.49-0.88]). During follow-up, women were just as likely as men to undergo a procedure (adjusted odds ratio 0.94 [95% CI 0.74-1.20]). Compared with men with baseline private insurance, men and women with other and no insurance had 34% to 81% lower odds of receiving procedures at baseline. Women with private insurance had 42% lower odds of having a procedure at baseline compared with men (adjusted odds ratio 0.58 [95% CI 0.42-0.78]) but had the same odds at follow-up (adjusted odds ratio 1.09 [95% CI 0.82-1.45]). At follow-up, gender differences in procedure use were eliminated for groups with baseline Medicaid or no insurance.

CONCLUSIONS

Overall gender differences in cardiac procedure use were narrowed markedly after progression of a serious illness, the assurance of health insurance, and entry into a comprehensive care system. Gender disparities in procedure use for different baseline insurance groups were largely equalized in follow-up. These findings suggest that provision of insurance with disease-managed care for a chronic disease can provide equalized access to care for women.

The effect of patient race and socio-economic status on physicians' perceptions of patients

Despite its potential influence on quality of care, there has been little research on the way physicians perceptions of and beliefs about patients are affected by patient race or socio-economic status. The lack of research in this area creates a critical gap in our understanding of how patients' demographic characteristics influence encounter characteristics, diagnoses, treatment recommendations, and outcomes. This study uses survey data to examine the degree to which patient race and socio-economic status affected physicians' perceptions of patients during a post-angiogram encounter. A total of 842 patient encounters were sampled, out of which 193 physicians provided data on 618 (73%) of the encounters sampled. The results of analyses of the effect of patient race and SES on physician perceptions of and attitude towards patients, controlling for patient age, sex, race, frailty/sickness, depression, mastery, social assertiveness and physician characteristics, are presented. These results supported the hypothesis that physicians' perceptions of patients were influenced by patients' socio-demographic characteristics. Physicians tended to perceive African-Americans and members of low and middle SES groups more negatively on a number of dimensions than they did Whites and upper SES patients. Patient race was associated with physicians' assessment of patient intelligence, feelings of affiliation toward the patient, and beliefs about patient's likelihood of risk behavior and adherence with medical advice; patient SES was associated with physicians' perceptions of patients' personality, abilities, behavioral tendencies and role demands. Implications are discussed in terms of further studies and potential interventions.

The influence of older patient-physician communication on health and health-related outcomes

Effective patient-physician communication significantly influences health outcomes of older patients. For example, concordance between patient and physician expectations and patient participation in the decision-making process affects older patients. Communication is also linked to patient recall, adherence, and satisfaction. Furthermore, communication impacts emotional and physical outcomes of older patients, although evidence of improved physical outcomes remains under-investigated in this population. Dimensions of communication, such as continuity of relationship, seem to be important in decreasing hospitalization of older patients. This article explores the link between communication and health care outcomes in the older population.

The outpatient medical encounter and elderly patients

There is little evidence of systematic negative bias against older patients in medical visits. The nature of the current narrative review, largely based on studies conducted after 1985, is consistent with the author's previous metaanalysis of over 40 studies published between 1965 and 1985. In that review, based on videotapes or audiotapes of medical visits, consistent relationships between patient age and physicians' interviewing skills were found. Older patients received more information, more total communication and questions concerning drugs, more courtesy, and perhaps more formality reflected in less laughter and joking than younger patients. Ultimately, the subtle ageism that may be present in medical visits with older patients is probably balanced somewhat by communication advantages afforded them challenging the negative views of older patients' care prevalent in the literature. This balance may help explain the ubiquitous finding that older patients are more satisfied with their health care, despite poorer health status, than younger patients. Nevertheless, other patients, especially those in the oldest cohorts, are at high risk for passive relationships and communication complications related to low literacy and poor health status and deserve the attention and special consideration of providers and health service researchers.

Patient participation in medical decision-making: a French study in adjuvant radio-chemotherapy for early breast cancer

BACKGROUND

Shared decision-making is increasingly advocated as an ideal model. However, very few studies have tested the feasibility of giving patients the opportunity to participate in the choice of treatment.

PATIENTS AND METHODS

Women, with non-metastatic breast cancer, eligible for non-intensified adjuvant chemotherapy attending our hospital were proposed two administrations of chemotherapy and radiotherapy: a sequential and a concomitant one. Two patient-questionnaires were used to elicit motivations for their choice and their degree of comfort with the process of decision-making and one questionnaire to test physicians' ability to predict patients' choice.

RESULTS

Participation rate in the study was 75.3% (n = 64). Majority (64%) of patients chose the concomitant treatment. Multivariate analysis revealed that patients with a lower level of education, who discussed the choice with social circle, and who most feared side-effects were more likely to choose the sequential treatment. Physicians were able to predict patients' choice in 66% of cases. 89% of patients declared that they were fully satisfied with having participated in the choice of treatment and 79% supported shared decision-making.

CONCLUSIONS

Results are in favour of promoting active participation of cancer-patients in medical decision-making. The adequate degree of such participation remains however to be elicited and tested for therapeutic choices implying more difficult trade-offs between quantity and quality of life.

Decision-making preference and opportunity in VA ambulatory care patients: association with patient satisfaction

Using data from the Veterans Health Study, associations were examined for decision-making preference, decision-making opportunity, and satisfaction with medical care among a sample of 266 men who use Department of Veterans Affairs (VA) ambulatory health care services. Results indicated that veterans with a high preference for involvement in decision-making and low provider-offered decision-making opportunities had significantly lower satisfaction with medical care compared to veterans with either low preference for decision-making involvement with high or low opportunity, or those with a high decision-making preference and high decision-making opportunity. The findings suggest that health care providers may increase patient satisfaction with medical care by providing opportunities for decision-making to patients who prefer involvement in their health care decision-making. Provider strategies for increasing patient decision-making involvement are discussed.

Patients' preferences for participation in clinical decision making: a review of published surveys

Models of doctor-patient relations vary between "paternalistic" and "informative." The paternalistic model emphasizes doctors' authority; alternative models allow patients to exercise their rights to autonomy. Published surveys indicate that most patients want to be informed about their diseases, that a proportion of patients want to participate in planning management of their illnesses, and that some patients would rather be completely passive and would avoid any information. The severity of the patients' conditions, and their being older, less well educated, and male are predictors of a preference for the passive role in the doctor-patient relationship, but demographic and situational characteristics explain only 20% or less of the variability in preferences. The only way a physician can gain insight into an individual patient's desire to participate in decision making is through direct enquiry. The ability to communicate health-related information and to determine the patients' desire to participate in medical decisions should be viewed as a basic clinical skill.

Perceived efficacy in patient-physician interactions (PEPPI): validation of an instrument in older persons

OBJECTIVE

To develop and validate a brief instrument--the Perceived Efficacy in Patient-Physician Interactions Questionnaire (PEPPI)--to measure older patients' self-efficacy in obtaining medical information and attention to their medical concerns from physicians.

DESIGN

Two consecutive validation surveys.

SETTING

Eleven senior multipurpose centers in Los Angeles County California.

POPULATION

A convenience sample of 163 community-dwelling older persons (Survey 1: n=59, mean age=77.1 years, 76.3% female; Survey 2: n=104, mean age=77.4 years, 57.7% female).

MEASURES

The 10-item PEPPI, subscales of the Patient Satisfaction Questionnaire, the Medical Outcomes Study (MOS) Coping Scale, the Mastery Scale, and global self-reported health and restricted activity days items.

RESULTS

The full 10-item and a 5-item short form of PEFPI demonstrated Cronbach's alphas of 0.91 and 0.83, respectively. PEPPI demonstrated discriminant and convergent validity as hypothesized, correlating negatively with avoidant coping (r=-.27, P=.001) and positively with active coping (r=.17, P=.03) and with patient satisfaction with physician interpersonal manner (r=.49, P < .0001) and communication (r=.51, P < .0001) (values from the overall sample). Further, in the second survey, PEPPI correlated positively with self-reported health (r=.42, P < .0001), education (r = .24, P=.01) and self-mastery (r=.29, P=.01) and negatively with restricted activity days (r=-.25, P=.01). PEPPI-5 demonstrated correlations similar in magnitude, direction, and statistical significance.

CONCLUSION

In either the 5- or 10-item version, PEPPI is a valid and reliable measure of older patients' perceived self-efficacy in interacting with physicians. This instrument may be useful in measuring the impact of empowerment interventions to increase older patients' personal sense of effectiveness in obtaining needed health care.

Perceptions of motivators and barriers to public prenatal care among first-time and follow-up adolescent patients and their providers

OBJECTIVES

To compare perceptions of the motivators and barriers to obtaining public prenatal care from the perspectives of pregnant adolescents coming for first-time and follow-up appointments, as well as among those of their prenatal care providers.

METHOD

The patient sample consisted of 250 consecutive, adolescent, public prenatal patients coming to one of the 5 prenatal clinics in one county in Arkansas. Patient responses were analyzed by appointment status (first-time vs. follow-up visitors). Sixteen providers at the same public prenatal clinics were also interviewed using the same survey instrument.

RESULTS

We observed striking differences between patients and providers with respect to their perceptions of both the motivators and barriers to prenatal care. Adolescents reported "concern over the health of their baby" as a primary motivation, while providers identified adolescents' "concern over their own health" as the most important reason. With regard to barriers, adolescents were more likely to identify system-related barriers (e.g., lack of finances and transportation, and waiting time for appointments), while providers were more likely to identify personal barriers (e.g., feeling depressed, fear of procedures, and needing time to deal with problems at home). Patients and providers agreed, however, that fear of procedures and not wanting to be pregnant were important barriers to care.

CONCLUSIONS

The differences in perceptions between adolescents and their prenatal care providers suggest that poor patient-provider communication may represent one of the single most important nonfinancial barriers to care. Possible explanations for inadequate patient-provider communication as well as solutions to improve their clinic interactions are discussed.

Physician variability and uncertainty in the management of breast cancer. Results from a factorial experiment

OBJECTIVES

The purpose of this research was to determine the influence of patient and physician characteristics on physicians' level of variability and certainty in breast cancer care.

METHODS

One hundred twenty-eight physicians viewed a videotape of a simulated physician-patient interaction in which the patient has an "atypical" breast lump. Six patient characteristics (age, race, socioeconomic status, physical mobility, comorbidity, presentation style) were manipulated experimentally, resulting in a balanced set of 32 different "patients." Physician subjects were recruited to fill four equal strata defined by specialty (surgeons versus nonsurgeons) and experience (< or = 15 or > 15 years since graduation from medical school).

RESULTS

More than half of the physicians offered a diagnosis of benign breast disease, a third offered a diagnosis of breast cancer, and the rest believed that the patient had a normal breast or something "other." Results also indicated that physicians' level of certainty and test ordering behavior varied with the diagnosis that was offered. Of the six patient characteristics, only socioeconomic status influenced physician certainty; physicians were more certain of their diagnosis when the patient was of a higher socioeconomic status. Surgeons were found to be more certain of their diagnosis compared with nonsurgeons. However, surgeons were less likely to order radiologic tests or a tissue sample for metastatic evaluation than were nonsurgeons.

CONCLUSIONS

Overall, physicians displayed considerable variability and uncertainty when diagnosing and managing possible breast cancer.

[Physician-patient interactions: a comparison of analysis systems]

OBJECTIVE

The medical interview has important diagnostic and therapeutic functions and requires the integration of doctor-centred and patient-centred interviewing techniques to collect accurate and complete biopsychosocial data from the patient. Analysis of the interaction between patient and doctors which occur during the medical interview allow to evaluate physicians' interview techniques and to eventually improve them.

OBJECTIVE

1. To review different Interaction Analysis Systems (IAS) used to describe doctor-patient communication in terms of clinical relevance, observational strategy, reliability and behavioural and verbal contents. 2. To critically evaluate these IASs on the basis of their relevant research outcomes.

METHOD

Previous reviews on interaction and keywords for Medline research (HealthGate) listed above were utilised to collect the relevant literature.

RESULTS

Seventeen classification systems were identified and ten were discussed in a chronological order. Starting from a general sociological or psycholinguistic approach, the IASs over the years have became more specific and detailed, focusing more on the medical interview and on specific topics, such as cancer or hospital medical consultations.

CONCLUSIONS

When studying interactions in general practice medicine, it is important to define the significant units of interaction which allow to identify a "patient-centred approach", since this is relevant not only for obtaining reliable and complete medical and social data, but also for the recognition of patients with emotional disorders and their correct diagnosis. Listening to the patient and facilitating the expression of emotions is an important aspect of patient education too, as patients learn that talking about psychological problems to their physician is appropriate and may be therapeutic.

Patient participation in deciding breast cancer treatment and subsequent quality of life

This investigation of patients with early breast cancer examined relationships among patient involvement in deciding treatment (i.e., whether to undergo breast removal or breast conservation), perceptions of control over treatment decisions, and subsequent health-related quality of life. It was predicted 1) that patients who more actively participated in consultations to decide treatment would perceive more decision control than would more passive patients and 2) that patients who perceived greater decision control would report better health-related quality of life following treatment than would patients perceiving less decision control. Sixty patients with stage I or II breast cancer allowed their consultations with surgeons to be audiorecorded. Following these visits, patients reported on their involvement in the consultation, optimism for the future, knowledge about treatment, and two aspects of perceived decision control, the perception of having a choice for treatment and the extent to which the doctor or patient was responsible for the decision. Six and 12 months postoperatively, 51 patients (85%) returned a follow-up survey assessing perceived decision control and health-related quality of life. The first prediction received some support. The patients who had more actively participated in their consultations, particularly in terms of offering opinions, assumed more responsibility for treatment decisions during the year following surgery than did less expressive patients. Also, the patients who reported more involvement in their consultations later believed they had had more of a choice for treatment. The second hypothesis was partially supported. Six and 12 months following treatment, the patients who believed they were more responsible for treatment decisions and believed they had more choice of treatment reported higher levels of quality of life than did the patients who perceived themselves to have less decision control. However, perceived control at the time of treatment did not predict later quality of life. Theoretical and clinical implications are discussed.

The effects of social support and education interventions on health care costs

OBJECTIVE

To determine whether experimentally developed social support and education about appropriate use of the health care system decrease health care costs without negatively affecting health status.

METHOD

Three hundred sixty-three health maintenance organization members with osteoarthritis were randomly assigned to 1 of 3 intervention groups or to a control group. Health status and health care use were assessed upon entering the study, and after 1 year and 2 years.

RESULTS

A savings of $1,156/participant/year was obtained when health care costs of the experimental groups were compared with those of the control group. Production or implementation costs were least for the social support intervention. The nearly equal effects of the 3 interventions on health care costs make implementation costs the primary focus when deciding which intervention to use.

CONCLUSION

We believe that the social support treatment is the most cost-effective intervention.