A questionnaire for patients' evaluations of their physicians' humanistic behaviors

Safety and upscaling of remote consulting for long-term conditions in primary health care in Nigeria and Tanzania (REaCH trials): stepped-wedge trials of training, mobile data allowance, and implementation

BACKGROUND

In-person health care poses risks to health workers and patients during pandemics. Remote consultations can mitigate these risks. The REaCH intervention comprised training and mobile data allowance provision for mobile phones to support remotely delivered primary care in Africa compared with no training and mobile data allowance. The aim of this study was to estimate the effects of REaCH among adults with non-communicable diseases on remote and face-to-face consultation rates, patient safety, and trustworthiness of consultations.

METHODS

In these two independent stepped-wedge cluster randomised controlled trials, we enrolled 20 primary care clusters in each of two settings (Oyo State, Nigeria, and Morogoro Region, Tanzania). Eligible clusters had 100 or more patients with diabetes, hypertension, and cardiovascular or pulmonary disease employing five health workers. Clusters were computer-randomised to one of ten (Nigeria) or one of seven (Tanzania) sequences to receive the REaCH intervention. Only outcome assessors were masked. Primary outcomes were consultation, prescription, and investigation rates, and trustworthiness collected monthly for 12 months (Nigeria) and 9 months (Tanzania) from open cohorts. Ten randomly sampled consulting patients per cluster-month completed patient reported outcome measures. This trial was registered with ISRCTN, ISRCTN17941313.

FINDINGS

Overall, 40 clusters comprising 8776 (Nigeria) and 3246 (Tanzania) patients' open cohort data were analysed (6377 [72·7%] of 8776 females in Nigeria, and 2235 [68·9%] of 3246 females in Tanzania). The mean age of the participants was 55·3 years (SD 13·9) in Nigeria and 59·2 years (14·2) in Tanzania. In Nigeria, no evidence of change in face-to-face consulting rate was observed (rate ratio [RR] 1·06, 95% CI 0·98 to 1·09; p=0·16); however, remote consultations increased four-fold (4·44, 1·34 to >10; p=0·01). In Tanzania, face-to-face (0·94, 0·61 to 1·67; p=0·99) and remote consulting rates (1·17, 0·56 to 5·57; p=0·39) were unchanged. There was no evidence of difference in prescribing rates (Nigeria: 1·05, 0·60 to 1·14; p=0·23; Tanzania: 0·92, 0·60 to 1·67; p=0·97), investigation rates (Nigeria: 1·06, 0·23 to 2·12; p=0·49; Tanzania: 1·15, 0·35 to 1·64; 0·58) or trustworthiness scores (Nigeria: mean difference 0·05, 95% CI -0·45 to 0·42; p=0·89; Tanzania: 0·07, -0·15 to 0·76; p=0·70).

INTERPRETATION

REaCH can be implemented and could improve intervention versus control health-care access. Remote consultations appear safe and trustworthy, supporting universal health coverage.

FUNDING

The UK Research and Innovation Collective Fund.

TRANSLATIONS

For the Swahili and Yoruba translations of the abstract see Supplementary Materials section.

The Ameliorating Role of A Playful Situational Game Intervention in School-Aged Children Undergoing Ophthalmic Surgeries: A Randomized Controlled Trial

PURPOSE

The objective of the study was to investigate if a playful situational game (PSG) intervention, as a perioperative procedure, could effectively alleviate stress and anxiety and improve postoperative outcomes for children to receive ophthalmic surgeries.

METHODS

This trial enrolled 153 children, among which 116 met inclusion criteria and were randomized to control (n = 58, who did not participate in PSG) or PSG group (n = 58, who participated PSG). In the PSG group, children were arranged in renovated wards and allocated to play situational games specifically designed to improve surgery readiness. Satisfaction of the care from parents, posthospitalization behavioral change incidences, Yale Preoperative Anxiety Scale (YPAS) scores, induction compliance checklist (ICC) scores, and pediatric anesthesia emergence delirium (PAED) scores were documented as postoperative assessments.

RESULTS

The PSG group demonstrated significantly higher satisfaction of the care from the parents (p = 0.004), and posthospitalization behavioral change incidences were markedly rarer in the PSG group (p = 0.015). The YPAS scores of the PSG group showed a slower increase compared to the control group before and after surgery (p < 0.001). ICC and PAED scores were also lower in the PSG group (p < 0.01).

CONCLUSION

Our data could support that PSG is an effective intervention in alleviating the anxiety of children undergoing ophthalmic surgery and PSG can increase the satisfaction rate among patients and decrease behavioral change incidences. The adoption of PSG in children could potentially been promoted in the clinical setting.

Examining the impact of video-based outpatient education on patient demand for a rheumatology CNS service

BACKGROUND

Patient demand for education and access to the clinical nurse specialists (CNSs) during the rheumatology clinic at one hospital in Ireland was increasing. Alternative methods of providing patient education had to be examined.

AIMS

To explore the efficacy of video-based outpatient education, and its impact on demand for the CNSs.

METHODS

A video was produced to play in a rheumatology outpatient department. A representative sample of 240 patients (120 non-exposed and 120 exposed to the video) attending the clinic was selected to complete a questionnaire exploring the effect of the video. Data were analysed using chi-square tests with Yates' continuity correction.

FINDINGS

Demand for the CNSs was six times higher in the non-exposed group compared with the exposed group (non-exposed: 25%, exposed: 4.8%) (χ²=15.7, P=0.00007), representing a significant decrease in resource demand.

CONCLUSION

High-quality educational videos on view in the rheumatology outpatient department provide patients with information sufficient to meet their educational needs, thus releasing CNS resources.

Actual and perceived patient health literacy: How accurate are residents' predictions?

Health literacy has repeatedly been shown to be associated with a multitude of negative health outcomes. Previous research has shown that patient health literacy levels are hard to predict by physicians and that assessment tools used to measure health literacy may be outdated or lacking. The purpose of this study is to replicate and extend the findings of previous research by examining residents’ ability to predict health literacy levels in patients and to use a newer validated measure of health literacy. A total of 38 patient encounters were included in this study. Patients were administered the Health Literacy Skills Instrument-Short Form to assess health literacy levels. Twenty resident physicians conducted visits with study participants and were asked to predict the health literacy of their patients. Results indicated that, consistent with previous research, residents’ predictions of patient health literacy were not consistent with patient health literacy levels as measured by the Health Literacy Skills Instrument-Short Form. Implications of these findings and future directions are discussed.

Eliciting the Impact of Digital Consulting for Young People Living With Long-Term Conditions (LYNC Study): Cognitive Interviews to Assess the Face and Content Validity of Two Patient-Reported Outcome Measures

BACKGROUND

Digital consulting, using email, text, and Skype, is increasingly offered to young people accessing specialist care for long-term conditions. No patient-reported outcome measures (PROMs) have been evaluated for assessing outcomes of digital consulting. Systematic and scoping reviews, alongside patient involvement, revealed 2 candidate PROMs for this purpose: the patient activation measure (PAM) and the physician's humanistic behaviors questionnaire (PHBQ). PAM measures knowledge, beliefs, and skills that enable people to manage their long-term conditions. PHBQ assesses the presence of behaviors that are important to patients in their physician-patient interactions.

OBJECTIVE

This study aimed to assess the face and content validity of PAM and PHBQ to explore whether they elicit important outcomes of digital consulting and whether the PROMs can isolate the digital consultation component of care.

METHODS

Participants were drawn from 5 clinics providing specialist National Health Service care to 16- to 24-year-olds with long-term health conditions participating in the wider LYNC (Long-Term Conditions, Young People, Networked Communications) study. Overall, 14 people undertook a cognitive interview in this substudy. Of these, 7 participants were young people with either inflammatory bowel disease, cystic fibrosis, or cancer. The remaining 7 participants were clinicians who were convenience sampled. These included a clinical psychologist, 2 nurses, 3 consultant physicians, and a community youth worker practicing in cancer, diabetes, cystic fibrosis, and liver disease. Cognitive interviews were transcribed and analyzed, and a spreadsheet recorded the participants' PROM item appraisals. Illustrative quotes were extracted verbatim from the interviews for all participants.

RESULTS

Young people found 11 of the PAM 13 items and 7 of the additional 8 PAM 22 items to be relevant to digital consulting. They were only able to provide spontaneous examples of digital consulting for 50% (11/22) of the items. Of the 7 clinicians, 4 appraised all PAM 13 items and 20 of the PAM 22 items to be relevant to evaluating digital consulting and articulated operationalization of the items with reference to their own digital consulting practice with greater ease than the young people. Appraising the PHBQ, in 14 of the 25 items, two-thirds of the young people's appraisals offered digital consulting examples with ease, suggesting that young people can detect and discern humanistic clinician behaviors via digital as well as face-to-face communication channels. Moreover, 17 of the 25 items were appraised as relevant by the young people. This finding was mirrored in the clinician appraisals. Both young people and the clinicians found the research task complex. Young participants required considerably more researcher prompting to elicit examples related to digital consulting rather than their face-to-face care.

CONCLUSIONS

PAM and PHBQ have satisfactory face and content validity for evaluating digital consulting to warrant proceeding to psychometric evaluation. Completion instructions require revision to differentiate between digital and face-to-face consultations.

Measuring patient-provider communication skills in Rwanda: Selection, adaptation and assessment of psychometric properties of the Communication Assessment Tool

OBJECTIVE

To identify, adapt and validate a measure for providers' communication and interpersonal skills in Rwanda.

METHODS

After selection, translation and piloting of the measure, structural validity, test-retest reliability, and differential item functioning were assessed.

RESULTS

Identification and adaptation: The 14-item Communication Assessment Tool (CAT) was selected and adapted.

VALIDITY AND RELIABILITY TESTING

Content validation found all items highly relevant in the local context except two, which were retained upon understanding the reasoning applied by patients. Eleven providers and 291 patients were involved in the field-testing. Confirmatory factor analysis showed a good fit for the original one factor model. Test-retest reliability assessment revealed a mean quadratic weighted Kappa = 0.81 (range: 0.69-0.89, N = 57). The average proportion of excellent scores was 15.7% (SD: 24.7, range: 9.9-21.8%, N = 180). Differential item functioning was not observed except for item 1, which focuses on greetings, for age groups (p = 0.02, N = 180).

CONCLUSION

The Kinyarwanda version of CAT (K-CAT) is a reliable and valid patient-reported measure of providers' communication and interpersonal skills. K-CAT was validated on nurses and its use on other types of providers may require further validation.

PRACTICE IMPLICATION

K-CAT is expected to be a valuable feedback tool for providers in practice and in training.

The role of digital communication in patient–clinician communication for NHS providers of specialist clinical services for young people [the Long-term conditions Young people Networked Communication (LYNC) study]: a mixed-methods study

Background

Young people (aged 16–24 years) with long-term health conditions tend to disengage from health services, resulting in poor health outcomes. They are prolific users of digital communications. Innovative UK NHS clinicians use digital communication with these young people. The NHS plans to use digital communication with patients more widely.

Objectives

To explore how health-care engagement can be improved using digital clinical communication (DCC); understand effects, impacts, costs and necessary safeguards; and provide critical analysis of its use, monitoring and evaluation.

Design

Observational mixed-methods case studies; systematic scoping literature reviews; assessment of patient-reported outcome measures (PROMs); public and patient involvement; and consensus development through focus groups.

Setting

Twenty NHS specialist clinical teams from across England and Wales, providing care for 13 different long-term physical or mental health conditions.

Participants

One hundred and sixty-five young people aged 16–24 years living with a long-term health condition; 13 parents; 173 clinical team members; and 16 information governance specialists.

Interventions

Clinical teams and young people variously used mobile phone calls, text messages, e-mail and voice over internet protocol.

Main outcome measures

Empirical work – thematic and ethical analysis of qualitative data; annual direct costs; did not attend, accident and emergency attendance and hospital admission rates plus clinic-specific clinical outcomes. Scoping reviews–patient, health professional and service delivery outcomes and technical problems. PROMs: scale validity, relevance and credibility.

Data sources

Observation, interview, structured survey, routinely collected data, focus groups and peer-reviewed publications.

Results

Digital communication enables access for young people to the right clinician when it makes a difference for managing their health condition. This is valued as additional to traditional clinic appointments. This access challenges the nature and boundaries of therapeutic relationships, but can improve them, increase patient empowerment and enhance activation. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, but clinicians and young people mitigate these risks. Workload increases and the main cost is staff time. Clinical teams had not evaluated the impact of their intervention and analysis of routinely collected data did not identify any impact. There are no currently used generic outcome measures, but the Patient Activation Measure and the Physicians’ Humanistic Behaviours Questionnaire are promising. Scoping reviews suggest DCC is acceptable to young people, but with no clear evidence of benefit except for mental health.

Limitations

Qualitative data were mostly from clinician enthusiasts. No interviews were achieved with young people who do not attend clinics. Clinicians struggled to estimate workload. Only eight full sets of routine data were available.

Conclusions

Timely DCC is perceived as making a difference to health care and health outcomes for young people with long-term conditions, but this is not supported by evidence that measures health outcomes. Such communication is challenging and costly to provide, but valued by young people.

Future work

Future development should distinguish digital communication replacing traditional clinic appointments and additional timely communication. Evaluation is needed that uses relevant generic outcomes.

Study registration

Two of the reviews in this study are registered as PROSPERO CRD42016035467 and CRD42016038792.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patient Perceptions of Clinician's Empathy: Measurement and Psychometrics

The prominence of reciprocal understanding in patient-doctor empathic engagement implies that patient perception of clinician's empathy has an important role in the assessment of the patient-clinician relationship. In response to a need for an assessment tool to measure patient's views of clinician empathy, we developed a brief (5-item) instrument, the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE). This review article reports evidence in support of the validity and reliability of the JSPPPE.

Interventions in Physician-Elderly Patient Interactions

Currently, most research in the area of physician-elderly patient interactions relates to either outcome, context, or interaction styles. There are limited data in the area of intervention studies. The authors recognize five specific areas of interventional research to consider: communication during encounters, characteristics of older patients, physical impairments, physician attributes, and the team approach to health care. Also highlighted are recognition and evaluation of the special needs of elderly patients through geriatric assessment. The authors recognize the need for more intervention studies that attempt to change patient or physician behaviors and the applicability of the classic randomized controlled model of research. Overall, the authors contend that the formation of strong, meaningful relationships between elderly patients and their physicians is best achieved through effective medical communication and care, and thus should be the function of appropriate interventions.

Communication training improves patient-centered provider behavior and screening for soldiers' mental health concerns

OBJECTIVE

To evaluate the effectiveness of patient-centered communication training for military providers who conduct post-deployment health screening. The half-day interactive workshop included simulated Soldier patients using video technology.

METHODS

Using a quasi-experimental design, all health care providers at four military treatment facilities were recruited for data collection during a four- to nine-day site visit (23 trained providers, 28 providers in the control group, and one provider declined to participate). All Soldiers were eligible to participate and were blinded to provider training status. Immediately after screening encounters, providers reported on their identification of mental health concerns and Soldiers reported on provider communication behaviors resulting in 1,400 matched pairs. Electronic health records were also available for 26,005 Soldiers.

RESULTS

The workshop was found to increase (1) providers' patient-centered communication behaviors as evaluated by Soldiers; (2) provider identification of Soldier mental health concerns; and (3), related health outcomes including provision of education and referral to a confidential counseling resource.

CONCLUSION

Results are promising, but with small effect sizes and study limitations, further research is warranted.

PRACTICE IMPLICATIONS

A brief intensive workshop on patient-centered communication tailored to the military screening context is feasible and may improve key outcomes.

Quality of bedside teaching in internal wards of Qaem and Imam Reza hospitals in Mashhad

Background:

Bedside teaching is a patient-based teaching method in medical education. The present study has been conducted with the aim of investigating the quality of bedside teaching in the internal wards of Qaem and Imam Reza Educational Hospitals.

Methods:

This study follows a mixed qualitative-quantitative approach using checklists on educational clinical rounds in Imam Reza and Qaem Hospitals in Mashhad. In the first stage consisting of qualitative study, the parts related to the quality of bedside teaching were recognized and a checklist was designed in three domains of patient comfort (8 questions), targeted teaching (14 questions) and group dynamics (8 questions), and its reliability and validity were verified. In the next step, data were collected and then analyzed using SPSS 16 software through statistical techniques of independent t-test, one-way ANOVA and variance analysis.

Results:

In total, 113 educational rounds were investigated in this study. Among them, 59 (52.2%) and 54 (47.8%) educational rounds have been investigated in Imam Reza and Qaem Hospitals, respectively. The average total score of bedside teaching was 180.8 out of 300 in the internal wards of both Imam Reza and Qaem Hospitals.

Conclusion:

The results of this study showed that generally the quality of bedside teaching in Imam Reza and Qaem Hospitals of Mashhad is low according to the qualitative standards considered in this study. Holding educational workshops along with more familiarity of the professors with effective bedside teaching strategies could be effective in improving the quality of educational rounds.

Training students with patient actors improves communication: a pilot study

PURPOSE

Effective patient communication is correlated with better health outcomes and patient satisfaction, but is challenging to train, particularly with difficult clinical scenarios such as loss of sight. In this pilot study, we evaluated the use of simulated patient encounters with actors to train optometric students.

METHODS

Students were recorded during encounters with actors and assigned to an enrichment group performing five interactions with instructor feedback (n = 6) or a no-enrichment group performing two interactions without feedback (n = 4). Student performance on first and last encounters was scored with (1) subjective rating of performance change using a visual analog scale (anchors: much worse/much better), (2) yes/no response: Would you recommend this doctor to a friend/relative?, and (3) average score on questions from the American Board of Internal Medicine (ABIM) assessment of doctor communication skills. Three clinical instructors, masked to student group assignments and the order of patient encounters they viewed, provided scores in addition to self-evaluation by students and patient-actors.

RESULTS

Using the visual analog scale, students who received enrichment were rated more improved than the no-enrichment group by masked examiners (+18 vs. -11% p = 0.04) and self-evaluation (+79 vs. +27% p = 0.009), but not by actors (+31 vs. +43%). The proportion of students recommended significantly increased following enrichment for masked examiners (61% vs. 94%; p < 0.001), but not actors (100 vs. 83%). Average ABIM assessment scores were not significantly different by any rating group: masked instructors, actors, or self-ratings.

CONCLUSIONS

The findings of this study suggest five simulated patient encounters with feedback result in measurable improvement in student-patient communication skills as rated by masked examiners.

Improving the care of children with advanced cancer by using an electronic patient-reported feedback intervention: results from the PediQUEST randomized controlled trial

PURPOSE

This study aimed to determine whether feeding back patient-reported outcomes (PROs) to providers and families of children with advanced cancer improves symptom distress and health-related quality of life (HRQoL).

PATIENTS AND METHODS

This study was a parallel, multicentered pilot randomized controlled trial. At most once per week, children age ≥ 2 years old with advanced cancer or their parent completed the computer-based Pediatric Quality of Life and Evaluation of Symptoms Technology (PediQUEST) survey consisting of age- and respondent-adapted versions of the Memorial Symptom Assessment Scale (MSAS), Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL4.0), and an overall Sickness question. In the intervention group (n = 51), oncologists and families received printed reports summarizing PROs; e-mails were sent to oncologists and subspecialists when predetermined scores were exceeded. No feedback was provided in the control group (n = 53). Primary outcomes included linear trends of MSAS, PedsQL4.0 total and subscale scores, and Sickness scores during 20 weeks of follow-up, along with child, parent, and provider satisfaction with PediQUEST feedback.

RESULTS

Feedback did not significantly affect average MSAS, PedsQL4.0, or Sickness score trends. Post hoc subgroup analyses among children age ≥ 8 years who survived 20 weeks showed that feedback improved PedsQL4.0 emotional (+8.1; 95% CI, 1.8 to 14.4) and Sickness (-8.2; 95% CI, -14.2 to -2.2) scores. PediQUEST reports were valued by children, parents, and providers and contributed at least sometimes to physician initiation of a psychosocial consult (56%).

CONCLUSION

Although routine feedback of PROs did not significantly affect the child's symptoms or HRQoL, changes were in expected directions and improvements observed in emotional HRQoL through exploratory analyses were encouraging. Importantly, children, parents, and providers value PRO feedback.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Feasibility and validation of real-time patient evaluations of internal medicine interns' communication and professionalism skills

BACKGROUND

Residents receive little information about how they interact with patients.

OBJECTIVE

This pilot study assessed the feasibility and validity of a new 16-item tool developed to assess patients' perspectives of interns' communication skills and professionalism and the team's communication.

METHODS

Feasibility was determined by the percentage of surveys completed, the average time for survey completion, the percentage of target interns evaluated, and the mean number of evaluations per intern. Generalizability was analyzed using an (evaluator:evaluatee) × item model. Simulated D studies estimated optimal numbers of items and evaluators. Factor analysis with varimax rotation was used to examine the structure of the items. Scores were correlated with other measures of communication and professionalism for validation.

RESULTS

Most patients (225 of 305 [74%]) completed the evaluation. Each survey took approximately 6.3 minutes to complete. In 43 days over 18 weeks, 45 of 50 interns (90%) were evaluated an average of 4.6 times. Fifty evaluations would be required to reach a minimally acceptable coefficient (0.57). Two factor structures were identified. The evaluation did not correlate with faculty evaluations of resident communication but did correlate weakly (r  =  0.140, P  =  .04) with standardized patient evaluations.

CONCLUSIONS

A large number of patient evaluations are needed to reliably assess intern and team communication skills. Evaluations by patients add a perspective in assessing these skills that is different from those of faculty evaluations. Future work will focus on whether this new information adds to existing evaluation systems and warrants the added effort.

Can quality from a care ethical perspective be assessed? A review

Background:

Ethics-of-care theories contain important notions regarding the quality of care; however, until now, concrete translations of the insights into instruments are lacking. This may be a result of the completely different type of epistemology, theories and concepts used in the field of quality of care research.

Objectives:

Both the fields of ‘ethics of care’ and ‘quality of care’ aim for improvement of care; therefore; insights could possibly meet by focusing on the following question: How could ethics-of-care theories contribute to better quality in care at a measurement level? This study reviews existing instruments with the aim of bridging this gap and examines the evidence of their psychometric properties, feasibility and responsiveness.

Research design:

A systematic search of the literature was undertaken using multiple electronic databases covering January 1990 through May 2012.

Method and findings:

Of the 3427 unique references identified, 55 studies describing 40 instruments were selected. Using a conceptual framework, an attempt was made to distinguish between related concepts and to group available instruments measuring different types of concepts. A total of 13 instruments that reflect essential aspects of ethics-of-care theory were studied in greater detail, and a quality assessment was conducted.

Conclusion:

Three promising qualitative instruments were found, which follow the logic of the patient and take their specific context into account.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of healthcare providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. However, the impact of these interventions directly on clinical encounters and indirectly on patient satisfaction, healthcare behaviour and health status has not been adequately evaluated.

OBJECTIVES

To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations.

SEARCH METHODS

For this update, we searched: MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), and CINAHL (EbscoHOST) from January 2000 to June 2010. The earlier version of this review searched MEDLINE (1966 to December 1999), EMBASE (1985 to December 1999), PsycLIT (1987 to December 1999), CINAHL (1982 to December 1999) and HEALTH STAR (1975 to December 1999). We searched the bibliographies of studies assessed for inclusion and contacted study authors to identify other relevant studies. Any study authors who were contacted for further information on their studies were also asked if they were aware of any other published or ongoing studies that would meet our inclusion criteria.

SELECTION CRITERIA

In the original review, study designs included randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for healthcare providers that promote patient-centred care in clinical consultations. In the present update, we were able to limit the studies to randomized controlled trials, thus limiting the likelihood of sampling error. This is especially important because the providers who volunteer for studies of PCC methods are likely to be different from the general population of providers. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). Within our definition, shared treatment decision-making was a sufficient indicator of PCC. The participants were healthcare providers, including those in training.

DATA COLLECTION AND ANALYSIS

We classified interventions by whether they focused only on training providers or on training providers and patients, with and without condition-specific educational materials. We grouped outcome data from the studies to evaluate both direct effects on patient encounters (consultation process variables) and effects on patient outcomes (satisfaction, healthcare behaviour change, health status). We pooled results of RCTs using standardized mean difference (SMD) and relative risks (RR) applying a fixed-effect model.

MAIN RESULTS

Forty-three randomized trials met the inclusion criteria, of which 29 are new in this update. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. Descriptive and pooled analyses showed generally positive effects on consultation processes on a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy; and patients' perception of providers' attentiveness to them and their concerns as well as their diseases. A new finding for this update is that short-term training (less than 10 hours) is as successful as longer training.The analyses showed mixed results on satisfaction, behaviour and health status. Studies using complex interventions that focused on providers and patients with condition-specific materials generally showed benefit in health behaviour and satisfaction, as well as consultation processes, with mixed effects on health status. Pooled analysis of the fewer than half of included studies with adequate data suggests moderate beneficial effects from interventions on the consultation process; and mixed effects on behaviour and patient satisfaction, with small positive effects on health status. Risk of bias varied across studies. Studies that focused only on provider behaviour frequently did not collect data on patient outcomes, limiting the conclusions that can be drawn about the relative effect of intervention focus on providers compared with providers and patients.

AUTHORS' CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behaviour and health status, outcomes not assessed in studies reviewed previously. The latter conclusion is tentative at this time and requires more data. The heterogeneity of outcomes, and the use of single item consultation and health behaviour measures limit the strength of the conclusions.

Family-centered rounds: views of families, nurses, trainees, and attending physicians

OBJECTIVE

To study the impact of family-centered rounds for general pediatrics inpatients.

METHODS

An observation tool and participant surveys was developed. The authors analyzed rounding time and rounds participants. Associations between family presence and participants' satisfaction were analyzed.

RESULTS

Data were collected on 295 patients and from 257 staff members. Average rounding time was reduced with increased family and nurse presence (8.7 minutes with both, 12.7 minutes without family, P = .0001). Families reported high satisfaction regardless of participants. Families present on rounds reported increased knowledge of team members' roles (54% vs 35%, P = .04). Attending physicians more often reported ease in managing rounds with families present. Senior residents perceived decreased autonomy with high family participation (11%) versus low family participation (70%; P = .02). Improved nurse satisfaction was associated with increased family and nurse participation.

CONCLUSION

Family participation may shorten inpatient rounds. Families and staff were satisfied with family-centered rounds, though senior resident autonomy requires attention.

Are doctors who have been ill more compassionate? Attitudes of resident physicians regarding personal health issues and the expression of compassion in clinical care

BACKGROUND

Compassion is an attribute central to professionalism and modern clinical care, yet little is known about how compassion is acquired and preserved in medical training. We sought to understand whether personal illness experiences are thought by residents to foster compassion.

METHODS

The authors surveyed 155 (71% response rate) second- and third-year residents at the University of New Mexico School of Medicine regarding their views of the relationship of personal life experience with illness to compassion and empathy for patients.

RESULTS

Residents believe that experience with personal health issues enhances physician compassion for patients. Residents who report more personal health concerns, such as physical or mental health problems and family health problems, endorse the connection between direct experience with illness and empathy.

CONCLUSION

Health care trainees' own illness experiences may increase compassionate patient care practices and foster empathy.

Does medical student membership in the gold humanism honor society influence selection for residency?

OBJECTIVES

With the creation of the Gold Humanism Honor Society (GHHS) in 2002, the Arnold P. Gold Foundation established a mechanism for recognizing medical students who demonstrate exemplary humanism/professionalism/communication skills. Currently, 80 medical schools have GHHS chapters. Selection is based on peer nomination using a validated tool. The objective of this survey was to assess the percentage of residency program directors (PDs) who are aware of and are using GHHS membership as a residency selection tool.

METHODS

Surgery (SURG) and internal medicine (IM) PDs in 4 United States regions were surveyed for familiarity with GHHS and perceived rank of GHHS membership relative to Alpha Omega Alpha (AOA) membership, class rank, medical student performance evaluation (MSPE), clerkship grade, and United States Medical Licensing Examination (USMLE) score, in evaluating an applicant's humanism/professionalism, service orientation, and fit with their program. Program demographics and familiarity with GHHS were also surveyed.

RESULTS

The response rate was 56% (149 respondents). IM PDs rated GHHS membership higher than did SURG PDs when evaluating professionalism/humanism and service orientation. PDs familiar with GHHS ranked membership higher when considering professionalism/humanism (4.1 vs 3.2; p < 0.05) and service orientation (4.1 vs 2.9; p < 0.01). Familiarity with GHHS correlated with being an IM PD, residency based at teaching hospital, large residency program, knowledge of residents who were GHHS members, and having a GHHS chapter at their school (p < 0.01). Familiarity with GHHS was related to rankings of GHHS (professionalism/humanism F = 3.36; p < 0.05; service orientation F = 3.86; p < 0.05) more than the PDs' specialty was. In all, 157 GHHS students (from all 4 United States regions) were also surveyed about the 1197 interviews they had with residency PDs. They reported that although a few PDs were aware of GHHS, PDs of core medical specialties were more aware of GHHS than SURG PDs.

CONCLUSIONS

IM PDs were more aware of GHHS (70%) than SURG PDs (30%). Awareness was related to the favorable ranking of GHHS as a selection criterion for humanism/professionalism/service orientation. PDs familiar with GHHS were from larger programs, were likely to know residents who were members, and were likely to think that GHHS membership predicted humanistic care. Membership in GHHS may set candidates apart from their peers and allow PDs to distinguish objectively the candidates who demonstrate compassionate medical care. Increased knowledge about the GHHS may therefore serve to be a useful adjunct for PDs when selecting medical students for their residency programs.

A blueprint to assess professionalism: results of a systematic review

PURPOSE

Assessing professionalism is hampered by varying definitions and these definitions' lack of a clear breakdown of the elements of professionalism into aspects that can be measured. Professionalism is multidimensional, so a combination of assessment tools is required. In this study, conducted during 2007-2008, the authors aimed to match assessment tools to definable elements of professionalism and to identify gaps where professionalism elements are not well addressed by existing assessment tools.

METHOD

The authors conducted literature reviews of definitions of professionalism and of relevant assessment tools, clustered the definitions of professionalism into assessable components, and clustered assessment tools of a similar nature. They then created a "blueprint" whereby the elements of professionalism are matched to relevant assessment tools.

RESULTS

Five clusters of professionalism were formed: adherence to ethical practice principles, effective interactions with patients and with people who are important to those patients, effective interactions with people working within the health system, reliability, and commitment to autonomous maintenance / improvement of competence in oneself, others, and systems. Nine clusters of assessment tools were identified: observed clinical encounters, collated views of coworkers, records of incidents of unprofessionalism, critical incident reports, simulations, paper-based tests, patients' opinions, global views of supervisor, and self-administered rating scales.

CONCLUSIONS

Professionalism can be assessed using a combination of observed clinical encounters, multisource feedback, patients' opinions, paper-based tests or simulations, measures of research and/or teaching activities, and scrutiny of self-assessments compared with assessments by others. Attributes that require more development in their measurement are reflectiveness, advocacy, lifelong learning, dealing with uncertainty, balancing availability to others with care for oneself, and seeking and responding to results of an audit.

Quality of health care and patient satisfaction in liver disease: the development and preliminary results of the QUOTE-Liver questionnaire

BACKGROUND

Consensus on how to adequately measure patient satisfaction with health care is limited, and has led to the development of many questionnaires with various methodological problems. The objective of this study was to develop a liver disease- and care-specific patient satisfaction instrument on the basis of previously tested methodology in patient satisfaction measurement, the so called QUOTE- series: Quality Of health care services Through the patients' Eyes. QUOTE methodology aims to standardise the measurement of satisfaction as the discrepancy between patients' needs, and the extent to which these needs are being met.

METHODS

As part of the QUOTE methodology routine, 11 Patients with chronic liver disease from the Erasmus MC (Rotterdam, the Netherlands) participated in focus-group meetings on patient satisfaction with the provided service at the outpatient hepatology clinic. Twenty-eight other patients were invited to rank the items generated during the focus-group meetings according to importance. With this information, the QUOTE-Liver was constructed. Face validity, construct validity, content validity, and reliability of the newly developed questionnaire were assessed in a test sample of 152 patients with chronic liver disease.

RESULTS

Two liver-disease specific, and the 18 items ranked as most important were included in the QUOTE-Liver. Face validity and content validity were acceptable: neither patients (n = 152) nor psychologists (n = 3) or a hepatologist suggested any extra items to be included. Construct validity was good: the overall score correlated significantly with the Visual Analogue Scale (VAS) measuring overall satisfaction (r = 0.69, p < 0.01). The reliability of the QUOTE-Liver was excellent (alpha = 0.90).

CONCLUSION

The QUOTE-Liver is an easy to complete instrument based on standardized state-of-the-art satisfaction measurement methodology. Preliminary evidence for its validity and reliability was demonstrated. The QUOTE-liver covers those aspects of satisfaction that CLD patients consider to be important when visiting the outpatient department of hepatology. Even though further substantiating of the favourable psychometric findings is desirable, it seems to be a useful instrument that can be used to identify those aspects of care that need improvement in order to optimise the provision of health care for patients with chronic liver disease.

Doctor performance assessment in daily practise: does it help doctors or not? A systematic review

CONTEXT

Continuous assessment of individual performance of doctors is crucial for life-long learning and quality of care. Policy-makers and health educators should have good insights into the strengths and weaknesses of the methods available. The aim of this study was to systematically evaluate the feasibility of methods, the psychometric properties of instruments that are especially important for summative assessments, and the effectiveness of methods serving formative assessments used in routine practise to assess the performance of individual doctors.

METHODS

We searched the MEDLINE (1966-January 2006), PsychINFO (1972-January 2006), CINAHL (1982-January 2006), EMBASE (1980-January 2006) and Cochrane (1966-2006) databases for English language articles, and supplemented this with a hand-search of reference lists of relevant studies and bibliographies of review articles. Studies that aimed to assess the performance of individual doctors in routine practise were included. Two reviewers independently abstracted data regarding study design, setting and findings related to reliability, validity, feasibility and effectiveness using a standard data abstraction form.

RESULTS

A total of 64 articles met our inclusion criteria. We observed 6 different methods of evaluating performance: simulated patients; video observation; direct observation; peer assessment; audit of medical records, and portfolio or appraisal. Peer assessment is the most feasible method in terms of costs and time. Little psychometric assessment of the instruments has been undertaken so far. Effectiveness of formative assessments is poorly studied. All systems but 2 rely on a single method to assess performance.

DISCUSSION

There is substantial potential to assess performance of doctors in routine practise. The longterm impact and effectiveness of formative performance assessments on education and quality of care remains hardly known. Future research designs need to pay special attention to unmasking effectiveness in terms of performance improvement.

Collective soul: the spirituality of an interdisciplinary palliative care team

OBJECTIVE

Although spirituality as it relates to patients is gaining increasing attention, less is known about how health care professionals (HCP) experience spirituality personally or collectively in the workplace. This study explores the collective spirituality of an interdisciplinary palliative care team, by studying how individuals felt about their own spirituality, whether there was a shared sense of a team spirituality, how spirituality related to the care the team provided to patients and whether they felt that they provided spiritual care.

METHODS

A qualitative autoethnographic approach was used. The study was conducted in a 10-bed Tertiary Palliative Care Unit (TPCU) in a large acute-care referral hospital and cancer center. Interdisciplinary team members of the TPCU were invited to participate in one-to-one interviews and/or focus groups. Five interviews and three focus groups were conducted with a total of 20 participants.

RESULTS

Initially participants struggled to define spirituality. Concepts of spirituality relating to integrity, wholeness, meaning, and personal journeying emerged. For many, spirituality is inherently relational. Others acknowledged transcendence as an element of spirituality. Spirituality was described as being wrapped in caring and often manifests in small daily acts of kindness and of love, embedded within routine acts of caring. Palliative care served as a catalyst for team members' own spiritual journeys. For some participants, palliative care represented a spiritual calling. A collective spirituality stemming from common goals, values, and belonging surfaced.

SIGNIFICANCE OF RESULTS

This was the first known study that focused specifically on the exploration of a collective spirituality. The culture of palliative care seems to foster spiritual reflection among health care professionals both as individuals and as a whole. While spirituality was difficult to describe, it was a shared experience often tangibly present in the provision of care on all levels.

Evaluation of resident communication skills and professionalism: a matter of perspective?

OBJECTIVE

Evaluation procedures that rely solely on attending physician ratings may not identify residents who display poor communication skills or unprofessional behavior. Inclusion of non-physician evaluators should capture a more complete account of resident competency. No published reports have examined the relationship between resident evaluations obtained from different sources in pediatric settings. The objective of this study was to determine whether parent and nurse ratings of specific resident behaviors significantly differ from those of attending physicians.

METHODS

Thirty-six pediatric residents were evaluated by parents, nurses, and attending physicians during their first year of training. For analysis, the percentage of responses in the highest response category was calculated for each resident on each item. Differences between attending physician ratings and those of parents and nurses were compared using the signed rank test.

RESULTS

Parent and attending physician ratings were similar on most items, but attending physicians indicated that they frequently were unable to observe the behaviors of interest. Nurses rated residents lower than did attending physicians on items that related to respecting staff (69% vs 97%), accepting suggestions (56% vs 82%), teamwork (63% vs 88%), being sensitive and empathetic (62% vs 85%), respecting confidentiality (73% vs 97%), demonstrating integrity (75% vs 92%), and demonstrating accountability (67% vs 83%). Nurse responses were higher than attending physicians on anticipating postdischarge needs (46% vs 25%) and effectively planning care (52% vs 33%).

CONCLUSIONS

Expanding resident evaluation procedures to include parents and nurses does enhance information that is gathered on resident communication skills and professionalism and may help to target specific behaviors for improvement. Additional research is needed to determine whether receiving feedback on parent and nurse evaluations will have a positive impact on resident competency.

What are the key attributes of primary care for patients? Building a conceptual 'map' of patient preferences

BACKGROUND

Responding to the preferences of patients is a key focus of current health policy and is especially important in primary care. Responding effectively to patient preferences requires a clear understanding of the way in which patients assess primary care services.

OBJECTIVE

This study was designed to provide a 'map' of the content and structure of the key attributes of patient preferences concerning primary care.

DESIGN

The development of the 'map' used secondary research methods. Electronic databases were searched for published conceptual reviews of patient preferences, which were used to develop a basic 'map' through content analysis. A search for recently published primary empirical studies of patient preferences was conducted to extend and develop the 'map'. The 'map' was tested by taking a random sample of patient assessment instruments and categorizing the item content.

RESULTS

Seven major categories and multiple subcategories were described. The major categories were access, technical care, interpersonal care, patient-centredness, continuity, outcomes, and hotel aspects of care. The coverage of these attributes in a selection of patient assessment instruments varied widely, and the coding of a proportion of items in the patient assessment instruments according to the 'map' was problematic.

CONCLUSIONS

The conceptual 'map' can be used to plan comprehensive assessment of patient preferences in primary care. It also raises many theoretical issues concerning the nature of attributes and their interrelationships. The implications for the measurement of patient preferences are discussed.

Review of the literature on survey instruments used to collect data on hospital patients' perceptions of care

OBJECTIVE

To review the existing literature (1980-2003) on survey instruments used to collect data on patients' perceptions of hospital care.

STUDY DESIGN

Eight literature databases were searched (PubMED, MEDLINE Pro, MEDSCAPE, MEDLINEplus, MDX Health, CINAHL, ERIC, and JSTOR). We undertook 51 searches with each of the eight databases, for a total of 408 searches. The abstracts for each of the identified publications were examined to determine their applicability for review.

METHODS OF ANALYSIS

For each instrument used to collect information on patient perceptions of hospital care we provide descriptive information, instrument content, implementation characteristics, and psychometric performance characteristics.

PRINCIPAL FINDINGS

The number of institutional settings and patients used in evaluating patient perceptions of hospital care varied greatly. The majority of survey instruments were administered by mail. Response rates varied widely from very low to relatively high. Most studies provided limited information on the psychometric properties of the instruments.

CONCLUSIONS

Our review reveals a diversity of survey instruments used in assessing patient perceptions of hospital care. We conclude that it would be beneficial to use a standardized survey instrument, along with standardization of the sampling, administration protocol, and mode of administration.

Brief communication: The Chinese medical interview satisfaction scale-revised (C-MISS-R): Development and validation

BACKGROUND

The Medical Interview Satisfaction Scale (MISS) measures patient consultation satisfaction. We validated a translated short-form of the original MISS on Hong Kong Chinese women with breast cancer.

METHODS

The four highest scoring MISS Cognitive and Affective sub-scales items were administered in Chinese (C-MISS) to 224 female out patients. Phrasing revisions (C-MISS-R) were tested on 82 women. Random split tested factor structure stability. Convergent, divergent and criterion validation against other instruments was performed on 405 women.

RESULTS

Two-factors accounted for 61.7% of variance but factor loadings differed from the original. Phrasing revision increased Affective sub-scale item-item correlations exceeding 0.3-64%. Two factors matching those of the original MISS, accounting for 65.2% of variance, explained 36.6% (Cognitive) and 28.8% (Affective) of variance, respectively. Alpha was 0.84,0.74 and 0.83 for the Cognitive and Affective sub-scales and total respectively. Correlations of difficulties with treatment decision making (r = -0.298), Self-efficacy (r = 0.194), optimism (r = 0.33), psychological morbidity (r = -209), marital status, education and age indicated acceptable validity. Test-retest reliability was 0.410.

DISCUSSION

The Chinese MISS-Revised (C-MISS-R) has suitable factor structure and psychometric properties for use in consultation studies among Chinese female populations. Further validation is needed for males.

Best practices for assessing competence and performance of the behavioral Health workforce

The need for mechanisms to assess the competence and performance of the behavioral health workforce has received increasing attention. This article reviews strategies used in general medicine and other disciplines for assessing trainees and practitioners. The possibilities and limitations of various approaches are reviewed, and the implications for behavioral health are addressed. A conceptual model of competence is presented, and practical applications of this model are reviewed. Finally, guidelines are proposed for building competency assessment protocols for behavioral health.

Assessing professional behavior: yesterday, today, and tomorrow

PURPOSE

The author interprets the state of the art of assessing professional behavior. She defines the concept of professionalism, reviews the psychometric properties of key approaches to assessing professionalism, conveys major findings that these approaches produced, and discusses recommendations to improve the assessment of professionalism.

METHOD

The author reviewed professionalism literature from the last 30 years that had been identified through database searches; included in conference proceedings, bibliographies, and reference lists; and suggested by experts. The cited literature largely came from peer-reviewed journals, represented themes or novel approaches, reported qualitative or quantitative data about measurement instruments, or described pragmatic or theoretical approaches to assessing professionalism.

RESULTS

A circumscribed concept of professionalism is available to serve as a foundation for next steps in assessing professional behavior. The current array of assessment tools is rich. However, their measurement properties should be strengthened. Accordingly, future research should explore rigorous qualitative techniques; refine quantitative assessments of competence, for example, through OSCEs; and evaluate separate elements of professionalism. It should test the hypothesis that assessment tools will be better if they define professionalism as behaviors expressive of value conflicts, investigate the resolution of these conflicts, and recognize the contextual nature of professional behaviors. Whether measurement tools should be tailored to the stage of a medical career and how the environment can support or sabotage the assessment of professional behavior are central issues. FINAL THOUGHT: Without solid assessment tools, questions about the efficacy of approaches to educating learners about professional behavior will not be effectively answered.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of health care providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care are increasingly advocated by consumers and clinicians and incorporated into training for health care providers. The effects of interventions that aim to promote patient-centred care need to be evaluated.

OBJECTIVES

To assess the effects of interventions for health care providers that aim to promote patient-centred approaches in clinical consultations.

SEARCH STRATEGY

We searched Medline (1966 - Dec 1999); Health Star (1975 - Dec 1999); PsycLit (1887- Dec 1999); Cinahl (1982 - Dec 1999); Embase (1985-Dec 1999) and the bibliographies of studies assessed for inclusion.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for health care providers that promote patient-centred care in clinical consultations. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). The participants were health care providers, including those in training.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data onto a standard form and assessed study quality for each study. We extracted all outcomes other than health care providers' knowledge, attitudes and intentions.

MAIN RESULTS

17 studies met the inclusion criteria. These studies display considerable heterogeneity in terms of the interventions themselves, the health problems or health concerns on which the interventions focused, the comparisons made and the outcomes assessed. All included studies used training for health care providers as an element of the intervention. Ten studies evaluated training for providers only, while the remaining studies utilised multi-faceted interventions where training for providers was one of several components. The health care providers were mainly primary care physicians (general practitioners or family doctors) practising in community or hospital outpatient settings. In two studies, the providers also included nurses. There is fairly strong evidence to suggest that some interventions to promote patient-centred care in clinical consultations may lead to significant increases in the patient centredness of consultation processes. 12 of the 14 studies that assessed consultation processes showed improvements in some of these outcomes. There is also some evidence that training health care providers in patient-centred approaches may impact positively on patient satisfaction with care. Of the eleven studies that assessed patient satisfaction, six demonstrated significant differences in favour of the intervention group on one or more measures. Few studies examined health care behaviour or health status outcomes.

REVIEWER'S CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations may significantly increase the patient centredness of care. However, there is limited and mixed evidence on the effects of such interventions on patient health care behaviours or health status; or on whether these interventions might be applicable to providers other than physicians. Further research is needed in these areas.

Training physicians to increase patient trust

Patient trust in the physician is an important aspect of the patient-physician relationship that has recently become a focus of interest, in part due to the rise of managed care in the US healthcare system. In a previous study, we identified physician behaviours reported by patients as important to establishing their trust in the physician. The current study attempted to modify these behaviours via a short training programme and thereby to increase patient trust and improve associated outcomes. After baseline measurements, 10 physicians were randomized to the intervention group and 10 remained as a control group. While intervention physicians showed a net improvement in 16 of 19 specific patient-reported behaviours when compared to control physicians, these differences were not statistically significant. There was also no significant difference in patient trust, patient satisfaction, continuity, self-reported adherence, number of referrals or number of diagnostic tests ordered. This short training course in a group of self-selected physicians was not a sufficiently strong intervention to achieve the desired effect. Suggestions are given for designing a stronger training intervention.

Humanism: is its evaluation captured in commonly used performance measures?

BACKGROUND

There is an increased awareness of the importance of humanistic behavior and its education in the medical school curriculum. Relatively little is known about correlations between humanism and other performance measures.

PURPOSES

To determine the correlation between humanism and other commonly used performance measures, and to determine if more humanistic students perform better, the same, or worse than less humanistic students.

METHODS

During the Family Medicine clerkship, standardized patients (SPs) used the Physician Humanism Scale to assess 428 students for humanism. Clinical preceptors, SPs, written assignments, and a national knowledge examination also assessed student performance. The humanism scores were correlated with the SP and non-SP performance measures.

RESULTS

Humanism scores were significantly and positively correlated to all of the performance measures, but the correlation coefficients were low, ranging from .12 to .31. Students in the lowest quartile for humanism consistently scored lower for all of the performance measures, including both local and national exams (two-tailed significance < .018). Students with very low humanism scores still passed other performance evaluations.

CONCLUSIONS

The correlation between humanism and other performance measures is quite low, indicating that a separate measure for humanism provides different and additional information that current performance measures do not include. More humanistic students perform better than their less humanistic peers, but current performance measures do not identify students with the lowest scores on humanistic behavior. This study supports the inclusion of humanism as an additional, independent performance measure.

Measuring patient satisfaction for quality improvement

BACKGROUND

Surveys used for health plan quality reporting are generally administered annually to health plan enrollees to assess satisfaction with both the health plan and health care services. Therefore, surveys may lack sensitivity to measure the effects of patient-focused, quality improvement initiatives that could demonstrate results in a shorter time period.

OBJECTIVES

We describe the development and testing of a multidimensional, visit-specific measure of satisfaction with primary care that may be used in quality improvement.

METHODS

Conducted in five adult and pediatric primary care sites serving a commercial, largely managed-care population, the survey includes the Medical Outcomes Study Visit-Specific Questionnaire, the American Board of Internal Medicine Patient Satisfaction Questionnaire, and locally developed items. We assessed the instrument's reliability, validity, and utility for quality improvement.

RESULTS

For both adult and pediatric samples, three factors emerged: satisfaction with the provider, satisfaction with access, and satisfaction with the office. Satisfaction with the provider and with the office were independently correlated with overall satisfaction in both samples; satisfaction with access was significantly correlated with overall satisfaction only for adults. For adults, patients who disenrolled from the health plan were less satisfied with the office compared with patients who remained with the health plan. Finally, for adults, we detected significant differences across practice sites in terms of satisfaction with office and access; for children, there were intersite differences in terms of satisfaction with provider, office, and access.

CONCLUSIONS

We have support for the reliability and validity of this instrument that has identified differences in satisfaction between practice sites that may be used for quality improvement.

Further validation and reliability testing of the Trust in Physician Scale. The Stanford Trust Study Physicians

OBJECTIVES

To further validate and assess the reliability and validity of the Trust in Physician Scale.

METHODS

Consecutive adult patients (n = 414) from 20 community-based, primary care practices were enrolled in a prospective, 6-month study. At enrollment, subjects completed the 11-item Trust in Physician Scale plus measures of demographics, preferences for care, and satisfaction with care received from the physician. Continuity, satisfaction with care, and self-reported adherence to treatment were measured at 6 months. Reliability, construct validity, and predictive validity were assessed using correlation coefficients and analysis of variance techniques.

RESULTS

The Trust in Physician Scale showed high internal consistency (Cronbach's alpha = .89) and good 1-month test-retest reliability (intraclass correlation coefficient = .77). As expected, trust increased with the length of the relationship and was higher among patients who actively chose their physician, who preferred more physician involvement, and who expected their physician to care for a larger proportion of their problems (P < 0.001 for all associations). Baseline trust predicted continuity with the physician, self-reported adherence to medication, and satisfaction at 6 months after adjustment for gender, age, education, length of the relationship, active choice of the physician, and preferences for care. After additional adjustment for baseline satisfaction with physician care, trust remained a significant predictor of continuity, adherence, and satisfaction.

CONCLUSIONS

The Trust in Physician Scale has desirable psychometric characteristics and demonstrates construct and predictive validity. It appears to be related to, but still distinct from, patient satisfaction with the physician and, thus, provides a valuable additional measure for assessment of the quality of the patient-physician relationship.

Assessing emergency medicine resident communication skills using videotaped patient encounters: gaps in inter-rater reliability

We report on a process for assessing the communication skills of emergency medicine residents that includes 1) a faculty development initiative; 2) videotaping of actual resident-patient encounters in the emergency department; and 3) creation of an observation instrument for evaluating communication behaviors. We tested this observation instrument for inter-rater reliability, finding moderate-to-high agreement for only 11 of 32 items. These related to personal introductions, conflict management, nonverbal communication, and overall performance. There was poor or no agreement for behaviors related to establishing rapport, gathering information, and contracting or informing. Challenges of assessing interpersonal skills of emergency medicine residents are discussed.

Patient-physician communication assessment instruments: 1986 to 1996 in review

This paper provides a comprehensive review and comparison of instruments used to assess patient-doctor interaction over the past decade. Instruments were identified from papers indexed by MEDLINE from 1986 to 1996 using the medical subject headings 'physician-patient relations', 'physician-patient communication', and 'education, medical', as well as requests for instruments currently in use by colleagues. Each instrument was reviewed under the following categories: name of the instrument; description; number of items; reliability; validity; current use and special notes. Overall, 44 instruments were obtained and reviewed. Of these, 21 were used in only one published study each in the last decade and 15 have never been validated. While most instruments have been shown to be reliable (usually inter-rater reliability), very few instruments have been directly compared with another instrument designed to assess patient-doctor interactions. We suggest that further validation of existing instruments and incorporation of assessment of non-verbal communication between the patient and the doctor are needed.

Meeting walk-in patients' expectations for testing. Effects on satisfaction

OBJECTIVE

To examine the relation between meeting expectations for tests and visit satisfaction in walk-in patients.

DESIGN

Survey of patients before and after the visit.

SETTING

Walk-in medical clinic at a Veterans Affairs Medical Center.

PATIENTS

143 male veterans were eligible for this study: 128 agreed to participate; 109 completed both questionnaires.

MEASUREMENTS

Before the visit, we measured health status, baseline satisfaction with care, and expectations for common tests. After the visit, we measured visit-specific satisfaction, patient perception of provider interpersonal behavior (provider humanism), and patient report of whether specific tests were received. Logistic regression was used to determine the effect of meeting expectations for tests while controlling for other factors.

RESULTS

Of all patients, 62% expected one or more tests, nearly as many as expected a medication or a diagnosis. In multivariate analysis restricted to those expecting tests, provider humanism was the sole significant predictor of visit-specific satisfaction (odds ration [OR] 6.4; 95% confidence interval [CI] 1.6, 26.1). The proportion of expectations for testing that were met was not significantly associated with satisfaction (OR 1.05; 95% CI 0.92, 1.21).

CONCLUSIONS

Meeting patient expectations for tests does not have an important effect on satisfaction. Even in the walk-in setting, patient perception of the providers' interpersonal behavior was a more important factor in satisfaction with the visit. Physicians who order tests solely to improve patient satisfaction may be able to reduce unnecessary testing without decreasing patient satisfaction.

Housestaff social history knowledge. Correlation with evaluation of interpersonal skills

It was hypothesized that internal medicine housestaff who inquire into their hospital patients' social histories would be rated by nurses and attendings as having better interpersonal skills. Thirty-seven internal medicine housestaff were asked to answer a questionnaire regarding the social history of up to three of their hospital patients. The score on these questionnaires was then compared to evaluations by nurses and attendings of housestaffs' interpersonal skills. We found that nurses' evaluations of housestaff interpersonal skills correlated with performance on the social history questionnaire, while attendings' evaluations did not. Social history inquiry by housestaff may be a marker for housestaff humanistic and interpersonal skills.

Do physicians take into account patients' expectations?

To determine whether patient expectations are fulfilled when they are expressed to physicians, self-administrated questionnaires were given to 360 consecutive ambulatory patients. Information was randomly given or not given to physicians. Diagnosis (94%), information about prognosis (82%) and prevention (76%), and continuing care (80%) were important expectations. There was no agreement between global or individual patient expectation and physician response (kappa < or = 0.3). The physicians prescribed more medications than expected, and almost never discussed prevention or prognosis. Finally, the characteristics of care were not different between the physicians who knew and those who did not know patient expectations. The authors conclude that ambulatory patients visit physicians to receive a diagnosis, continuing care, and information about prognosis and prevention. In this study, physician knowledge of those expectations did not increase their fulfillment.