Toward a biopsychosocial understanding of the patient-physician relationship: an emerging dialogue

Needs and Experiences With Health Care Providers of Adult Rare Disease Patients and Caregivers of People With Rare Diseases: Protocol for a Qualitative Study

BACKGROUND

Rare diseases in Europe are defined as diseases with a prevalence of less than 5 per 10,000 people. Despite their individual rarity, the total number of rare diseases is considerable. Rare diseases are often chronic and complex, affecting physical, mental, and neurological health. People with rare diseases face challenges such as delayed diagnosis, limited medical support, and financial burden. Caregivers, usually family members, bear significant physical and emotional burdens. Understanding the experiences of patients with rare disease and their caregivers is critical to effective care, but this is still underresearched. Better support and understanding of the challenges faced by both patients and caregivers is clearly needed. Our study will explore the experiences and needs of people with rare diseases and caregivers of people with rare diseases in relation to accessing health services.

OBJECTIVE

This study aims to explore the experiences of patients with rare disease and their caregivers with Slovenian health care providers and to create a theoretical model of needs and experiences.

METHODS

This is a qualitative thematic analysis study, using the codebook approach. The study will conduct semi-open-ended interviews to understand the experiences and needs of people with rare diseases and caregivers of people with rare diseases in relation to accessing health services. The interview questions will be based on an extensive literature review. Data from the interviews will be analyzed using thematic analysis to identify patterns and build a thematic map. Data will be analyzed by at least 2 coders. To ensure reliability, respondent validation will be conducted and negative cases investigated. Any discrepancies will be resolved by consulting the entire research team until a consensus is reached.

RESULTS

This study was not specifically funded. However, author TČ is supported by grant number P3-0339 from the Slovenian Agency for Research and Innovation. This study was approved by the Medical Ethics Committee of the Republic of Slovenia (0120-47/2022/3), and recruitment is expected to begin in May 2024, with data analysis results anticipated by the end of 2025.

CONCLUSIONS

This study will fill an important research gap in Slovenia by exploring the needs and experiences of people living with rare diseases and their caregivers. The results will contribute to the broader field of rare diseases and add knowledge that can inform future research processes and intervention strategies. It also aims to identify neglected areas that have a significant impact on the lives of people with rare diseases. This study is important not only because it addresses the immediate needs of the Slovenian rare disease community, but also because it contributes to a discussion on patient-centered care, health policy design, and the inclusion of psychosocial components in health care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/53362.

Antecedents of rapport and its mediating role on relational cohesion in patient-physician interaction

Increasing competition in healthcare services, it is imperative that physicians and family-care practitioners seek ways to attract and retain patients. Building relationships with existing patients is one sure way to continued patronage and increased clientele. The purpose of this paper is to examine antecedents of rapport and its influence on perceived relationships in the context of patient-physician interaction. Study using cross-sectional survey method with structured questionnaire was used for data collection. Structural Equation Modeling was used for analyzing the data collected from 326 patients residing in Karnataka, India. The finding suggests that respect, responsibility and understanding have significant influence on relational cohesion with rapport acting as mediating variable. The results add to the empirical validity of the relationship among rapport, respect & relationship, as it is required to understand studied in Indian context. The finding provides new directions for both healthcare professionals and institutions in their endeavor of building relationships with their customers (Patients) by emphasizing the need for developing 'rapport' as an integral part of service interaction. Future research like longitudinal and experimental studies can provide more conclusive evidence regarding the influence of service behaviour on rapport.

Rural health dialogue for the sustainability of help-seeking behaviors among older patients: grounded theory approach

BACKGROUND

Help-seeking behaviors (HSBs) are essential for disease prevention and health promotion. Dialogues with peers and medical professionals can improve HSBs, both qualitatively and quantitatively. Rural communities lacking healthcare resources require effective HSBs for healthcare sustainability. The current study aimed to investigate the effect of health dialogues between medical professionals and rural citizens on their HSBs.

METHODS

All procedures complied with the Declaration of Helsinki and its subsequent amendments. The Unnan City Hospital Clinical Ethics Committee approved the study protocol (No. 20,220,002). A grounded theory approach was employed for the health dialogue participants in rural communities. Health dialogues with family physicians were conducted once a month at rural community centers. The dialogues and focus group interviews were recorded and coded to investigate changes in participants' perceptions and behaviors regarding HSBs.

RESULTS

Twenty-one dialogues were conducted in two rural community centers, with a total of 112 participants. The average age of the participants was 70.2 years (standard deviation = 5.4), with 24% being males. Analysis of the grounded theory approach revealed four themes, namely joy-driven dialogue driving the realization of HSBs, reflection on personal HSBs through learning from others, revising HSBs based on rural social resources, and familiarity with physicians, hence motivating safe and secure HSBs.

CONCLUSIONS

Mitigation of barriers between citizens and medical professionals and improvement of psychological safety in communities can drive effective HSBs in rural communities.

How our hearts beat together: a study on physiological synchronization based on a self-paced joint motor task

Cardiac physiological synchrony is regarded as an important component of social interaction due to its putative role in prosocial behaviour. Yet, the processes underlying physiological synchrony remain unclear. We aim to investigate these processes. 20 dyads (19 men, 21 women, age range 18-35) engaged in a self-paced interpersonal tapping synchronization task under different levels of tapping synchrony due to blocking of sensory communication channels. Applying wavelet transform coherence analysis, significant increases in heart rate synchronization from baseline to task execution were found with no statistically significant difference across conditions. Furthermore, the control analysis, which assessed synchrony between randomly combined dyads of participants showed no difference from the original dyads' synchrony. We showed that interindividual cardiac physiological synchrony during self-paced synchronized finger tapping resulted from a task-related stimulus equally shared by all individuals. We hypothesize that by applying mental effort to the task, individuals changed into a similar mental state, altering their cardiac regulation. This so-called psychophysiological mode provoked more uniform, less variable fluctuation patterns across all individuals leading to similar heart rate coherence independent of subsequent pairings. With this study, we provide new insights into cardiac physiological synchrony and highlight the importance of appropriate study design and control analysis.

Effectiveness of metronidazole gel and mobile telephone short-message service reminders on gingivitis in orthodontic patients

OBJECTIVES

To compare the effectiveness of metronidazole gel and mobile telephone short-message service (SMS) reminders on gingivitis in patients undergoing fixed orthodontic treatment.

MATERIALS AND METHODS

The trial was double blinded (patient and investigator), and only the clinical trial unit pharmacist was unblinded. Data were collected from patients undergoing fixed orthodontic treatment for at least 6 months. A total of 66 patients were randomly assigned to either 0.8% metronidazole gel (n = 22), SMS reminder and placebo gel (n = 22), or placebo (control) group only (n = 22). Gingival index (GI), bleeding index (BI), and orthodontic plaque index (OPI) were evaluated on several teeth at baseline (T0) and after 4 weeks (T1). Paired-sample t-tests were used to compare mean differences of indexes at T0 and T1 in the groups, and independent-sample t-tests were used to determine the effects of interventions compared with the controls.

RESULTS

Data from 64 patients were analyzed; there were 2 dropouts. There were statistically significant (P < .05) reductions in GI, BI, and OPI scores from T0 to T1 for each intervention. However, there were no significant differences between each intervention and the control group. There were no adverse effects.

CONCLUSIONS

The null hypothesis could not be rejected. There is no difference between interventions (application of 0.8% metronidazole gel and SMS reminder for reinforcing oral hygiene) in reducing gingival inflammation in orthodontic patients.

'Maybe we are losing sight of the human dimension' - physicians' approaches to existential, spiritual, and religious needs among patients with chronic pain or multiple sclerosis. A qualitative interview-study

Objective

Research suggests that existential, spiritual, and religious issues are important for patient’s psychological adjustment when living with chronic pain and multiple sclerosis. However, there is a paucity of studies investigating how physicians experience and approach these patients’ needs.

Design

Physicians’ experiences with and approaches to existential, spiritual, and religious needs when treating chronic pain or multiple sclerosis were studied in eight semi-structured interviews and analysed using interpretative phenomenological analysis (IPA).

Results

Physicians found that only few patients had spiritual and religious needs; however, they experienced that every patient were struggling with existential challenges related to the illness and rooted in a changed identity and approaching death. How the physicians approached these needs appeared to be influenced by six conditions: Their medical culture, training, role, experiences of time pressure, their personal interests, and interpersonal approach.

Conclusion

Physicians’ training seems better suited to meet biomedical objectives and their patients’ concrete needs than patients’ wish for a relational meeting focused on their subjective lifeworld. This challenge is discussed in relation to modern patient-centeredness, doctor-patient relationship, culturally constructed experiences of privacy, and future clinical practice and research needs.

Partners in Recovery: an early phase evaluation of an Australian mental health initiative using program logic and thematic analysis

Background

Mental illness is a leading cause of illness and disability and around 75% of people suffering mental illness do not have access to adequate care. In Australia, nearly half the population experiences mental illness at some point in their life. The Australian Government developed a National program called Partners in Recovery (PIR) to support those with severe and persistent mental illness. The program was implemented through 48 consortia across Australia. One of these was led by the Nepean Blue Mountains Medicare Local who adapted the program according to its specific local needs.

Methods

We conducted an early evaluation of the PIR program in Nepean Blue Mountains (NBMPIR) using a program logic model (PLM) to frame the evaluation and complemented this with an additional thematic analysis. Participants (n = 73) included clients and carers, program management and staff of the Consortium and other partners and agencies, and clinical, allied health, and other service providers. Our PLM utilised multiple data sources that included document review, open and closed survey questions, and semi-structured interviews. Quantitative data received a descriptive analysis and qualitative data was analysed both in alignment with the PLM framework and inductively.

Results

We aligned our results to PLM domains of inputs, activities, outputs, outcomes and impacts. The NBMPIR consortium implemented a recovery approach and provided greater access to services by enhancing healthcare provider partnerships. Our thematic analysis further described five key themes of collaboration; communication; functioning of PIR; structural/organisational challenges; and understanding of PIR approaches. Facilitators and barriers to the NBMPIR program centred on the alignment of vision and purpose; building an efficient system; getting the message out and sharing information; understanding roles and support and training of staff; building capacity and systems change; addressing service gaps; and engaging peers.

Conclusions

Our study provided helpful insights into the coordinated management of complex mental illness. The NBMPIR’s focus on partnerships and governance, service coordination, and systems change has relevance for others engaged in this work. This PLM effectively mapped the program, including its processes and resources, and is a useful framework providing a baseline for future evaluations.

Full report available at https://researchdirect.westernsydney.edu.au/islandora/object/uws:33977/

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4360-2) contains supplementary material, which is available to authorized users.

The Role of Patient-Practitioner Relationships in Placebo and Nocebo Phenomena

INTRODUCTION

Placebo and nocebo effects form part of all therapeutic environments and play a significant role in the effectiveness of treatment outcomes. Patient expectancies drive these phenomena, which can be shaped through contextual factors including verbal suggestions, conditioning, and social observation.

OBJECTIVES

This review seeks to identify the biopsychosocial factors of the patient-practitioner interaction that play a role in the development of placebo and nocebo effects, as well as the anthropological elements of the biodynamic process of relating that are meaningful in the development of expectancies.

METHODS

We conducted a narrative review of frameworks of the placebo and nocebo effect, including the impact of expectancies and interpersonal relationships in the context of healing and the clinical setting.

RESULTS

Expectancies leading to placebo and nocebo effects can be modified by macro and micro factors, such as culture and society, as well as individual psychobiological traits, respectively. The developmental sociobiological adaptations that form and consolidate mindsets and meaningful contexts play an important role in shaping patient expectancies, as well as patients' conscious and subconscious reactions to signs and actions taking place within the clinical environment. Practitioner characteristics, like empathy, friendliness, and competence, favor the formation of positive expectancies. Caring and warm patient-practitioner interactions can enhance the therapeutic value of clinical encounters when patients' positive expectancies are actively encouraged and engaged.

CONCLUSION

A patient-centered approach rooted in demonstrating care and empathy can positively enhance a patient's experience within the clinical environment and activate psychosociobiological adaptations associated with the placebo phenomenon. Pain patients could particularly benefit from non-invasive approaches for improving treatment effectiveness and quality-of-life.

Placebo hypoalgesic effects in pain: Potential applications in dental and orofacial pain management

Placebo and nocebo effects are present within every treatment and intervention, and can be purposefully enhanced and reduced, respectively, in order to improve patients' clinical outcomes. A plethora of research has been conducted on the mechanisms of placebo hypoalgesia and nocebo hyperalgesia in experimental and clinical settings. However, its implications in particular clinical settings such as orthodontic pain management remain underexplored. We conducted a search of the literature regarding placebo analgesia, orthodontic pain management, and orofacial and dental pain. Articles were qualitatively assessed and selected based on the scope of this narrative review. Although no studies investigating the extent of the implications of the placebo and nocebo phenomena in the orthodontic clinical setting were found, we herein present a comprehensive review on the influences of placebo and nocebo effects in experimental and clinical pain management, as well as on the potential for engaging placebo-related endogenous pain modulation for orthodontic pain management. Ethical considerations for the clinical application of placebos are discussed, and future research directions are presented.

Biopsychosocial model of illnesses in primary care: A hermeneutic literature review

Biopsychosocial model is a useful worldview for primary care or family doctors. However, it is often considered as impractical or too complicated. The objective of this study is to review the implementation of the biopsychosocial model in clinical practice, and its contributions to clinical outcomes. Hermeneutic circle literature review was conducted to provide experiential learning in an attempt to understand biopscyhosocial model, first developed by George Engel. Literature search started with review articles in Medline and Scopus as search engines. Citations from previous articles, editorials, and research articles were identified and interpreted in the context of the knowledge derived from all identified relevant articles. The progress of biopsychosocial model has been slow, and primary care doctors do not implement biopsychosocial medicine in their practice, while biomedical thinking and approach are still the dominant model. Biopsychosocial research addressed chronic illnesses and functional disorders as conditions in need for biopsychosocial model implementation. As payment scheme, clinical guidelines and clinical performance indicators are biomedically oriented, there is no incentive for primary care doctors to adopt biopsychosocial model in their practice. Workload and lack of competence in primary care may hinder the implementation of biopsychosocial model. Biopsychosocial model helps primary care doctors to understand interactions among biological and psychosocial components of illnesses to improve the dyadic relationship between clinicians and their patients and multidisciplinary approaches in patient care. Biopsychosocial model potentially improves clinical outcomes for chronic diseases and functional illnesses seen in primary care.

Interpersonal Autonomic Physiology: A Systematic Review of the Literature

Interpersonal autonomic physiology is defined as the relationship between people’s physiological dynamics, as indexed by continuous measures of the autonomic nervous system. Findings from this field of study indicate that physiological activity between two or more people can become associated or interdependent, often referred to as physiological synchrony. Physiological synchrony has been found in both new and established relationships across a range of contexts, and it correlates with a number of psychosocial constructs. Given these findings, interpersonal physiological interactions are theorized to be ubiquitous social processes that co-occur with observable behavior. However, this scientific literature is fragmented, making it difficult to evaluate consistency across reports. In an effort to facilitate more standardized scholarly approaches, this systematic review provides a description of existing work in the area and highlights theoretical, methodological, and statistical issues to be addressed in future interpersonal autonomic physiology research.

Clinician empathy is associated with differences in patient-clinician communication behaviors and higher medication self-efficacy in HIV care

OBJECTIVE

We examined associations of clinicians' empathy with patient-clinician communication behaviors, patients' rating of care, and medication self-efficacy.

METHODS

We analyzed 435 adult patients and 45 clinicians at four outpatient HIV care sites in the United States. Negative binomial regressions investigated associations between clinician empathy and patient-clinician communication, assessed using the Roter Interaction Analysis System (RIAS). Logistic regressions investigated associations between clinician empathy and patient ratings of clinician communication, overall satisfaction, and medication self-efficacy.

RESULTS

Clinicians in the highest vs. lowest empathy tertile engaged in less explicitly emotional talk (IRR 0.79, p<0.05), while clinicians in the middle vs. lowest engaged in more positive talk (IRR 1.31, p<0.05), more questions (IRR 1.42, p<0.05), and more patient activating talk (IRR 1.43, p<0.05). Patients of higher empathy clinicians disclosed more psychosocial and biomedical information. Patients of clinicians in both the middle and highest (vs. lowest) empathy tertiles had greater odds of reporting highest medication self-efficacy (OR 1.80, 95% CI 1.16-2.80; OR 2.13, 95% CI 1.37-3.32).

CONCLUSIONS

Clinician empathy may be expressed through addressing patient engagement in care, by fostering cognitive, rather than primarily emotional, processing.

PRACTICE IMPLICATIONS

Clinicians should consider enhancing their own empathic capacity, which may encourage patients' self-efficacy in medication adherence.

Is a good death possible in Australian critical and acute settings?: physician experiences with end-of-life care

Background

In Australia approximately 70% of all deaths are institutionalised but over 15% of deaths occur in intensive care settings where the ability to provide a “good death” is particularly inhibited. Yet, there is a growing trend for death and dying to be managed in the ICU and physicians are increasingly challenged to meet the new expectations of their specialty. This study examined the unexplored interface between specialised Australian palliative and intensive care and the factors influencing a physician’s ability to manage deaths well.

Method

A qualitative investigation was focused on palliative and critical/acute settings. A thematic analysis was conducted on semi-structured in-depth interviews with 13 specialist physicians. Attention was given to eliciting meanings and experiences in Australian end-of-life care.

Results

Physicians negotiated multiple influences when managing dying patients and their families in the ICU. The way they understood and experienced end-of-life care practices was affected by cultural, institutional and professional considerations, and personal values and beliefs. Interpersonal and intrapsychic aspects highlighted the emotional and psychological relationship physicians have with patients and others. Many physicians were also unaware of what their cross-disciplinary colleagues could or could not do; poor professional recognition and collaboration, and ineffective care goal transition impaired their ability to assist good deaths. Experience was subject to the efficacy of physicians in negotiating complex bedside dynamics.

Conclusions

Regardless of specialty, all physicians identified the problematic nature of providing expert palliation in critical and acute settings. Strategies for integrating specialised palliative and intensive care were offered with corresponding directions for future research and clinical development.

Decisions that hasten death: double effect and the experiences of physicians in Australia

BACKGROUND

In Australian end-of-life care, practicing euthanasia or physician-assisted suicide is illegal. Despite this, death hastening practices are common across medical settings. Practices can be clandestine or overt but in many instances physicians are forced to seek protection behind ambiguous medico-legal imperatives such as the Principle of Double Effect. Moreover, the way they conceptualise and experience such practices is inconsistent. To complement the available statistical data, the purpose of this study was to understand the reasoning behind how and why physicians in Australia will hasten death.

METHOD

A qualitative investigation was focused on palliative and critical/acute settings. A thematic analysis was conducted on semi-structured in-depth interviews with 13 specialist physicians. Attention was given to eliciting meanings and experiences in Australian end-of-life care.

RESULTS

Highlighting the importance of a multidimensional approach, physicians negotiated multiple influences when death was regarded as hastened. The way they understood and experienced end-of-life care practices were affected by politico-religious and cultural influences, medico-legal imperatives, and personal values and beliefs. Interpersonal and intrapsychic aspects further emphasised the emotional and psychological investment physicians have with patients and others. In most cases death occurred as a result of treating suffering, and sometimes to fulfil the wishes of patients and others who requested death. Experience was especially subject to the efficacy with which physicians negotiated complex but context-specific situations, and was reflective of how they considered a good death. Although many were compelled to draw on the Principle of Double Effect, every physician reported its inadequacy as a medico-legal guideline.

CONCLUSIONS

The Principle of Double Effect, as a simplistic and generalised guideline, was identified as a convenient mechanism to protect physicians who inadvertently or intentionally hastened death. But its narrow focus on the physician's intent illuminated how easily it may be manipulated, thus impairing transparency and a physician's capacity for honesty. It is suggested the concept of "force majeure" be examined for its applicability in Australian medical end-of-life law where, consistent with a multidimensional and complex world, a physician's motivations can also be understood in terms of the emotional and psychological pressures they face in situations that hasten death.

The Biology of Caring

Caring, a core tenet of nursing practice, grew out of a holistic approach. Nurse theorists often note the establishment of a therapeutic relationship as the beginning point of caring, with subsequent nursing interventions reliant upon this relationship for effectiveness. Relational exchange serves as a source of either stress or healing between participants, and rarely is its impact neutral. Relational stress, in fact, has become a primary contributor to many disease processes in terms of promotion and progression and perhaps even initiation. Patient–provider relationships have a long history in medical and nursing literature as critical to providing effective interventions, but our understanding of relational dynamics between patients and providers remains fairly superficial. This theoretical article adapts a previously described biobehavioral model to illustrate the nature and centrality of caring relationships in nursing practice. The dynamic process of face-to-face engagement is deconstructed from a psychobiological standpoint in order to understand the physiological, emotional, cognitive, and behavioral impacts of relational interaction. This understanding is then applied to the patient–provider relationship. Finally, the utility of biomarkers of stress, positive emotion and resonance, and of disease is discussed relative to the patient-provider relationship. Methodological and interpretive challenges inherent in this line of research, along with suggestions to address such challenges, are also presented.

Let's talk about medication: concordance in rating medication adherence among multimorbid patients and their general practitioners

BACKGROUND

Medication adherence can be essential for improving health outcomes. Patients with multiple chronic conditions, often receiving multiple medications, are at higher risk for medication nonadherence. Previous research has focused on concordance between patients and providers about which medication should be taken. However, the question of whether patients and providers are concordant in rating actual medication intake has not been answered as yet. This study aimed to explore the extent and predictors of patient - provider concordance in rating medication adherence in patients with multiple chronic conditions.

METHODS

Overall medication adherence was measured by self-report (Medication Adherence Report Scale, MARS-D) in a sample of 92 patients with multiple chronic conditions. Twelve treating primary care physicians were asked to rate medication adherence in these patients using a mirrored version of the MARS-D. Concordance between external rating and self-reported medication adherence was analyzed descriptively. Predictors of concordance in rating medication adherence were explored in a multilevel analysis.

RESULTS

Patients rate their medication adherence markedly higher than their general practitioner. Accordingly, the percentage of concordance ranges between 40% (forgot to take medication) and 61% (deliberately omitted a dose). In multilevel analysis, concordance in rating medication adherence was positively associated with being the single primary care provider (β 2.24, P < 0.0001) and frequent questioning about medication use (β 0.66, P = 0.0031). At the patient level, "not [being] married" (β -0.81, P = 0.0064) and "number of prescribed medications" (β -0.10, P = 0.0203) were negative predictors of patient - provider concordance in rating medication adherence.

CONCLUSION

Concordance for rating medication adherence between general practitioners and their patients was low. Talking about medication on a regular basis and better continuity of care may enhance patient - provider concordance in rating medication adherence as a prerequisite for shared decisions concerning medication in patients with multiple chronic conditions.

Disability assessment in temporomandibular disorders and masticatory system rehabilitation

The consequences of a disease or condition such as temporomandibular disorders (TMD) include functional limitation and psychosocial disability. These two concepts refer to the individual's experience of limitations in function associated with the affected part of the body and to disarray in one's life, respectively. Models of disability emphasize the individual's self-report in describing these states and the centrality of these concepts as part of the disease and illness process. However, assessment approaches typically used in medicine and especially in dentistry do not yet routinely include these domains. TMD, as a musculoskeletal pain condition, can clearly lead to both limitation and disability, and the available evidence suggests that dentofacial disorders can also lead to both consequences. The relatively low contribution of disease impairment (measured changes in function through objective tests), however, to the reported limitation or disability in either TMD or dentofacial disorders remains complex and poorly understood. This article reviews the overall model of disablement, the necessary properties of measures to assess disablement, the present state of knowledge about these concepts, and what measures should be considered as part of routine assessment.

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

BACKGROUND

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

OBJECTIVE

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

CONCLUSION

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

The medical consultation viewed as a value chain: a neurobehavioral approach to emotion regulation in doctor-patient interaction

OBJECTIVE

To present a model of the medical consultation as a value chain, and to apply a neurobehavioral perspective to analyze each element in the chain with relevance for emotion regulation.

METHODS

Current knowledge on four elements in medical consultations and neuroscientific evidence on corresponding basic processes are selectively reviewed.

RESULTS

The four elements of communication behaviours presented as steps in a value chain model are: (1) establishing rapport, (2) patient disclosure of emotional cues and concerns, (3) the doctor's expression of empathy, and (4) positive reappraisal of concerns.

CONCLUSION

The metaphor of the value chain, with emphasis on goal orientation, helps to understand the impact of each communicative element on the outcome of the consultation. Added value at each step is proposed in terms of effects on outcome indicators; in this case patients affect regulation. Neurobehavioral mechanisms are suggested to explain the association between communication behaviour and affect regulation outcome.

PRACTICE IMPLICATIONS

The value chain metaphor and the emphasis on behaviour-outcome-mechanisms associations may be of interest as conceptualizations for communications skills training.

Analyzing the "nature" and "specific effectiveness" of clinical empathy: a theoretical overview and contribution towards a theory-based research agenda

OBJECTIVE

To establish sound empirical evidence that clinical empathy (abbreviated as CE) is a core element in the clinician-patient relationship with profound therapeutic potential, a substantial theoretical-based understanding of CE in medical care and medical education is still required. The two aims of the present paper are, therefore, (1) to give a multidisciplinary overview of the "nature" and "specific effectiveness" of CE, and (2) to use this base as a means of deriving relevant questions for a theory-based research agenda.

METHOD

We made an effort to identify current and past literature about conceptual and empirical work focusing on empathy and CE, which derives from a multiplicity of disciplines. We review the material in a structured fashion.

RESULTS

We describe the "nature" of empathy by briefly summarizing concepts and models from sociology, psychology, social psychology, education, (social-)epidemiology, and neurosciences. To explain the "specific effectiveness" of CE for patients, we develop the "Effect model of empathic communication in the clinical encounter", which demonstrates how an empathically communicating clinician can achieve improved patient outcomes. Both parts of theoretical findings are synthesized in a theory-based research agenda with the following key hypotheses: (1) CE is a determinant of quality in medical care, (2) clinicians biographical experiences influence their empathic behavior, and (3) CE is affected by situational factors.

CONCLUSION

The main conclusions of our review are twofold. First of all, CE seems to be a fundamental determinant of quality in medical care, because it enables the clinician to fulfill key medical tasks more accurately, thereby achieving enhanced patient health outcomes. Second, the integration of biographical experiences and situational factors as determinants of CE in medical care and medical education appears to be crucial to develop and promote CE and ultimately ensuring high-quality patient care.

PRACTICE IMPLICATIONS

Due to the complexity and multidimensionality of CE, evidence-based investigations of the derived hypotheses require both well-designed qualitative and quantitative studies as well as an interdisciplinary research approach.

Expanding clinical empathy: an activist perspective

BACKGROUND

Discussions of empathy in health care offer important ways of enabling communication and interpersonal connection that are therapeutic for the patient and satisfying for the physician. While the best of these discussions offer valuable insights into the patient-physician relationship, many of them lack an action component for alleviating the patient's suffering and emphasize the physician's experience of empathy rather than the patient's experience of illness.

METHODS

By examining educational methods, such as reflective writing exercises and the study of literary texts, and by analyzing theoretical approaches to empathy and suggestions for clinical practice, this article considers how to mindfully keep the focus on what the patient is going through.

CONCLUSION

Clinical empathy can be improved by strategies that address (1) the patient's authority in providing first-person accounts of illness and disability, (2) expanding the concept of empathy to include an action component geared toward relieving patients' suffering, and (3) the potential value of extending empathy to include the social context of illness.

Missed opportunities for interval empathy in lung cancer communication

BACKGROUND

Empathy is important in patient-physician communication and is associated with improved patient satisfaction and adherence to physicians' recommendations.

METHODS

To evaluate empathic opportunities and physician responses, we conducted a qualitative thematic analysis of 20 audiorecorded, transcribed consultations between patients with lung cancer and their thoracic surgeons or oncologists, from a larger observational study of 137 patients in a Veterans Affairs hospital in the southern United States. Using qualitative analysis, we collaboratively developed themes and subthemes until saturation. Then, each transcript was coded, using grounded theory methods, until consensus was achieved, counting and sequentially analyzing patient empathic opportunities and physician responses.

RESULTS

Subthemes regarding patients' statements about lung cancer included (1) morbidity or mortality concerns, (2) cancer-related symptoms, (3) relationship to smoking, (4) decisions about treatment, (5) beliefs about or mistrust of medical care, (6) factors limiting ability to treat cancer, and (7) confusion regarding cancer status and treatment. We identified 384 empathic opportunities and found that physicians had responded empathically to 39 (10%) of them. Otherwise, physicians provided little emotional support, often shifting to biomedical questions and statements. We defined this phenomenon as missed opportunities for "interval empathy." When empathy was provided, 50% of these statements occurred in the last one-third of the encounter, whereas patients' concerns were evenly raised throughout the encounter.

CONCLUSIONS

Physicians rarely responded empathically to the concerns raised by patients with lung cancer, and empathic responses that did occur were more frequently in the last third of the encounter. Our results may provide a typologic approach to help physicians recognize empathic opportunities and with further development may aid in improving physicians' communication skills.