Effectiveness of intensive physician training in upfront agenda setting

Storylines of family medicine VI: ways of being-in the office with patients

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VI: ways of being-in the office with patients', authors address the following themes: 'Patient-centred care-cultivating deep listening skills', 'Doctor as witness', 'Words matter', 'Understanding others-metaphor and its use in medicine', 'Communicating with patients-making good use of time', 'The patient-centred medical home-aspirations for the future', 'Routine, ceremony or drama?' and 'The life course'. May readers better appreciate the nuances of patient care through these essays.

Communication in Primary Healthcare: A State-of-the-Art Literature Review of Conversation-Analytic Research

We report the first state-of-the-art review of conversation-analytic (CA) research on communication in primary healthcare. We conducted a systematic search across multiple bibliographic databases and specialist sources and employed backward and forward citation tracking. We included 177 empirical studies spanning four decades of research and 16 different countries/health systems, with data in 17 languages. The majority of studies originated in United States and United Kingdom and focused on medical visits between physicians and adult patients. We generated three broad research themes in order to synthesize the study findings: managing agendas, managing participation, and managing authority. We characterize the state-of-the-art for each theme, illustrating the progression of the work and making comparisons across different languages and health systems, where possible. We consider practical applications of the findings, reflect on the state of current knowledge, and suggest some directions for future research. Data reported are in multiple languages.

Qualitatively exploring the impact of a relationship-centered communication skills training program in improving patient perceptions of care

Objective

To explore qualitative patient experience comments before and after a relationship-centered communication skills training to understand patient experience, program impact, and opportunities for improvement.

Methods

Qualitative patient experience evaluation data was captured from January 2016 to December 2018 for 483 health care clinicians who participated in the skills training. A random sampling of available open-ended patient comments (N = 33,223) were selected pre-training (n = 668) and post-training (n = 566). Comments were coded for valence (negative/neutral/positive), generality versus specificity, and based on 12 communication behaviors reflective of training objectives.

Results

No significant difference was found in the valence of comments, or generality versus specificity of comments before and after the training. A significant decrease was present in perceived clinician concern. "Confidence in care provider" was the communication skill most frequently identified in comments both pre- and post-training.

Conclusion

Perceptions of interactions largely remained the same following training. Key relationship-centered communication skills require further attention in future training efforts. Measurements of patient satisfaction and engagement may not adequately represent patient experience.

Innovation

This study identified areas for improvement in the training program and offers a model for utilizing patient experience qualitative data in understanding communication training impact.

Physician Communication Coaching: How Psychologists can Elevate Skills and Support Resident Education, Professionalism, and Well-being

Many factors influence resident physician communication, including rigorous training demands that can contribute to professionalism issues or burnout. The University of Rochester Physician Communication Coaching program launched for attendings in 2011, and expanded to residency programs within 11 clinical departments of our institution. In this model, psychologists serve as coaches, drawing on their expertise in communication skills, behavior change, and wellness promotion. These coaches conduct real-time observation of patient encounters, coding communication with an expanded Cambridge-Calgary Patient-Centered Observational Checklist. Residents receive a written report with individualized feedback. From 2013 to 2020, 279 residents were coached. Since 2018, residents have been formally surveyed for feedback (n = 70 surveys completed; 61% response rate), with 97% rating the experience Very Helpful or Helpful. Of the 70 completed surveys, 54 (77%) included qualitative feedback that has also been positive. Due to the feasibility and growing demand for communication coaching from other residency and fellowship programs, in 2018 two authors (SM and LD-R) developed a 2-year, part-time program to train communication coaches.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

Communication principles and practices for making shared decisions about renal replacement therapy: a review of the literature

PURPOSE OF REVIEW

To provide an overview of the skill set required for communication and person-centered decision making for renal replacement therapy (RRT) choices, especially conservative kidney management (CKM).

RECENT FINDINGS

Research on communication and decision-making skills for shared RRT decision making is still in infancy. We adapt literature from other fields such as primary care and oncology for effective RRT decision making.

SUMMARY

We review seven key skills: (1) Announcing the need for decision making (2) Agenda Setting (3) Educating patients about RRT options (4) Discussing prognoses (5) Eliciting patient preferences (6) Responding to emotions and showing empathy, and (7) Investing in the end. We also provide example sentences to frame the conversations around RRT choices including CKM.

Webside manner: maskless communication

Telemedicine has seen a rapid expansion lately, with virtual visits ushering in telediagnosis. Given the shift in the interpersonal and technical aspects of communications in a virtual visit, it is prudent to understand its effect on the patient-provider relationships. A range of interpersonal and communication skills can be utilized during telemedicine consultations in establishing relationships, and reaching a diagnosis. We propose a construct of "webside manner," a structured approach to ensure the core elements of bedside etiquette are translated into the virtual encounter. This approach entails the totality of any interpersonal exchange on a virtual platform, to ensure a clinician's presence, empathy and compassion is translated through this medium.

Agenda setting and visit openings in primary care visits involving patients taking opioids for chronic pain

Background

Agenda setting is associated with more efficient care and better patient experience. This study develops a taxonomy of visit opening styles to assess use of agenda and non-agenda setting visit openings and their effects on participant experience.

Methods

This observational study analyzed 83 video recorded US primary care visits at a single academic medical center in California involving family medicine and internal medicine resident physicians (n = 49) and patients (n = 83) with chronic pain on opioids. Using conversation analysis, we developed a coding scheme that assessed the presence of agenda setting, distinct visit opening styles, and the number of total topics, major topics, surprise patient topics, and returns to prior topics discussed. Exploratory quantitative analyses were conducted to assess the relationship of agenda setting and visit opening styles with post-visit measures of both patient experience and physician perception of visit difficulty.

Results

We identified 2 visit opening styles representing agenda setting (agenda eliciting, agenda reframing) and 3 non-agenda setting opening styles (open-ended question, patient launch, physician launch). Agenda setting was only performed in 11% of visits and was associated with fewer surprise patient topics than visits without agenda setting (mean (SD) 2.67 (1.66) versus 4.28 (3.23), p = 0.03).

Conclusions

In this study of patients with chronic pain, resident physicians rarely performed agenda setting, whether defined in terms of “agenda eliciting” or “agenda re-framing.” Agenda setting was associated with fewer surprise topics. Understanding the communication context and outcomes of agenda setting may inform better use of this communication tool in primary care  practice.

Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review

BACKGROUND

Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience).

METHODS

We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes.

RESULTS

Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands.

DISCUSSION

Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

IMPORTANCE

Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

OBJECTIVE

To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

EVIDENCE REVIEW

Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

FINDINGS

The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).

CONCLUSIONS AND RELEVANCE

This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

The elicitation and management of multiple health concerns in GP consultations

OBJECTIVE

To describe the nature of patient concerns and to explore if, when and how they are addressed by GPs in the UK.

METHODS

Detailed coding and descriptive analysis of 185 video recordings from the EPaC study (Elicitation of Patient Concerns, EPaC) RESULTS: An average of 2.1 concerns were raised per consultation and the most common concerns were musculoskeletal, administrative (e.g. test results and medication related issues), and skin symptoms. GPs who had been trained as part of the EPaC intervention to solicit for additional concerns in the opening phase of the consultation did so 92.6% of the time. In contrast, those in the control arm did so only 7% of the time. However, the particular formulation of the GP soliciting question does not seem to be associated with the likelihood of the patient volunteering an additional concern.

CONCLUSIONS

GP consultations are complex encounters in which multiple concerns are dealt with across a wide range of disease areas. GPs can be trained to solicit for problems/concerns early in the consultation.

PRACTICE IMPLICATIONS

Soliciting for additional concerns is not routinely done. But very brief training can substantially help in eliciting concerns early in the consultation, which may help with organising the consultation.

Effects of an entertaining, culturally targeted narrative and an appealing expert interview on the colorectal screening intentions of African American women

Universal screening for colorectal cancer (CRC) is recommended for individuals 50-75 years of age, but screening uptake is suboptimal and African Americans have suffered persistent racial disparities in CRC incidence and deaths. We compared a culturally tailored fictional narrative and an engaging expert interview on the ability to increase intentions to be screened for CRC among African American women. In a post-only experiment, women (N = 442) in face-to-face listening groups in African American churches heard audio recordings of either a narrative or an expert interview. Questionnaires were completed immediately afterward and 30 days later. Women who heard narratives reported stronger intentions to be screened with a home stool blood test than women who heard the interview; the effect lasted at least 30 days. Culturally tailored, fictional narratives appear to be an effective persuasive strategy for reducing racial disparities in CRC outcomes.

Findings from a feasibility study to improve GP elicitation of patient concerns in UK general practice consultations

OBJECTIVES

To establish: a) feasibility of training GPs in a communication intervention to solicit additional patient concerns early in the consultation, using specific lexical formulations ("do you have 'any' vs. 'some' other concerns?") noting the impact on consultation length, and b) whether patients attend with multiple concerns and whether they voiced them in the consultation.

METHODS

A mixed-methods three arm RCT feasibility study to assess the feasibility of the communication intervention.

RESULTS

Intervention fidelity was high. GPs can be trained to solicit additional concerns early in the consultation (once patients have presented their first concern). Whilst feasible the particular lexical variation of 'any' vs 'some' seemed to have no bearing on the number of patient concerns elicited, on consultation length or on patient satisfaction. The level of missing questionnaire data was low, suggesting patients found completion of questionnaires acceptable.

CONCLUSION

GPs can solicit for additional concerns without increasing consultation length, but the particular wording, specifically 'any' vs. 'some' may not be as important as the placement of the GP solicitation.

PRACTICE IMPLICATIONS

GPs can solicit early for additional concerns and GPs can establish patients' additional concerns in the opening of the consultation, which can help to plan and prioritise patients multiple concerns.

Patients Typing Their Own Visit Agendas Into an Electronic Medical Record: Pilot in a Safety-Net Clinic

Collaborative visit agenda setting between patient and doctor is recommended. We assessed the feasibility, acceptability, and utility of patients attending a large primary care safety-net clinic typing their agendas into the electronic visit note before seeing their clinicians. One hundred and one patients and their 28 clinicians completed post-visit surveys. Patients and clinicians agreed that the agendas improved patient-clinician communication (patients 79%, clinician 74%), and wanted to continue having patients type agendas in the future (73%, 82%). Enabling patients to type visit agendas may enhance care by engaging patients and giving clinicians an efficient way to prioritize patients' concerns.

Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study

BACKGROUND

New patients are a particularly vulnerable population because they are at high risk of missing a subsequent visit or dropping out of care completely. However, few data exist on what new patients value in the beginning of a relationship with a new provider. Persons with HIV infection may be an ideal population to study the drivers of a positive initial patient-provider relationship, as it is a chronic and serious condition that requires a reliable, ongoing relationship with a provider. Informed by patients' real experiences, this study aims to identify what patients see as the most critical elements for building trust and rapport from the outset.

METHODS

We conducted longitudinal, in-person interviews with 21 patients new to the HIV clinic at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, from August 2013 to March 2015. Patients were interviewed across three time points: once before their first provider visit, a second time within two weeks after the first visit, and a third time at 6 to 12 months after the first provider visit.

RESULTS

We conducted 61 h of patient interviews. The mean age was 53 years; 52% were non-Hispanic white, 23% were non-Hispanic black and 19% were Hispanic. Patients described significant anxiety and vulnerability not just from HIV itself, but also in starting a relationship as a new patient to a new provider. Our analysis of these experiences revealed five actions providers can take to reduce their patients' anxiety and build trust early in the first visit: 1) provide reassurance to patients, 2) tell patients it's okay to ask questions, 3) show patients their lab results and explain what they mean, 4) avoid language and behaviors that are judgmental of patients, and 5) ask patients what they want [i.e., treatment goals and preferences].

CONCLUSIONS

Our study incorporates direct input from patients and highlights the unique psychological challenges that patients face in seeking care from a new provider. The actionable opportunities cited by patients have the potential to mitigate patients' feelings of anxiety and vulnerability, and thereby improve their overall health care experience.

Communication Skills Training for Physicians Improves Patient Satisfaction

BACKGROUND

Skilled physician communication is a key component of patient experience. Large-scale studies of exposure to communication skills training and its impact on patient satisfaction have not been conducted.

OBJECTIVE

We aimed to examine the impact of experiential relationship-centered physician communication skills training on patient satisfaction and physician experience.

DESIGN

This was an observational study.

SETTING

The study was conducted at a large, multispecialty academic medical center.

PARTICIPANTS

Participants included 1537 attending physicians who participated in, and 1951 physicians who did not participate in, communication skills training between 1 August 2013 and 30 April 2014.

INTERVENTION

An 8-h block of interactive didactics, live or video skill demonstrations, and small group and large group skills practice sessions using a relationship-centered model.

MAIN MEASURES

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), Jefferson Scale of Empathy (JSE), Maslach Burnout Inventory (MBI), self-efficacy, and post course satisfaction.

KEY RESULTS

Following the course, adjusted overall CGCAHPS scores for physician communication were higher for intervention physicians than for controls (92.09 vs. 91.09, p < 0.03). No significant interactions were noted between physician specialty or baseline CGCAHPS and improvement following the course. Significant improvement in the post-course HCAHPS Respect domain adjusted mean was seen in intervention versus control groups (91.08 vs. 88.79, p = 0.02) and smaller, non-statistically significant improvements were also seen for adjusted HCAHPS communication scores (83.95 vs. 82.73, p = 0.22). Physicians reported high course satisfaction and showed significant improvement in empathy (116.4 ± 12.7 vs. 124 ± 11.9, p < 0.001) and burnout, including all measures of emotional exhaustion, depersonalization, and personal accomplishment. Less depersonalization and greater personal accomplishment were sustained for at least 3 months.

CONCLUSIONS

System-wide relationship-centered communication skills training improved patient satisfaction scores, improved physician empathy, self-efficacy, and reduced physician burnout. Further research is necessary to examine longer-term sustainability of such interventions.

Soliciting additional concerns in the primary care consultation and the utility of a brief communication intervention to aid solicitation: A qualitative study

OBJECTIVE

To investigate the perspectives of general practitioners (GPs) on the practice of soliciting additional concerns (ACs) and the acceptability and utility of two brief interventions (prompts) designed to aid the solicitation.

METHODS

Eighteen GPs participating in a feasibility randomised controlled trial were interviewed. Interviews were semi-structured and audio-recorded. Data were analysed using a Framework Approach.

RESULTS

Participants perceived eliciting ACs as important for: reducing the need for multiple visits, identifying serious illness early, and increasing patient and GP satisfaction. GPs found the prompts easy to use and some continued their use after the study had ended to aid time management. Others noted similarities between the intervention and their usual practice. Nevertheless, soliciting ACs in every consultation was not unanimously supported.

CONCLUSION

The prompts were acceptable to GPs within a trial context, but there was disagreement as to whether ACs should be solicited routinely. Some GPs considered the intervention to aid their prioritisation efficiency within consultations.

PRACTICE IMPLICATIONS

Some GPs will find prompts which encourage ACs to be solicited early in the consultation enable them to better organise priorities and manage time-limited consultations more effectively.

Agenda-setting revisited: When and how do primary-care physicians solicit patients' additional concerns?

OBJECTIVE

Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve patients' health outcomes and satisfaction, and physicians' time management. We assess the distribution, content, and effectiveness of physicians' post-chief-complaint, agenda-setting questions.

METHODS

We coded videotapes/transcripts of 407 primary-, acute-care visits between adults and 85 general-practice physicians operating in 46 community-based clinics in two states representing urban and rural care. Measures are the incidence of physicians' questions, their linguistic format, position within visits, likelihood of being responded to, and the nature of such responses.

RESULTS

Physicians' questions designed to solicit concerns additional to chief concerns occurred in only 32% of visits (p<.001). Compared to questions whose communication format explicitly solicited 'questions' (e.g., "Do you have any questions?"), those that were formatted so as to allow for 'concerns' (e.g., "Any other concerns?") were significantly more likely to generate some type of agenda item (Chi(2) (1, N=131)=11.96, p=.001), and to do so more frequently when positioned 'early' vs. 'late' during visits (Chi(2) (1, N=73)=4.99, p=.025).

CONCLUSIONS

Agenda setting is comparatively infrequent. The communication format and position of physicians' questions affects patients' provision of additional concerns/questions.

PRACTICE IMPLICATIONS

Physicians should increase use of optimized forms of agenda setting.

How to gather information from talkative patients in a respectful and efficient manner: a qualitative study of GPs' communication strategies

BACKGROUND

Gathering information from talkative patients presents a challenge to clinicians. Empirical evidence on how to effectively deal with this challenge is scant.

OBJECTIVE

This study explores communication strategies and their underlying mechanisms that GPs consider effective when gathering information from talkative patients in order to inform the development of best practices.

METHODS

We conducted a qualitative study with experienced GPs. We held individual stimulated-recall interviews (SRIs) with six GPs using their videotaped consultations as a stimulus. The transcripts that ensued were triangulated with data from three focus-group discussions (FGs). We performed a thematic network analysis during an iterative process of data collection and analysis.

RESULTS

To deal with talkative patients during consultations, GPs first try to pinpoint the cause of patients' talkativeness before deciding on the approach to take. Moreover, they resort to the familiar communication strategies, however, in doing so adopt take a more directive attitude. To prevent such attitude from damaging the relationship, GPs take a stepped approach in which they try not to be overly directive, make the patient co-responsible for efficient time management and make use of empathic interrupting.

CONCLUSIONS

In the absence of evidence, this description of GPs' communication strategies can guide clinicians, residents and students in gathering information from talkative patients in an efficient, yet empathic and respectful manner. When developing best practices, heed should be paid to the causes of patients' talkativeness and the tension between taking a directive approach and building a doctor-patient relationship.

How patients understand physicians' solicitations of additional concerns: implications for up-front agenda setting in primary care

In the more than 1 billion primary-care visits each year in the United States, the majority of patients bring more than one distinct concern, yet many leave with "unmet" concerns (i.e., ones not addressed during visits). Unmet concerns have potentially negative consequences for patients' health, and may pose utilization-based financial burdens to health care systems if patients return to deal with such concerns. One solution to the problem of unmet concerns is the communication skill known as up-front agenda setting, where physicians (after soliciting patients' chief concerns) continue to solicit patients' concerns to "exhaustion" with questions such as "Are there some other issues you'd like to address?" Although this skill is trainable and efficacious, it is not yet a panacea. This article uses conversation analysis to demonstrate that patients understand up-front agenda-setting questions in ways that hamper their effectiveness. Specifically, we demonstrate that up-front agenda-setting questions are understood as making relevant "new problems" (i.e., concerns that are either totally new or "new since last visit," and in need of diagnosis), and consequently bias answers away from "non-new problems" (i.e., issues related to previously diagnosed concerns, including much of chronic care). Suggestions are made for why this might be so, and for improving up-front agenda setting. Data are 144 videotapes of community-based, acute, primary-care, outpatient visits collected in the United States between adult patients and 20 family-practice physicians.

Exploring the Patient and Staff Experience With the Process of Primary Care

PURPOSE

Previous studies suggest that the highest-risk patients value accessible, coordinated primary care that they perceive to be of high technical quality. We have limited understanding, however, of how low-income, chronically ill patients and the staff who care for them experience each individual step in the primary care process.

METHODS

We conducted qualitative interviews with uninsured or Medicaid patients with chronic illnesses, as well as with primary care staff. We interviewed 21 patients and 30 staff members with a variety of job titles from 3 primary care practices (1 federally qualified health center and 2 academically affiliated clinics).]

RESULTS

The interviews revealed 3 major issues that were present at all stages of a primary care episode: (1) information flow throughout an episode of care is a frequent challenge, despite systems that are intended to improve communication; (2) misaligned goals and expectations among patients, clinicians, and staff members are often an impediment to providing and obtaining care; and (3) personal relationships are highly valued by both patients and staff.

CONCLUSIONS

Vulnerable populations and the primary care staff who work with them perceive some of the same challenges throughout the primary care process. Improving information flow, aligning goals and expectations, and developing personal relationships may improve the experience of both patients and staff.

What is agenda setting in the clinical encounter? Consensus from literature review and expert consultation

OBJECTIVE

To establish consensus on the core domains of agenda setting in consultations.

METHODS

We reviewed the healthcare literature and, using a modified Delphi technique to embrace both patient and clinician perspectives, conducted an iterative online survey, with 30 experts in health communication. Participants described agenda setting and rated the importance of proposed domains. Consensus was determined where the group median was ≥5 on a 7-point Likert-like response scale, and the interquartile range fell to within one point on this scale.

RESULTS

Relevant publications were identified in three overlapping bodies of healthcare literature. Survey respondents considered that agenda setting involved a process whereby patients and clinicians establish a joint focus for both their conversation and their working relationship. Consensus was obtained on six core domains: identifying patient talk topics, identifying clinician talk topics, agreement of shared priorities, establishing conversational focus, collaboration and engagement. New terminology--agenda mapping and agenda navigation--is proposed.

CONCLUSION

We identified core agenda setting domains that embraced patient and clinician perspectives.

PRACTICE IMPLICATIONS

An integrated conceptualization of agenda setting may now be used by researchers and educators in both clinician and patient focused interventions.

Using the Patient Centered Observation Form: Evaluation of an online training program

OBJECTIVE

The Patient Centered Observation Form (PCOF) helps trainees identify and describe specific communication skills and enhance self-awareness about skill use. We studied the effectiveness and ease of use of the Improving Communication Assessment Program (ICAP), an online module that prepares trainees to use the PCOF.

METHODS

Students, residents and medical educators viewed two videos (common and better skill use) of the same interaction and rated each video using the PCOF. Video sequence was randomized. We assessed agreement with experts, ease of use, concepts learned, and areas of confusion.

RESULTS

Trainees (211) achieved strong agreement (.83) with experts and were highly satisfied (mean 4.18 out of 5). Viewing the common video first produced higher agreement (.87 vs .79; ES=.4) with experts and greater satisfaction (4.36 vs 4.02, ES .4) than viewing the better video first. Trainees reported diverse areas of learning and minimal confusion.

CONCLUSION

ICAP training to use the PCOF may facilitate teaching and assessment of communication skills and enrich training through peer observation and feedback. We offer several educational strategies.

PRACTICE IMPLICATIONS

Learning to use the PCOF via the ICAP module may accelerate communication training for medical students, residents, medical educators and practicing clinicians.

Context factors in consultations of general practitioner trainees and their impact on communication assessment in the authentic setting

OBJECTIVE

Acquiring adequate communication skills is an essential part of general practice (GP) specialty training. In assessing trainee proficiency, the context in which trainees communicate is usually not taken into account. The present paper aims to explore what context factors can be found in regular GP trainee consultations and how these influence their communication performance.

METHODS

In a randomly selected sample of 44 videotaped, real-life GP trainee consultations, we searched for context factors previously identified in GP consultations and explored how trainee ratings change if context factors are taken into account. Trainee performance was rated twice using the MAAS-Global, first without and then with incorporating context factors. Item score differences were calculated using a paired samples t-test and effect sizes were computed.

RESULTS

All previously identified context factors were again observed in GP trainee consultations. In communication assessment scores, we found a significant difference in 5 out of 13 MAAS-Global items, mostly in a positive direction. The effect size was moderate (0.57).

CONCLUSIONS

GP trainee communication is influenced by contextual factors; they seem to adapt to context in a professional way.

PRACTICE IMPLICATIONS

GP specialty training needs to focus on a context-specific application of communication skills. Communication raters need to be taught how to incorporate context factors into their assessments.

Learning to listen: effects of using conversational transcripts to help medical students improve their use of open questions in soliciting patient problems

OBJECTIVE

This study reports effects of a 'bottom-up' pedagogy using doctor-patient conversation transcripts to improve medical students' use of open questions in soliciting patient problems.

METHODS

We implemented an innovative approach involving students reviewing transcripts of medical interviews, skills practice using role-play and standardized patients (SPs), and reflection on these practices. We analyzed three open question categories (general, biomedical, and psychosocial) used by 27 Taiwanese medical students from two SP interviews, conducted before and after training.

RESULTS

Across the full encounter, use of general and psychosocial open questions increased significantly after training (from 27 to 92 general questions and 15 to 33 psychosocial questions). The high rates of narrowly focused opening questions (52% of initial position questions, 74% of second position questions, and 85% of third position questions) prior to training were reduced to 11%, 15%, and 15% respectively after training. Students also shifted from a micro (narrow) to a macro (broad) pattern of questioning.

CONCLUSION

The 'bottom-up' approach facilitated by using conversation transcripts is effective in improving communication skills.

PRACTICE IMPLICATIONS

By carefully reviewing transcripts of their own performance as part of an overall communication training package, beginning medical students can become more patient-centered in soliciting patient problems.

Agenda setting in psychiatric consultations: an exploratory study

OBJECTIVE

Patient- or consumer-centeredness has been recognized as a critical component of quality in primary health care, but is only beginning to be recognized and studied in mental health. Among the first opportunities to be consumer-centered is collaboratively producing an agenda of topics to be covered during a clinic visit. Early agenda setting sets the stage for what is to come and can affect the course, direction, and quality of care. The purpose of this work is to study agenda setting practices among 8 prescribers (5 psychiatrists and 3 nurse practitioners) at the beginning of their encounters with 124 consumers diagnosed with schizophrenia spectrum disorders (56%), bipolar disorder (23%), major depression (15%), and other disorders (6%).

METHOD

We modified an extant agenda-setting rubric by adding behaviors identified by a multidisciplinary team who iteratively reviewed transcripts of the visit openings. Once overall consensus was achieved, two research assistants coded all of the transcripts. Twenty-five transcripts were scored by both raters to establish interrater reliability.

RESULTS

We identified 10 essential elements of agenda setting. Almost 10% of visits had no agenda set, and only 1 of 3 encounters had partial or complete elicitation of a single concern. Few additional concerns (4%) were solicited, and no encounter contained more than 6 essential elements.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Collaborative agenda setting represents a unique opportunity to translate the concept of consumer-centeredness into mental health care. Initial results suggest the rating system is reliable, but the essential elements are not being used in practice.

Design, dissemination, and evaluation of an advanced communication elective at seven U.S. medical schools

PURPOSE

To test educational methods that continue communication training into the fourth year of medical school.

METHOD

The authors disseminated and evaluated an advanced communication elective in seven U.S. medical schools between 2007 and 2009; a total of 9 faculty and 22 fourth-year students participated. The elective emphasized peer learning, practice with real patients, direct observation, and applications of video technology. The authors used qualitative and quantitative survey methods and video review to evaluate the experience of students and faculty.

RESULTS

Students reported that the elective was better than most medical school clerkships they had experienced. Their self-confidence in time management and in the use of nine communication skills improved significantly. The most valued course components were video review, repeated practice with real patients, and peer observation. Analysis of student videos with real patients and in role-plays showed that some skills (e.g., agenda setting, understanding the patient perspective) were more frequently demonstrated than others (e.g., exploring family and cultural values, communication while using the electronic health record). Faculty highly valued this learner-centered model and reported that their self-awareness and communication skills grew as teachers and as clinicians.

CONCLUSIONS

Learner-centered methods such as peer observation and video review and editing may strengthen communication training and reinforce skills introduced earlier in medical education. The course design may counteract a "hidden curriculum" that devalues respectful interactions with trainees and patients. Future research should assess the impact of course elements on skill retention, attitudes for lifelong learning, and patients' health outcomes.

Re-thinking shared decision-making: context matters

OBJECTIVE

Traditional perspectives on shared decision-making (SDM) focus attention on the point in a clinical encounter where discussion of a treatment decision begins. We argue that SDM is shaped not only by initiation of a treatment decision, but also by the entire clinical encounter, and, even more broadly, by the nature of the patient-provider relationship.

METHOD

The four habits approach to effective clinical communication, a validated and widely used framework for patient-provider communication, was used to understand how SDM is integrally tied to the entire clinical encounter, as well as to the broader patient-provider relationship.

RESULTS

The Four Habits consists of four categories of behaviors: (1) invest in the beginning; (2) elicit the patient's perspective; (3) demonstrate empathy; and (4) invest in the end. We argue that the behaviors included in all four of these categories work together to create and maintain an environment conducive to SDM.

CONCLUSION

SDM cannot be understood in isolation, and future SDM research should reflect the influence that the broader communicative and relational contexts have on decisions.

PRACTICE IMPLICATIONS

SDM training might be more effective if training focused on the broader context of communication and relationships, such as those specified by the Four Habits framework.