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Abukmail E, Bakhit M, Hoffmann TC. Evaluation of natural history communication and shared decision making for self-limiting conditions: Analysis of UK primary care consultations. PATIENT EDUCATION AND COUNSELING 2024; 129:108409. [PMID: 39216148 DOI: 10.1016/j.pec.2024.108409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 08/08/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To analyse communication about the natural course of self-limiting illnesses, as part of shared decision-making (SDM), in general practice consultations. METHODS Natural history communication and SDM (using Observing Patient Involvement in Decision-Making (OPTION-12) and Assessing Communication about Evidence and Patient Preferences (ACEPP) items) were rated by two raters using transcripts from the UK 'One in a Million' database. RESULTS Of 55 eligible consultations, a 'wait and see' option was mentioned in 27 consultations (49 %), using varying terminology, with a general recovery timeframe provided in 21. Mean OPTION-12 score (of 100) was 25.2 (SD=7.4), indicating a low level of SDM. Mean ACEPP score (out of 5) was 1.2 (SD=0.5), indicating minimal communication about the options' benefits and harms. Recovery likelihood was quantified in only two consultations, while harms were quantified in none. CONCLUSION Communication about the natural history of self-limiting illnesses was generally limited. The 'wait and see' approach, along with its benefits and harms, was typically not explicitly presented as an option for patients to consider. PRACTICE IMPLICATIONS Improving clinicians' awareness of the importance of and skills for communicating the natural history of self-limiting illnesses, as part of SDM, may facilitate informed decision-making in managing these conditions.
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Affiliation(s)
- Eman Abukmail
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia.
| | - Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia.
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia.
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2
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Patel B, Gheihman G, Katz JT, Begin AS, Solomon SR. Navigating Uncertainty in Clinical Practice: A Structured Approach. J Gen Intern Med 2024; 39:829-836. [PMID: 38286969 PMCID: PMC11043270 DOI: 10.1007/s11606-023-08596-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/28/2023] [Indexed: 01/31/2024]
Abstract
The practice of clinical medicine is imbued with uncertainty. The ways in which clinicians and patients think about, communicate about, and act within situations of heightened uncertainty can have significant implications for the therapeutic alliance and for the trajectory and outcomes of clinical care. Despite this, there is limited guidance about the best methods for physicians to recognize, acknowledge, communicate about, and manage uncertainty in clinical settings. In this paper, we propose a structured approach for discussing and managing uncertainty within the context of a clinician-patient relationship. The approach involves four steps: Recognize, Acknowledge, Partner, and Seek Support (i.e., the RAPS framework). The approach is guided by existing literature on uncertainty as well as our own experience as clinicians working at different stages of career. We define each component of the approach and present sample language and actions for how to implement it in practice. Our aim is to empower clinicians to regard situations of high uncertainty as an opportunity to deepen the therapeutic alliance with the patient, and simultaneously to grow and learn as practitioners.
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Affiliation(s)
- Badar Patel
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Galina Gheihman
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Joel T Katz
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Arabella Simpkin Begin
- Harvard Medical School, Boston, MA, USA
- Lincoln College, University of Oxford, Oxford, UK
| | - Sonja R Solomon
- Harvard Medical School, Boston, MA, USA.
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
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3
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Myronenko A, van der Velde P, Derksen SMJC, Peerdeman KJ. How should uncertainty about upcoming painful procedures be communicated? An experimental study into highly uncertain pain predictions. PATIENT EDUCATION AND COUNSELING 2024; 118:108008. [PMID: 37871353 DOI: 10.1016/j.pec.2023.108008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/29/2023] [Accepted: 10/05/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVE Uncertainty is unavoidable in the context of painful medical procedures. It is important to investigate the impact of different ways of communicating uncertainty on upcoming pain. METHODS In our exploratory study, healthy participants (n = 30) were repeatedly presented with three highly uncertain pain predictions communicated by a hypothetical doctor. A direct statement of high uncertainty ("I don't know") was compared to more indirect predictions (social prediction: "It varies widely among people"; range prediction: "… not painful at all to very highly painful"), followed by individually calibrated electrical stimuli of non-, moderately, or very highly painful intensity. RESULTS The direct expression of uncertainty led to the most intense pain sensation (for moderately painful stimuli only), lowest and most certain pain expectations, lowest trust in the hypothetical doctor, and lowest feeling of being well-informed, especially as compared to the social prediction. No differential effects on anxiety were observed. CONCLUSIONS Expressing high uncertainty indirectly, with reference to the common experiences of others, may be beneficial for optimizing pain experiences and enhancing patients' trust in a medical professional. PRACTICE IMPLICATIONS Our findings inform on how high uncertainty about upcoming pain may impact patient and health outcomes, pointing to some advantages of indirect communication.
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Affiliation(s)
- Anastasiia Myronenko
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
| | - Pien van der Velde
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
| | - Suzanne M J C Derksen
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
| | - Kaya J Peerdeman
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, Leiden University, Leiden, the Netherlands.
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4
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McKoane A, Sherman DK. Diagnostic uncertainty in patients, parents, and physicians: a compensatory control theory perspective. Health Psychol Rev 2023; 17:439-455. [PMID: 35672909 DOI: 10.1080/17437199.2022.2086899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 06/02/2022] [Indexed: 11/04/2022]
Abstract
Medical diagnoses offer a structure by which psychological uncertainty can be attenuated, allowing patients to diminish psychological threats and focus on health prognosis. Yet when no diagnosis can be made, patients may experience diagnostic uncertainty - perceiving the medical field as unable to provide an accurate explanation of the cause of their health problems. This review examines the psychological threat that diagnostic uncertainty imposes on individuals' need for control and understanding, and the resulting consequences experienced by patients, parents of pediatric patients, and physicians. Using compensatory control theory as a framework, we propose a taxonomy of behaviors that people may adopt in order to regain control in the face of diagnostic uncertainty and to reaffirm that the world is not random and chaotic. To manage diagnostic uncertainty, people may bolster their personal agency, affiliate with external systems they see as acting in their interest, affirm clear connections between behaviors and outcomes, and affirm nonspecific epistemic structure. Diagnostic uncertainty is approached from the perspectives of patients, parents of pediatric patients, and physicians, demonstrating how each group responds in order to maintain a sense that the world has structure and is not random. Discussion centers on moderators, limitations, and implications for clinical practice.
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Affiliation(s)
- Ashley McKoane
- Psychological & Brain Sciences, University of California, Santa Barbara, CA, USA
| | - David K Sherman
- Psychological & Brain Sciences, University of California, Santa Barbara, CA, USA
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5
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Lee C, Hall KH, Anakin M. Finding Themselves, Their Place, Their Way: Uncertainties Identified by Medical Students. TEACHING AND LEARNING IN MEDICINE 2023:1-11. [PMID: 37435723 DOI: 10.1080/10401334.2023.2233003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 05/19/2023] [Accepted: 06/16/2023] [Indexed: 07/13/2023]
Abstract
Phenomenon: Navigating uncertainty is a core skill when practicing medicine. Increasingly, the need to better prepare medical students for uncertainty has been recognized. Our current understanding of medical students' perspectives on uncertainty is primarily based on quantitative studies with limited qualitative research having been performed to date. We need to know from where and how sources of uncertainty can arise so that educators can better support medical students learning to respond to uncertainty. This research's aim was to describe the sources of uncertainty that medical students identify in their education. Approach: Informed by our previously published framework of clinical uncertainty, we designed and distributed a survey to second, fourth-, and sixth-year medical students at the University of Otago, Aotearoa New Zealand. Between February and May 2019, 716 medical students were invited to identify sources of uncertainty encountered in their education to date. We used reflexive thematic analysis to analyze responses. Findings: Four-hundred-sixty-five participants completed the survey (65% response rate). We identified three major sources of uncertainty: insecurities, role confusion, and navigating learning environments. Insecurities related to students' doubts about knowledge and capabilities, which were magnified by comparing themselves to peers. Role confusion impacted upon students' ability to learn, meet the expectations of others, and contribute to patient care. Navigating the educational, social, and cultural features of clinical and non-clinical learning environments resulted in uncertainty as students faced new environments, hierarchies, and identified challenges with speaking up. Insights: This study provides an in-depth understanding of the wide range of sources of medical students' uncertainties, encompassing how they see themselves, their roles, and their interactions with their learning environments. These results enhance our theoretical understanding of the complexity of uncertainty in medical education. Insights from this research can be applied by educators to better support students develop the skills to respond to a core element of medical practice.
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Affiliation(s)
- Ciara Lee
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Katherine Helen Hall
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Megan Anakin
- Education Unit, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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6
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Harendza S, Bacher HJ, Berberat PO, Kadmon M, Gärtner J. Implicit expression of uncertainty in medical students during different sequences of clinical reasoning in simulated patient handovers. GMS JOURNAL FOR MEDICAL EDUCATION 2023; 40:Doc7. [PMID: 36923315 PMCID: PMC10010770 DOI: 10.3205/zma001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 08/19/2022] [Accepted: 11/23/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Dealing with medical uncertainty is an essential competence of physicians. During handovers, communication of uncertainty is important for patient safety, but is often not explicitly expressed and can hamper medical decisions. This study examines medical students' implicit expression of uncertainty in different sequences of clinical reasoning during simulated patient handovers. METHODS In 2018, eighty-seven final-year medical students participated in handovers of three simulated patient cases, which were videotaped and transcribed verbatim. Sequences of clinical reasoning and language references to implicit uncertainty that attenuate and strengthen information based on a framework were identified, categorized, and analyzed with chi-square goodness-of-fit tests. RESULTS A total of 6358 sequences of clinical reasoning were associated with the four main categories "statement", "assessment", "consideration", and "implication", with statements occurring significantly (p<0.001) most frequently. Attenuated sequences of clinical reasoning occurred significantly (p<0.003) more frequently than strengthened sequences. Implications were significantly more often attenuated than strengthened (p<0.003). Statements regarding results occurred significantly more often plain or strengthened than statements regarding actions (p<0.0025). CONCLUSION Implicit expressions of uncertainty in simulated medical students' handovers occur in different degrees during clinical reasoning. These findings could contribute to courses on clinical case presentations by including linguistic terms and implicit expressions of uncertainty and making them explicit.
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Affiliation(s)
- Sigrid Harendza
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Hans Jakob Bacher
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
| | - Pascal O. Berberat
- Technische Universität München, Fakultät für Medizin, TUM Medical Education Center, München, Germany
| | - Martina Kadmon
- Universität Augsburg, Medizinische Fakultät, Dekanat, Augsburg, Germany
| | - Julia Gärtner
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
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7
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Dahm MR, Cattanach W, Williams M, Basseal JM, Gleason K, Crock C. Communication of Diagnostic Uncertainty in Primary Care and Its Impact on Patient Experience: an Integrative Systematic Review. J Gen Intern Med 2023; 38:738-754. [PMID: 36127538 PMCID: PMC9971421 DOI: 10.1007/s11606-022-07768-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 08/10/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Diagnostic uncertainty is a pervasive issue in primary care where patients often present with non-specific symptoms early in the disease process. Knowledge about how clinicians communicate diagnostic uncertainty to patients is crucial to prevent associated diagnostic errors. Yet, in-depth research on the interpersonal communication of diagnostic uncertainty has been limited. We conducted an integrative systematic literature review (PROSPERO CRD42020197624, unfunded) to investigate how primary care doctors communicate diagnostic uncertainty in interactions with patients and how patients experience their care in the face of uncertainty. METHODS We searched MEDLINE, PsycINFO, and Linguistics and Language Behaviour Abstracts (LLBA) from inception to December 2021 for MeSH and keywords related to 'communication', 'diagnosis', 'uncertainty' and 'primary care' environments and stakeholders (patients and doctors), and conducted additional handsearching. We included empirical primary care studies published in English on spoken communication of diagnostic uncertainty by doctors to patients. We assessed risk of bias with the QATSDD quality assessment tool and conducted thematic and content analysis to synthesise the results. RESULTS Inclusion criteria were met for 19 out of 1281 studies. Doctors used two main communication strategies to manage diagnostic uncertainty: (1) patient-centred communication strategies (e.g. use of empathy), and (2) diagnostic reasoning strategies (e.g. excluding serious diagnoses). Linguistically, diagnostic uncertainty was either disclosed explicitly or implicitly through diverse lexical and syntactical constructions, or not communicated (omission). Patients' experiences of care in response to the diverse communicative and linguistic strategies were mixed. Patient-centred approaches were generally regarded positively by patients. DISCUSSION Despite a small number of included studies, this is the first review to systematically catalogue the diverse communication and linguistic strategies to express diagnostic uncertainty in primary care. Health professionals should be aware of the diverse strategies used to express diagnostic uncertainty in practice and the value of combining patient-centred approaches with diagnostic reasoning strategies.
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Affiliation(s)
- Maria R Dahm
- Institute for Communication in Health Care (ICH), ANU College of Arts and Social Sciences, The Australian National University, Baldessin Precinct Building, 110 Ellery Crescent, Canberra, ACT 2600, Australia.
| | - William Cattanach
- ANU Medical School, ANU College of Health and Medicine, The Australian National University, Canberra, Australia
| | | | - Jocelyne M Basseal
- Discipline of Infectious Diseases & Immunology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Kelly Gleason
- Johns Hopkins School of Nursing, Baltimore City, MD, USA
| | - Carmel Crock
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia
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8
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Begin AS, Hidrue MK, Lehrhoff S, Lennes IT, Armstrong K, Weilburg JB, del Carmen MG, Wasfy JH. Association of Self-reported Primary Care Physician Tolerance for Uncertainty With Variations in Resource Use and Patient Experience. JAMA Netw Open 2022; 5:e2229521. [PMID: 36048444 PMCID: PMC9437748 DOI: 10.1001/jamanetworkopen.2022.29521] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 07/17/2022] [Indexed: 11/26/2022] Open
Abstract
Importance Inappropriate variations in clinical practice are a known cause of poor quality and safety, with variations often associated with nonclinical factors, such as individual differences in cognitive processing. The differential response of physicians to uncertainty may explain some of the variations in resource use and patient experience. Objective To examine the association of physician tolerance for uncertainty with variations in resource use and patient experience. Design, Setting, and Participants This survey study linked physician survey data (May to June 2019), patient experience survey data (January 2016 to December 2019), and billing data (January 2019 to December 2019) among primary care physicians (PCPs) at Massachusetts General Hospital with at least 10 visits in 2019. The statistical analysis was performed in 2021. Main Outcomes and Measures The analysis examined associations of PCP tolerance for uncertainty with the tendency to order diagnostic tests, the frequency of outpatient visits, hospital admissions, emergency department visits, and patient experience data (focused on physician communication and overall rating). A 2-stage hierarchical framework was used to account for clustering of patients under PCPs. Binary outcomes were modeled using a hierarchical logistic model, and count outcomes were modeled using hierarchical Poisson or negative binomial models. The analysis was adjusted for patient demographic variables (age, sex, and race and ethnicity), socioeconomic factors (payer and neighborhood income), and clinical comorbidities. Results Of 217 included physicians, 137 (63.1%) were women, and 174 (80.2%) were adult PCPs. A total of 62 physicians (28.6%) reported low tolerance, 59 (27.2%) reported medium tolerance, and 96 (44.2%) reported high tolerance for uncertainty. Physicians with a low tolerance for uncertainty were less likely to order complete blood cell counts (odds ratio [OR], 0.66; 95% CI, 0.50-0.88), thyroid tests (OR, 0.67; 95% CI, 0.52-0.88), a basic metabolic profile (OR, 0.78; 95% CI, 0.60-1.00), and liver function tests (OR, 0.72; 95% CI, 0.53-0.99) than physicians with a high tolerance for uncertainty. Physicians who reported higher tolerance for uncertainty were more likely to receive higher patient experience scores for listening to patients carefully (OR, 0.65; 95% CI, 0.50-0.83) and higher overall ratings (OR, 0.80; 95% CI, 0.66-0.98) than physicians with medium tolerance. Conversely, no association was found between physician tolerance for uncertainty and patient outpatient visits, hospital admissions, or emergency department visits. Conclusions and Relevance In clinical practice, identifying and effectively managing inappropriate variations and improving patient experience have proven to be difficult, despite increased attention to these issues. This study supports the hypothesis that physicians' tolerance for uncertainty is associated with differences in resource use and patient experience. Whether enhancing physicians' tolerance for uncertainty could help reduce unwarranted practice variations, improve quality and patient safety, and improve patient's experience remains to be established.
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Affiliation(s)
- Arabella S. Begin
- Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | - Sara Lehrhoff
- Massachusetts General Physicians Organization, Boston
| | | | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Columbia University Irving Medical Center, New York, New York
| | - Jeffrey B. Weilburg
- Massachusetts General Physicians Organization, Boston
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Marcela G. del Carmen
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Physicians Organization, Boston
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston
| | - Jason H. Wasfy
- Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston
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Doty AM, Rising KL, Hsiao T, Amadio G, Gentsch AT, Salcedo VJ, McElwee I, Cameron KA, Salzman DH, Papanagnou D, McCarthy DM. "Unfortunately, I don't have an answer for you": How resident physicians communicate diagnostic uncertainty to patients during emergency department discharge. PATIENT EDUCATION AND COUNSELING 2022; 105:2053-2057. [PMID: 35168855 PMCID: PMC9177889 DOI: 10.1016/j.pec.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/24/2021] [Accepted: 12/05/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To describe how emergency medicine resident physicians discuss diagnostic uncertainty during a simulated ED discharge discussion. METHODS A secondary content analysis of simulated clinical encounter audiotapes completed by emergency medicine residents across two sites. RESULTS When discussing lack of diagnosis, residents explained the evaluation revealed no cause for symptoms, noted concerning diagnoses that were excluded, and acknowledged both symptoms and patients' feelings. Residents used explicit and implicit language to discuss diagnostic uncertainty with similar frequency. Almost half of the residents discussed the ED role as focused on emergent illness to give patients context for their uncertain diagnoses. However, 28% of residents in this study did not discuss diagnostic uncertainty in any form. All residents provided reassurance. CONCLUSION Residents use a range of approaches to discuss diagnostic uncertainty with patients at the time of a simulated ED discharge, with some residents omitting discussion of uncertainty entirely. PRACTICE IMPLICATIONS These findings represent the current state of communication, which needs improvement. These findings do not immediately transfer to clinical practice recommendations, but rather support a need for both further study and development of formal communication training on this topic.
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Affiliation(s)
- Amanda Mb Doty
- Center for Connected Care, Thomas Jefferson University, Philadelphia, USA.
| | - Kristin L Rising
- Center for Connected Care, Thomas Jefferson University, Philadelphia, USA; Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA
| | - TingAnn Hsiao
- Center for Connected Care, Thomas Jefferson University, Philadelphia, USA
| | - Grace Amadio
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA
| | | | - Venise J Salcedo
- Center for Connected Care, Thomas Jefferson University, Philadelphia, USA
| | - Ian McElwee
- Center for Connected Care, Thomas Jefferson University, Philadelphia, USA
| | - Kenzie A Cameron
- Department of Medicine, Northwestern University, Chicago, USA; Research Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, USA
| | - David H Salzman
- Department of Medical Education, Feinberg School of Medicine, Northwestern University, Chicago, USA; Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Dimitrios Papanagnou
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA
| | - Danielle M McCarthy
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
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Medendorp NM, Stiggelbout AM, Aalfs CM, Han PKJ, Smets EMA, Hillen MA. A scoping review of practice recommendations for clinicians' communication of uncertainty. Health Expect 2021; 24:1025-1043. [PMID: 34101951 PMCID: PMC8369117 DOI: 10.1111/hex.13255] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/21/2021] [Accepted: 03/23/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Health-care providers increasingly have to discuss uncertainty with patients. Awareness of uncertainty can affect patients variably, depending on how it is communicated. To date, no overview existed for health-care professionals on how to discuss uncertainty. OBJECTIVE To generate an overview of available recommendations on how to communicate uncertainty with patients during clinical encounters. SEARCH STRATEGY A scoping review was conducted. Four databases were searched following the PRISMA-ScR statement. Independent screening by two researchers was performed of titles and abstracts, and subsequently full texts. INCLUSION CRITERIA Any (non-)empirical papers were included describing recommendations for any health-care provider on how to orally communicate uncertainty to patients. DATA EXTRACTION Data on provided recommendations and their characteristics (eg, target group and strength of evidence base) were extracted. Recommendations were narratively synthesized into a comprehensible overview for clinical practice. RESULTS Forty-seven publications were included. Recommendations were based on empirical findings in 23 publications. After narrative synthesis, 13 recommendations emerged pertaining to three overarching goals: (a) preparing for the discussion of uncertainty, (b) informing patients about uncertainty and (c) helping patients deal with uncertainty. DISCUSSION AND CONCLUSIONS A variety of recommendations on how to orally communicate uncertainty are available, but most lack an evidence base. More substantial research is needed to assess the effects of the suggested communicative approaches. Until then, health-care providers may use our overview of communication strategies as a toolbox to optimize communication about uncertainty with patients. PATIENT OR PUBLIC CONTRIBUTION Results were presented to stakeholders (physicians) to check and improve their practical applicability.
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Affiliation(s)
- Niki M. Medendorp
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
| | - Anne M. Stiggelbout
- Medical Decision MakingDepartment of Biomedical Data SciencesLeiden University Medical CenterLeidenThe Netherlands
| | - Cora M. Aalfs
- Division of Biomedical GeneticsDepartment of GeneticsUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Paul K. J. Han
- Center for Outcomes Research and EvaluationMaine Medical Center Research InstitutePortlandMEUSA
| | - Ellen M. A. Smets
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
| | - Marij A. Hillen
- Department of Medical PsychologyAmsterdam UMCAmsterdam Public HealthAmsterdamThe Netherlands
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11
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van Someren JL, Lehmann V, Stouthard JM, Stiggelbout AM, Smets EMA, Hillen MA. Oncologists' Communication About Uncertain Information in Second Opinion Consultations: A Focused Qualitative Analysis. Front Psychol 2021; 12:635422. [PMID: 34135806 PMCID: PMC8201772 DOI: 10.3389/fpsyg.2021.635422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Uncertainty is omnipresent in cancer care, including the ambiguity of diagnostic tests, efficacy and side effects of treatments, and/or patients' long-term prognosis. During second opinion consultations, uncertainty may be particularly tangible: doubts and uncertainty may drive patients to seek more information and request a second opinion, whereas the second opinion in turn may also affect patients' level of uncertainty. Providers are tasked to clearly discuss all of these uncertainties with patients who may feel overwhelmed by it. The aim of this study was to explore how oncologists communicate about uncertainty during second opinion consultations in medical oncology. Methods: We performed a secondary qualitative analysis of audio-recorded consultations collected in a prospective study among cancer patients (N = 69) who sought a second opinion in medical oncology. We purposively selected 12 audio-recorded second opinion consultations. Any communication about uncertainty by the oncologist was double coded by two researchers and an inductive analytic approach was chosen to allow for novel insights to arise. Results: Seven approaches in which oncologists conveyed or addressed uncertainty were identified: (1) specifying the degree of uncertainty, (2) explaining reasons of uncertainty, (3) providing personalized estimates of uncertainty to patients, (4) downplaying or magnifying uncertainty, (5) reducing or counterbalancing uncertainty, and (6) providing support to facilitate patients in coping with uncertainty. Moreover, oncologists varied in their (7) choice of words/language to convey uncertainty (i.e., "I" vs. "we"; level of explicitness). Discussion: This study identified various approaches of how oncologists communicated uncertain issues during second opinion consultations. These different approaches could affect patients' perception of uncertainty, emotions provoked by it, and possibly even patients' behavior. For example, by minimizing uncertainty, oncologists may (un)consciously steer patients toward specific medical decisions). Future research is needed to examine how these different ways of communicating about uncertainty affect patients. This could also facilitate a discussion about the desirability of certain communication strategies. Eventually, practical and evidence-based guidance needs to be developed for clinicians to optimally inform patients about uncertain issues and support patients in dealing with these.
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Affiliation(s)
- Jamie L van Someren
- Department of Medical Psychology, Amsterdam Public Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Vicky Lehmann
- Department of Medical Psychology, Amsterdam Public Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | | | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam Public Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam Public Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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12
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Medendorp NM, van Maarschalkerweerd PEA, Murugesu L, Daams JG, Smets EMA, Hillen MA. The impact of communicating uncertain test results in cancer genetic counseling: A systematic mixed studies review. PATIENT EDUCATION AND COUNSELING 2020; 103:1692-1708. [PMID: 32278626 DOI: 10.1016/j.pec.2020.03.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Cancer genetic counseling increasingly involves discussing uncertain test results, for example because multiple genes are sequenced simultaneously. This review was performed to provide insight into how counselors' communication of uncertain test results during genetic counseling for cancer affects counselors and counselees. METHODS A systematic mixed studies review was undertaken to review research on the effects of communicating uncertain test results. Four databases were searched using a PICO search strategy. Study findings of articles meeting the inclusion criteria were synthesized narratively. RESULTS Twenty-four articles were included. Uncertain test results encompassed either an inconclusive test result or a variant of unknown significance (VUS). Counselees involved almost exclusively women at risk of hereditary breast and/or ovarian cancer. None of the articles reported effects on counselor outcomes. Counselee outcomes were categorized as cognitive, affective or behavioral. Interpretation of a VUS was overall reported as difficult, and counselees' distress and worry were repeatedly found to decrease over time after the discussion of any uncertain test result. For most other outcomes, findings were sparse and/or inconsistent. CONCLUSION Evidence on effects on counselee outcomes is scant and inconsistent. Future studies are warranted to provide insight into how counselees and counselors are affected. PRACTICE IMPLICATIONS Clinical practice could benefit from guidelines on how to address uncertain test results during pre- and posttest genetic consultations.
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Affiliation(s)
- Niki M Medendorp
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands.
| | | | - Laxsini Murugesu
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Joost G Daams
- Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
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Stortenbeker I, Houwen J, van Dulmen S, Olde Hartman T, Das E. Quantifying implicit uncertainty in primary care consultations: A systematic comparison of communication about medically explained versus unexplained symptoms. PATIENT EDUCATION AND COUNSELING 2019; 102:2349-2352. [PMID: 31288956 DOI: 10.1016/j.pec.2019.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE General practitioners (GPs) disclose more uncertainty (e.g. "I don't know") in consultations with patients presenting medically unexplained symptoms (MUS) versus medically explained symptoms (MES), which could negatively affect patient outcomes. This study assessed if this pattern also holds for more subtle, implicit uncertainty expressions (e.g. "maybe", "might") during different consultation phases, and assessed their relation to patient pre-post consultation anxiety. METHODS We quantified implicit markers of uncertainty of 18 GPs in 82 consultations about MUS or MES during different consultation phases. Relative frequencies of implicit uncertainty per consultation were regressed on differences in momentary anxiety pre and post consultation. RESULTS We coded 2590 GP utterances. Uncertainty expressions were more frequent in MUS versus MES consultations (OR = 1.54, p = .004), especially during diagnosis and treatment recommendations compared to physical examinations (OR =0 .45, p = .001). Implicit uncertainty was not related to patients' changes in anxiety (b = -0.11, p = .817). CONCLUSIONS GPs express more uncertainty during MUS (versus MES) consultations, especially during the diagnostic phase and treatment recommendations. This does not necessarily affect patient anxiety. PRACTICE IMPLICATIONS Implicit uncertainty expressions reflect the mere complexity of communicating a medically unexplained diagnosis, which does not affect patient anxiety.
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Affiliation(s)
- Inge Stortenbeker
- Centre for Language Studies, Radboud University, Nijmegen, The Netherlands.
| | - Juul Houwen
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands.
| | - Sandra van Dulmen
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands; NIVEL (Netherlands institute for health services research), Utrecht, The Netherlands; Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway.
| | - Tim Olde Hartman
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands; Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands.
| | - Enny Das
- Centre for Language Studies, Radboud University, Nijmegen, The Netherlands.
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Communicating Uncertainty: a Narrative Review and Framework for Future Research. J Gen Intern Med 2019; 34:2586-2591. [PMID: 31197729 PMCID: PMC6848305 DOI: 10.1007/s11606-019-04860-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 12/03/2018] [Accepted: 01/02/2019] [Indexed: 10/26/2022]
Abstract
Discussing the uncertainty associated with a clinical decision is thought to be a critical element of shared decision-making. Yet, empirical evidence suggests that clinicians rarely communicate clinical uncertainty to patients, and indeed the culture within healthcare environments is often to equate uncertainty with ignorance or failure. Understanding the rationale for discussion of uncertainty along with the current evidence about approaches to communicating and managing uncertainty can advance shared decision-making as well as highlight gaps in evidence. With an increasing focus on personalized healthcare, and advances in genomics and new disease biomarkers, a more sophisticated understanding of how to communicate the limitations and errors that come from applying population-based, epidemiologic findings to predict individuals' futures is going to be essential. This article provides a narrative review of studies relating to the communication of uncertainty, highlighting current strategies together with challenges and barriers, and outlining a framework for future research.
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Blanch-Hartigan D, van Eeden M, Verdam MGE, Han PKJ, Smets EMA, Hillen MA. Effects of communication about uncertainty and oncologist gender on the physician-patient relationship. PATIENT EDUCATION AND COUNSELING 2019; 102:1613-1620. [PMID: 31101428 DOI: 10.1016/j.pec.2019.05.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/15/2019] [Accepted: 05/01/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Physicians are increasingly expected to share uncertain information, yet there is concern about possible negative effects on patients. How uncertainty is conveyed and by whom may influence patients' response. We tested the effects of verbally and non-verbally communicating uncertainty by a male vs. female oncologist on patients' trust and intention to seek a second opinion. METHODS In an experimental video vignettes study conducted in The Netherlands, oncologist communication behavior (verbal vs. non-verbal and high vs. low uncertainty) and gender (male vs. female) were systematically manipulated. Former cancer patients viewed one video variant and reported trust, intention to seek a second opinion, and experience of uncertainty. RESULTS Non-verbal communication of high uncertainty by the oncologist led to reduced trust (β = -0.72 (SE = 0.15), p < .001) and increased intention to seek a second opinion (β = 0.67 (SE = 0.16), p < .001). These effects were partly explained by patients' increased experience of uncertainty (β = -0.48 (SE = 0.12), p < .001; and β = 0.34 (SE = 0.09), p < .001 respectively). Neither verbal uncertainty nor oncologists' gender influenced trust or intention to seek a second opinion. CONCLUSION Non-verbal communication of uncertainty by oncologists may affect patient trust and intention to seek a second-opinion more than verbal communication. PRACTICE IMPLICATIONS Further research to understand and improve oncologists' non-verbal uncertainty behavior is warranted.
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Affiliation(s)
| | - Marceline van Eeden
- Amsterdam UMC, University of Amsterdam, Department of Medical Psychology, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Mathilde G E Verdam
- Amsterdam UMC, University of Amsterdam, Department of Medical Psychology, Amsterdam Public Health, Amsterdam, The Netherlands; Leiden University, Institute of Psychology, Leiden, The Netherlands
| | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, USA
| | - Ellen M A Smets
- Amsterdam UMC, University of Amsterdam, Department of Medical Psychology, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Marij A Hillen
- Amsterdam UMC, University of Amsterdam, Department of Medical Psychology, Amsterdam Public Health, Amsterdam, The Netherlands.
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Schreckenbach T, Ochsendorf F, Sterz J, Rüsseler M, Bechstein WO, Bender B, Bechtoldt MN. Emotion recognition and extraversion of medical students interact to predict their empathic communication perceived by simulated patients. BMC MEDICAL EDUCATION 2018; 18:237. [PMID: 30314497 PMCID: PMC6186136 DOI: 10.1186/s12909-018-1342-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/27/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND This study assessed the impact of medical students' emotion recognition ability and extraversion on their empathic communication, as perceived by simulated patients in a training context. METHODS This study used a crossed-effect data structure and examined 245 students in their fourth year of medical school. The students' personality traits were assessed based on a self-assessment questionnaire of the short form of the Big Five Inventory; their emotion recognition ability was measured using a performance test (Diagnostic Analysis of Nonverbal Accuracy-2, Adult Facial Expressions). Simulated patients evaluated the medical students' empathic communication. RESULTS Students with a combination of high emotion recognition ability and extraversion received more positive ratings from simulated patients than their fellow students with a combination of emotion recognition ability and low extraversion. The main effects of emotion recognition or extraversion were not sufficient to yield similar effects. There were no other effects related to the remaining Big Five variables. CONCLUSIONS The results support the hypothesis that to build rapport with patients, medical staff need to combine emotional capabilities with a dispositional interest in interpersonal encounters.
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Affiliation(s)
- Teresa Schreckenbach
- Department of General and Visceral Surgery, Frankfurt University Hospital, Goethe-University Frankfurt/Main, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany
| | - Falk Ochsendorf
- Department of Dermatology, Frankfurt University Hospital, Frankfurt/Main, Germany
| | - Jasmina Sterz
- Department of Trauma Surgery, Frankfurt University Hospital, Frankfurt/Main, Germany
| | - Miriam Rüsseler
- Department of Trauma Surgery, Frankfurt University Hospital, Frankfurt/Main, Germany
| | - Wolf Otto Bechstein
- Department of General and Visceral Surgery, Frankfurt University Hospital, Goethe-University Frankfurt/Main, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany
| | - Bernd Bender
- Department of Trauma Surgery, Frankfurt University Hospital, Frankfurt/Main, Germany
| | - Myriam N. Bechtoldt
- Department of Management & Economics, EBS University of Business and Law, Oestrich-Winkel, Germany
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Mast MS, Kadji KK. How female and male physicians' communication is perceived differently. PATIENT EDUCATION AND COUNSELING 2018; 101:1697-1701. [PMID: 29903628 DOI: 10.1016/j.pec.2018.06.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/09/2018] [Accepted: 06/06/2018] [Indexed: 05/14/2023]
Abstract
OBJECTIVE This paper is based on a 2017 Baltimore International Conference on Communication in Healthcare (ICCH) plenary presentation by the first author and addresses how female and male physicians' communication is perceived and evaluated differently. Female physicians use patient-centered communication which is the interaction style clearly preferred by patients. Logically, patients should be much more satisfied with female than male physicians. However, research shows that this is not the case. METHODS This article provides an overview on how female and male physician communication is evaluated and perceived differently by patients and discusses whether and how gender stereotypes can explain these differences in perception and evaluation. RESULTS Male physicians obtain good patient outcomes when verbally expressing patient-centeredness while female physicians have patients who report better outcomes when they adapt their nonverbal communication to the different needs of their patients. CONCLUSION The analysis reveals that existing empirical findings cannot simply be explained by the adherence or not to gender stereotypes. Female physicians do not always get credit for showing gender role congruent behavior. All in all, female and male physicians do not obtain credit for the same behaviors. PRACTICE IMPLICATIONS Physician communication training might put different accents for female and male physicians.
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Affiliation(s)
| | - Keou Kambiwa Kadji
- Department of Organizational Behavior, University of Lausanne, Switzerland
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18
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Hill KM, Blanch-Hartigan D. Physician gender and apologies in clinical interactions. PATIENT EDUCATION AND COUNSELING 2018; 101:836-842. [PMID: 29241976 DOI: 10.1016/j.pec.2017.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 11/27/2017] [Accepted: 12/08/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We examine whether patients have a preference for affective (i.e., focused on patient's emotions) or cognitive (i.e., focused on the process that led to the error) apologies that are dependent on the apologizing physician's gender. We hypothesize patients will prefer gender-congruent apologies (i.e., when females offer affective apologies and males offer cognitive apologies). METHODS We randomly assigned analogue patients (APs: participants instructed to imagine they were a patient) to read a scenario in which a female or male physician makes an error and provides a gender-congruent or incongruent apology. APs reported on their perceptions of the physician and legal intentions. RESULTS An apology-type and gender congruency effect was found such that APs preferred apologies congruent with the gender of the apologizing physician. An indirect effect of congruency on legal intentions through physician perceptions was confirmed (b=-0.24, p=0.02). CONCLUSION Our results suggest that physician gender plays a role in patient reactions to different apology types. PRACTICE IMPLICATIONS Apology trainings should incorporate how physician characteristics can influence how patients assess and respond to apologies.
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Affiliation(s)
- Krista M Hill
- Marketing Division, Babson College, Babson Park, USA.
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Bhise V, Meyer AND, Menon S, Singhal G, Street RL, Giardina TD, Singh H. Patient perspectives on how physicians communicate diagnostic uncertainty: An experimental vignette study. Int J Qual Health Care 2018; 30:2-8. [PMID: 29329438 DOI: 10.1093/intqhc/mzx170] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/29/2017] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE We evaluated the effects of three different strategies for communicating diagnostic uncertainty on patient perceptions of physician competence and visit satisfaction. DESIGN/SETTING Experimental vignette-based study design involving pediatric cases presented to a convenience sample of parents living in a large US city. PARTICIPANTS/INTERVENTION(S) Three vignettes were developed, each describing one of three different ways physicians communicated diagnostic uncertainty to parents-(i) explicit expression of uncertainty ('not sure' about diagnosis), (ii) implicit expression of uncertainty using broad differential diagnoses and (iii) implicit expression of uncertainty using 'most likely' diagnoses. Participants were randomly assigned to one of the three vignettes and then answered a 37-item web-based questionnaire. MAIN OUTCOME MEASURE(S) Outcome variables included parent-perceived technical competence of physician, trust and confidence, visit satisfaction and adherence to physician instructions. Differences between the three groups were compared using analysis of variance, followed by individual post hoc analyses with Bonferroni correction. RESULTS Seventy-one participants completed the vignette questions. Demographic characteristics and scores on activation (parent activation measure [PAM]) and intolerance to uncertainty were similar across the three groups. Explicit expression of uncertainty was associated with lower perceived technical competence, less trust and confidence, and lower patient adherence as compared to the two groups with implicit communication. These latter two groups had comparable outcomes. CONCLUSION Parents may react less negatively in terms of perceived competence, physician confidence and trust, and intention to adhere when diagnostic uncertainty is communicated using implicit strategies, such as using broad differential diagnoses or most likely diagnoses. Evidence-based strategies to communicate diagnostic uncertainty to patients need further development.
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Affiliation(s)
- Viraj Bhise
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, 2002 Holcombe Boulevard, Houston, TX 77030, USA
| | - Ashley N D Meyer
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, 2002 Holcombe Boulevard, Houston, TX 77030, USA
| | - Shailaja Menon
- Houston Community College, 1300 Holman Street, Houston, TX 77004, USA
| | - Geeta Singhal
- Pediatric Hospital Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA
| | - Richard L Street
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, 2002 Holcombe Boulevard, Houston, TX 77030, USA
- Department of Communication, Texas A&M University, 4234 TAMU, College Station, TX 77843, USA
| | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, 2002 Holcombe Boulevard, Houston, TX 77030, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, 2002 Holcombe Boulevard, Houston, TX 77030, USA
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Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review. J Gen Intern Med 2018; 33:103-115. [PMID: 28936618 PMCID: PMC5756158 DOI: 10.1007/s11606-017-4164-1] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 06/26/2017] [Accepted: 08/11/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Physicians routinely encounter diagnostic uncertainty in practice. Despite its impact on health care utilization, costs and error, measurement of diagnostic uncertainty is poorly understood. We conducted a systematic review to describe how diagnostic uncertainty is defined and measured in medical practice. METHODS We searched OVID Medline and PsycINFO databases from inception until May 2017 using a combination of keywords and Medical Subject Headings (MeSH). Additional search strategies included manual review of references identified in the primary search, use of a topic-specific database (AHRQ-PSNet) and expert input. We specifically focused on articles that (1) defined diagnostic uncertainty; (2) conceptualized diagnostic uncertainty in terms of its sources, complexity of its attributes or strategies for managing it; or (3) attempted to measure diagnostic uncertainty. KEY RESULTS We identified 123 articles for full review, none of which defined diagnostic uncertainty. Three attributes of diagnostic uncertainty were relevant for measurement: (1) it is a subjective perception experienced by the clinician; (2) it has the potential to impact diagnostic evaluation-for example, when inappropriately managed, it can lead to diagnostic delays; and (3) it is dynamic in nature, changing with time. Current methods for measuring diagnostic uncertainty in medical practice include: (1) asking clinicians about their perception of uncertainty (surveys and qualitative interviews), (2) evaluating the patient-clinician encounter (such as by reviews of medical records, transcripts of patient-clinician communication and observation), and (3) experimental techniques (patient vignette studies). CONCLUSIONS The term "diagnostic uncertainty" lacks a clear definition, and there is no comprehensive framework for its measurement in medical practice. Based on review findings, we propose that diagnostic uncertainty be defined as a "subjective perception of an inability to provide an accurate explanation of the patient's health problem." Methodological advancements in measuring diagnostic uncertainty can improve our understanding of diagnostic decision-making and inform interventions to reduce diagnostic errors and overuse of health care resources.
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Affiliation(s)
- Viraj Bhise
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Suja S Rajan
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Dean F Sittig
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA
- UT-Memorial Hermann Center for Health Care Quality and Safety, Houston, TX, USA
| | - Robert O Morgan
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Pooja Chaudhary
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA.
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Transformational Impact of Health Information Technology on the Clinical Practice of Child and Adolescent Psychiatry. Child Adolesc Psychiatr Clin N Am 2017; 26:55-66. [PMID: 27837942 DOI: 10.1016/j.chc.2016.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Compared with other medical specialties, psychiatrists have been slower adopters of health information technology (IT) practices, such as electronic health records (EHRs). This delay in implementation could compromise patient safety and impede integration into accountable care organizations and multidisciplinary treatment settings. This article focuses on optimizing use of EHRs for clinical practice, leveraging health IT to improve quality of care, and focusing on the potential for future growth in health IT in child and adolescent psychiatric practice. Aligning with other medical fields and focusing on transparency of mental health treatment will help psychiatrists reach parity with other medical specialties.
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Carrard V, Schmid Mast M, Cousin G. Beyond "One Size Fits All": Physician Nonverbal Adaptability to Patients' Need for Paternalism and Its Positive Consultation Outcomes. HEALTH COMMUNICATION 2016; 31:1327-33. [PMID: 27030260 DOI: 10.1080/10410236.2015.1052871] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
In this study, we tested whether physicians' ability to adapt their nonverbal behavior to their patients' preferences for a paternalistic interaction style is related to positive consultation outcomes. We hypothesized that the more physicians adapt their nonverbal dominance behavior to match their patients' preferences for physician paternalism, the more positively the patients perceive the medical interaction. We assessed the actual nonverbal dominance behavior of 32 general practitioners when interacting with two of their patients and compared it with each of their patients' preferences for paternalism to obtain a measure of adaptability. Additionally, we measured patient outcomes with a questionnaire assessing patient satisfaction, trust in the physician, and evaluation of physician competence. Results show that the more nonverbal dominance the physician shows toward the patient who prefers a more paternalistic physician, as compared to toward the patient who prefers a less paternalistic physician (i.e., the more the physician shows nonverbal behavioral adaptability), the more positive the consultation outcomes are. This means that physicians' ability to adapt aspects of their nonverbal dominance behavior to their individual patients' preferences is related to better outcomes for patients. As this study shows, it is advantageous for patients when a physician behaves flexibly instead of showing the same behavior towards all patients. Physician training might want to focus more on teaching a diversity of different behavior repertoires instead of a given set of behaviors.
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Affiliation(s)
- Valérie Carrard
- a Department of Organizational Behavior , University of Lausanne , Lausanne , Switzerland
| | - Marianne Schmid Mast
- a Department of Organizational Behavior , University of Lausanne , Lausanne , Switzerland
| | - Gaëtan Cousin
- b Institute of Work and Organizational Psychology, University of Neuchâtel , Neuchâtel , Switzerland
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Tarn DM, Paterniti DA, Wenger NS. Provider Recommendations in the Face of Scientific Uncertainty: An Analysis of Audio-Recorded Discussions about Vitamin D. J Gen Intern Med 2016; 31:909-17. [PMID: 27008650 PMCID: PMC4945557 DOI: 10.1007/s11606-016-3667-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 01/25/2016] [Accepted: 03/07/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about how providers communicate recommendations when scientific uncertainty exists. OBJECTIVES To compare provider recommendations to those in the scientific literature, with a focus on whether uncertainty was communicated. DESIGN Qualitative (inductive systematic content analysis) and quantitative analysis of previously collected audio-recorded provider-patient office visits. PARTICIPANTS Sixty-one providers and a socio-economically diverse convenience sample of 603 of their patients from outpatient community- and academic-based primary care, integrative medicine, and complementary and alternative medicine provider offices in Southern California. MAIN MEASURES Comparison of provider information-giving about vitamin D to professional guidelines and scientific information for which conflicting recommendations or insufficient scientific evidence exists; certainty with which information was conveyed. RESULTS Ninety-two (15.3 %) of 603 visit discussions touched upon issues related to vitamin D testing, management and benefits. Vitamin D deficiency screening was discussed with 23 (25 %) patients, the definition of vitamin D deficiency with 21 (22.8 %), the optimal range for vitamin D levels with 26 (28.3 %), vitamin D supplementation dosing with 50 (54.3 %), and benefits of supplementation with 46 (50 %). For each of the professional guidelines/scientific information examined, providers conveyed information that deviated from professional guidelines and the existing scientific evidence. Of 166 statements made about vitamin D in this study, providers conveyed 160 (96.4 %) with certainty, without mention of any equivocal or contradictory evidence in the scientific literature. No uncertainty was mentioned when vitamin D dosing was discussed, even when recommended dosing was higher than guideline recommendations. CONCLUSIONS AND RELEVANCE Providers convey the vast majority of information and recommendations about vitamin D with certainty, even though the scientific literature contains inconsistent recommendations and declarations of inadequate evidence. Not communicating uncertainty blurs the contrast between evidence-based recommendations and those without evidence. Providers should explore best practices for involving patients in decision-making by acknowledging the uncertainty behind their recommendations.
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Affiliation(s)
- Derjung M Tarn
- Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, 10880 Wilshire Blvd., Suite 1800, Los Angeles, CA, 90024, USA.
| | - Debora A Paterniti
- Department of Sociology, Sonoma State University, Sacramento, CA, USA.,Departments of Internal Medicine and Sociology, University of California-Davis Medical Center, Sacramento, CA, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, CA, USA
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Etkind SN, Koffman J. Approaches to managing uncertainty in people with life-limiting conditions: role of communication and palliative care. Postgrad Med J 2016; 92:412-7. [PMID: 27129911 DOI: 10.1136/postgradmedj-2015-133371] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 04/12/2016] [Indexed: 12/21/2022]
Abstract
Patients with any major illness can expect to experience uncertainty about the nature of their illness, its treatment and their prognosis. Prognostic uncertainty is a particular source of patient distress among those living with life-limiting disease. Uncertainty also affects professionals and it has been argued that the level of professional tolerance of uncertainty can affect levels of investigation as well as healthcare resource use. We know that the way in which uncertainty is recognised, managed and communicated can have important impacts on patients' treatment and quality of life. Current approaches to uncertainty in life-limiting illness include the use of care bundles and approaches that focus on communication and education. The experience in communicating in difficult situations that specialist palliative care professionals can provide may also be of benefit for patients with life-limiting illness in the context of uncertainty. While there are a number of promising approaches to uncertainty, as yet few interventions targeted at recognising and addressing uncertainty have been fully evaluated and further research is needed in this area.
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Affiliation(s)
- S N Etkind
- Department of Palliative Care, Policy and Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - J Koffman
- Department of Palliative Care, Policy and Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
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Saligheh Rad H, Fathi Kazerooni A. Know-How on Clinical MRI Research in Iran. J Am Coll Radiol 2016; 13:750-3. [PMID: 26768545 DOI: 10.1016/j.jacr.2015.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 10/30/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Hamidreza Saligheh Rad
- Quantitative MR Imaging and Spectroscopy Group, Research Center for Molecular and Cellular Imaging, Institute for Advanced Medical Technologies, and the Department of Medical Physics and Biomedical Engineering, Tehran University of Medical Sciences, Tehran, Iran.
| | - Anahita Fathi Kazerooni
- Quantitative MR Imaging and Spectroscopy Group, Research Center for Molecular and Cellular Imaging, Institute for Advanced Medical Technologies, and the Department of Medical Physics and Biomedical Engineering, Tehran University of Medical Sciences, Tehran, Iran
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Parvez S, Abdel-Kader K, Song MK, Unruh M. Conveying Uncertainty in Prognosis to Patients with ESRD. Blood Purif 2015; 39:58-64. [DOI: 10.1159/000368954] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Prognosis is a component of medical practice imbued with uncertainty. In nephrology, where mortality rates of elderly patients on dialysis are comparable to those of cancer patients, the implications of prognosis are unavoidable. Yet while most patients with end-stage renal disease (ESRD) desire to hear their prognosis, many nephrologists balk at this prospect in part owing to the uncertainty inherent in prognostic estimates. Summary: In this review, the concept of ‘uncertainty' in clinical practice is considered from physician and patient perspectives. From the training perspective, providers learn that uncertainty is inescapable in medicine and develop strategies to manage its presence, including the avoidance of communicating uncertainty to their patients. This presages infrequent discussions of prognosis, which in turn influence patient preferences for treatments that have little therapeutic benefits. A general approach to conveying prognostic uncertainty to ESRD patients includes confronting our own emotional reaction to uncertainty, learning how to effectively communicate uncertainty to our patients, and using an effective interdisciplinary team approach to demonstrate an ongoing commitment to our patients despite the presence of prognostic uncertainty. Key Messages: Uncertainty in prognosis is inevitable. Once providers learn to incorporate it into their discussions of prognosis and collaborate with their ESRD patients, such discussions can foster trust and reduce anxiety for both sides.
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Bennett K, Frisby BN, Young LE, Murray D. Vitamin D: an examination of physician and patient management of health and uncertainty. QUALITATIVE HEALTH RESEARCH 2014; 24:375-386. [PMID: 24558016 PMCID: PMC3951658 DOI: 10.1177/1049732314523681] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Vitamin D has been a topic of much research interest and controversy, and evidence is mixed concerning its preventive effects and health benefits. The purpose of our study was to explore the decision-making strategies used by both primary care providers and community members surrounding vitamin D in relation to uncertainty management theory. We conducted semistructured interviews with primary care providers (n = 7) and focus groups with community members (n = 89), and transcribed and coded using the constant comparative method. Themes for providers included awareness, uncertainty, patient role, responsibility, skepticism, uncertainty management, and evolving perceptions. Community member focus group themes included uncertainty, information sources, awareness/knowledge, barriers, and patient-provider relationship. Both providers and community members expressed uncertainty about vitamin D but used conflicting strategies to manage uncertainty. Awareness of this disconnect might facilitate improved patient-provider communication.
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Affiliation(s)
| | | | | | - Deborah Murray
- Deborah Murray, University of Georgia, Athens Georgia, USA
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Blanch-Hartigan D. Patient satisfaction with physician errors in detecting and identifying patient emotion cues. PATIENT EDUCATION AND COUNSELING 2013; 93:56-62. [PMID: 23669151 DOI: 10.1016/j.pec.2013.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 04/08/2013] [Accepted: 04/11/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Previous research has examined physicians' ability to respond to or identify the type of emotion cues. Yet in physician-patient interactions, identification and response are preceded by the ability to detect whether an emotion cue has occurred. This research assesses consequences of emotion detection errors for patient satisfaction. METHODS Participants responding to an online survey read one of six randomly assigned descriptions of a physician-patient interaction varying on: whether the patient presented an emotion cue; whether the physician detected an emotion cue; and whether the physician correctly identified the cue. Participants then rated satisfaction with the physician. RESULTS Satisfaction was highest when the physician correctly detected the patient's emotion cue and lowest when the physician failed to detect the patient's emotion. Failing to detect the emotion cue had lower satisfaction than other emotion processing errors, including falsely detecting an emotion cue that was not there or incorrectly identifying the type of emotion. CONCLUSIONS Emotion cue detection has implications for patient satisfaction distinct from emotion identification. PRACTICE IMPLICATIONS Results suggest it may be better for physicians to incorrectly identify than miss an emotion. Training for healthcare providers should consider incorporating emotion detection.
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Affiliation(s)
- Danielle Blanch-Hartigan
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892, USA.
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Cousin G, Schmid Mast M, Jaunin-Stalder N. When physician-expressed uncertainty leads to patient dissatisfaction: a gender study. MEDICAL EDUCATION 2013; 47:923-931. [PMID: 23931541 DOI: 10.1111/medu.12237] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 01/21/2013] [Accepted: 03/15/2013] [Indexed: 06/02/2023]
Abstract
CONTEXT Communication guidelines often advise physicians to disclose to their patients medical uncertainty regarding the diagnosis, origin of the problem, and treatment. However, the effect of the expression of such uncertainty on patient outcomes (e.g. satisfaction) has produced conflicting results in the literature that indicate either no effect or a negative effect. The differences in the results of past studies may be explained by the fact that potential gender effects on the link between physician-expressed uncertainty and patient outcomes have not been investigated systematically. OBJECTIVES On the basis of previous research documenting indications that patients may judge female physicians by more severe criteria than they do male physicians, and that men are more prejudiced than women towards women, we predicted that physician-expressed uncertainty would have more of a negative impact on patient satisfaction when the physician in question was female rather than male, and especially when the patient was a man. METHODS We conducted two studies with complementary designs. Study 1 was a randomised controlled trial conducted in a simulated setting (120 analogue patients Analogue patients are healthy participants asked to put themselves in the shoes of real medical patients by imagining being the patients of physicians shown on videos); Study 2 was a field study conducted in real medical interviews (36 physicians, 69 patients). In Study 1, participants were presented with vignettes that varied in terms of the physician's gender and physician-expressed uncertainty (high versus low). In Study 2, physicians were filmed during real medical consultations and the level of uncertainty they expressed was coded by an independent rater according to the videos. In both studies, patient satisfaction was assessed using a questionnaire. RESULTS The results confirmed that expressed uncertainty was negatively related to patient satisfaction only when the physician was a woman (Studies 1 and 2) and when the patient was a man (Study 2). CONCLUSIONS We believe that patients have the right to be fully informed of any medical uncertainties. If our results are confirmed in further research, the question of import will refer not to whether female physicians should communicate uncertainty, but to how they should communicate it. For instance, if it proves true that uncertainty negatively impacts on (male) patients' satisfaction, female physicians might want to counterbalance this impact by emphasizing other communication skills.
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Affiliation(s)
- Gaetan Cousin
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX4 1SZ, UK.
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Henry SG, Eggly S. The effect of discussing pain on patient-physician communication in a low-income, black, primary care patient population. THE JOURNAL OF PAIN 2013; 14:759-66. [PMID: 23623573 PMCID: PMC3846383 DOI: 10.1016/j.jpain.2013.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 01/29/2013] [Accepted: 02/09/2013] [Indexed: 11/25/2022]
Abstract
UNLABELLED Patients and physicians report that discussions about pain are frequently frustrating and unproductive. However, the relationship between discussions about pain and patient-physician communication is poorly understood. We analyzed 133 video-recorded visits and patient self-report data collected at a clinic providing primary care to a low-income, black patient population. We used "thin slice" methods to rate two or three 30-second video segments from each visit on variables related to patient and physician affect (ie, displayed emotion) and patient-physician rapport. Discussions about pain were associated with a .32 increase in patient unease (P < .001) and a .21 increase in patient positive engagement (P = .004; standardized coefficients) compared to discussions about other topics during the same visit. Discussions about pain were not significantly associated with patient-physician rapport, physician unease, or physician positive engagement. Patient pain severity was significantly associated with greater physician and patient unease (P = .01), but not with other variables. Findings suggest that primary care patients, but not their physicians, display significantly greater emotional intensity during discussions about pain compared to discussions about other topics. PERSPECTIVE This study used direct observation of video-recorded primary care visits to show that discussions about pain are associated with heightened displays of both positive and negative patient emotions. These displays of emotion could potentially influence pain-related outcomes.
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Affiliation(s)
- Stephen G Henry
- Division of General Medicine, Geriatrics, & Bioethics, University of California Davis, Sacramento, California 95817, USA.
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Reiner BI. Using analysis of speech and linguistics to characterize uncertainty in radiology reporting. J Digit Imaging 2013; 25:703-7. [PMID: 23053909 DOI: 10.1007/s10278-012-9535-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Bruce I Reiner
- Department of Radiology, Veterans Affairs Maryland Healthcare System, Baltimore, MD 21201, USA.
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The validity of using analogue patients in practitioner-patient communication research: systematic review and meta-analysis. J Gen Intern Med 2012; 27:1528-43. [PMID: 22700392 PMCID: PMC3475831 DOI: 10.1007/s11606-012-2111-8] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 04/11/2012] [Accepted: 05/03/2012] [Indexed: 12/04/2022]
Abstract
When studying the patient perspective on communication, some studies rely on analogue patients (patients and healthy subjects) who rate videotaped medical consultations while putting themselves in the shoes of the video-patient. To describe the rationales, methodology, and outcomes of studies using video-vignette designs in which videotaped medical consultations are watched and judged by analogue patients. Pubmed, Embase, Psychinfo and CINAHL databases were systematically searched up to February 2012. Data was extracted on: study characteristics and quality, design, rationales, internal and external validity, limitations and analogue patients' perceptions of studied communication. A meta-analysis was conducted on the distribution of analogue patients' evaluations of communication. Thirty-four studies were included, comprising both scripted and clinical studies, of average-to-superior quality. Studies provided unspecific, ethical as well as methodological rationales for conducting video-vignette studies with analogue patients. Scripted studies provided the most specific methodological rationales and tried the most to increase and test internal validity (e.g. by performing manipulation checks) and external validity (e.g. by determining identification with video-patient). Analogue patients' perceptions of communication largely overlap with clinical patients' perceptions. The meta-analysis revealed that analogue patients' evaluations of practitioners' communication are not subject to ceiling effects. Analogue patients' evaluations of communication equaled clinical patients' perceptions, while overcoming ceiling effects. This implies that analogue patients can be included as proxies for clinical patients in studies on communication, taken some described precautions into account. Insights from this review may ease decisions about including analogue patients in video-vignette studies, improve the quality of these studies and increase knowledge on communication from the patient perspective.
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Decision-making in oncology: a selected literature review and some recommendations for the future. Curr Opin Oncol 2012; 24:381-90. [PMID: 22572724 DOI: 10.1097/cco.0b013e328354b2f6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Decision-making in oncology is associated with uncertainty and potential decisional conflict. The purpose of this paper is to review strategies suggested to improve treatment decision-making, discuss their limits and describe recommendations that have been made to improve the decision-making process. RECENT FINDINGS To improve the decision-making process, uncertainty reduction, shared decision-making and multidisciplinary teamwork have been initially proposed. Due to their limits, alternative approaches such as uncertainty management, collaborative decision-making and collaborative multidisciplinary teamwork have been recommended. Uncertainty management considers uncertainty as a multilevel concept. It may be achieved through collaborative decision-making and collaborative multidisciplinary teamwork. Collaborative decision-making is an in-depth personalized iterative assessment of patient medical, psychological and social status. It promotes the patient's proactive role as a key stakeholder of decision-making and the physician's proactive role as a key support to patient decision-making. Collaborative multidisciplinary teamwork promotes an optimal environment for collaborative decision-making in which patients are key stakeholders and all relevant healthcare professionals are actively involved. These approaches require developing interventions for patients, and trainings for physicians and multidisciplinary teams. SUMMARY On the basis of these recent approaches, we propose a 'three-step model of multidisciplinary collaborative treatment decision-making' in oncology. This model should be tested for its validity.
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Uncertainty in medicine: Meanings of menopause and hormone replacement therapy in medical textbooks. Soc Sci Med 2011; 73:1238-45. [DOI: 10.1016/j.socscimed.2011.07.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 07/22/2011] [Accepted: 07/26/2011] [Indexed: 11/15/2022]
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Finset A, Visser A. EACH 2008 in Oslo: In the pursuit of the good consultation. PATIENT EDUCATION AND COUNSELING 2009; 76:293-295. [PMID: 19647972 DOI: 10.1016/j.pec.2009.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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