Agreement of physician and patient ratings of communication in medical encounters: A systematic review and meta-analysis of interrater agreement

Development of an instrument for medical students' self-assessment of facets of competence for patient-centred care

OBJECTIVE

To develop a facets of competence self-assessment instrument (FOCSI) with operationalised items for ten competence facets required for patient-centred care at the beginning of residency.

METHODS

We conducted focus groups and cognitive interviews with final-year medical students to develop items that match students' clinical experience. We tested 50 items in two samples and analysed model fit and internal consistency of all possible combinations to identify the optimal ten-item-solution. Item analysis was performed as well as correlation with six personality traits.

RESULTS

An optimal ten-item solution for the self-assessment instrument emerged for sample 1 (n = 101, 27.2 ± 3.5 years, 75.2 % female). We validated the model fit with sample 2 (n = 135, 27.7 ± 3.9 years, 66.7 % female): χ2(35) = 49.3, p = .055, CFI = .94, RMSEA = .055, SRMR = .058, Cronbach's alpha = .78. The personality factors 'Conscientiousness' and 'Extraversion' correlate positively with most FOCSI items.

CONCLUSION

The operationalised FOCSI items support undergraduate medical students close to graduation in realistic self-assessment of facets of competences for patient-centred care in their transition to residency.

PRACTICE IMPLICATIONS

Realistic self-assessment of facets of competence will provide medical students with the opportunity to monitor their competence development as part of self-directed learning for gaining adaptive expertise in professional, patient-centred care.

Application of the skills network approach to measure physician competence in shared decision making based on self-assessment

Several approaches to and definitions of 'shared decision making' (SDM) exist, which makes measurement challenging. Recently, a skills network approach was proposed, which conceptualizes SDM competence as an organized network of interacting SDM skills. With this approach, it was possible to accurately predict observer-rated SDM competence of physicians from the patients' assessments of the physician's SDM skills. The aim of this study was to assess whether using the skills network approach allows to predict observer-rated SDM competence of physicians from their self-reported SDM skills. We conducted a secondary data analysis of an observational study, in which outpatient care physicians rated their use of SDM skills with the physician version of the 9-item Shared Decision Making Questionnaire (SDM-Q-Doc) during consultations with chronically ill adult patients. Based on the estimated association of each skill with all other skills, an SDM skills network for each physician was constructed. Network parameters were used to predict observer-rated SDM competence, which was determined from audio-recorded consultations using three widely used measures (OPTION-12, OPTION-5, Four Habits Coding Scheme). In our study, 28 physicians rated consultations with 308 patients. The skill 'deliberating the decision' was central in the population skills network averaged across physicians. The correlation between parameters of the skills networks and observer-rated competence ranged from 0.65 to 0.82 across analyses. The use and connectedness of the skill 'eliciting treatment preference of the patient' showed the strongest unique association with observer-rated competence. Thus, we found evidence that processing SDM skill ratings from the physicians' perspective according to the skills network approach offers new theoretically and empirically grounded opportunities for the assessment of SDM competence. A feasible and robust measurement of SDM competence is essential for research on SDM and can be applied for evaluating SDM competence during medical education, for training evaluation, and for quality management purposes. [A plain language summary of the study is available at https://osf.io/3wy4v.].

Effective healthcare communication with children and young people: a systematic review of barriers and facilitators

OBJECTIVE

To identify children and young people's preferences for effective healthcare communication.

DESIGN

A systematic review of qualitative studies was conducted to identify evidence from children and young people on effective healthcare communication. Electronic databases and reference lists of relevant articles were searched to July 2020.

RESULTS

A total of 13 studies were included. Five major themes were identified: medical information (timing, amount, coordination and futures), person not patient (creating relationships, time, nurse involvement, sensitivity), type of communication (creative and interactive, behavioural, talking and listening, written communication), consultations (first impressions, with and without parents, actively promoting involvement, open and honest, age appropriate) and communication with parents (using parental knowledge, support).

CONCLUSIONS

Research in this area remains sparse and consistent implementation is debateable. Children and young people articulate a preference for two-way healthcare communication. General principles for effective communication are identified as well as the need to avoid making assumptions and to tailor approaches to individuals. Establishing and maintaining relationships is essential and requires time and resources. Parents and carers have a positive role in healthcare communication which needs to be balanced with the needs and rights of children. All these factors also apply to children with communication difficulties or from marginalised groups, but additional extra support may be required.

PROSPERO REGISTRATION NUMBER

CRD42019145539.

Midwives' empathy and shared decision making from women's perspective - sensitivity of an assessment to compare quality of care in prenatal and obstetric care

Background

For quality-oriented evaluation of prenatal and obstetric care, it is important to systematically consider the perspective of the women receiving care in order to comprehensively assess and optimize quality in a woman-centered manner. Empathy and Shared Decision Making (SDM) are essential components of woman-centered midwifery care. The aim of the study was to analyze measurement invariance of the items of the Consultation and Relational Empathy (CARE) and Shared Decision Making-Questionnaire (SDM-Q-9) scales depending on the prenatal versus obstetric care setting.

Methods

One hundred fifty women retrospectively assessed aspects of woman-centered midwifery care in both prenatal and obstetric care setting. The birth of the child was a maximum of 12 months ago. A structural equation modelling approach was adopted to separate true effects from response shift (RS) effects depending on care setting. The latter were analyzed in terms of recalibration (changing women’s internal measurement standards), Reprioritization (changing associations of items and construct) as well as Reconceptualization (redefining the target construct).

Results

A response shift model was identified for both assessments (pregnancy/birth: CFI = .96/.96; SRMR = .046/.051). At birth, both scales indicated lower quality of care compared with prenatal care (SDM-Q-9-M/CARE-8-M:|d| = 0.190/0.392). Although no reconceptualization is required for the items of both scales, RS effects are evident for individual items. Due to recalibration and reprioritization effects, the true differences in the items are partly underestimated (SDM-Q-9-M/CARE-8-M: 3/2 items) or overestimated (4/2 items).

Conclusion

The structure of the constructs SDM and Empathy, indicating woman-centered midwifery care, are moderated by the care settings. To validly assess midwives’ empathy and shared decision making from women’s perspective, setting-dependent response shift effects have to be considered. The proven item-specific response effects contribute to a better understanding of construct characteristics in woman-centered care by midwives during pregnancy and childbirth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05041-y.

Patient Perspectives on Medical Trauma Related to Inflammatory Bowel Disease

Post-traumatic stress symptoms (PTSS) in response to medical trauma are understudied in inflammatory bowel disease (IBD). Two studies identify surgery, hospitalizations, and disease severity as risk factors. We aimed to document IBD-related patient experiences and how these relate to PTSS via a qualitative study. Adult patients with confirmed IBD recruited from two gastroenterology clinics underwent a semi-structured interview with a psychologist and completed the Post Traumatic Stress Disorder Symptom Scale for DSM5 (PSSI-5). Interviews were analyzed using an interpretive phenomenological approach. Themes and subthemes with representative quotations were documented based on thematic saturation. 16 participants, five met PSSI-5 criteria for PTSD. Five themes emerged: disease uncertainty, information exchange/quality, medical procedures, surgery, and coping. Patients with IBD may experience medical PTSS from several sources. Information, communication, and trust in clinicians is vital but may be sub-optimal. Both adaptive and maladaptive coping strategies are used to mitigate PTSS.

Patient and physician shared decision-making behaviors in oncology: Evidence on adequate measurement properties of the iSHARE questionnaires

OBJECTIVES

We have developed two Dutch questionnaires to assess the shared decision-making (SDM) process in oncology; the iSHAREpatient and iSHAREphysician. In this study, we aimed to determine: scores, construct validity, test-retest agreement (iSHAREpatient), and inter-rater (iSHAREpatient-iSHAREphysician) agreement.

METHODS

Physicians from seven Dutch hospitals recruited cancer patients, and completed the iSHAREphysician and SDM-Questionnaire-physician version. Their patients completed the: iSHAREpatient, nine-item SDM-Questionnaire, Decisional Conflict Scale, Combined Outcome Measure for Risk communication And treatment Decision-making Effectiveness, and five-item Perceived Efficacy in Patient-Physician Interactions. We formulated, respectively, one (iSHAREphysician) and 10 (iSHAREpatient) a priori hypotheses regarding correlations between the iSHARE questionnaires and questionnaires assessing related constructs. To assess test-retest agreement patients completed the iSHAREpatient again 1-2 weeks later.

RESULTS

In total, 151 treatment decision-making processes with unique patients were rated. Dimension and total iSHARE scores were high both in patients and physicians. The hypothesis on the iSHAREphysician and 9/10 hypotheses on the iSHAREpatient were confirmed. Test-retest and inter-rater agreement were>.60 for most items.

CONCLUSIONS

The iSHARE questionnaires show high scores, have good construct validity, substantial test-retest agreement, and moderate inter-rater agreement.

PRACTICE IMPLICATIONS

Results from the iSHARE questionnaires can inform both physician- and patient-directed efforts to improve SDM in clinical practice.

A co-design study to develop supportive interventions to improve psychological and social adaptation among adults with new-onset type 1 diabetes in Denmark and the UK

OBJECTIVE

To develop supportive interventions for adults with new-onset type 1 diabetes (T1D) to facilitate positive adaptive strategies during their transition into a life with diabetes.

DESIGN

The study used a co-design approach informed by Design Thinking to stimulate participants' reflections on their experiences of current care and generate ideas for new supportive interventions. Visual illustrations were used to depict support needs and challenges. Initial discussions of these needs and challenges were facilitated by researchers and people with diabetes in workshops. Data comprising transcribed audio recordings of the workshop discussions and materials generated during the workshops were analysed thematically.

SETTINGS

Specialised diabetes centres in Denmark and the United Kingdom.

PARTICIPANTS

Adults with new-onset T1D (n=24) and healthcare professionals (HCPs) (n=56) participated in six parallel workshops followed by four joint workshops with adults (n=29) and HCPs (n=24) together.

RESULTS

The common solution prioritised by both adults with new-onset T1D and HCP participants was the development of an integrated model of care addressing the psychological and social elements of the diagnosis, alongside information on diabetes self-management. Participants also indicated a need to develop the organisation, provision and content of care, along with the skills HCPs need to optimally deliver that care. The co-designed interventions included three visual conversation tools that could be used flexibly in the care of adults with new-onset T1D to support physical, psychological and social adaptation to T1D.

CONCLUSION

This co-design study has identified the care priorities for adults who develop T1D, along with some practical conversational tools that may help guide HCPs in attending to the disruptive experience of the diagnosis and support adults in adjusting into a life with diabetes.

Deepening the teaching and learning of clinical communication

Aims: clinical communication (CC) relates to health professionals’ interaction with patients/families. CC is fundamental for the physicians’ role. This paper aims to contribute to the discussion about reflection and feedback for meaningful teaching and learning of CC.Methods: the authors provided a short review and conceptual discussion of the history and nature of CC teaching, followed by exploring the role of reflection and feedback in teaching CC.Results: communicating well can be challenging as it requires medical students and professionals to adapt their communication to each patient/family while obtaining all the needed information, conveying trustworthiness, care, and compassion. The teaching of CC to medical students involves deepening the doctor-patient relationship’s technical, relational, and emotional elements. CC requires teaching that is flexible and tailored to the participants’ needs. Therefore, teaching CC must go beyond asking the appropriate question or applying specific checklist-based behaviours. In teaching CC, it is crucial to give medical students support to discuss personal and institutional barriers and attitudes and explore how to transfer their learning to clinical practice. To that end, reflection should be encouraged to allow students to express difficulties and feelings and enhance their understanding of themselves and others. Within this process, feedback is essential to moving beyond skill-based teaching to reflection-based learning.Conclusion: the move from skills-based learning requires using reflective processes and feedback to allow students to learn about their communication tendencies and needs to become more flexible and attuned to different patient’s needs in clinical encounters.

Variance components of ratings of physician-patient communication: A generalizability theory analysis

Background

The ratings of physician-patient communication are an important indicator of the quality of health care delivery and provide guidance for many important decisions in the health care setting and in health research. But there is no gold standard to assess physician-patient communication. Thus, depending on the specific measurement condition, multiple sources of variance may contribute to the total score variance of ratings of physician-patient communication. This may systematically impair the validity of conclusions drawn from rating data.

Objective

To examine the extent to which different measurement conditions and rater perspectives, respectively contribute to the variance of physician-patient communication ratings.

Methods

Variance components of ratings of physician-patient communication gained from 32 general practitioners and 252 patients from 25 family practices in Germany were analyzed using generalizability theory. The communication dimensions “shared decision making”, “effective and open communication” and “satisfaction” were considered.

Results

Physician-patient communication ratings most substantially reflect unique rater-perspective and communication dimension combinations (32.7% interaction effect). The ratings also represented unique physician and rater-perspective combinations (16.3% interaction effect). However, physicians’ communication behavior and the observed communication dimensions revealed only a low extent of score variance (1% physician effect; 3.7% communication dimension effect). Approximately half of the variance remained unexplained (46.2% three-way interaction, confounded with error).

Conclusion

The ratings of physician-patient communication minimally reflect physician communication skills in general. Instead, these ratings exhibit primarily differences among physicians and patients in their tendency to perceive shared decision making and effective and open communication and to be satisfied with communication, regardless of the communication behavior of physicians. Rater training and assessing low inferential ratings of physician-patient communication dimensions should be considered when subjective aspects of rater perspectives are not of interest.

Improving communication between healthcare providers and pulmonary arterial hypertension patients: a survey of patient preferences

Effective communication within the patient–provider relationship is a key aspect of shared decision-making and associated with several positive patient outcomes. Although previous studies suggest that patients’ and providers’ conceptualization of what constitutes effective communication differ, there is no available literature discussing patient preferences for communication. The objective of this study was to determine the words and phrases pulmonary arterial hypertension patients prefer to hear when discussing their disease with their physician. A total of 227 pulmonary arterial hypertension patients completed a survey that included a 20-item questionnaire specifically designed to assess patient preference for words and phrases when discussing their disease and treatment; statistically significant differences were observed across all items of the questionnaire. Patients preferred their physician ask them how they have “been feeling” (63%) rather than how they have “been doing”. In addition, 96% of patients indicated that they wanted to hear that this is “… the best medicine for you” rather than this is “the best medicine”. Considerably more patients (60%) indicated they want their physician to say, “We want you to have fewer symptoms” rather than “We want you to feel more normal.” They also indicated they wanted the “most effective” medicine (82%) rather than the “most aggressive” medicine (7%). The results of this study suggest that pulmonary arterial hypertension patients have strong preferences for the language their providers use when discussing their disease and treatment options. Given the role that effective communication has on important health outcomes, pulmonary arterial hypertension providers need to consider these findings when communicating with patients.

Modes of Interaction in Naturally Occurring Medical Encounters With General Practitioners: The "One in a Million" Study

In this article, we qualitatively explore the manner and style in which medical encounters between patients and general practitioners (GPs) are mutually conducted, as exhibited in situ in 10 consultations sourced from the One in a Million: Primary Care Consultations Archive in England. Our main objectives are to identify interactional modes, to develop a classification of these modes, and to uncover how modes emerge and shift both within and between consultations. Deploying an interactional perspective and a thematic and narrative analysis of consultation transcripts, we identified five distinctive interactional modes: question and answer (Q&A) mode, lecture mode, probabilistic mode, competition mode, and narrative mode. Most modes are GP-led. Mode shifts within consultations generally map on to the chronology of the medical encounter. Patient-led narrative modes are initiated by patients themselves, which demonstrates agency. Our classification of modes derives from complete naturally occurring consultations, covering a wide range of symptoms, and may have general applicability.

Exploring how differently patients and clinical tutors see the same consultation: building evidence for inclusion of real patient feedback in medical education

BACKGROUND

Undergraduate medical education recognises that patient feedback is potentially valuable for student learning and development as a component of multi-source feedback. However greater exploration of how patient feedback perspectives differ to clinical educators is required for curriculum development and improving student feedback literacy. This study aimed to determine how two sources of feedback, patients and clinical tutors, compare on the same patient-centred, interpersonal criteria.

METHODS

A patient feedback instrument designed for the undergraduate medical education setting was used to compare patients' feedback with clinical tutors' feedback following a student-patient consultation in the learning context. Assessments from 222 learning consultations involving 40 medical students were collected. Descriptive statistics for tutors and patients for each question were calculated and correlations between patient and tutor were explored using Spearman's rank-order correlation. Mixed effects ordered logistic regression was used to compare each question with an overall rating for tutor and patients in addition to comparing patient with tutor ratings.

RESULTS

Clinical tutor and patient assessments had a weak but significant positive correlation in all areas except questions related to respect and concern. When making judgements compared with overall assessment, patients' ratings of respect, concern, communication and being understood in the consultation have a greater effect. After eliminating the effect of generally higher ratings by patients compared with tutors using comparative ordered logistic regression, patients rated students relatively less competent in areas of personal interaction.

CONCLUSION

This study provides insight about patient feedback, which is required to continue improving the use and acceptability of this multisource feedback to students as a valuable component of their social learning environment. We have revealed the different perspective-specific judgement that patients bring to feedback. This finding contributes to building respect for patient feedback through greater understanding of the elements of consultations for which patients can discriminate performance.

Instruments to Measure Perceptions in the Emergency Department Provider-Patient with Sickle Cell Disease Interaction: Findings of an Integrative Review from a Ph.D. Project

Background & Purpose:

The purpose of this review is to examine instruments that measure providers' perceptions of adult patients with Sickle Cell Disease (SCD), examine instruments that measure adult patients with SCD perceptions of providers' behaviors, and determine optimal instruments to use in evaluating the perceptions of Emergency Department (ED) providers and adult patients with SCD of one another's behaviors after an interaction in the ED.

Methods:

An integrative review was conducted searching EBSCOhost and PubMed databases using the keywords: measure [OR] measure* [OR] assess* [OR] scale [OR] survey [OR] tool [AND] stigma* [OR] stereotype [OR] prejudice [OR] bias [OR] perception [OR] attitude [OR] discrimination [OR] racism [OR] behavior [AND] interaction [OR] relationship [OR] communication [AND] sickle cell. Initial search located 256 articles, but only 15 articles were included in the final review.

Results:

Fifteen articles reporting six instruments were reviewed. Four instruments evaluated a provider’s perceptions of patients with SCD behaviors, and two instruments evaluated how patients with SCD perceived provider behaviors. The two patient-focused instruments and three provider-focused instruments were found to be adequately reliable and valid according to the Psychometric Grading Framework (PGF).

Conclusions:

The findings suggest that the General Perceptions About Sickle Cell Disease Patients Scale would be an optimal instrument to evaluate ED providers' perceptions of adult patients with SCD behaviors. One patient-focused instrument, The Sickle Cell Health-Related Stigma Scale (SCD-HRSS), reported adequate reliability and validity but was not specific to measuring the patient's perceptions of ED providers' behaviors, nor was it administered in the ED environment. The SCD-HRSS Doctors subscale has potential adaptability for use in measuring patients with SCD perceptions of ED provider behaviors in the ED environment.