Communication between surgeons and patients in routine office visits

The impact of compassion-based interventions on perioperative anxiety and depression: A systematic review and meta-analysis

BACKGROUND

The perioperative period can be a stressful time for many patients. Concerns for the procedure or fearing potential complications contribute to perioperative anxiety and depression, which significantly impact patient wellbeing and recovery. Understanding the psychological impact of the perioperative period can inform individualized care focused on each patient's unique stressors. Compassion-based interventions are limited but have shown benefits in non-surgical healthcare settings, and can provide support by prioritizing empathy and understanding in the perioperative period. This review evaluates the impact of compassion-based interventions on anxiety and depression among adult surgical patients.

METHODS

A systematic review of 25 randomized controlled trials was conducted with a meta-analysis of 14 studies for anxiety and 9 studies for depression that provided sufficient information.

RESULTS

The included studies tested compassion-based interventions that focused on enhanced communication, emotional support, and individualized attention from healthcare professionals. In 72 % of the studies, the interventions decreased anxiety and depression, compared to control groups. These interventions improved health-related outcomes such patient satisfaction and postoperative complications. The meta-analysis indicated a large effect of the compassion-based interventions for anxiety (g = -0.95) and depressive symptoms (g = -0.82). The findings were consistent among various surgeries and patient populations.

LIMITATIONS

Many of the included studies lacked clarity in their methods and only 14 studies provided sufficient information for the meta-analysis.

CONCLUSIONS

Given the growing evidence suggesting that compassion-based psychological interventions are feasible and applicable in the perioperative setting, their inclusion in routine care could reduce depression and anxiety around surgery and improve patient outcomes and experiences.

Thyroid Cancer-Related Fear & Anxiety in Patients With Benign Thyroid Nodules: A Mixed-Methods Study

INTRODUCTION

Thyroid cancer diagnosis often evokes strong negative emotions in patients, yet little is understood about such responses in those with benign thyroid nodules. This study explored the impact of a hypothetical cancer diagnosis, the provision of treatment information, and emotional support from surgeons on patients with benign nodules.

METHODS

Patients within 30 d of a thyroid nodule biopsy were asked to imagine their nodule was cancerous and write down their feelings about this diagnosis. They then viewed a video depicting a patient-surgeon discussion of thyroid cancer treatment options, with or without added emotional support (1:1 randomized allocation). Validated measures assessed anxiety and thyroid cancer-related fear before and after video-viewing. Thematic analysis evaluated participants' feelings about the hypothetical diagnosis.

RESULTS

Of 221 eligible patients, 118 participated (53.4%). While participants state anxiety increased after performing the thought exercise and watching the video (9 [6, 11]-12 [8, 14]; P < 0.001), thyroid cancer-related fear decreased over the same period (27 [22, 30]-25 [20, 29]; P < 0.001). Emotional support by the surgeon in the video did not affect anxiety or fear. Themes that emerged from participants imagining they have thyroid cancer included information seeking, trust in medicine, cancer experience, thyroid cancer knowledge, apprehension about surgery, and impact on family.

CONCLUSIONS

Patients with recently diagnosed benign thyroid nodules experience heightened anxiety when contemplating thyroid cancer. Provision of treatment and disease information mitigates cancer-related fear, while emotional support does not. Offering patients with thyroid nodules information about thyroid cancer before biopsy may offer emotional benefits.

Association of non-English language preference with postoperative hospital visits among California Medicaid enrollees

BACKGROUND

Patients with non-English language preference encounter language barriers across phases of surgical care. Patients with a non-English language preference represent 35% of California households and are disproportionately insured by Medicaid. To determine whether language predicts surgical outcomes, we investigated the association of patient non-English language preference with postoperative emergency department visits and readmissions among California Medicaid enrollees.

METHODS

Our retrospective analysis of adult Medicaid enrollees undergoing 1 of 10 common inpatient operations using California hospital administrative data (2016-2019) modeled the association between non-English language preference and 30-day postoperative emergency department visits and readmissions using mixed effects logistic regression with hospital random intercept, adjusting for patient, operation, hospital, and community characteristics. Secondary analyses stratified by operation urgency and by insurance type in an all-payor cohort.

RESULTS

Of 115,527 Medicaid enrollees, 17.2% had non-English language preference (n = 19,881), 66% were female (n = 73,653), and 40% were Hispanic/Latino (n = 45,541). Patients with non-English language preference experienced fewer postoperative emergency department visits (non-English language preference: 13.5%, English preference: 17.9%, P < .001) and readmissions (non-English language preference: 7.5%, English preference: 8.5%, P < .001), which persisted in adjusted models (adjusted odds ratio emergency department, 0.80, 95% confidence interval, 0.77-0.85; readmissions: adjusted odds ratio, 0.86, 95% confidence interval, 0.80-0.92). Non-English language preference was associated with fewer emergency department visits after elective (adjusted odds ratio, 0.80; 95% confidence interval, 0.73-0.88) and urgent/emergent surgery (adjusted odds ratio, 0.80; 95% confidence interval, 0.75-0.85) but not readmissions after elective surgery (adjusted odds ratio, 0.89; 95% confidence interval, 0.78-1.01). This pattern was only observed for Medicaid and not other insurance types.

CONCLUSION

Patients with non-English language preference who receive Medicaid have fewer postoperative emergency department visits and readmissions, even after urgent surgery. Our findings suggest that patterns of health care seeking after surgery vary by patient language, and investigating explanatory mechanisms is needed.

Exploring patient ideas, concerns, and expectations in surgeon-patient consultations

OBJECTIVES

This study explores patient perspectives (ideas, concerns, and expectations) in surgeon-patient consultations.

METHODS

We examined 54 video-recorded consultations using applied conversation analysis. Consultations took place from 2012 to 2017 in an Australian metropolitan hospital clinic centre and involved seven surgeons across six specialties.

RESULTS

Patient perspectives emerged in less than one third of consultations. We describe the initiation of and response to potential perspectives sequences, demonstrating how patients and surgeons co-construct these sequences when they do occur.

CONCLUSIONS

Findings suggest a need for greater attention to supporting patient agency through explicit pursuit of patient perspectives. The implications extend to the Calgary-Cambridge Guide, suggesting that it may benefit from a focus on active pursuit and appropriate responsiveness to patient perspectives.

PRACTICE IMPLICATIONS

This study highlights the need for surgeons to actively engage with the patient perspective offered in consultations, emphasising the importance of respect for the patient's knowledge and expectations to improve patient satisfaction and healthcare outcomes.

The ebbs and flows of empathy: a qualitative study of surgical trainees in the UK

BACKGROUND

Empathy is widely recognised as an important element of medical practice contributing to patient outcomes and satisfaction. It is also an important element of collaborative work in a healthcare team. However, there is evidence to suggest that empathy towards patients declines over time, particularly in surgical specialities. There is little qualitative research on this decline in surgical trainees, particularly in the UK. Therefore, the aim of this study was to explore how trainee surgeons experience empathy over the course of their career, both towards patients and colleagues and how they perceive it in others.

METHODS

10 semi-structured interviews were carried out with surgical trainees of different grades and specialties in January and February 2022. Framework analysis was used to interpret the data.

RESULTS

Participants experienced an evolution in empathy over their career as their personal and professional experience was added to. They drew a distinction between desensitisation and actual decline in empathy and identified more with experiencing the former in their careers. Participants also felt interprofessional relationships require empathy, and this could be improved upon. Finally, they highlighted specific impacts of the COVID-19 pandemic upon their training, including reduced theatre time.

CONCLUSIONS

Participants felt training could be improved in regard to accessing training opportunities and relationships with colleagues, although many felt empathy between colleagues is better than it has been in the past. This project highlighted areas for future research, such as with surgeons in later stages of their careers, or mixed-methods projects.

Levels of Surgical Patients' Education Related to Surgical Interventions Among Patients in Saudi Arabia

BACKGROUND

Patient education and counseling should simplify and clarify the condition, surgery, postoperative care, and potential complications. This study aimed to determine the levels of surgical patients' education regarding surgical interventions among patients in Saudi Arabia.

METHOD

This was an online survey study that was conducted between January and May 2023 to determine the levels of surgical patients' education regarding surgical interventions among patients in Saudi Arabia. The study population was patients who underwent surgeries (elective and emergency) living in Saudi Arabia. The questionnaire tool used in this study was developed based on an extensive literature review in the field of patients' education regarding surgical interventions. Binary logistic regression analysis was used to identify predictors of satisfaction with the callouts and the surgeon-consultant's communication quality.

RESULTS

A total of 1360 participants were involved in this study. Around 40.5% of the participants reported that they met the surgeon after diagnosing and recommending the issue. Almost 70.0% of research participants reported that the consultant surgeon personally explained a diagnosis or strategy to attain it and the surgical technique, method, and purpose before signing the informed consent. The majority of study participants reported that the consulting surgeon or a member of his surgical team explained the stages of reaching a diagnosis and the steps he/she will take to diagnose their condition (83.2%), discussed the diagnosis with them and how certain they are of the diagnosis (88.1%), described the surgery clearly and simply (85.5%), informed them of alternatives to surgical intervention (63.1%), and discussed the entire postoperative treatment plan (81.8%), informed them of possible postoperative complications (79.6%), used additional callout during the discussion (81.3%), and spoke to them after the surgery and before they left the hospital (69.2%). After a conversation with their doctors, 36.3% of study participants said they did not require an outside source to understand the diagnosis, operation, probable problems, treatment plan, and follow-up. Discussion "Just talk," sketching, and pictograms were the most popular callouts during patient education, with 78.3%, 22.3%, and 17.9%, respectively. Saudi participants were more likely to be satisfied with the quality of communication by the surgeon-consultant (p<0.05). At the same time, participants who live in the Southern area were less likely to be satisfied with the quality of communication by the surgeon-consultant (p<0.05).

CONCLUSION

This study highlights the crucial role of surgeons in preoperative patient education as well as the significance of surgical team participation in this process. In order to increase patient knowledge, facilitate treatment decisions, and assure informed consent, it is necessary to establish guidelines and roles to improve surgeon-patient communication, increase patient and surgeon awareness, nurture patient concern expression, and encourage non-medical patient participation.

Conflict resolution styles and skills and variation among medical students

BACKGROUND

Conflict is inevitable on healthcare teams, yet few professional school curricula teach or assess conflict resolution skills. Little is known about the variation in conflict resolution styles across medical students and how these styles might impact conflict resolution skills.

METHODS

This is a prospective, single blinded, group randomized quasi experimental trial to assess the impact of knowing one's own conflict resolution style on conflict resolution skills in a simulated encounter. Graduating medical students completed a mandatory conflict resolution session with standardized patients acting as nurses during a transition to residency course. Coaches reviewed videotapes of the simulation, focusing on students' skills with negotiation and emotional intelligence. Retrospectively, we assessed the impact of the students knowing their conflict resolution style prior to simulation, student gender, race, and intended field of practice on conflict resolution skills as judged by coaches.

RESULTS

One hundred and eight students completed the simulated conflict session. Sixty-seven students completed the TKI before the simulated patient (SP) encounter and 41 after. The most common conflict resolution style was accommodating (n = 40). Knowing one's conflict resolution style in advance of the simulation and one's identified race/ethnicity did not impact skill as assessed by faculty coaches. Students pursuing diagnosis-based specialties had higher negotiation (p = 0.04) and emotional quotient (p = 0.006) scores than those pursuing procedural specialties. Females had higher emotional quotient scores (p = 0.02).

CONCLUSIONS

Conflict resolution styles vary among medical students. Male gender and future practice in a procedural specialty impacted conflict resolution skills but knowing conflict resolution style did not.

Program Leaders' and Educators' Perspectives on the Factors Impacting the Implementation and Sustainment of Compassion Training Programs: A Qualitative Study

PHENOMENON

Training programs have been used to improve compassion in healthcare, but the factors necessary to make such programs successful and sustainable have not been identified. This thematic analysis aimed to bridge the gap between theory and practice by drawing on the experiences of international leaders and educators of compassion training programs to develop a clear understanding of what is relevant and effective and how compassion training is implemented and sustained.

APPROACH

International leaders and educators of compassion training programs (N = 15) were identified through convenience sampling based on academic and gray literature searches. Semi-structured face-to-face interviews with these participants were conducted between June 2020 and November 2020 in order to identify facilitators, barriers, and environmental conditions influencing the implementation and maintenance of compassion training programs. The interviews were recorded, transcribed verbatim, and analyzed using thematic analysis.

FINDINGS

Six categories affecting the operationalization of compassion training programs were identified 1) origins, foundational principles and purpose, 2) curricular content, 3) methods of teaching and learning, 4) trainer qualities, 5) challenges and facilitators, and 6) evaluation and impact.

INSIGHTS

Compassion training should be rooted in the construct of interest and incorporate patients' needs and their experience of compassion, with patient-reported compassion scores integrated before and after training. Compassion training should be delivered by highly qualified educators who have an understanding of the challenges associated with integrating compassion into clinical practice, a dedicated contemplative practice, and a compassionate presence in the classroom. Prior to implementing compassion training, leadership support should be secured to create an ethos of compassion throughout the organization.

Physician-patient communication in vascular surgery: Analysis of encounters in academic practice

Objective:

To assess physician–patient communication in vascular consults with the aim of identifying areas for improvement.

Introduction:

Shared decision-making in clinical consults can enhance patient outcomes. Its potential benefits are significant in vascular surgery, where decisions are dependent on the patient’s definition of quality of life and outcomes are influenced by significant lifestyle changes.

Methods:

In this qualitative cross-sectional study, encounters between five vascular surgeons and their patients with two asymptomatic vascular diseases were audio recorded, transcribed, and analyzed for validated sociolinguistic statistics. The nine-item shared decision-making questionnaire was used to gauge subjective patient perspective.

Results:

Physicians spent an average of 19 min and 28 s (±8:55) per consult and an average of 12 min and 7 s talking to the patient (±6:33). Physicians used formalized language about 10.3 times an encounter (±8.39), checked for understanding 6.4 times (±4.84), and asked more close-ended than open-ended questions (10.5 ± 6.15 versus 4.6 ± 2.37). Physicians accounted for 46.34% of utterances (±6%) and averaged 5.8 interruptions per encounter (±4). Patients and company accounted for 53.66% of total utterances (±6%) and averaged 10.1 clarification questions (±9.78). The average nine-item shared decision-making questionnaire Likert-type score per patient was 2.82 on a range of −3 to +3 (±0.33), with positive numbers indicating agreement. On average, patients strongly (+2) or completely (+3) agreed that physicians covered the nine criteria.

Conclusion:

The 9-item shared decision-making questionnaire data showed that patients mostly felt their physician was adequate in exhibiting shared decision-making behaviors. However, physicians asked closed-ended questions that elicited “yes/no” or brief responses, continuously interrupted patient narratives, and rarely checked for understanding from their patients. These subliminal behaviors restrict patient participation in shared decision-making and may be corrected via longitudinal intervention.

Optimizing the implementation of a multisite feasibility trial of a mind-body program in acute orthopedic trauma

The Toolkit for Optimal Recovery (TOR) is a mind-body program for patients with acute orthopedic injuries who are at risk for persistent pain/disability. In preparation for a multisite feasibility trial of TOR at three orthopedic trauma centers, we aim to qualitatively identify barriers and facilitators to study implementation and strategies to mitigate the implementation barriers and leverage facilitators.We conducted 18 live video focus groups among providers and three one-on-one interviews with department chiefs at Level 1 trauma centers in three geographically diverse sites (N = 79 participants). Using a content analysis approach, we detected the site-specific barriers and facilitators of implementation of TOR clinical trial. We organized the data according to 26 constructs of the Consolidated Framework for Implementation Research (CFIR), mapped to three Proctor implementation outcomes relevant to the desired study outcomes (acceptability, appropriateness, and feasibility). Across the three sites, we mapped six of the CFIR constructs to acceptability, eight to appropriateness, and three to feasibility. Prominent perceived barriers across all three sites were related to providers' lack of knowledge/comfort addressing psychosocial factors, and organizational cultures of prioritizing workflow efficiency over patients' psychosocial needs (acceptability), poor fit between TOR clinical trial and the fast-paced clinic structure as well as basic needs of some patients (appropriateness), and limited resources (feasibility). Suggestions to maximize the implementation of the TOR trial included provision of knowledge/tools to improve providers' confidence, streamlining study recruitment procedures, creating a learning collaborative, tailoring the study protocol based on local needs assessments, exercising flexibility in conducting research, dedicating research staff, and identifying/promoting champions and using novel incentive structures with regular check-ins, while keeping study procedures as nonobtrusive and language as de-stigmatizing as possible. These data could serve as a blueprint for implementation of clinical research and innovations in orthopedic and other medical settings.

My Life, My Story: Integrating a Life Story Narrative Component Into Medical Student Curricula

INTRODUCTION

Medical students experience burnout, depersonalization, and decreases in empathy throughout medical training. My Life, My Story (MLMS) is a narrative medicine project that aims to combat these adverse outcomes by teaching students to interview patients about their life story, with the goal of improving patient-centered care competencies, such as empathy.

METHODS

The MLMS project was started in the Veterans Affairs (VA) system and has since spread to dozens of VA sites. We adapted and integrated this project into the Warren Alpert Medical School of Brown University curriculum. As part of the required curriculum, first- and third-year medical students participated in a life story interview with a community-based volunteer or a patient in the inpatient hospital setting, transcribed the story, and reviewed the written story with the patient. We assessed student perceptions of the project, changes in empathy, and changes in burnout symptoms.

RESULTS

A total of 240 students participated in this project. Students spent an average of 70.7 minutes interviewing patients. A majority of the students believed MLMS was a good use of time (77%), fostered connection with patients (79%), and was effective in recognizing patients' thoughts and feelings (69%).

DISCUSSION

To our knowledge, this is one of the first life story interview interventions to be implemented into a required medical school curriculum and outside the VA setting. MLMS may assist students in improving clinical empathy skills and create a structure for medical trainees to better understand their patients.

Improving the Quality of Patient Care and Healthcare Staff Well-Being through an Empathy Immersion Educational Programme in New Zealand: Protocol of a Feasibility and Pilot Study

Empathy is positively related to healthcare workers and patients’ wellbeing. There is, however, limited research on the effects of empathy education delivered in acute clinical settings and its impact on healthcare consumers. This research tests the feasibility and the potential efficacy outcomes of an immersive education programme developed by the research team in collaboration with clinical partners and a multidisciplinary advisory group. Healthcare worker participants in the intervention ward will receive an 8-week immersive empathy education. The primary outcome (feasibility) will be assessed by evaluating the acceptability of the intervention and the estimated resources. The secondary outcome (efficacy) will be assessed using a quasi-experimental study design. Non-parametric tests will be used to test healthcare worker participants’ empathy, burnout, and organisational satisfaction (within-group and across groups), and healthcare consumer participants’ satisfaction (between-group) over time. Despite growing interest in the importance of empathy in professional relationships, to our knowledge, the present pilot study is the first to explore the feasibility and efficacy of an immersive empathy education in New Zealand. Our findings will provide critical evidence to support the development of a randomised cluster trial and potentially provide preliminary evidence for the effectiveness of this type of empathy education.

Parental Expression of Emotions and Surgeon Responses During Consultations for Obstructive Sleep-Disordered Breathing in Children

Importance

Little is known about emotional communication between parents and surgeons. Understanding the patterns and correlates of emotional communication may foster collaboration during surgical consultations.

Objective

To describe the emotional expressions by parents when bringing their child for evaluation of obstructive sleep-disordered breathing (SDB) as well as surgeon responses to these emotional expressions and to evaluate the association between parental demographic characteristics and surgeon response types.

Design, Setting, and Participants

This cross-sectional study analyzed the audio-recorded consultations between otolaryngologists and parents of children who underwent their initial otolaryngological examination for obstructive SDB at 1 of 3 outpatient clinical sites in Maryland from April 1, 2016, to May 31, 2017. Data analysis was performed from November 1 to December 31, 2019.

Main Outcomes and Measures

Emotional expressions by parents and surgeon responses were audio recorded, transcribed, and coded using the Verona Coding Definitions of Emotional Sequences.

Results

A total of 59 consultations, of which 40 (67.8%) contained at least 1 emotional expression, were included. Participants included 59 parents (53 women [89.8%]; mean [SD] age, 33.4 [6.4] years) and 7 surgeons (4 men [57.1%]; mean [SD] age, 42.8 [7.9] years). Parents made 123 distinct emotional expressions (mean [SD], 3.08 [2.29] expressions per visit), which were often expressed as subtle cues (n = 103 of 123 [83.7%]) vs explicit concerns (n = 20 [16.3%]). Most expressions (n = 98 [79.7%]) were related to medical issues experienced by the child (eg, symptoms and surgical risks). Most surgeon responses provided parents space for elaboration of emotional expressions (n = 86 [69.9%]) and were nonexplicit (n = 55 [44.7%]). Surgeons were less likely to explore the emotions of parents from racial and ethnic minority groups compared with White parents (OR, 0.47; 95% CI, 0.18-0.98).

Conclusions and Relevance

This cross-sectional study found that emotional communication occurs between surgeons and parents of pediatric patients with obstructive SDB. However, surgeon responses varied according to parental race and ethnicity, suggesting the existence of implicit biases in surgeon-patient communication and calling for further research to inform efforts to promote family-centered, culturally competent communication in surgery.

Education research - Understanding the factors involved in inpatient communication for orthopedic trainees

BACKGROUND

"Interpersonal and Communication Skills" (ICS) is a core competency set forth by the ACGME. No structured curriculum exists to train orthopedics residents in ICS.

METHODS

Twenty-four out of thirty-five orthopedics residents completed the survey (69%). The survey had the following domains: [1] Demographics, [2] Communication Needs/Goals, and [3] Communication Barriers.

RESULTS

Eighty-three percent of respondents wanted to improve their communication skills and their patient's experience. Interns-PGY4s wanted to improve on similar specific communication skills. All residents desired training in conflict management.

CONCLUSION

There is a need among orthopedics residents for a communication skills curriculum early in residency training, specifically in conflict management.

In Orthopaedic Speciality Care, Longer Explanations Are Not More Caring or More Satisfying

BACKGROUND

Research consistently documents no correlation between the duration of a musculoskeletal specialty care visit and patient experience (perceived empathy of the specialist and satisfaction with care). Based on a combination of clinical experience and other lines of research, we speculate that longer visits are often related to discordance between specialist and patient interpretation of symptoms and weighting of available test and treatment options. If this is true, then the specific duration of time discussing the specialist's interpretations and options with the patient (expertise transfer) might correlate with satisfaction with care and perceived empathy of the clinician even if the total visit time does not.

QUESTIONS/PURPOSES

(1) What demographic or mental health factors are associated with the duration of expertise transfer? (2) What factors, including the duration of expertise transfer, are associated with the patient's satisfaction with the visit and perceived clinician empathy?

METHODS

In a cross-sectional study, 128 new and returning English-speaking adult outpatients seeking care from one of three orthopaedic specialists in two urban practices between September and November 2019 were enrolled and agreed to audio recording of the visit. A total of 92% (118) of patients completed the questionnaire and had a usable recording. Participants completed a sociodemographic survey, the Patient-Reported Outcome Measure Information System Depression computer adaptive test (PROMIS Depression CAT; a measure of symptoms of depression), the Short Health Anxiety Index (SHAI-5; a measure of symptoms of hypochondriasis, a form of symptoms misinterpretation), the Pain Catastrophizing Scale (PCS-4; a measure of misinterpretation of symptoms), an ordinal measure of patient satisfaction (dichotomized into satisfied or not because of strong ceiling effects), and the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE; a measure of perceived clinician empathy). The duration of expertise transfer and the total duration of the visit were measured by two raters with acceptable reliability using software that facilitates segmentation of the visit audio recording. To determine factors associated with the duration of expertise transfer, satisfaction, and empathy, we planned a multivariable analysis controlling for potential confounding variables identified in exploratory bivariable analysis. However, there were insufficient associations to merit multivariable analysis.

RESULTS

A longer duration of expertise transfer had a modest correlation with catastrophic thinking (r = 0.24; p = 0.01). Complete satisfaction with the visit was associated with less health anxiety (6 [interquartile range 5 to 7] for complete satisfaction versus 7 [5 to 7] for less than complete satisfaction; p = 0.02) and catastrophic thinking (4 [1 to 7] versus 5 [3 to 11]; p = 0.02), but not with the duration of expertise transfer. Greater perceived clinician empathy had a slight correlation with less health anxiety (r = -0.19; p = 0.04).

CONCLUSION

Patients with greater misinterpretation of symptoms experience a slightly less satisfying visit and less empathetic relationship with a musculoskeletal specialist despite a longer duration of expertise transfer. This supports the concept that directive strategies (such as teaching healthy interpretation of symptoms) may be less effective then guiding strategies (such as nurturing openness to alternative, healthier interpretation of symptoms using motivational interviewing tactics, often over more than one visit or point of contact).

LEVEL OF EVIDENCE

Level II, therapeutic study.

Improving consultations for persistent musculoskeletal low back pain in orthopaedic spine settings: an intervention development

BACKGROUND

There is a need to improve consultations between patients with persistent musculoskeletal low back pain and orthopaedic spine clinicians when surgery is not indicated. Poor communication and lack of education about self- management in these consultations have been shown to be associated with increased distress and higher subsequent health care seeking.

AIM

To develop a standardised intervention to improve spine care consultations for patients for whom surgery is not beneficial.

METHOD

The intervention was developed in six stages. The first three stages included: interviews with patients, an interactive workshop with clinicians from a mix of disciplines, and interviews with spine clinicians about their perspective of the recommendations, their perceived difficulties and potential improvements. Information from these stages was synthesised by an expert panel, creating a draft intervention structure and content. The main features of the intervention and the materials developed were then reviewed by patients and spine clinicians. Finally, the research team incorporated the recommended amendments to produce the intervention.

RESULTS

In total, 36 patients and 79 clinicians contributed to the development of the intervention. The final intervention includes three components: a pre-consultation letter with information suggesting that surgery is one possible intervention amongst many, introducing the staff, and alerting patients to bring with them a potted history of interventions tried previously. The intervention includes short online training sessions to improve clinicians' communication skills, during the consultation, in reference to listening skills, validation of patients' pain, and use of appropriate language. Clinicians are also supplied with a list of evidence-based sources for advice and further information to share with patients. Finally, post consultation, a follow up letter includes a short summary of the patients' clinical journey, the results of their examination and tests, and a reminder of recommendations for self-management.

CONCLUSION

The intervention includes aspects around patient education and enhanced clinician skills. It was developed with input from a multitude of stakeholders and is based on patients' perceptions of what they would find reassuring and empowering when surgery is excluded. The intervention has the potential to improve the patients care journey and might lead to changes in practice in spine clinicians.

Effectiveness of a Question Prompt List Intervention for Older Patients Considering Major Surgery: A Multisite Randomized Clinical Trial

Importance

Poor preoperative communication can have serious consequences, including unwanted treatment and postoperative conflict.

Objective

To compare the effectiveness of a question prompt list (QPL) intervention vs usual care on patient engagement and well-being among older patients considering major surgery.

Design, Setting, and Participants

This randomized clinical trial used a stepped-wedge design to randomly assign patients to a QPL intervention (n = 223) or usual care (n = 223) based on the timing of their visit with 1 of 40 surgeons at 5 US study sites. Patients were 60 years or older with at least 1 comorbidity and an oncologic or vascular (cardiac, neurosurgical, or peripheral vascular) problem that could be treated with major surgery. Family members were also enrolled (n = 263). The study dates were June 2016 to November 2018. Data analysis was by intent-to-treat.

Interventions

A brochure of 11 questions to ask a surgeon developed by patient and family stakeholders plus an endorsement letter from the surgeon were sent to patients before their outpatient visit.

Main Outcomes and Measures

Primary patient engagement outcomes included the number and type of questions asked during the surgical visit and patient-reported Perceived Efficacy in Patient-Physician Interactions scale assessed after the surgical visit. Primary well-being outcomes included (1) the difference between patient's Measure Yourself Concerns and Well-being (MYCaW) scores reported after surgery and scores reported after the surgical visit and (2) treatment-associated regret at 6 to 8 weeks after surgery.

Results

Of 1319 patients eligible for participation, 223 were randomized to the QPL intervention and 223 to usual care. Among 446 patients, the mean (SD) age was 71.8 (7.1) years, and 249 (55.8%) were male. On intent-to-treat analysis, there was no significant difference between the QPL intervention and usual care for all patient-reported primary outcomes. The difference in MYCaW scores for family members was greater in usual care (effect estimate, 1.51; 95% CI, 0.28-2.74; P = .008). When the QPL intervention group was restricted to patients with clear evidence they reviewed the QPL, a nonsignificant increase in the effect size was observed for questions about options (odds ratio, 1.88; 95% CI, 0.81-4.35; P = .16), expectations (odds ratio, 1.59; 95% CI, 0.67-3.80; P = .29), and risks (odds ratio, 2.41; 95% CI, 1.04-5.59; P = .04) (nominal α = .01).

Conclusions and Relevance

The results of this study were null related to primary patient engagement and well-being outcomes. Changing patient-physician communication may be difficult without addressing clinician communication directly.

Trial Registration

ClinicalTrials.gov identifier: NCT02623335.

It's not you, it's me: A descriptive study of patient complaints and surgeon understanding

BACKGROUND

Patient complaints are an underutilized and under-addressed issue in general surgery. They represent a unique sphere of interaction for surgeons and patients to understand motivations and failures in the delivery of healthcare. The aims of this study were to identify motivators of patient complaints and understand surgeon's awareness of this issue.

METHODS

A retrospective review of patient complaint data in a single regional general surgical department was undertaken between the periods October 2017 to June 2020 and June 2018 to October 2020 relating to patient demographics and subject of complaint. Secondly, an anonymous survey was conducted across the same department and results tabulated by seniority.

RESULTS

Two hundred and nineteen complaints were received during the study period. One hundred and thirteen were made by patients, while 56 were made by family members. One hundred and fifty-nine complaints were related to an inpatient episode of care, and 152 were made in writing. The majority of complainants were female, with a mean age of 52. The most common reason for complaint was "treatment" (n = 102), followed by communication (n = 48), and humaneness/caring (n = 44). Consultant surgeons and surgical trainees placed communication, humaneness/caring, and professionalism as most likely to incite complaints, while interns were more likely to prioritize other measures such as patient healthcare rights and medications.

CONCLUSION

Patient complaints remain a relatively under-utilized resource in addressing the downfalls of general surgical departments. This study reports patient demographics that are congruent with the literature and highlights that surgeons prioritize many non-technical skills in the maintenance of the doctor-patient relationship, in contrast to preconceptions.

Informed Consent and Informed Decision-Making in High-Risk Surgery: A Quantitative Analysis

BACKGROUND

Informed consent is an ethical and legal requirement that differs from informed decision-making-a collaborative process that fosters participation and provides information to help patients reach treatment decisions. The objective of this study was to measure informed consent and informed decision-making before major surgery.

STUDY DESIGN

We audio-recorded 90 preoperative patient-surgeon conversations before major cardiothoracic, vascular, oncologic, and neurosurgical procedures at 3 centers in the US and Canada. Transcripts were scored for 11 elements of informed consent based on the American College of Surgeons' definition and 9 elements of informed decision-making using Braddock's validated scale. Uni- and bivariate analyses tested associations between decision outcomes as well as patient, consultation, and surgeon characteristics.

RESULTS

Overall, surgeons discussed more elements of informed consent than informed decision-making. They most frequently described the nature of the illness, the operation, and potential complications, but were less likely to assess patient understanding. When a final treatment decision was deferred, surgeons were more likely to discuss elements of informed decision-making focusing on uncertainty (50% vs 15%, p = 0.006) and treatment alternatives (63% vs 27%, p = 0.02). Conversely, when surgery was scheduled, surgeons completed more elements of informed consent. These results were not associated with the presence of family, history of previous surgery, location, or surgeon specialty.

CONCLUSIONS

Surgeons routinely discuss components of informed consent with patients before high-risk surgery. However, surgeons often fail to review elements unique to informed decision-making, such as the patients' role in the decision, their daily life, uncertainty, understanding, or patient preference.

'Reassurance and healthcare seeking in people with persistent musculoskeletal low back pain consulting orthopaedic spine practitioners: A prospective cohort study'

BACKGROUND

Guidelines recommend self-management for most people living with persistent musculoskeletal low back pain (PMLBP) when surgery is ruled out. Conveying this message to patients can be challenging. This study examined patients' perceptions of reassuring communications from surgical spine team practitioners attempting to deliver this message in a single consultation.

METHODS

Pre-consultation baseline measures included levels of pain, disability and previous consultation history. Patients' perceptions of reassuring communications were measured within 1-week post-consultation. The outcome variables, measured at 3-month follow-up, included patients' report of subsequent GP visits for back pain, the number of other healthcare providers consulted for back pain and distress.

RESULTS

Data from 296 patients (9.8% loss to follow-up) were analysed using hierarchical regression models, controlling for demographic, clinical and study-related factors. In each model, perceived reassurance accounted for a small but significant variance, above and beyond other predictors. Further GP visits were predicted by disability at baseline and perceived reassurance (adjusted R² of 14.6%). Subsequent consultations with any healthcare professionals were predicted by a shorter duration of back pain, disability at baseline and perceived reassurance (adj. R²  = 10.6%). Distress was predicted by older age, disability and reassurance (adj. R²  = 59.5%).

CONCLUSION

Findings suggest that better communication in consultations with orthopaedic spine clinicians might help reduce unnecessary subsequent healthcare utilization and distress.

SIGNIFICANCE

Low back pain patients' perceptions of their communication with orthopaedic spine practitioners are associated with subsequent healthcare seeking and distress at follow-up. This study examines the intersection of two important but fairly neglected areas in the pain research: provider communication and patient healthcare utilization.

A qualitative dominant mixed methods exploration of novel educational material for patients considering total knee arthroplasty

PURPOSE

To optimize non-operative management and decision making surrounding TKR we created educational whiteboard videos for patients with knee OA. The purpose of this study was to pilot our educational videos with end-users (patients) to determine patients' experiences and perspectives regarding the content and clarity of videos and to better understand their potential impact on patient's health behaviour. Materials and methods: This was a mixed methods evaluation, using a qualitative descriptive approach, of patients attending their first consultation with an arthroplasty surgeon for TKR. We conducted in-depth semi-structured interviews with patients. Three members of the research team coded data independently, implementing a thematic analysis. Results: Thirteen participants were included. Participants indicated that the videos enhanced their confidence and clarity surrounding their decision to undergo TKR. The videos also addressed several knowledge gaps in their understanding of OA management. Barriers to uptake of the education were identified including limited access to PTs and the challenge of weight loss. Conclusions: The current educational intervention was valued by patients with knee OA. Implementation of these videos may have important implications for patients, providers, and our health care system.IMPLICATIONS FOR REHABILITATIONPatients with knee OA referred by primary care physicians to arthroplasty surgeons have knowledge gaps that may influence their self-management and decision making surrounding their condition.Educational materials can address these gaps and support patients in their understanding and management of their condition, which may have important downstream implications.Barriers to accessing non-operative care including physiotherapy must be pre-emptively addressed to ensure that enhanced knowledge is met with improved access for patients.

Communication With Patients Before an Operation: Their Preferences on Method of Communication

Background With the constantly evolving communication technologies, it is essential for all healthcare professionals to try utilising various methods in communicating with patients. This will lead to better healthcare outcomes and patient satisfaction. Objective The aim of the study was to compare a patient's preference to various communication methods regarding their appointments and to evaluate if we're giving our patients an appropriate notice period prior to their operation. Methods A questionnaire was given to 111 patients who underwent elective orthopaedic procedures. Results Factors like age and gender affect the choice of communication method. Traditional letters still have a role for an older population aged 65 and over. However, younger patients showed higher preference for other communication methods such as phone calls, texts, and e-mails. Gender also had a role in choosing a preference where male patients chose a range of options whilst female patients preferred phone calls. Most patients stated they received an appropriate notice period, with 88% of patients stating they would like to be notified one-two weeks prior to their operation. Conclusion More research needs to be conducted into using text messages and e-mails in communicating with elective surgical patients, in addition to implementing newer technologies like mobile phone applications and secure online messaging portals, as this has the potential to reshape the communication process with our patients and lead to better health outcomes and patient satisfaction.

Revitalizing the Patient-Surgeon Relationship: Surgical Curriculum Including the Patient Perspective

OBJECTIVE

General Surgery residents have increasing obligations that limit time with patients. This affects the patient-physician relationship, decreases meaning in work and increases burnout. Patient-Centric Resident Conferences (PCRC)¹ incorporate patients in resident didactics to promote meaning in work and improve resident confidence in counseling and consenting patients for surgery.

DESIGN

Prospective cohort study of General Surgery residents who participated in standard didactic conferences (control) and modified conferences (PCRC) between 2017 and 2019. Control conferences covered a relevant surgical topic. PCRC had shortened didactics and discussions with patients who had undergone the relevant index operation. Pre- and postconference surveys measured teaching effectiveness, confidence in counseling and consenting, and resident perception of how well the conference supported their decision to pursue surgery. Survey data was compared using chi-squared tests. Qualitative data analysis used ground theory methodology.

SETTING

This study was performed by the Department of Surgery at Oregon Health and Science University in Portland, Oregon.

PARTICIPANTS

All active General Surgery residents were asked to participate in conferences.

RESULTS

Eighty-one residents completed 136 surveys over 5 control conferences and 207 surveys over 7 PCRC. Residents reported increased confidence in counseling and consenting for surgery following control conferences (p < 0.0001) and PCRC (p < 0.0001). Residents' perception of effectiveness of teaching pathophysiology (p = 0.008) and operative steps (p = 0.013) was greater in control conferences whereas effectiveness of teaching surgical complications was greater in PCRC (p = 0.006). Resident responses indicated greater support for a surgical career following PCRC compared to control conferences (p = 0.013). Themes like "patient perspective," "impact on surgeon," and "psychological effects of surgery" were common in PCRC and rare in control conferences.

CONCLUSIONS

PCRC were associated with stronger motivations for a surgical career and included patient-centered themes, which can enhance meaning in work. These conferences complement but do not replace standard didactics.

The Art of Surgery: Balancing Compassionate With Virtual Care

The recent drive to include virtual care in surgical practice has been accelerated due to the COVID-19 pandemic. Many physicians feel that communicating via telehealth is unlike traditional methods of providing health care, and thus guidance on maintaining excellence in communication is necessary, especially as academic literature on virtual care in surgery is nonexistent. Challenges faced in transitioning to virtual care include the inability to utilize body language, barriers to traditional physical examination, exacerbation of existing vulnerabilities and inequities in patient groups, the declining quality of medical education, and the fragmentation of the multidisciplinary health care team. This paper seeks to resolve these challenges by focusing on the pillars of good communication, including preparation, professionalism, empathy, respect, and the virtual physical examination.

A Qualitative Analysis of the Preoperative Needs of Patients With Papillary Thyroid Cancer

BACKGROUND

Thyroid cancer patients report unmet needs after diagnosis. However, little is known about their specific needs. Therefore, we sought to characterize the needs of patients with thyroid cancer before undergoing surgery.

MATERIAL AND METHODS

We conducted semistructured interviews with 32 patients with papillary thyroid cancer after their preoperative surgical consultation. Data were analyzed using thematic content analysis.

RESULTS

The central need of patients with thyroid cancer was a strong patient-surgeon relationship characterized by informational and emotional support, and respect for the patient as a person. Patients preferred disease- and treatment-related information to be individualized and to take into account aspects of their daily life. They wanted adequate time for asking questions with thoughtful answers tailored to their case. Patients additionally desired emotional support from the surgeon characterized by empathy and validation of their cancer experience. They particularly wanted surgeons to address their fears and anxiety. Patients also highly valued the surgeons' ability to see beyond their disease and acknowledge them as a unique person with respect to their occupation, psychosocial state, and other individual characteristics. When surgeons met patients' needs, they felt reassured, comfortable with their cancer diagnosis, and prepared for treatment. Suboptimal support increased patients' anxiety particularly when they felt the surgeon minimized their concerns.

CONCLUSIONS

Preoperatively, patients with thyroid cancer desire a strong patient-surgeon relationship. They rely on the surgeon to provide adequate informational and emotional support and respect them as individuals. In turn, patients feel reassured and prepared for treatment.

Health Services Management in Turkey: Failure or Success?

Background:

The unfair distribution and delivery of health-care resources have been recognized as a problem in the worldwide. In the past 18 years, Turkey has undergone rapid social, cultural, and economic changes. The lifestyle and dietary habits of its people have also been changing, and the rates of diabetes, obesity, cancer, and other chronic diseases have increased dramatically over the past two decades. The health transformation program (HTP) has improved the Turkish health-care system since 2003. The main goal of HTP was to progress government, to provide equality between citizens, to give satisfaction to users and providers, and to subsidise the health-care system in Turkey.

Aim:

The aim of this study is to assess health-care services and health care quality delivery in the Republic of Turkey with special emphasis on governmental hospitals, university hospitals, primary healthcare centers (PHC) and to make comparison with low-, medium- and high-income countries.

Methods:

This is a retrospective, descriptive study. The ministry of health Annual Reports, websites of the Central Intelligence Agency (CIA), The World Fact Book, organization for economic cooperation and development report, Compendium of Health Statistics, the Google engine, and PubMed were searched for information about Turkey's health-care system and its history. Papers and websites in English were evaluated. There was no restriction on types of articles and sources.

Results:

Turkey has made outstanding reforms in health status in the last two decades, especially after the implementation of the HTP. The doctor's perception has more influence regarding consultation length and visit than the patient’s. The results of consultations in volunteer practices in Istanbul showed that the mean and SD of the consultation length for the whole sample of 360 patients was 7.95 ± 4.38, (with range = 3–25 min). Consultation time has been affected by the patients’ diseases, genders that women got longer consultation time, medical practices at the urban or rural areas, and ages which older patients required longer consultation time. The current study revealed that increasing doctor's workload leads to decrease the length of consultations. Moreover, average life expectancy reached 75.3 for men and 80.7 for women in 2015. The infant mortality rate decreased to 10.7/1000 live births in 2015, down from 117.5 in 1980. The leading causes of death are diseases of the circulatory system followed by cancer.

Conclusions:

The Turkish health system and health-care delivery have been improved over the last decade. Still far from perfect, there is a particular planning to increase medical workforce in PHC including well-trained staffs for a specific area. An urgent need is to acquire more accurate and reliable data from hospital and PHC centers in Turkey. Additional some attempts should be made to assess quality of healthcare in relation to services and process.

Stereotypes about surgeon warmth and competence: The role of surgeon gender

Past research indicates that patient perceptions of surgeon warmth and competence influence treatment expectancies and satisfaction with treatment outcomes. Stereotypes have a powerful impact on impression formation. The present research explores stereotypes about surgeon warmth and competence and investigates the extent to which surgeon gender influences perceptions of female and male surgeons. A between-subjects experiment was conducted online using crowdsourcing technology to derive a representative sample from the general population. Four hundred and fifteen participants were randomly assigned to evaluate the warmth and competence of males, females, surgeons, male surgeons, or female surgeons, using validated measures. Planned contrasts revealed that as a group, surgeons received higher warmth and competence ratings than non-surgeons (p = .007). Consistent with gender stereotypes, female surgeons received higher warmth ratings (p < .001) and lower competence ratings (p = .001) than male surgeons. The stereotype of surgeons held by the general public is that they are high in warmth and competence relative to other occupational groups. Surgeon gender appears to influence general beliefs about the warmth and competence of female and male surgeons.

Consumer satisfaction with antipsychotic medication-monitoring appointments: the role of consumer-prescriber communication patterns

OBJECTIVE

The study was designed to explore patterns of prescriber communication behaviors as they relate to consumer satisfaction among a serious mental illness sample.

METHODS

Recordings from 175 antipsychotic medication-monitoring appointments between veterans with psychiatric disorders and their prescribers were coded using the Roter Interaction Analysis System (RIAS) for communication behavioral patterns.

RESULTS

The frequency of prescriber communication behaviors (i.e., facilitation, rapport, procedural, psychosocial, biomedical, and total utterances) did not reliably predict consumer satisfaction. The ratio of prescriber to consumer utterances did predict consumer satisfaction.

CONCLUSIONS

Consistent with client-centered care theory, antipsychotic medication consumers were more satisfied with their encounters when their prescriber did not dominate the conversation.

PRACTICE IMPLICATIONS

Therefore, one potential recommendation from these findings could be for medication prescribers to spend more of their time listening to, rather than speaking with, their SMI consumers.

Do doctors' attachment styles and emotional intelligence influence patients' emotional expressions in primary care consultations? An exploratory study using multilevel analysis

OBJECTIVE

To investigate whether and how doctors' attachment styles and emotional intelligence (EI) might influence patients' emotional expressions in general practice consultations.

METHODS

Video recordings of 26 junior doctors consulting with 173 patients were coded using the Verona Coding Definition of Emotional Sequences (VR-CoDES). Doctors' attachment style was scored across two dimensions, avoidance and anxiety, using the Experiences in Close Relationships: Short Form questionnaire. EI was assessed with the Mayer-Salovey-Caruso Emotional Intelligence Test. Multilevel Poisson regressions modelled the probability of patients' expressing emotional distress, considering doctors' attachment styles and EI and demographic and contextual factors.

RESULTS

Both attachment styles and EI were significantly associated with frequency of patients' cues, with patient- and doctor-level explanatory variables accounting for 42% of the variance in patients' cues. The relative contribution of attachment styles and EI varied depending on whether patients' presenting complaints were physical or psychosocial in nature.

CONCLUSION

Doctors' attachment styles and levels of EI are associated with patients' emotional expressions in primary care consultations. Further research is needed to investigate how these two variables interact and influence provider responses and patient outcomes.

PRACTICE IMPLICATIONS

Understanding how doctors' psychological characteristics influence PPC may help to optimise undergraduate and postgraduate medical education.

Total Knee Replacement and the Effect of Technology on Cocreation for Improved Outcomes and Delivery: Qualitative Multi-Stakeholder Study

BACKGROUND

The growth in patient-centered care delivery combined with the rising costs of health care have perhaps not unsurprisingly been matched by a proliferation of patient-centered technology. This paper takes a multistakeholder approach to explore how digital technology can support the cocreation of value between patients and their care teams in the delivery of total knee replacement (TKR) surgery, an increasingly common procedure to return mobility and relieve pain for people suffering from osteoarthritis.

OBJECTIVE

The aim of this study was to investigate communications and interactions between patients and care teams in the delivery of TKR to identify opportunities for digital technology to add value to TKR health care service by enhancing the cocreation of value.

METHODS

A multistakeholder qualitative study of user needs was conducted with Australian stakeholders (N=34): surgeons (n=12), physiotherapists (n=3), patients (n=11), and general practitioners (n=8). Data from focus groups and interviews were recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Encounters between patients and their care teams are information-rich but time-poor. Results showed seven different stages of the TKR journey that starts with referral to a surgeon and ends with a postoperative review at 12 months. Each stage of the journey has different information and communication challenges that can be enhanced by digital technology. Opportunities for digital technology include improved waiting list management, supporting and reinforcing patient retention and recall of information, motivating and supporting rehabilitation, improving patient preparation for hospital stay, and reducing risks and anxiety associated with postoperative wound care.

CONCLUSIONS

Digital technology can add value to patients' care team communications by enhancing information flow, assisting patient recall and retention of information, improving accessibility and portability of information, tailoring information to individual needs, and by providing patients with tools to engage in their own health care management. For care teams, digital technology can add value through early detection of postoperative complications, proactive surveillance of health data for postoperative patients and patients on waiting lists, higher compliance with rehabilitation programs, and reduced length of stay. Digital technology has the potential to improve patient satisfaction and outcomes, as well as potentially reduce hospital length of stay and the burden of disease associated with postoperative morbidity.

A Review of Empathy, Its Importance, and Its Teaching in Surgical Training

BACKGROUND

There has been much discussion in the medical literature about the importance of empathy and physician communication style in medical practice. Empathy has been shown to have a very real positive effect on patient outcomes. Most of the existing literature speaks to its role in medical education, with relatively little empiric study about empathy in the surgical setting.

OBJECTIVE

Review of empathy and its importance as it pertains to the surgeon-patient relationship and improving patient outcomes, and the need for increased education in empathy during surgical training.

METHODS

The published, peer-reviewed literature on patient-physician and patient-surgeon communication, medical student and resident education in empathy, and empathy research was reviewed. PubMed was queried for MESH terms including "empathy," "training," "education," "surgery," "resident," and "communication."

RESULTS

There is evidence of a decline in empathy that begins during the clinical years of medical school, which continues throughout residency training. Surgeons are particularly susceptible to this decline as by-product of the nature of their work, and the current lack of formalised training in empathic patient communication poses a unique problem to surgical residents.

CONCLUSIONS

The literature suggests that empathy training is warranted and should be incorporated into surgical residencies through didactics, role-playing and simulations, and apprenticeship to empathic attending role models.

Compassionomics: Hypothesis and experimental approach

Recent reports indicate that healthcare is experiencing a compassion crisis - an absence of (or inconsistency in) compassionate patient care. It is currently unclear if, or to what extent, this exerts significant effects on health and healthcare. Experimental data are few, and this represents a critical knowledge gap for all health sciences. We hypothesize that compassionate care is beneficial for patients (better outcomes), healthcare systems and payers (lower costs), and healthcare providers (lower burnout). Compassionomics is the branch of knowledge and scientific study of the effects of compassionate healthcare, and herein we describe a framework for hypothesis testing. If the hypotheses are confirmed, compassionate healthcare can be established in the domain of evidence-based medicine.

Outpatient clinic waiting time, provider communication styles and satisfaction with healthcare in India

Purpose - The purpose of this paper is to evaluate the impact of extended waiting time on patients' perceptions of provider communication skills and in-clinic satisfaction, in three major cities in India. Design/methodology/approach - In total, 625 patients were interviewed. The multivariate general linear model was used to determine the causality and relationship between the independent and the dependent variable. A moderation analysis was also conducted to assess waiting time role as a potential moderator in doctor-patient communication. Findings - Results show that patients with higher waiting time were less satisfied with health care quality. Male patients and patients of male providers were more affected by extended waiting time than female patients and patients of female providers. The advanced regression analysis, however, suggests weak support for waiting time and its effect on overall satisfaction with clinic quality. Waiting time did not moderate the relationship between satisfaction with dominant communication style, and overall satisfaction at the outpatient clinic. Research limitations/implications - A cross-sectional study does not easily lend itself to explaining causality with certainty. Thus, sophisticated techniques, such as structural equation modelling may also be utilized to assess the influence of extended waiting time on satisfaction with healthcare at outpatient clinics. Practical implications - Findings are relevant for providers as the onus is on them to ensure patient satisfaction. They should initiate a workable waiting time assessment model at the operational level. Originality/value - There has been a relatively lesser focus on patient waiting time in patient-provider satisfaction studies. In India, this aspect is still vastly unexplored especially in the context of outpatient clinics. Gender wise pattern of patient satisfaction and waiting time is also missing in most studies.

Racial Disparities in Lower Extremity Arthroplasty Outcomes and Use

Race-associated disparities often occur in patients who undergo lower extremity total joint arthroplasty (TJA). Although it is imperative to elucidate and describe the disparities in race and ethnicity that may influence patient perception, satisfaction, and surgical outcomes, there is a paucity of reports detailing the nature of potential racial disparities in TJA. Therefore, the purpose of this review was to examine racial and ethnic disparities in the (1) physician-patient relationship; (2) use of TJA; (3) intraoperative and 30-day postoperative complications; and (4) patient-reported outcomes. Although there are limited studies that evaluated this topic, it has been shown that there are race-specific differences in physician-patient relationships. Specifically, African American patients report lower satisfaction rates in communication with their physician than their Caucasian counterparts and physicians were more apt to describe African Americans as less "medically cooperative." The majority of the studies the authors found regarding TJA use indicated that African Americans and Hispanics were less likely to undergo lower extremity TJA than Caucasians. Furthermore, racial minorities may have higher 30-day readmission and intra- and postoperative complication rates compared with Caucasians. Despite these compelling findings, concrete conclusions are difficult to make due to the presence of multiple confounding patient factors, and more studies examining the racial and ethnic disparities in patients with TJA are needed.

Exploring information provision in reconstructive breast surgery: A qualitative study

OBJECTIVE

Women considering reconstructive breast surgery (RBS) require adequate information to make informed treatment decisions. This study explored patients' and health professionals' (HPs) perceptions of the adequacy of information provided for decision-making in RBS.

METHODS

Semi-structured interviews with a purposive sample of patients who had undergone RBS and HPs providing specialist care explored participants' experiences of information provision prior to RBS.

RESULTS

Professionals reported providing standardised verbal, written and photographic information about the process and outcomes of surgery. Women, by contrast, reported varying levels of information provision. Some felt fully-informed but others perceived they had received insufficient information about available treatment options or possible outcomes of surgery to make an informed decision.

CONCLUSIONS

Women need adequate information to make informed decisions about RBS and current practice may not meet women's needs. Minimum agreed standards of information provision, especially about alternative types of reconstruction, are recommended to improve decision-making in RBS.

Does a Directive to an Internet Site Enhance the Doctor-Patient Interaction? A Prospective Randomized Study for Patients with Carpal Tunnel Syndrome

BACKGROUND

Sixty-two percent of patients would like their doctor to recommend a specific web site to find health information, but only 3% of patients receive such recommendations. We investigated whether providing patients with an Internet web-site link recommended by their physician would improve patient knowledge and satisfaction. Our hypothesis was that directing patients to a reliable web site would improve both.

METHODS

Sixty patients with a new diagnosis of carpal tunnel syndrome were prospectively randomized into two groups. Twenty-three patients in the control group had a traditional physician office visit and received standard care for carpal tunnel syndrome. Thirty-seven patients in the treatment group received a handout that directed them to the American Society for Surgery of the Hand (ASSH) web page on carpal tunnel syndrome in addition to the standard care provided in the office visit. Patients later completed a ten-question true-or-false knowledge questionnaire and a six-item satisfaction survey. Differences in scores were analyzed using two-sample t tests.

RESULTS

Less than half (48%) of the patients who were given the Internet directive reported that they had visited the recommended web site. The mean scores on the knowledge assessment (6.84 of 10 for the treatment group and 6.96 of 10 for the control group) and the satisfaction survey (4.49 of 5 for the treatment group and 4.43 of 5 for the control group) were similar for both groups. The mean score for knowledge was similar for the patients who had used the ASSH web site and for those who had not (6.89 and 6.97 respectively). Moreover, compared with patients who had not used the Internet at all to learn about carpal tunnel syndrome, patients who used the Internet scored 6.6% better (mean score, 7.14 for those who used the Internet compared with 6.70 for those who had not; p > 0.05). Regardless of Internet usage, most patients scored well on the knowledge assessment and reported a high level of satisfaction.

CONCLUSIONS

Whether the patient was given a handout or had visited the ASSH or other Internet web sites, the knowledge and satisfaction scores for all patients were similar. Since the physician was the common denominator in both groups, the results indicate that the patient-physician relationship may be more valuable than the Internet in providing patient education.

CLINICAL RELEVANCE

Effective communication between patients and practitioners is at the cornerstone of delivering excellent care and building trusting relationships. This study examines whether reliable Internet information should be embraced as a tool to enhance patient-surgeon communication in a clinical context.

Communication between health professionals and patients: review of studies using the RIAS (Roter Interaction Analysis System) method

OBJECTIVE

Systematic review of studies that investigate the communication between patients and health professionals with the application of the RIAS methodology.

METHODS

Keyword Roter Interaction Analysis System was searched in the following bibliographic resources: Academic Search Complete, Current Contents, ISI Proceedings, PubMed, Elsevier, SpringerLink, Web of Science, RCAAP, Solo and the official RIAS site. Selection period: 2006 to 2011. Studies were selected using multicriteria dichotomous analysis and organized according to PRISMA.

RESULTS

Identification of 1,262 articles (455 unrepeated). 34 articles were selected for analysis, distributed by the following health professions: family medicine and general practitioners (14), pediatricians (5), nurses (4), geneticists (3), carers of patients with AIDS (2), oncologists (2), surgeons (2), anesthetists (1) and family planning specialists (1). The RIAS is scarcely used and publicized within the scope of healthcare in Portuguese speaking countries.

DISCUSSION

Main themes studied include the influence of tiredness, anxiety and professional burnout on communication and the impact of specific training actions on professional activities. The review enabled the identification of the main strengths and weaknesses of synchronous and dyadic verbal communication within the provision of healthcare.

CONCLUSION

Scientific investigation of the communication between health professionals and patients using RIAS has produced concrete results. An improvement is expected in health outcomes through the application of the RIAS.

Complications after surgery for colorectal cancer affect quality of life and surgeon-patient relationship

AIM

This multicentric prospective study aimed to investigate how postoperative complications after surgery for colorectal cancer affect patients' quality of life and satisfaction with care.

METHOD

One hundred and sixteen patients operated on for colorectal cancer were enrolled in this study. Patients answered three questionnaires about generic (EORTC QLQ-C30) and disease-specific (EORTC QLQ-CR29) quality of life and treatment satisfaction (EORTC IN-PATSAT32) at the time of admission and at 1 and 6 months after surgery. Non-parametric tests and linear multiple regression models were used for statistical analysis.

RESULTS

Twelve patients had complications requiring further surgery (anastomotic leakage, abdominal bleeding, abdominal wall sepsis, wound infection). Patients with complications that required surgery reported a worse score of physical function, emotional function and anxiety than patients without such complications 1 month after surgery. These patients judged their general satisfaction with the quality of care and doctors' interpersonal skills, technical skills, information provision and availability to be worse than in patients without such complications. The presence of postoperative psychiatric complications and anastomotic leakage were independent predictors of quality of life (β = -0.30, P = 0.004, and β = -0.42, P < 0.001).

CONCLUSION

In patients undergoing surgery for colorectal cancer, complications requiring any kind of surgical management significantly affected patients' perception of all doctor-related items suggesting an impairment of the entire surgeon-patient relationship. Convincing patients that 'zero risk' cannot be achieved in surgical practice is therefore a priority.

Patients' anxiety and hope: predictors and adherence intentions in an acute care context

CONTEXT

Good patient-provider interactions promote satisfaction with health care, adherence to treatment recommendations and improved health. However, little research has examined patients' emotions and how they relate to patients' experiences with health care and their adherence intentions in acute care settings.

OBJECTIVE

This study examined the predictors and consequences of two emotions pertinent to the uncertainty of acute health-care experiences: anxiety and hopefulness.

DESIGN

Patients who arrived at a general surgery clinic for an initial consultation were interviewed before and after the consultation. Prior to the consultation with a physician, patients completed baseline measures of their emotional state. Following the consultation, patients completed measures of understanding of the information provided by the surgeon, perceived control over treatment decisions, adherence intentions and emotional state.

RESULTS

Understanding and control predicted less anxiety and greater hopefulness, compared to baseline. Only hopefulness predicted adherence intentions. These relationships remained even after controlling for characteristics of the patients and interactions.

DISCUSSION

These findings identify aspects of psychosocial care that are critical for promoting positive (and mitigating negative) emotional states in patients. Even in a brief consultation in a clinic setting, physicians may be able to improve patients' emotional state by promoting a sense of control and clarifying information they convey, and patients' positive emotional states may be critical for raising adherence intentions.

Patient-centered care in medicine and surgery: guidelines for achieving patient-centered subspecialty care

Patient-centered care is based on the principle that equality between physician and patient is mutually advantageous. This model of care recently has largely supplanted the historical paternalistic model of the physician-patient relationship. Patient-centered care differs from the disease-centered model of evidence-based medicine, but the two are not mutually exclusive. Patient-centered care has 5 core components: the biopsychosocial perspective, the patient as person, sharing power and responsibility, the therapeutic alliance, and the doctor as person. This article explores these components, explains the differences between patient-centered care and evidence-based medicine, and offers guidelines for achieving patient-centered subspecialty care in hand surgery.

Attitudes Toward and Experiences in End-of-life Care Education in the Intensive Care Unit: A Survey of Resident Physicians

INTRODUCTION

Resident physicians provide the most physician care to intensive care unit (ICU) patients. The body of literature about residents' palliative and end-of-life care (PC/EOLC) experiences in the ICU is limited. To our knowledge, this is the first study to assess resident physicians in multiple specialties regarding PC/EOLC in the ICU.

METHODS

A Web-based survey was developed and administered to all resident physicians in a single academic institution who had completed at least 1 dedicated ICU rotation.

RESULTS

Residents reported moderate comfort in dealing with end-of-life (EOL) issues and felt somewhat prepared to care for critically ill patients at the EOL. Feedback should be provided to residents regarding their PC/EOLC skills, and education should be tailored to residents rotating in the ICU.

Who is satisfied with general surgery clinic visits?

BACKGROUND

Patient satisfaction is an important patient outcome because it informs researchers and practitioners about patients' experience and identifies potential problems with their care. Patient satisfaction is typically studied through physician-patient interactions in primary care settings, and little is known about satisfaction with surgical consultations.

METHODS

Participants responded to questionnaires before and after a surgical consultation. The study was conducted in a diverse outpatient clinic within a county hospital in Southern California. Participants were patients who came to the surgery clinic for their first appointment after referral from a primary care provider for a surgical consultation.

RESULTS

Patients' ethnicity, educational attainment, and insurance status predict their satisfaction, and patients reliably differed in their satisfaction with care providers and with the hospital where they received their care.

CONCLUSIONS

These findings add to knowledge about patient care by highlighting associations between patients' demographic characteristics and patients' differential satisfaction with particular entities within the context of surgical care.

Doctor–patient communication, patient knowledge and health literacy: how difficult can it all be?

Patients who understand their injuries, the aims and potential of their treatment are likely to experience superior outcomes. We review the literature on positive, encouraging doctor–patient communication, and the impact of health literacy and education on patient knowledge in medicine and surgery, with a particular emphasis on orthopaedic surgery. We also highlight methods of improving doctor–patient communication and patient knowledge.

Surgeon-patient communication in oncology

Little is known about the quality of post-operative communications following oncological surgery and the satisfaction of patients with the communication process. Thirty-eight patients who underwent surgery for primary gastrointestinal cancer were interviewed before being discharged from the hospital. The patients' recall of information concerning the surgery, histological diagnosis, post-operative therapy and treatment goal was assessed. The congruence between the information provided by the surgeons and that retained by the patients was evaluated. The information provided by the surgeons about the diagnosis, histology and post-operative therapy plan was correctly recalled by over 92%, 81% and 97% of the patients respectively. Only 70% of the patients correctly recalled information about the goal of the treatment. Moreover, patients receiving only palliative treatment showed less recall of information about the treatment goal than patients receiving curative treatment (33% versus 89%). The surgeons reported that only 35% of the patients left the hospital completely informed. Overall, the patients were highly satisfied with their communication with their surgeon, and the patients' recall of information was generally good. The information given by the surgeons was often incomplete, however. Our explorative analysis showed that the quality of communication was often worse for patients with a palliative treatment goal than for patients with a curative treatment goal.

A systematic review of surgeon-patient communication: strengths and opportunities for improvement

OBJECTIVE

Effective communication is critical to patient satisfaction, outcomes of care and malpractice prevention. Surgeons need particularly effective communication skills to discuss complicated procedures and help patients make informed choices. We conducted a systematic review of the literature on surgeon-patient communication.

METHODS

Searches were conducted in MEDLINE, PsycINFO, and Sociological Abstract. Two reviewers screened citations and full-text articles. Quality was appraised using the Critical Appraisal Skills Program tool. Studies were categorized into content of communication, patient satisfaction, relationship of communication to malpractice, and duration of visits.

RESULTS

2794 citations and 74 full-text articles, 21 studies and 13 companion reports were included. Surgeons spent the majority of their time educating patients and helping them to make choices. Surgeons were generally thorough in providing details about surgical conditions and treatments. Surgeons often did not explore the emotions or concerns of patients. Potential areas of improvement included discussing some elements of informed decision making, and expressing empathy.

CONCLUSION

Surgeons can enhance their communication skills, particularly in areas of relative deficiency. Studies in primary care demonstrate communication programs are effective in teaching these skills.

PRACTICE IMPLICATIONS

These can be adapted to surgical training and ultimately lead to improved outcomes and satisfaction with care.

Communication as a core skill of palliative surgical care

Excellence as a surgeon requires not only the technical and intellectual ability to effectively take care of surgical disease but also an ability to respond to the needs and questions of patients. This article provides an overview of the importance of communication skills in optimal surgical palliation and offers suggestions for a multidisciplinary team approach, using the palliative triangle as the ideal model of communication and interpersonal skills. This article also discusses guidelines for advanced surgical decision making and outlines methods to improve communication skills.