Improving physician-patient interactions: a review

Enhancing Nonverbal Communication Through Virtual Human Technology: Protocol for a Mixed Methods Study

BACKGROUND

Communication is a critical component of the patient-provider relationship; however, limited research exists on the role of nonverbal communication. Virtual human training is an informatics-based educational strategy that offers various benefits in communication skill training directed at providers. Recent informatics-based interventions aimed at improving communication have mainly focused on verbal communication, yet research is needed to better understand how virtual humans can improve verbal and nonverbal communication and further elucidate the patient-provider dyad.

OBJECTIVE

The purpose of this study is to enhance a conceptual model that incorporates technology to examine verbal and nonverbal components of communication and develop a nonverbal assessment that will be included in the virtual simulation for further testing.

METHODS

This study will consist of a multistage mixed methods design, including convergent and exploratory sequential components. A convergent mixed methods study will be conducted to examine the mediating effects of nonverbal communication. Quantitative (eg, MPathic game scores, Kinect nonverbal data, objective structured clinical examination communication score, and Roter Interaction Analysis System and Facial Action Coding System coding of video) and qualitative data (eg, video recordings of MPathic-virtual reality [VR] interventions and student reflections) will be collected simultaneously. Data will be merged to determine the most crucial components of nonverbal behavior in human-computer interaction. An exploratory sequential design will proceed, consisting of a grounded theory qualitative phase. Using theoretical, purposeful sampling, interviews will be conducted with oncology providers probing intentional nonverbal behaviors. The qualitative findings will aid the development of a nonverbal communication model that will be included in a virtual human. The subsequent quantitative strand will incorporate and validate a new automated nonverbal communication behavior assessment into the virtual human simulation, MPathic-VR, by assessing interrater reliability, code interactions, and dyadic data analysis by comparing Kinect responses (system recorded) to manually scored records for specific nonverbal behaviors. Data will be integrated using building integration to develop the automated nonverbal communication behavior assessment and conduct a quality check of these nonverbal features.

RESULTS

Secondary data from the MPathic-VR randomized controlled trial data set (210 medical students and 840 video recordings of interactions) were analyzed in the first part of this study. Results showed differential experiences by performance in the intervention group. Following the analysis of the convergent design, participants consisting of medical providers (n=30) will be recruited for the qualitative phase of the subsequent exploratory sequential design. We plan to complete data collection by July 2023 to analyze and integrate these findings.

CONCLUSIONS

The results from this study contribute to the improvement of patient-provider communication, both verbal and nonverbal, including the dissemination of health information and health outcomes for patients. Further, this research aims to transfer to various topical areas, including medication safety, informed consent processes, patient instructions, and treatment adherence between patients and providers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46601.

Efficacy of three-dimensionally integrated exercise for scoliosis in patients with adolescent idiopathic scoliosis: study protocol for a randomized controlled trial

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is one of the most prevalent spinal deformities that may progress sharply during growth. The aim of this study will be to evaluate the efficacy of three-dimensionally integrated exercise on the Cobb angle, angle of trunk rotation, sagittal profile, and quality of life in patients with AIS.

METHODS/DESIGN

The study is designed as a randomized controlled trial. Participants include 42 patients with AIS aged 10-16 years. Randomly assigned patients will follow a 6-month treatment, either in a control group with standard care of observation following the Scoliosis Research Society criteria or in an experimental group with three-dimensionally integrated exercise for scoliosis. Blinded assessments at baseline and immediately after intervention will include the change of Cobb angle, angle of trunk rotation, sagittal index, and quality of life.

DISCUSSION

If we find that the intervention is effective in improving Cobb angle, angle of trunk rotation, sagittal profile, and quality of life in patients with AIS, this trial will have a positive impact and warrant a change in clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03427970 . Registered on February 9, 2018, and revised on July 24, 2018.

The effect of Schroth exercises added to the standard of care on the quality of life and muscle endurance in adolescents with idiopathic scoliosis-an assessor and statistician blinded randomized controlled trial: "SOSORT 2015 Award Winner"

Background

In North America, care recommendations for adolescents with small idiopathic scoliosis (AIS) curves include observation or bracing. Schroth scoliosis-specific exercises have demonstrated promising results on various outcomes in uncontrolled studies. This randomized controlled trial (RCT) aimed to determine the effect of Schroth exercises combined with the standard of care on quality-of-life (QOL) outcomes and back muscle endurance (BME) compared to standard of care alone in patients with AIS.

Material and Methods

Fifty patients with AIS, aged 10–18 years, with curves 10–45 °, recruited from a scoliosis clinic were randomized to receive standard of care or supervised Schroth exercises plus standard of care for 6 months. Schroth exercises were taught over five sessions in the first two weeks. A daily home program was adjusted during weekly supervised sessions. The assessor and the statistician were blinded. Outcomes included the Biering-Sorensen (BME) test, Scoliosis Research Society (SRS-22r) and Spinal Appearance Questionnaires (SAQ) scores. Intention-to-treat (ITT) and per protocol (PP) linear mixed effects models were analyzed. Because ITT and PP analyses produced similar results, only ITT is reported.

Results

After 3 months, BME in the Schroth group improved by 32.3 s, and in the control by 4.8 s. This 27.5 s difference in change between groups was statically significant (95 % CI 1.1 to 53.8 s, p = 0.04). From 3 to 6 months, the self-image improved in the Schroth group by 0.13 and deteriorated in the control by 0.17 (0.3, 95 % CI 0.01 to 0.59, p = 0.049). A difference between groups for the change in the SRS-22r pain score transformed to its power of four was observed from 3 to 6 months (85.3, 95 % CI 8.1 to 162.5, p = 0.03), where (SRS-22 pain score)⁴ increased by 65.3 in the Schroth and decreased by 20.0 in the control group. Covariates: age, self-efficacy, brace-wear, Schroth classification, and height had significant main effects on some outcomes. Baseline ceiling effects were high: SRS-22r (pain = 18.4 %, function = 28.6 %), and SAQ (prominence = 26.5 %, waist = 29.2 %, chest = 46.9 %, trunk shift = 12.2 % and shoulders = 18.4 %).

Conclusions

Supervised Schroth exercises provided added benefit to the standard of care by improving SRS-22r pain, self-image scores and BME. Given the high prevalence of ceiling effects on SRS-22r and SAQ questionnaires’ domains, we hypothesize that in the AIS population receiving conservative treatments, different QOL questionnaires with adequate responsiveness are needed.

Trial registration

Schroth Exercise Trial for Scoliosis NCT01610908.

Electronic supplementary material

The online version of this article (doi:10.1186/s13013-015-0048-5) contains supplementary material, which is available to authorized users.

Issues in Physician—Elderly Patient Interaction

The basis of an effective and satisfactory physician–patient relationship is found in the communication which occurs between these two individuals. By studying the interaction, we can learn much about the identities of the physician and patient, and how they view each other and the world. The interactional dynamics between physician and patient are unique. For example, even in initial medical encounters which involve the meeting of two strangers, patients and physicians deal with concerns as diverse as life and death as well as other intimate or personal issues. Researchers of physician–patient interaction seek to discover how communication evolves and how that communication reveals the multiple levels of meaning in the medical encounter.

Impact of physician sitting versus standing during inpatient oncology consultations: patients' preference and perception of compassion and duration. A randomized controlled trial

The purpose of this study was to determine the impact of physician sitting versus standing on the patient's preference of physician communication style, and perception of compassion and consult duration. Sixty-nine patients were randomized to watch one of two videos in which the physician was standing and then sitting (video A) or sitting and then standing (video B) during an inpatient consultation. Both video sequences lasted 9.5 minutes. Thirty-five patients (51%) blindly preferred the sitting physician, 16 (23%) preferred the standing, and 18 (26%) had no preference. Patients perceived that their preferred physician was more compassionate and spent more time with the patient when compared with the other physician. There was a strong period effect favoring the second sequence within the video. The patients blinded choice of preference (P = 0.003), perception of compassion (P = 0.0016), and other attributes favored the second sequence seen in the video. The significant period effect suggests that patients prefer the second option presented, notwithstanding a stated preference for a sitting posture (55/68, 81%). Physicians should ask patients for their preference regarding physician sitting or standing as a way to enhance communication.

Effects of video interaction analysis training on nurse-patient communication in the care of the elderly

This paper describes an empirical evaluation of communication skills training for nurses in elderly care. The training programme was based on Video Interaction Analysis and aimed to improve nurses' communication skills such that they pay attention to patients' physical, social and emotional needs and support self care in elderly people. The effects of the training course were measured in an experimental and control group. They were rated by independent observers, by comparing videotapes of nursing encounters before and after training. Forty nurses participated in 316 videotaped nursing encounters. Multi-level analysis was used to take into account similarity among same nurse encounters. It was found that nurses who followed the training programme, provided the patients with more information about nursing and health topics. They also used more open-ended questions. In addition, they were rated as more involved, warmer and less patronizing. Due to limitations in the study design, it could not be demonstrated that these findings can entirely be ascribed to the training course. Further research, incorporating a randomized controlled design and larger sample sizes, is recommended to determine whether the results can be attributed to this specific type of training.

Non-verbal behaviour in nurse-elderly patient communication

This study explores the occurrence of non-verbal communication in nurse-elderly patient interaction in two different care settings: home nursing and a home for the elderly. In a sample of 181 nursing encounters involving 47 nurses a study was made of videotaped nurse-patient communication. Six non-verbal behaviours were observed: patient-directed eye gaze, affirmative head nodding, smiling, forward leaning, affective touch and instrumental touch. With the exception of instrumental touch these non-verbal behaviours are important in establishing a good relationship with the patient. To study the relationship between non-verbal and verbal communication, verbal communication was observed using an adapted version of Roter's Interaction Analysis System, which distinguishes socio-emotional and task-related communication. Data were analysed in hierarchical linear models. The results demonstrated that nurses use mainly eye gaze, head nodding and smiling to establish a good relation with their patients. The use of affective touch is mainly attributable to nurses' personal style. Compared to nurses in the community, nurses in the home for the elderly more often display non-verbal behaviours such as patient-directed gaze and affective touch.

Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain: a randomized controlled trial

OBJECTIVE

To assess the effect of a combined exercise and motivation program on the compliance and level of disability of patients with chronic and recurrent low back pain.

DESIGN

A double-blind prospective randomized controlled trial.

SETTING

Physical therapy outpatient department, tertiary care.

PATIENTS

Ninety-three low back pain patients were randomly assigned to either a standard exercise program (n = 49) or a combined exercise and motivation program (n = 44).

INTERVENTIONS

Patients were prescribed 10 physical therapy sessions and were advised to continue exercising after treatment termination. The motivation program consisted of five compliance-enhancing interventions. Follow-up assessments were performed at 3 1/2 weeks, 4 months, and 12 months.

MAIN OUTCOME MEASURES

Disability (low back outcome score), pain intensity, physical impairment (modified Waddell score, fingertip-to-floor distance, abdominal muscle strength), working ability, motivation, and compliance.

RESULTS

The patients in the motivation group were significantly more likely to attend their exercise therapy appointments (p = .0005). Four and 12 months after study entry there was a significant difference in favor of the motivation group with regard to the disability score (p = .004) and pain intensity (p < or = .026). At 4 months, there was a significant advantage for the motivation group in the fingertip-to-floor distance (p = .01) and in abdominal muscle strength (p = .018). No significant differences were found in motivation scores, self-reported compliance with long-term exercise, and modified Waddell score. In terms of working ability, there was a trend favoring the combined exercise and motivation program.

CONCLUSION

The combined exercise and motivation program increased the rate of attendance at scheduled physical therapy sessions, ie, short-term compliance, and reduced disability and pain levels by the 12-month follow-up. However, there was no difference between the motivation and control groups with regard to long-term exercise compliance.

The role of communication in nursing care for elderly people: a review of the literature

Communication in nursing care is an important topic assessing the specific needs of elderly patients and providing nursing care that is tailored to the individual patient's needs. In this review of the literature, we describe the role attributed to communication in theoretical nursing models and we report how research in communication in nursing elderly patients has taken place over the last ten years. It appears that since the eighties there has been an increase in observation studies into nurse-patient communication. There still is, however, a lack of observation instruments to do justice to the interactive nature of nurse-patient communication. Special attention should be paid to reliability and validity.

Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon

In this study, culturally sensitive visual aids designed to help convey drug information to nonliterate female adults who had a prescription for a solid oral dosage form of antibiotic medications were developed and evaluated. The researchers conceptualized the educational messages while a local artist produced the visual aids. Seventy-eight female ambulatory patients were evaluated for comprehension and compliance with antibiotic prescription instructions. The study was conducted in three health centers in Cameroon, West Africa and followed a pre-test, post-test, and follow-up format for three groups: two experimental, and one control. All participants were randomly assigned to either experimental or control groups, 26 patients to each group. Subjects in the experimental groups received visual aids alone or visual aids plus an Advanced Organizer. A comparison of the three groups showed that subjects in the experimental groups scored significantly higher than the control group in both the comprehension and compliance measures.

The role of adjunctive therapy in the management of chronic nonmalignant pain

The management of chronic nonmalignant pain is an increasing challenge to clinicians and their patients. Adjunctive therapy, which includes a wide range of physical, psychoeducational, and multidisciplinary interventions, can play an important role in the treatment of pain. This article discusses the role and efficacy of adjunctive therapy in the management of pain associated with musculoskeletal conditions, the most common and disabling sources of chronic nonmalignant pain. Findings from meta-analyses, review articles, and recent clinical trials are reviewed that suggest that interventions that combine exercise and psychoeducational approaches designed to enhance communication, control, problem-solving, and coping can have a clinically significant impact on reducing pain and improving functional status for many conditions.

Health education intervention strategies: recommendations for future research

While the ultimate goal of health education interventions is to positively influence health status, more proximal indicators of success are changes in intermediate outcomes, or impact. Because health education interventions work through intermediate outcomes, the linkage to health status is often assumed to be at a conceptual or theoretical level. The term health education intervention strategy is a heuristic device used to conceptualize and organize a large variety of activities. There is a wide range of studies and reports in the literature that either test specific intervention strategies or report on larger health education efforts combining several strategies. This article organizes the discussion to focus on individual-, community-, and policy-level interventions. Mass communications are also considered, and the authors comment on program planning issues that cut across specific interventions at the individual, community, and policy levels. Eleven recommendations are offered for future health education intervention research.

Creating capacity through health education: what we know and what we don't

Researchers in health education have rarely convened to outline research priorities in the field. This article discusses the results of a meeting to develop a research agenda aimed at creating capacity to promote and maintain health. Salient research findings related to individual and community health are summarized and priority issues for future research are presented.

Doctor-patient communication in rheumatological disorders

Organized educational programmes and individual educational counselling are primary means by which health care providers equip rheumatic disease patients with the skills and knowledge necessary to monitor and manage variable symptoms. Many outpatients educational programmes were evaluated in the 1980s. In brief, well designed programmes are generally effective in improving knowledge and compliance with a regimen, and in reducing pain, depression, and disability. However, most persons with arthritis never use such programmes. Greater emphasis is needed on education of patients at the time of the clinical encounter, where the greatest opportunity lies for reaching the greatest number. Researchers have examined the dynamics of the doctor-patient interaction during the clinical encounter. Results show that: better information sharing leads to improved patient satisfaction, compliance, and health outcomes; information sharing could be greatly improved; and doctors and patients can be trained to improve information sharing, resulting in improved outcomes. A review of attribution and decision-making theory and the empirical literature on doctor-patient communication suggests a number of techniques that could be usefully incorporated into the management of each patient. These include: (1) encouraging patients to write down their concerns before each visit; (2) addressing each concern specifically, however briefly; (3) asking patients what they think has caused their problems; (4) tailoring treatments to patients' goals and preferences as possible; (5) explaining the purpose, dosage, common side-effects and inconveniences, and how to judge the efficacy of each treatment, including length of trial; (6) checking patients' understanding; (7) anticipating problems in compliance with treatment plans, and discussing methods to cope with common problems; (8) writing down the diagnosis and treatment plan to help patients remember; (9) giving out written materials that are now widely available; (10) reinforcing patients' confidence in their ability to manage their regimen; (11) using ancillary personnel in patient education; and (12) referring patients to organized programmes in the community.

Arthritis education: opportunities and state of the art

Health education research in arthritis and musculoskeletal disease experienced extraordinary growth in the 1980s. In this article we discuss opportunities for health education in arthritis and musculoskeletal disease, and the effectiveness of evaluated programs to influence knowledge, behavior, and health status of persons with arthritis. Additionally, we review developments in theory and trends in research that we expect to be influential in the next decade. Educational opportunities for primary prevention of arthritis are limited. However, a large variety of organized programs, planned according to commonly accepted principles of education, psychology, and psychotherapy, and applied consistently by personnel with some kind of training, have been able to produce desirable changes in knowledge, behavior, and health outcome in arthritis patients, over and above the medical treatment and incidental education to which they have already been exposed. As a result, national dissemination of programs and standards for arthritis patient education is in progress. In the next decade, researchers will increasingly turn to new populations and methods of delivery, investigation of conditions less well studied, such as osteoporosis, education of patients in generic communication and coping skills, and development of arthritis-specific applications of theory, especially in areas such as social support, control and helplessness, cognitive processing, and pain management.

Advances in patient education in rheumatic disease

Education of patients with arthritis began with an emphasis on conveying knowledge, grew to include behaviour change, compliance, and more general coping and management of disease and then progressed to consider physical and psychosocial health outcomes. Research continues in all these areas. Control, in many forms (locus of control, self perceived efficacy, learned helplessness), is now suggested to be a central mediating variable. Evaluation of programmes is moving away from programme v usual care towards comparison of alternative methods of delivery and matching of method to learner. The first generation of researchers in arthritis education tended to be care givers with little formal education in behavioural sciences and evaluation methodology; the programmes they designed were often empirically based. The current generation, nurtured in large part by funds from the Arthritis Foundation and the National Institutes of Health, is better trained in designing programmes grounded in behavioural sciences and educational theory. In the long run, collaborations with care givers and patients will considerably strengthen the effectiveness of education programmes for patients. A variety of educational strategies have been shown to change the knowledge, behaviour, and health of patients with arthritis for the better. Many methods seem to work, so long as the programme is planned, has a goal, and is accountable. There is much work still to be done to teach care givers to be better teachers, and patients to be better managers of their diseases, in concert with their doctors, and to focus on high risk groups. Although most work has been done with patients with rheumatoid arthritis and osteoarthritis, many of these findings can and should be safely generalised to less studied rheumatic diseases. Finally, we need to consider the patient first as a person, and to provide education through all avenues, not just the medical care system.

The doctor-patient relationship and counseling for preventive care

Theories and research related to the doctor-patient relationship have developed in a context of therapeutic care. This context is an increasingly inadequate definition of the boundaries of the doctor-patient relationship, as expectations grow for the physician's role in counseling for disease prevention and health promotion. This paper reviews the literature of the doctor-patient relationship, and extends its application to this newer context. Suggestions are discussed for overcoming some of the obstacles to the successful incorporation of counseling for preventive care in daily medical practice. Doctors and patients will benefit from a clarified understanding of their counseling responsibilities in disease prevention and health promotion as the theoretical and practical complexities of providing health care in medical institutions are examined.

Assessing physician/patient perceptions in rheumatoid arthritis. A vital component in patient education

Patient education surveys were completed by 101 patients with rheumatoid arthritis and by 28 rheumatologists to assess and compare patients' reports with physicians' perceptions of patients' needs regarding content, provider, and education program delivery methods. Both groups agreed on the importance of patients' education about arthritis, especially on the topics of medication, physician/patient communication, quackery, and maintaining ambulation. A higher proportion of physicians reported that patient education was needed in psychosocial areas, activities of daily living, sexual concerns, and community resources. Patients sought more education in disease process, diagnostic procedures, and nutrition. Patients rated pharmacists and nutritionists significantly more important as educational sources than did physicians. Both groups reported individual patient/practitioner meetings as the preferred delivery method. Physicians reported group education to be valuable for some psychosocial topics; patients disagreed significantly. Despite considerable consensus, disagreements were evident in the psychosocial area and in the role of allied health professionals. Clarification, understanding, and resolution of these differences should be sought before implementing patient education programs.