[Evolution of the communication profile of family medicine residents]

[Accomplishment of preventive activities proposed by resident doctors of Family Medicine in Primary Care and its relationship with communication skills]

OBJECTIVE

To determine the offer of preventive activities by resident physicians of family medicine in the Primary Care consultations and the relation with their communication habilities.

DESIGN

A descriptive multicentre study assessing medical consultations video recording.

LOCATION

Eight Primary Healthcare centres in Jaen (Andalucia).

PARTICIPANTS

Seventy-three resident physicians (4th year) filmed and observed with patients.

PRINCIPAL MEASUREMENTS

Offer of preventive activities (according to the Spanish Program of Preventive Activities and Health Promotion -PAPPS-). Doctor, patient and consultation characteristics. Peer-review of the communication between physicians and patients, using a CICAA scale. A descriptive, bivariate, logistic regression analysis was performed.

RESULTS

Two hundred and sixty interviews were evaluated (duration 8.5±4.0min) of 73 residents (50.7% women, mean age 32.9±7.7 years, 79% urban environment). The patient is more frequently a woman (60%) who comes alone (72%) due to acute processes (80%) and with 2.1±1.0 demands. Preventive activities are offered in 47% (duration less than one minute) of primary (70%) and secondary (59%) prevention, offered through advice (72%) or screening (52%) and focused on the cardiovascular area (52%) and lifestyles (53%). Eighty percent related to the patient's reason for consultation. Communication skills 41% improvable, 26% adequate, 23% excellent. The offer of preventive activities is related to the duration of the consultation (OR=1.1, 95% CI 1.01; 1.16) and communication skills (OR=1.03, 95% CI 1.01; 1.10).

CONCLUSIONS

Preventive activities are carried out in almost half of the consultations, although focused on advice and screening and linked to the patient's demand. Consultation time and communication skills favor a greater preventive offer.

Communication with patients and the duration of family medicine consultations

OBJECTIVE

To determine the distribution of consultation times, the factors that determine their length, and their relationship with a more participative, patient-centred consulting style.

DESIGN

Cross-sectional multicentre study.

LOCATION

Primary Healthcare Centres in Andalusia, Spain.

PARTICIPANTS

A total of 119 tutors and family medicine physician residents.

PRINCIPAL MEASUREMENTS

Consultation length and communication with the patient were analysed using the CICCAA scale (Connect, Identify, Understand, Consent, Help) during 436 interviews in Primary Care.

RESULTS

The mean duration of consultations was 8.8min (sd: 3.6). The consultation tended to be longer when the physician had a patient-centred approach (10.37±4.19min vs 7.54±2.98min; p=0.001), and when there was joint decision-making (9.79±3.96min vs 7.73±3.42min: p=0.001). In the multivariable model, longer consultations were associated with obtaining higher scores on the CICAA scale, a wider range of reasons for consultation, whether they came accompanied, in urban centres, and a smaller number of daily visits (r²=0.32). There was no correlation between physician or patient gender, or problem type.

CONCLUSION

A more patient centred medical profile, increased shared decision-making, a wider range of reasons for consultation, whether they came accompanied, in urban centres, and less professional pressure all seem to be associated with a longer consultation.

Communication skills of tutors and family medicine physician residents in Primary Care clinics

Aim

To determine the communicative profiles of family physicians and the characteristics associated with an improved level of communication with the patient.

Design

A descriptive multicentre study.

Location

Primary Healthcare Centres in Almeria, Granada, Jaen and Huelva.

Participants

119 family physicians (tutors and 4th year resident physicians) filmed and observed with patients.

Principal measurements: Demographic and professional characteristics. Analysis of the communication between physicians and patients, using a CICAA (Connect, Identify, Understand, Agree and Assist, in English) scale. A descriptive, bivariate, multiple linear regression analysis was performed.

Results

There were 436 valid interviews. Almost 100% of physicians were polite and friendly, facilitating a dialogue with the patient and allowing them to express their doubts. However, few physicians attempted to explore the state of mind of the patient, or enquire about their family situation or any important stressful events, nor did they ask open questions. Furthermore, few physicians summarised the information gathered. The mean score was 21.43 ± 5.91 points (maximum 58). There were no differences in the total score between gender, city, or type of centre. The linear regression verified that the highest scores were obtained from tutors (B: 2.98), from the duration of the consultations (B: 0.63), and from the age of the professionals (B: −0.1).

Conclusion

Physicians excel in terms of creating a friendly environment, possessing good listening skills, and providing the patient with information. However the ability to empathise, exploring the psychosocial sphere, carrying out shared decision-making, and asking open questions must be improved. Being a tutor, devoting more time to consultations, and being younger, results in a significant improvement in communication with the patient.

[Opinions of family doctors on the involvement of patients in the taking of decisions: a study with focus groups]

OBJECTIVE

To determine what family doctors think about various aspects of patient involvement in clinical decision making in Primary Care.

DESIGN

Qualitative study using focus groups.

LOCATION

Primary Care.

PARTICIPANTS

Family physicians with and without expertise in clinical communication.

METHODS

Three focus groups were developed, involving 6-8 professionals per group, and took part in two meetings. The conversations were recorded and transcribed verbatim. The discussion was analysed using literature-based categories and other emerging from the text, encoding the information and making an inductive interpretation.

RESULTS

Family physicians refer mainly to involving the patient in decisions by proposing a plan tailored to the knowledge of patient problems and then verifying their approval or rejection. However, some professionals ponder whether this could be classified as patient involvement, questioning the real role that both players would take at the time of deciding.

CONCLUSIONS

The explanation of how family physicians would involve the patient in decisions clashes with the most widespread theories on the subject and, also opposes the view of patients who would like to be involved more actively. Taking into account discordant reflections on the relevance of considering this process as real patient involvement, it is necessary to describe a realistic theoretical model that allows further development of strategies to improve the attitude and training of professionals to patient involvement in clinical decisions.

[Implementation of preventive activities by family and community medicine residents in primary care clinics]

OBJECTIVE

To determine the level of preventive activities carried out by Family and Community Medicine medical residents during their stay in the Health Centre, as well as to estimate the time involved in carrying them out.

DESIGN

Cross-sectional, descriptive, observational study.

SETTING

Teaching Health Centres in the Central- Cordoba and Guadalquivir Primary Care Districts.

PARTICIPANTS

Forty medical residents and 384 clinical interviews with patients who were seen at the clinic.

MAIN MEASUREMENTS

The consultations were video recorded and looked at by three medical residents who recorded the preventive activities carried out according to the 2005 PAPPS (Health Promotion and Disease Prevention Activities) recommendations, as well as the time employed in performing these activities.

RESULTS

No preventive activities were performed in 72.1% (95% CI: 67.6 to 76.5%) of the consultations. The most frequent activities were secondary prevention (70.1%), mainly the taking of blood pressure (8.1%). The mean consultation time when there were no preventive activities carried out was 5.6 min (SD=3.1), whilst in those that did perform them it was 7.04 min (SD=3.05) (P<0.0001).

CONCLUSIONS

The performing of preventive activities by medical residents in Primary Care clinics is very limited. A consultation that includes preventive activities requires a significantly longer time than in those that do not include them.

[Evaluation of the patient centered clinical relationship: analysis of psychometric properties using the CICAA scale]

OBJECTIVE

To analyse the psychometric properties by a scale for evaluating patient centered clinical communication.

DESIGN

Validation and observational study of a measurement tool.

SETTING

Health centres and hospital outpatient clinics.

PARTICIPANTS

Three researchers independently evaluated video recorded interviews of different sub-samples: health professionals (family medicine medical residents, family doctors, specialist care physicians, and primary care nurses), actual patients who consulted for chronic or acute health problems, and standardised patients.

PRIMARY MEASUREMENTS

Dimensionality (exploratory factor analysis), internal consistency (alpha de Cronbach), intra- and inter-observer agreement (Kappa index, intraclass correlation coefficient [ICC], generalisability), sensitivity to change (Student t test) and convergent validity with the GATHA questionnaire (Pearson correlation coefficient).

RESULTS

Six factors have been identified that explain 66.0% of the variance. The overall internal consistency of the test was alpha=0.94. The overall intra-observer agreement, measured with the ICC, varied between 0.94 and 0.97, whilst the inter-observer was between 0.82-0.90. The number of completed questionnaires required for the evaluator to obtain adequate reproducibility (generalisability) varied between 6 and 12. Statistical significance was not obtained when testing the sensitivity to change. The CICAA scale and the GATHA questionnaire had a correlation of 0.67.

CONCLUSIONS

The CICAA scale is a generic patient centered clinical communication evaluation tool that may be used in different clinical contexts and situations, since it has shown to be reliable, valid and efficient.

The effect of patients' met expectations on consultation outcomes. A study with family medicine residents

OBJECTIVES

To know the patients' expectations and the fulfillment of these at family medicine consultations by resident doctors and to assess their effect on some consultation outcomes.

DESIGN

A prospective cohort study.

PARTICIPANTS

Patients attending family medicine consultations held by 38 resident doctors: 1,301 eligible patients, 702 filled in all questionnaires.

MEASUREMENTS

Before each visit, the patients' expectations about that particular consultation were registered. Right after the visit was over, their perception of several aspects of the communicative interaction with the doctor was measured. Later, patients were interviewed on the phone to know how their expectations had been fulfilled, how satisfied they were about the consultation, how they had followed the doctor's suggestions, if they were going to seek further care for the same cause later, and the evolution of their clinical problem. Logistic regression was the main analysis used.

RESULTS

The most common expectations were the doctor showing interest and listening (30.5%), getting some information about the diagnosis (16.3%), and sharing problems and doubts (11.1%). The rate of main expectations that were met was 76.5%. Satisfaction with the encounter was associated with the clinical evolution [odds ratio (OR) 2.23; confidence interval (CI): 1.32-3.75], and the fulfilling of the patients' main or two main expectations was significantly related to all the measured outcomes (satisfaction OR 3.51, CI: 1.73-7.8; adherence OR 1.80, CI: 1.11-2.92; clinical evolution OR 1.54, CI: 1.01-2.35; and seeking further care later OR 0.54, CI:0.36-0.81)

CONCLUSIONS

Patients prioritize expectations of a more general sort when they attend primary care consultations and residents fulfill these acceptably. The fulfillment of expectations seems to affect the studied outcomes more than other factors.

Physician-patient communication: a study on the observed behaviours of specialty physicians and the ways their patients perceive them

OBJECTIVE

To explore the communicative behaviours as used by specialty physicians, and their patients' perception of the communicative act as well as their satisfaction with the encounter.

METHODS

Cross-sectional study involving 27 specialty physicians and 257 outpatients. Encounters were video-recorded and analysed through the GATHA-ESP scale. Patients rated the quality of the interaction and their satisfaction with it in a questionnaire.

RESULTS

Most specialist doctors use a "managerial" style where there is no exploration of their patients' emotions (22%), expectations (28%) or psychosocial aspects (10-20%). Less than one doctor out of every four ever gave the patient an opportunity to participate in any type of decision making at the surgery. Patients were more satisfied with those encounters they felt more patient-centred (F: 11.37; p<0.001); higher scores on the GATHA-ESP characterised these visits.

CONCLUSIONS

Specialty physicians show a limited range of communicative skills as they use a doctor-centred style that allows for little patient participation. Patients' perceptions of patient-centeredness are linked to satisfaction more than the analysis of doctors' behaviour at the consultation does.

PRACTICE IMPLICATIONS

It seems important to foster training in communication skills in the different specialist vocational training programs. Studies on physician-patient communication should deal with the perceived and observed perspectives on this domain.

[What are users views of medical residents attending primary care consultations?]

OBJECTIVE

To find what users think of the presence of medical residents (MIR) at primary care consultations.

DESIGN

Observational and cross-sectional descriptive study.

SETTING

Urban health centre.

PATIENTS

421 patients, selected by systematic sampling, attending consultations of MIR tutors.

METHOD

A structured questionnaire was drawn up, with some closed questions with multiple-option replies on the Likert scale; and others with a yes/no or "indifferent" reply. The questionnaires were filled out in the waiting-rooms.

RESULTS

100% (63% women, 37% men) answered the questionnaire. 71% preferred to be seen by the same doctor; and 68% thought they were better treated if they were always seen by the same doctor. 89% thought that the presence of the resident was a necessary part of his/her training; 90% were not bothered by his/her presence during the consultation; 82% thought the resident did not obstruct in any way their relationship with the doctor; 94% thought that the presence of the resident had never stopped them mentioning something important; 55% thought that patients had the right to an opinion on the presence of the resident.

CONCLUSIONS

Most patients valued the presence of residents at consultations positively and thought it a necessary part of their training.

[MIR family medicine program: cross-professional interaction in a complex reality]

OBJECTIVE

To find the view of trainers (tutors and teaching assistants) of third-year family and community medicine (FCM) residents concerning their own teaching activity in areas such as training, the skills and qualities required to be a teacher and the inter-professional relationships that are current and that are needed in a primary care teaching team.

DESIGN

Qualitative study developed between June 2000 and May 2002. Sample design with a volunteer population.

SETTING

FCM teaching unit under the Primary Care Administration of Murcia. PARTICIPANTS AND/OR CONTEXTS: Tutors and teaching assistants in the FCM residents' programme.

METHOD

Semi-structured interview for information gathering. Contents analysis to construct results on the basis of the semiological analysis of the textual discourse. Systematic return of the results.

RESULTS

Belonging to the teaching team is the highest motivation for taking part in teaching. It gives the tutors more benefits (affective, care load) than difficulties (organisational adaptation). The tutor profile is sustained by his/her scientific-technical and personal qualities; that of the nurse, by his/her community qualities. Collaboration between nurse and tutor is informal and the teaching strategies most employed by tutors are guidance, guide-lines and encouragement of residents' autonomy. Nurses collaborate with teaching by transmitting a model of professional development and facilitating teamwork.

CONCLUSIONS

The complexity of the training process stands out. Postgraduate FCM training is cross-professional, not exclusively circumscribed by the tutor-resident teaching relationship. The qualitative paradigm is shown to be useful for obtaining a vision of the teaching process from the perspective of different actors.