Agenda setting in psychiatric consultations: an exploratory study

Agenda-setting in first sessions of business coaching-a focus on coaches' practices to manage the agenda and establish the working alliance

Introduction

Agenda-setting is a central communicative task for professionals and a joint activity of all participants particularly at the onset of helping interactions such as coaching. Agreeing on goal(s) and assigning tasks alongside establishing a trustful bond prepare the ground for the success of the interaction. The professional agent initiates and sets the agenda as part of their professional role and responsibility, i.e., based on their professional epistemic and deontic authority. Concurrently, by orienting to clients' epistemic authority and by yielding power, control, and agency to clients to co-manage the ensuing interaction, agenda-setting is the first opportunity for client-centeredness, which is a central characteristic and success factor for the working alliance in coaching.

Procedure and Methods

We take first steps in filling a research gap by providing a first analysis of the interactional unfolding of agenda-setting in coaching and by showcasing that and how agenda-setting as a joint activity of coach and client contributes to their working alliance. More precisely, we investigate agenda-management practices in five first sessions of business coaching to (1) document and analyze how the joint activity 'agenda-setting' is implemented via various (coach-initiated) social actions, (2) detail their contribution to establishing the working alliance, and (3) to interpret the emerging practices of agenda-management against the concept of 'client-centeredness'. For the analysis, we draw on conceptual and methodological resources from interactional linguistics alongside linguistic pragmatics and conversation analysis.

Results

We found 117 instances of 'agenda-setting' in our data which can be assigned to the seven social actions "Delivering Agenda Information", "Requesting Agenda Information", "Requesting Agenda Agreement", "Requesting Agenda Action", "Suggesting Agenda Action", "Offering Agenda Action" and "Proposing Agenda Action".

Discussion

The social actions display that agenda-setting serves to establish a common ground regarding goals, tasks and the relational bond of coach and client, and (after this has been achieved) to negotiate future coaching actions. Thus, the joint activity of 'doing' agenda-setting can be shown to be 'doing' working alliance at the same time.

Effectiveness and Clinical Usefulness of Electronic Agenda-setting in Psychiatric Practices: A South Texas Psychiatric PBRN Study

There is a general consensus that the doctor-patient interview should be as productive and efficient as possible. This is becoming increasingly difficult in a health care insurance system that demands shorter appointment times. Clinicians must therefore find ways to condense the clinical encounter without sacrificing quality. The purposes of this study were: (1) to facilitate shared decision-making between psychiatrist and patient via pre-visit patient agenda-setting, (2) to evaluate the effectiveness and ease of use of the agenda-setting tool, and (3) to determine patient and clinician satisfaction with the clinical encounter. Patients completed questionnaires to assist in agenda-setting via an electronic tablet while in the waiting area before seeing the psychiatrist. Both patients and psychiatrists then completed post-visit questionnaires to assess their satisfaction with the encounter. We measured patient satisfaction and the extent to which the psychiatrist addressed concerns before and after the visit, as well as ease of use for the patient, psychiatrist satisfaction, and clinical helpfulness to the treating psychiatrist. Additional analyses also indicated that there was a significant increase in patient satisfaction scores, compared with an average of all previous visits, and a significant increase in the number of concerns addressed during the current visit when compared with the average number of previous concerns addressed. Patients reported little difficulty using the tablet. Similarly, psychiatrists reported that the device was helpful in the clinical setting and they expressed high levels of satisfaction with the visit. We hope our work will encourage others to use this agenda-setting tool in their practices to facilitate better patient care.

Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): Rationale, study design, methods, and sample characteristics

BACKGROUND

Chronic pain is associated with profound negative effects, and racial disparities are well-documented in chronic pain treatment. In addition, Black patients report poorer communication with providers and exhibit lower levels of patient activation (self-management self-efficacy) than White patients. Although the causes of healthcare disparities are complex and require intervention at multiple levels, empowering patients is one critical path to achieving health equity. The current study is a coaching intervention focused on increasing patient activation and building communication skills for Black patients with chronic pain.

METHODS

In this randomized controlled trial, 250 Black patients with chronic pain were randomized to either the coaching intervention or an attention control arm. Intervention patients attended 6 telephone-delivered individual coaching sessions over 12 weeks. Coaching focused on clarifying and prioritizing goals and on communication skills, such as agenda setting. The primary outcome is patient activation. Secondary outcomes include communication self-efficacy, pain intensity and interference, and psychological functioning.

DISCUSSION

Having the knowledge and confidence to participate in one's pain care, coupled with the skills needed to effectively communicate with providers, is essential to optimize chronic pain care. This is particularly important for Black patients who often experience lower quality pain care. Interventions such as COOPERATE hold promise for helping patients to acquire the requisite tools to take greater control of their chronic pain care.

TRIAL REGISTRATION

clinicaltrials.gov, # NCT03562793.

Communication principles and practices for making shared decisions about renal replacement therapy: a review of the literature

PURPOSE OF REVIEW

To provide an overview of the skill set required for communication and person-centered decision making for renal replacement therapy (RRT) choices, especially conservative kidney management (CKM).

RECENT FINDINGS

Research on communication and decision-making skills for shared RRT decision making is still in infancy. We adapt literature from other fields such as primary care and oncology for effective RRT decision making.

SUMMARY

We review seven key skills: (1) Announcing the need for decision making (2) Agenda Setting (3) Educating patients about RRT options (4) Discussing prognoses (5) Eliciting patient preferences (6) Responding to emotions and showing empathy, and (7) Investing in the end. We also provide example sentences to frame the conversations around RRT choices including CKM.

Centering the Voice of the Client: On Becoming a Collaborative Practitioner with Low-Income Individuals and Families

Despite current interest in collaborative practices, few investigations document the ways practitioners can facilitate collaboration during in-session interactions. This investigation explores verbatim psychotherapy transcripts to describe and illustrate therapist's communications that facilitate or hinder centering client's voice in work with socioeconomically disadvantaged populations. Four exemplar cases were selected from a large intervention trial aimed at improving shared decision making (SDM) skills of psychotherapists working with low-income clients. The exemplar cases were selected because they showed therapist's different degrees of success in facilitating SDM. Therapist's verbalizations were grouped into five distinct communicative practices that centered or de-centered the voice of clients. Communication practices were examined through the lens of collaborative approaches in family therapy. The analysis suggests that cross-fertilization between SDM and family-oriented collaborative and critical approaches shows promise to illuminate and enhance the challenging road from clinician-led to client-led interactions. This paper also stresses the importance of incorporating relational intersectionality with individuals and families who may not feel entitled to express their expectations or raise questions when interacting with authority figures.

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

IMPORTANCE

Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

OBJECTIVE

To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

EVIDENCE REVIEW

Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

FINDINGS

The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).

CONCLUSIONS AND RELEVANCE

This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

Eliciting the Patient's Agenda- Secondary Analysis of Recorded Clinical Encounters

BACKGROUND

Eliciting patient concerns and listening carefully to them contributes to patient-centered care. Yet, clinicians often fail to elicit the patient's agenda and, when they do, they interrupt the patient's discourse.

OBJECTIVE

We aimed to describe the extent to which patients' concerns are elicited across different clinical settings and how shared decision-making tools impact agenda elicitation.

DESIGN AND PARTICIPANTS

We performed a secondary analysis of a random sample of 112 clinical encounters recorded during trials testing the efficacy of shared decision-making tools.

MAIN MEASURES

Two reviewers, working independently, characterized the elicitation of the patient agenda and the time to interruption or to complete statement; we analyzed the distribution of agenda elicitation according to setting and use of shared decision-making tools.

KEY RESULTS

Clinicians elicited the patient's agenda in 40 of 112 (36%) encounters. Agendas were elicited more often in primary care (30/61 encounters, 49%) than in specialty care (10/51 encounters, 20%); p = .058. Shared decision-making tools did not affect the likelihood of eliciting the patient's agenda (34 vs. 37% in encounters with and without these tools; p = .09). In 27 of the 40 (67%) encounters in which clinicians elicited patient concerns, the clinician interrupted the patient after a median of 11 seconds (interquartile range 7-22; range 3 to 234 s). Uninterrupted patients took a median of 6 s (interquartile range 3-19; range 2 to 108 s) to state their concern.

CONCLUSIONS

Clinicians seldom elicit the patient's agenda; when they do, they interrupt patients sooner than previously reported. Physicians in specialty care elicited the patient's agenda less often compared to physicians in primary care. Failure to elicit the patient's agenda reduces the chance that clinicians will orient the priorities of a clinical encounter toward specific aspects that matter to each patient.

Better care through an optimized mental health services continuum (Eastern Townships, Québec, Canada): A systematic and multisource literature review

INTRODUCTION

In 2014, the health authorities of the Eastern Townships (Québec, Canada) commissioned an evaluation of the mental health admission system for adults (GASMA) to identify the best GASMA organizational or structural elements and optimize the mental health services continuum.

METHODS

To develop better services, seven indicators (ie, accessibility to services, integration of levels of services, user satisfaction, guidance and management time, evaluation tools, professional composition, and interprofessional collaboration) were examined through four evaluation questions. A three-step systematic and multisource evaluation was realized. A systematic review of the scientific and gray literature was performed. This evaluation also included key informant opinions to contextualize results from this review.

RESULTS

Results from 91 scientific articles, 40 gray literature documents, and 10 interviews highlighted determinants and barriers associated with the examined indicators. From these results, 24 preliminary recommendations were formulated and discussed in a steering committee. These recommendations were then weighted and validated. This served to formulate three final recommendations.

CONCLUSION

To optimize the regional mental health services continuum, stakeholders should (1) implement a single-window access for adults with mental health needs, (2) develop alternative services based on users' needs, and (3) test the effectiveness of new methods, initiatives, and tools.

Patient priorities and the doorknob phenomenon in primary care: Can technology improve disclosure of patient stressors?

OBJECTIVE

Patients with multiple chronic conditions face many stressors (e.g. financial, safety, transportation stressors) that are rarely prioritized for discussion with the primary care provider (PCP). In this pilot randomized controlled trial we examined the effects of a novel technology-based intervention called Customized Care on stressor disclosure.

METHODS

The main outcomes were stressor disclosure, patient confidence and activation, as assessed by self-report and observational methods (transcribed and coded audio-recordings of the office visit).

RESULTS

Sixty patients were enrolled. Compared with care as usual, intervention patients were 6 times more likely to disclose stressors to the PCP (OR=6.16, 95% CI [1.53, 24.81], p=0.011) and reported greater stressor disclosure confidence (exp[B]=1.06, 95% CI [1.01, 1.12], p=0.028). No differences were found in patient activation or the length of the office visit.

CONCLUSION

Customized Care improved the likelihood of stressor disclosure without affecting the length of the PCP visit.

PRACTICE IMPLICATIONS

Brief technology-based interventions, like Customized Care could be made available through patient portals, or on smart phones, to prime patient-PCP discussion about difficult subjects, thereby improving the patient experience and efficiency of the visit.

Correlates of observer-rated active involvement in psychiatric treatment visits

Among people with serious mental illness, increased patient activation has been linked to a range of key recovery outcomes. To date, patient activation has been measured largely through self-report. The present study investigated correlates of a new tool that assesses active involvement through rating audio-recordings of treatment visits. The key domains of patient activation assessed in visits included: patients asking questions, discussing with providers instances of being active in managing illness outside the session, talking about goals, bringing up concerns, making evaluative statements about treatment, setting the agenda for the visit, and making requests about the course of treatment. The new coding scheme proved to be a feasible and reliable method for identifying multi-faceted behavioral indicators of patient activation. Contrary to our hypotheses, in a sample of 166 people diagnosed with severe mental illnesses, self-reported activation and observer-rated indices of activation were often not correlated or correlated in unexpected directions with the new behavioral measure of patient activation. This suggests the nature of patient activation may be complex and work is needed to understand how observer-rated and self-rated activation may predict differential recovery outcomes.

Getting on the same page: Communication, patient involvement and shared understanding of "decisions" in oncology

Background

Patients and clinicians do not often agree on whether a decision has been made about cancer care. This could be explained by factors related to communication quality and/or the type of decision being made.

Methods

We used a self‐developed coding scheme to code a random sample of 128 encounters in which patients and clinicians either agreed (n=64) or disagreed (n=64) that a cancer care decision was made and tested for associations between concordance and key communication behaviours. We also identified and characterized cancer care decisions by topic and level of patient involvement and looked for trends.

Results

We identified 378 cancer care decisions across 128 encounters. Explicit decisions were most commonly made about topics wherein decision control could be easily delegated to a clear and present expert (eg either the patient or the clinician). Related to this, level of patient involvement varied significantly by decision topic. Explicit decisions were rarely made in an observable way about social, non‐clinical or self‐management related topics, although patients and clinicians both reported having made a cancer care decision in encounters where no decisions were observed. We found no association between communication behaviours and concordance in our sample.

Conclusions

What counts as a “decision” in cancer care may be constructed within disparate social roles that leave many agendas unaddressed and decisions unmade. Changing the content of conversations to encourage explicit decisions about self‐management and life context‐related topics may have greater value in enabling shared understanding than promoting communication behaviours among already high‐performing communicators.

Periodic health examinations and missed opportunities among patients likely needing mental health care

OBJECTIVES

Periodic health examinations (PHEs) are the most common reason adults see primary care providers. It is unknown if PHEs serve as a "safe portal" for patients with mental health needs to initiate care. We examined how physician communication styles impact mental health service delivery in PHEs.

STUDY DESIGN

Retrospective observational study using audio-recordings of 255 PHEs with patients likely to need mental health care.

METHODS

Mixed-methods examined the timing of a mental health discussion (MHD), its quality, and the relationship between MHD quality and physician practice styles. MHD quality was measured against evidence-based practices as a 3-level variable (evidence-based, perfunctory, or absent). Physician practice styles were measured by: visit length, verbal dominance, and elicitation of a patient's agenda. A generalized ordered logit model was used.

RESULTS

Many patients came with mental health concerns, as over 50% of the MHDs occurred in the first 5 minutes of the visit. One-third of the 255 patients had an evidence-based MHD, another third had a perfunctory MHD, and the remaining had no MHD. MHD quality was significantly associated with physician communication styles. Visits with physicians who tend to spend more time with patients, fully elicit patients' agendas, and let patients talk (instead of being verbally dominant) were more likely to deliver evidence-based MHD.

CONCLUSIONS

If done well, PHEs could be a safe portal for patients to seek mental health care, but most PHEs fell short. Improving PHE quality may require reimbursement for longer visits and coaching for physicians to more fully elicit patients' agendas and to listen more attentively.

Communication and decision-making in mental health: A systematic review focusing on Bipolar disorder

OBJECTIVES

To systematically review studies of communication and decision-making in mental health-based samples including BP patients.

METHODS

Qualitative systematic review of studies using PsychINFO, MEDLINE, SCOPUS, CINAHL, and EMBASE (January 2000-March 2015). One author assessed study eligibility, verified by two co-authors. Data were independently extracted by two authors, and cross-checked by another co-author. Two independent raters assessed eligible studies using a validated quality appraisal.

RESULTS

Of 519 articles retrieved, 13 studies were included (i.e., 10 quantitative/1 qualitative/1 mixed-methods). All were cross-sectional; twelve were rated good/strong quality (>70%). Four inter-related themes emerged: patient characteristics and patient preferences, quality of patient-clinician interactions, and influence of SDM/patient-centred approach on patient outcomes. Overall BP patients, like others, have unmet decision-making needs, and desire greater involvement. Clinician consultation behaviour influenced patient involvement; interpersonal aspects (e.g., empathy, listening well) fostered therapeutic relationships and positive patient outcomes, including: improved treatment adherence, patient satisfaction with care, and reduced suicidal ideation.

CONCLUSIONS

This review reveals a paucity of studies reporting bipolar-specific findings. To inform targeted BP interventions, greater elucidation of unmet decision-making needs is needed.

PRACTICE IMPLICATIONS

Eliciting patient preferences and developing a collaborative therapeutic alliance may be particularly important in BP, promoting improved patient outcomes.

Agenda-setting revisited: When and how do primary-care physicians solicit patients' additional concerns?

OBJECTIVE

Soliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve patients' health outcomes and satisfaction, and physicians' time management. We assess the distribution, content, and effectiveness of physicians' post-chief-complaint, agenda-setting questions.

METHODS

We coded videotapes/transcripts of 407 primary-, acute-care visits between adults and 85 general-practice physicians operating in 46 community-based clinics in two states representing urban and rural care. Measures are the incidence of physicians' questions, their linguistic format, position within visits, likelihood of being responded to, and the nature of such responses.

RESULTS

Physicians' questions designed to solicit concerns additional to chief concerns occurred in only 32% of visits (p<.001). Compared to questions whose communication format explicitly solicited 'questions' (e.g., "Do you have any questions?"), those that were formatted so as to allow for 'concerns' (e.g., "Any other concerns?") were significantly more likely to generate some type of agenda item (Chi(2) (1, N=131)=11.96, p=.001), and to do so more frequently when positioned 'early' vs. 'late' during visits (Chi(2) (1, N=73)=4.99, p=.025).

CONCLUSIONS

Agenda setting is comparatively infrequent. The communication format and position of physicians' questions affects patients' provision of additional concerns/questions.

PRACTICE IMPLICATIONS

Physicians should increase use of optimized forms of agenda setting.

Patient agenda setting in respiratory outpatients: A randomized controlled trial

Soliciting a patient's agenda (the reason for their visit, concerns and expectations) is fundamental to health care but if not done effectively outcomes can be adversely affected. Forms to help patients consider important issues prior to a consultation have been tested with mixed results. We hypothesized that using an agenda form would impact the extent to which patients felt their doctor discussed the issues that were important to them. Patients were randomized to receive an agenda form to complete whilst waiting or usual care. The primary outcome measure was the proportion of patients agreeing with the statement 'My doctor discussed the issues that were important to me' rated on a four-point scale. Secondary outcomes included other experience and satisfaction measures, consultation duration and patient confidence. There was no significant effect of agenda form use on primary or secondary outcomes. Post hoc exploratory analyses suggested possible differential effects for new compared to follow-up patients. There was no overall benefit from the form and a risk of detrimental impact on patient experience for some patients. There is a need for greater understanding of what works for whom in supporting patients to get the most from their consultation.

Deciding about (neo-)adjuvant rectal and breast cancer treatment: Missed opportunities for shared decision making

BACKGROUND

The first step in shared decision making (SDM) is creating choice awareness. This is particularly relevant in consultations concerning preference-sensitive treatment decisions, e.g. those addressing (neo-)adjuvant therapy. Awareness can be achieved by explicitly stating, as the 'reason for encounter', that a treatment decision needs to be made. It is unknown whether oncologists express such reason for encounter. This study aims to establish: 1) if 'making a treatment decision' is stated as a reason for the encounter and if not, what other reason for encounter is provided; and 2) whether mentioning that a treatment decision needs to be made is associated with enhanced patient involvement in decision making.

MATERIAL AND METHODS

Consecutive first consultations with: 1) radiation oncologists and rectal cancer patients; or 2) medical oncologists and breast cancer patients, facing a preference-sensitive treatment decision, were audiotaped. The tapes were transcribed and coded using an instrument developed for the study. Oncologists' involvement of patients in decision making was coded using the OPTION-scale.

RESULTS

Oncologists (N = 33) gave a reason for encounter in 70/100 consultations, usually (N = 52/70, 74%) at the start of the consultation. The reason for encounter stated was 'making a treatment decision' in 3/100 consultations, and 'explaining treatment details' in 44/100 consultations. The option of foregoing adjuvant treatment was not explicitly presented in any consultation. Oncologist' involvement of patients in decision making was below baseline (Md OPTION-score = 10). Given the small number of consultations in which the need to make a treatment decision was stated, we could not investigate the impact thereof on patient involvement.

CONCLUSION

This study suggests that oncologists rarely express that a treatment decision needs to be made in consultations concerning preference-sensitive treatment decisions. Therefore, patients might not realize that foregoing (neo-)adjuvant treatment is a viable choice. Oncologists miss a crucial opportunity to facilitate SDM.

What is agenda setting in the clinical encounter? Consensus from literature review and expert consultation

OBJECTIVE

To establish consensus on the core domains of agenda setting in consultations.

METHODS

We reviewed the healthcare literature and, using a modified Delphi technique to embrace both patient and clinician perspectives, conducted an iterative online survey, with 30 experts in health communication. Participants described agenda setting and rated the importance of proposed domains. Consensus was determined where the group median was ≥5 on a 7-point Likert-like response scale, and the interquartile range fell to within one point on this scale.

RESULTS

Relevant publications were identified in three overlapping bodies of healthcare literature. Survey respondents considered that agenda setting involved a process whereby patients and clinicians establish a joint focus for both their conversation and their working relationship. Consensus was obtained on six core domains: identifying patient talk topics, identifying clinician talk topics, agreement of shared priorities, establishing conversational focus, collaboration and engagement. New terminology--agenda mapping and agenda navigation--is proposed.

CONCLUSION

We identified core agenda setting domains that embraced patient and clinician perspectives.

PRACTICE IMPLICATIONS

An integrated conceptualization of agenda setting may now be used by researchers and educators in both clinician and patient focused interventions.

Why are you here again? Concordance between consumers and providers about the primary concern in recurring psychiatric visits

Patient-centered care has become increasingly important over the last decade, both in physical and mental health care. In support of patient-centered care, providers need to understand consumers׳ primary concerns during treatment visits. The current study explored what primary concerns were brought to recurring psychiatric visits for a sample of adults with severe mental illness (N=164), whether these concerns were concordant with those recognized by providers, and which factors predicted concordance. We identified 17 types of primary concerns, most commonly medications and symptoms, with only 50% of visits showing evidence of at least partial agreement between consumers and providers. Contrary to expectations, consumer demographics, activation, trust, and perceptions of patient-centeredness were not predictive, while greater preferences for autonomy predicted poorer agreement. Our findings highlight the need for interventions to promote a shared understanding of primary concerns in recurring psychiatric visits. Further attention is needed to ensure the provision of patient-centered care such that consumer concerns are acknowledged and addressed within recurring psychiatric visits.