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Ruben MA, Stosic MD. Documenting Race and Gender Biases in Pain Assessment and a Novel Intervention Designed to Reduce Biases. THE JOURNAL OF PAIN 2024:104550. [PMID: 38692397 DOI: 10.1016/j.jpain.2024.104550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 04/12/2024] [Accepted: 04/19/2024] [Indexed: 05/03/2024]
Abstract
Disparities in pain care are well-documented such that women and people of color have their pain undertreated and underestimated compared to men and White people. One of the contributors of the undertreatment of pain for people of color and women may be the inaccurate assessment of pain. Understanding the pain assessment process is an important step in evaluating the magnitude of and intervening on pain disparities in care. In the current work, we focus on documenting intersectional race and gender biases in pain assessment and present the results of a novel intervention for reducing these biases. Across 3 studies (N = 532) and a mini meta-analysis using real videotaped people in pain as stimuli, we demonstrate that observers disproportionately underestimated women of color's pain compared to all other groups (men of color, White women, and White men). In study 3 (N = 232), we show that a novel intervention focused on behavioral skill building (ie, practice and immediate feedback) significantly reduced observers' pain assessment biases toward marginalized groups compared to all other types of trainings (raising awareness of societal biases, raising awareness of self-biases, and a control condition). While it is an open question as to how long this type of intervention lasts, behavioral skills building around assessing marginalized people's pain more accurately is a promising training tool for health care professionals. PERSPECTIVE: This article demonstrates the underestimation of pain among people of color and women. We also found support that a novel intervention reduced observers' pain assessment biases toward marginalized groups. This could be used in medical education or clinical care to reduce intersectional pain care disparities.
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Affiliation(s)
- Mollie A Ruben
- Department of Psychology, University of Rhode Island, Kingston, Rhode Island.
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Bani M, Ardenghi S, Rampoldi G, Russo S, Strepparava MG. Impact of facemasks on psychotherapy: Clinician's confidence and emotion recognition. J Clin Psychol 2023; 79:1178-1191. [PMID: 36459660 PMCID: PMC9877818 DOI: 10.1002/jclp.23468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/04/2022] [Accepted: 11/20/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES Facial emotion recognition is a key component of human interactions, and in clinical relationships contributes to building and maintaining the therapeutic alliance with patients. The introduction of facemasks has reduced the availability of facial information in private and professional relationships. This study aimed to assess the impact of facemasks on clinicians' perception of clinical interactions as well as their ability to read facial expressions. METHODS In this cross-sectional study, a purposive sample of 342 clinical psychologists or psychotherapists completed an online survey including the assessment of burnout, alexithymia, emotion dysregulation, and self-perceived ability to build effective relationships and communication with patients with/without facemasks. Participants were randomly assigned to the standardized facial emotion recognition task Diagnostic Analysis of Nonverbal Accuracy FACES 2-Adult Faces including 24 faces representing anger, fear, sadness, and happiness. RESULTS Facemasks impaired the self-perceived ability of clinicians to build effective relationships and communicate with patients and reduced satisfaction in clinical encounters. The ability of clinicians to recognize facial emotions is significantly reduced for masked happy and angry faces, but not for sad and afraid ones. The perceived difficulty in building good relationships and communication with patients had a positive correlation with alexithymia and emotion dysregulation; higher levels of discomfort when wearing facemasks had a positive correlation with burnout and emotion dysregulation. CONCLUSION Facemasks reduced clinicians' self-confidence in clinical encounters with patients wearing facemasks, but their facial emotion recognition performance was only partially impaired.
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Affiliation(s)
- Marco Bani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza (MB), Italy
| | - Stefano Ardenghi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza (MB), Italy
| | - Giulia Rampoldi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza (MB), Italy
| | - Selena Russo
- School of Medicine and Surgery, University of Milano-Bicocca, Monza (MB), Italy
| | - Maria Grazia Strepparava
- School of Medicine and Surgery, University of Milano-Bicocca, Monza (MB), Italy.,Department of Mental Health, Clinical Psychology Unit, San Gerardo Hospital, ASST-Monza, Monza (MB), Italy
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Bejarano G, Csiernik B, Young JJ, Stuber K, Zadro JR. Healthcare students' attitudes towards patient centred care: a systematic review with meta-analysis. BMC MEDICAL EDUCATION 2022; 22:324. [PMID: 35477455 PMCID: PMC9047330 DOI: 10.1186/s12909-022-03371-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 04/11/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Patient centred care is commonly recommended in clinical practice guidelines to improve patient outcomes and reduce healthcare costs. Identifying measurement tools used to assess healthcare students' attitudes towards patient centered care and determining their attitudes is the first step to ensuring patient centred care is provided in the future. The primary aim of this review was to describe the measurement tools used to assess healthcare students' attitudes towards patient centred care. The secondary aim was to quantify healthcare students' attitudes towards patient centred care. METHODS An electronic database search was conducted in MEDLINE, EMBASE, CINAHL from inception until March 1, 2021, with combined terms relating to 'patient centred care', 'attitudes', and 'healthcare students'. Studies that quantitatively assessed healthcare students' attitudes towards patient centred care were included. Measurement tools used in the included studies were qualitatively described. Meta-analysis was conducted to quantify healthcare students' attitudes towards patient centred care and assess the respective influence of gender, profession, and study geographical location on healthcare students' attitudes towards patient centred care. RESULTS The electronic search identified 3948 total studies. One hundred twenty-nine full texts were screened, and 49 studies were included. There were 16 measurement tools used to assess healthcare students' attitudes towards patient centered care. Most studies (53%, n = 26) used the Patient-Practitioner Orientation Scale (PPOS) to assess patient centered care. Meta-analyses of 20 studies with 26 total groups resulted in a pooled mean PPOS score of 4.16 on a 0-6 scale (95% Confidence Interval [CI]: 3.95, 4.37), indicating low attitudes towards patient centered care. Additional analyses found that women have significantly higher attitudes towards patients centred care than men (pooled effect 0.14 [95% CI: 0.05, 0.23], n = 8 studies) and mean PPOS scores appear similar among sub-groups of only medical students (pooled mean 4.13, 95% CI: 3.85, 4.42, n = 13 studies) and only American healthcare students (pooled mean 4.49, 95% CI: 4.35, 4.64, n = 5 studies). CONCLUSIONS Several different measurement tools have been used to assess healthcare students' attitudes towards patient centred care, but the most commonly used is the PPOS. Our results indicate that healthcare students have low attitudes towards patient centred care. Future studies should evaluate if attitudes towards patient centred care can be improved during healthcare education.
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Affiliation(s)
- Geronimo Bejarano
- Michael & Susan Dell Center for Healthy Living, The University of Texas Health Science Center at Houston (UTHealth), 1616 Guadalupe Street, Austin, TX, 78702, USA.
| | - Ben Csiernik
- Canadian Memorial Chiropractic College, Toronto, Canada
| | - James J Young
- Canadian Memorial Chiropractic College, Toronto, Canada
- Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Kent Stuber
- Canadian Memorial Chiropractic College, Toronto, Canada
| | - Joshua R Zadro
- Sydney School of Public Health, Faculty of Medicine and Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia
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Berney A, Carrard V, Berney S, Schlegel K, Gaume J, Gholam M, Bart PA, Preisig M, Wac K, Schmid Mast M, Bourquin C. Study protocol for the ETMED-L project: longitudinal study of mental health and interpersonal competence of medical students in a Swiss university using a comprehensive framework of empathy. BMJ Open 2021; 11:e053070. [PMID: 34862292 PMCID: PMC8647527 DOI: 10.1136/bmjopen-2021-053070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Physician interpersonal competence is crucial for patient care. How interpersonal competence develops during undergraduate medical education is thus a key issue. Literature on the topic consists predominantly of studies on empathy showing a trend of decline over the course of medical school. However, most existing studies have focused on narrow measures of empathy. The first aim of this project is to study medical students' interpersonal competence with a comprehensive framework of empathy that includes self-reported cognitive and affective empathy, performance-based assessments of emotion recognition accuracy, and a behavioural dimension of empathy. The second aim of the present project is to investigate the evolution of mental health during medical school and its putative link to the studied components of interpersonal competence. Indeed, studies documented a high prevalence of mental health issues among medical students that could potentially impact their interpersonal competence. Finally, this project will enable to test the impact of mental health and interpersonal competence on clinical skills as evaluated by experts and simulated patients. METHODS AND ANALYSIS This project consists of an observational longitudinal study with an open cohort design. Each year during the four consecutive years of the project, every medical student (curriculum years 1-6) of the University of Lausanne in Switzerland will be asked to complete an online questionnaire including several interpersonal competence and mental health measures. Clinical skills assessments from examinations and training courses with simulated patients will also be included. Linear mixed models will be used to explore the longitudinal evolutions of the studied components of interpersonal competence and mental health as well as their reciprocal relationship and their link to clinical skills. ETHICS AND DISSEMINATION The project has received ethical approval from the competent authorities. Findings will be disseminated through internal, regional, national and international conferences, news and peer-reviewed journals.
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Affiliation(s)
- Alexandre Berney
- Psychiatric Liaison Service, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Valerie Carrard
- Psychiatric Liaison Service, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Sylvie Berney
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Service of General Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Katja Schlegel
- Institute of Psychology, University of Bern, Bern, Switzerland
| | - Jacques Gaume
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Alcohol Treatment Centre, Lausanne University Hospital, Lausanne, Switzerland
| | - Mehdi Gholam
- Institute of Mathematics, EPFL, Lausanne, Switzerland
| | - Pierre-Alexandre Bart
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Department of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Martin Preisig
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Centre for Psychiatric Epidemiology and Psychopathology, Lausanne University Hospital, Lausanne, Switzerland
| | - Katarzyna Wac
- Department of Computer Science, University of Geneva, Geneva, Switzerland
| | - Marianne Schmid Mast
- Department of Organizational Behavior, University of Lausanne, Lausanne, Switzerland
| | - Céline Bourquin
- Psychiatric Liaison Service, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Abstract
PURPOSE OF REVIEW Our goal was to provide healthcare professionals (HCPs) with evidence-based data about what can be done to handle prognostic discussions with empathy. RECENT FINDINGS First, disclosing prognosis involves a good reason to do so and making sure that the patient will be able to process the discussion. Second, communication tips are given for the three dimensions of empathy: "establishing rapport with the patient," which should not be overlooked; the emotional dimension, which involves an accurate understanding of the patient and communication skills; and the "active/positive" dimension which is about giving hope, explaining things clearly and helping patients take control with shared decision-making and a planned future. Although communication tips are helpful, empathy training should be based more on the development of HCPs' emotional skills, in order to help them regulate their emotions and thus be more comfortable with those of patients and families. Furthermore, research into empathy toward minorities and relatives is needed.
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Affiliation(s)
- Sophie Lelorain
- Univ. Lille, CNRS, UMR 9193 - SCALab - Sciences Cognitives et Sciences Affectives, F-59000, Lille, France.
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Schlegel K. The Effects of Emotion Recognition Training on Interpersonal Effectiveness. BASIC AND APPLIED SOCIAL PSYCHOLOGY 2021. [DOI: 10.1080/01973533.2021.1883021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Schlegel K, Gugelberg HMV, Makowski LM, Gubler DA, Troche SJ. Emotion Recognition Ability as a Predictor of Well-Being During the COVID-19 Pandemic. SOCIAL PSYCHOLOGICAL AND PERSONALITY SCIENCE 2021. [DOI: 10.1177/1948550620982851] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examined emotion recognition ability (ERA) as a predictor of positive and negative affect in two Australian and one German-speaking samples (total N = 469) during the first 2 weeks of major public life restrictions in the COVID-19 pandemic in March/April 2020. Individuals with higher ERA did not report more positive affect, but they felt less burdened and reported less negative affect. This association was fully mediated by lower COVID-19-related media consumption and less negative affect after reading an eyewitness report from an Italian city with a high COVID-19 death toll. However, higher ERA was also related to arguing more with close others. For low-to-medium ERA, an adaptive cognitive emotion regulation style predicted lower media consumption and for medium-to-high ERA, a maladaptive regulation style marginally increased the perceived likelihood of experiencing a similar situation as in Italy, suggesting that regulation style may moderate the ERA–affect relationship.
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Schlegel K, Palese T, Mast MS, Rammsayer TH, Hall JA, Murphy NA. A meta-analysis of the relationship between emotion recognition ability and intelligence. Cogn Emot 2019; 34:329-351. [PMID: 31221021 DOI: 10.1080/02699931.2019.1632801] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The ability to recognise others' emotions from nonverbal cues (emotion recognition ability, ERA) is measured with performance-based tests and has many positive correlates. Although researchers have long proposed that ERA is related to general mental ability or intelligence, a comprehensive analysis of this relationship is lacking. For instance, it remains unknown whether the magnitude of the association varies by intelligence type, ERA test features, as well as demographic variables. The present meta-analysis examined the relationship between ERA and intelligence based on 471 effect sizes from 133 samples and found a significant mean effect size (controlled for nesting within samples) of r = .19. Different intelligence types (crystallized, fluid, spatial, memory, information processing speed and efficiency) yielded similar effect sizes, whereas academic achievement measures (e.g. SAT scores) were unrelated to ERA. Effect sizes were higher for ERA tests that simultaneously present facial, vocal, and bodily cues (as compared to tests using static pictures) and for tests with higher reliability and more emotions. Results were unaffected by most study and sample characteristics, but effect size increased with higher mean age of the sample. These findings establish ERA as sensory-cognitive ability that is distinct from, yet related to, intelligence.
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Affiliation(s)
- Katja Schlegel
- Institute for Psychology, University of Bern, Bern, Switzerland
| | - Tristan Palese
- Faculty of Business and Economics, University of Lausanne, Lausanne, Switzerland
| | - Marianne Schmid Mast
- Faculty of Business and Economics, University of Lausanne, Lausanne, Switzerland
| | | | - Judith A Hall
- Department of Psychology, Northeastern University, Boston, MA, USA
| | - Nora A Murphy
- Department of Psychology, Loyola Marymount University, Los Angeles, CA, USA
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Schmid Mast M, Hall JA. The Impact of Interpersonal Accuracy on Behavioral Outcomes. CURRENT DIRECTIONS IN PSYCHOLOGICAL SCIENCE 2018. [DOI: 10.1177/0963721418758437] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Interpersonal accuracy, the ability to correctly assess other people’s states or traits, has been studied for over 60 years, and many correlates have been uncovered. Furthermore, theorists routinely propose that having this kind of skill matters for social and workplace outcomes. However, much of the empirical work concerned with interpersonal accuracy does not directly address real-life outcomes for people who have, or lack, this skill. The present article summarizes literature pointing to behavioral correlates of interpersonal accuracy and illustrates when and why interpersonal accuracy is related to favorable interaction outcomes. There seems to be no specific behavior associated with high interpersonal accuracy. Instead, interpersonal accuracy seems to foster behavioral adaptability, the ability to change one’s behavior to match the expectations of the social interaction partner. This behavioral adaptability might be responsible for the positive interaction outcomes related to interpersonal accuracy. We illustrate the mechanism and boundary conditions underlying and framing how interpersonal accuracy affects interaction outcomes and discuss future directions in research on interpersonal accuracy.
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Kraft-Todd GT, Reinero DA, Kelley JM, Heberlein AS, Baer L, Riess H. Empathic nonverbal behavior increases ratings of both warmth and competence in a medical context. PLoS One 2017; 12:e0177758. [PMID: 28505180 PMCID: PMC5432110 DOI: 10.1371/journal.pone.0177758] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 05/03/2017] [Indexed: 01/10/2023] Open
Abstract
In medicine, it is critical that clinicians demonstrate both empathy (perceived as warmth) and competence. Perceptions of these qualities are often intuitive and are based on nonverbal behavior. Emphasizing both warmth and competence may prove problematic, however, because there is evidence that they are inversely related in other settings. We hypothesize that perceptions of physician competence will instead be positively correlated with perceptions of physician warmth and empathy, potentially due to changing conceptions of the physician’s role. We test this hypothesis in an analog medical context using a large online sample, manipulating physician nonverbal behaviors suggested to communicate empathy (e.g. eye contact) and competence (the physician’s white coat). Participants rated physicians displaying empathic nonverbal behavior as more empathic, warm, and more competent than physicians displaying unempathic nonverbal behavior, adjusting for mood. We found no warmth/competence tradeoff and, additionally, no significant effects of the white coat. Further, compared with male participants, female participants perceived physicians displaying unempathic nonverbal behavior as less empathic. Given the significant consequences of clinician empathy, it is important for clinicians to learn how nonverbal behavior contributes to perceptions of warmth, and use it as another tool to improve their patients’ emotional and physical health.
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Affiliation(s)
- Gordon T. Kraft-Todd
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Psychology, Yale University, New Haven, Connecticut, United States of America
- * E-mail:
| | - Diego A. Reinero
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Psychology, New York University, New York, New York, United States of America
| | - John M. Kelley
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Psychology, Endicott College, Beverly, Massachusetts, United States of America
| | - Andrea S. Heberlein
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Psychology, Boston College, Chestnut Hill, Massachusetts, United States of America
| | - Lee Baer
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
| | - Helen Riess
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
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Goh JX, Hall JA, Rosenthal R. Mini Meta-Analysis of Your Own Studies: Some Arguments on Why and a Primer on How. SOCIAL AND PERSONALITY PSYCHOLOGY COMPASS 2016. [DOI: 10.1111/spc3.12267] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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October TW, Hinds PS, Wang J, Dizon ZB, Cheng YI, Roter DL. Parent Satisfaction With Communication Is Associated With Physician's Patient-Centered Communication Patterns During Family Conferences. Pediatr Crit Care Med 2016; 17:490-7. [PMID: 27058750 PMCID: PMC4893980 DOI: 10.1097/pcc.0000000000000719] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the association between physician's patient-centered communication patterns and parental satisfaction during decision-making family conferences in the PICU. DESIGN Single-site, cross-sectional study. SETTING Forty-four-bed PICUs in a free-standing children's hospital. PARTICIPANTS Sixty-seven English-speaking parents of 39 children who participated in an audiorecorded family conference with 11 critical care attending physicians. MEASUREMENTS AND MAIN RESULTS Thirty-nine family conferences were audiorecorded. Sixty-seven of 77 (92%) eligible parents were enrolled. The conference recordings were coded using the Roter Interaction Analysis System and a Roter Interaction Analysis System-based patient-centeredness score, which quantitatively evaluates the conversations for physician verbal dominance and discussion of psychosocial elements, such as a family's goals and preferences. Higher patient-centeredness scores reflect higher proportionate dialogue focused on psychosocial, lifestyle, and socioemotional topics relative to medically focused talk. Parents completed satisfaction surveys within 24 hours of the conference. Conferences averaged 45 minutes in length (SD, 19 min), during which the medical team contributed 73% of the dialogue compared with parental contribution of 27%. Physicians dominated the medical team, contributing 89% of the team contribution to the dialogue. The majority of physician speech was medically focused (79%). A patient-centeredness score more than 0.75 predicted parental satisfaction (β = 12.05; p < 0.0001), controlling for the length of conference, child severity of illness, parent race, and socioeconomic status. Parent satisfaction was negatively influenced by severity of illness of the patient (β = -4.34; p = 0.0003), controlling for previously mentioned factors in the model. CONCLUSIONS Parent-physician interactions with more patient-centered elements, such as increased proportions of empathetic statements, question asking, and emotional talk, positively influence parent satisfaction despite the child's severity of illness.
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Affiliation(s)
- Tessie W October
- 1Department of Critical Care Medicine, Children's National Health Systems, Washington, DC. 2Department of Pediatrics, George Washington University School of Medicine, Washington, DC. 3Department of Nursing Research and Quality Outcomes, Children's National Health Systems, Washington, DC. 4Center for Translational Science, Department of Pediatrics, Children's National Health Systems, Washington, DC. 5Department of Epidemiology and Biostatistics, George Washington University School of Medicine, Washington, DC. 6Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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