The patient-centred clinical method. 1. A model for the doctor-patient interaction in family medicine

Stories that matter: a qualitative study of general practitioners' reflections and experiences of exploring patients' impactful life stories

PURPOSE

There is solid evidence of the impact of life experiences on health. Yet, knowledge of how general practitioners (GPs) relate to patients' stories of such experiences is sparse. This study explored GPs' reflections and experiences concerning managing potentially impactful patient stories.

METHODS

We conducted four focus group interviews among Norwegian and Danish GPs and analysed them using Reflexive thematic analysis.

RESULTS

Three main themes were developed. First, GPs apply various strategies to recognize and unfold impactful stories. Second, they attribute diverse purposes to engaging with these stories, from viewing them as instrumentally useful to recognizing their intrinsic value. These views influence GPs' objectives and strategies when managing impactful stories. The instrumental utility approach can lead to an unfair dismissal of impactful stories. Finally, the commitment of some of the GPs to patients' impactful stories is considered fulfilling and highly satisfactory but also associated with external resistance.

CONCLUSIONS

Patients and GPs encounter difficulties in addressing impactful stories, which resonate with the theory of epistemic injustice. Nevertheless, engaging with these stories is vital for providing ethically grounded and meaningful primary care. The paper proposes strategies and a conceptual framework to support work with impactful stories in clinical practice.

Recommending surgical or non-surgical treatments in medical consultations: The case in Chinese contexts

OBJECTIVES

This study examines the design and delivery of surgical and non-surgical treatment recommendations in China.

METHODS

We examined 936-minute recordings of medical consultations using conversation analysis. Data were collected from two tertiary hospitals in China. They are authentic interactions from the departments of orthopedics and proctology.

RESULTS

Non-surgical treatment recommendations are proposed after diagnoses delivery. They are delivered in straightforward and simple form, and as already determined. Surgical treatment recommendations are proposed early and sometimes occupy the diagnostic slot. They are delivered in straightforward, simple, but mitigated form. These recommendations are formulated as a matter that is not fully settled and requires further discussions.

CONCLUSIONS

Patients' stances toward specific treatments are made manifest in the tailoring of doctors' recommendations. The formulations of treatment recommendations exhibit doctors' understanding of what patients are anticipating or resisting. Chinese patients' preference for non-surgical treatments over surgery is reflected in how doctors present the recommendations for surgical and non-surgical treatments.

PRACTICE IMPLICATIONS

Patients' concerns vary depending on the treatments recommended. Doctors should incorporate these concerns into their medical advice. In China, for non-surgical patients, the focus is on clearly explaining the treatment plan. For surgical patients, doctors should first assist them in making informed treatment decisions.

Relationally competent attitudes and actions: a systematic review of general practice literature

OBJECTIVE

To explore core elements from Teachers' Relational Competence in general practice literature regarding building relationships in consultations, specifying actions doctors take to create and maintain relationship quality with patients. This systematic literature review aims to map and propose a similar framework for the doctor-patient relationship.

BACKGROUND

The doctor-patient relationship, a well-researched yet complex field, often lacks clear descriptions. In recent definitions of patient-centred medicine, the responsibility of this relationship falls on the doctor, though how both relationship and responsibility is enacted needs clarification. Pedagogical literature on the student-teacher relationship provides a framework for relational competence, incorporating the needs and interactions between teacher and student and their alignment with institutional goals.

METHODS

A systematic review of two databases yielded 1256 hits. After screening, 15 studies were included and assessed. A qualitative synthesis was conducted through iterative and thematic deductive analysis.

RESULTS

Four relationally competent attitudes identified were: Attention to emotion, Devotion, Mentalization, and Time-oriented presence. Four relationally competent actions identitfied were: Being open, Attunement, Offering Support, and Using humor. Additionally, Trust and Continued connectedness were found as components of both attitudes and actions.

CONCLUSION

An explanatory framework for professional relational competence for GPs includes concrete actions and specific attitudes before and during consultations. These consist of four key attitudes and four categories of actions with several subgroups of actions. Two additional components to the framework was found.

Development of a PROM to measure patient-centredness in chronic care consultations in primary care

INTRODUCTION

Validated patient-reported outcome measures (PROMs) are crucial for assessing patients' experiences in the healthcare system. Both clinically and theoretically, patient-centered consultations are essential in patient-care, and are often suggested as the optimal strategy in caring for patients with multimorbidity.

AIM

To either identify or develop and validate a patient-reported outcome measure (PROM) to assess patient-centredness in consultations for patients with multimorbidity in general practice.

METHODS

We attempted to identify an existing PROM through a systematic literature review. If a suitable PROM was not identified, we planned to (1) construct a draft PROM based on items from existing PROMs, (2) conduct group and individual interviews among members of the target population to ensure comprehensibility, comprehensiveness and relevance, and (3) perform a psychometric validation in a broad sample of patients from primary care.

RESULTS

We did not identify an eligible PROM in the literature review. The item extraction and face validity meetings resulted in a new PROM consisting of 47 items divided into five domains: biopsychosocial perspective; `patient-as-person'; sharing power and responsibility; therapeutic alliance; and coordinated care. The interviews resulted in a number of changes to the layout and phrasing as well as the deletion of items. The PROM used in the psychometric validation consisted of 28 items. Psychometric validation showed high internal consistency, overall high reliability, and moderate fit indices in the confirmatory factor analysis for all five domains. Few items demonstrated differential item functioning concerning variables such as age, sex, and education.

CONCLUSIONS

This study successfully developed and validated a PROM to measure patient-centredness in consultations for patients with multimorbidity. The five domains demonstrated high reliability and validity, making it a valuable tool for measuring patient-centredness of consultations in general practice.

TRIAL REGISTRATION

Trial registration number (data for psychometric validation): https://clinicaltrials.gov : NCT05676541 Registration Date: 2022-12-16.

GPs' reflections on prescribing addictive hypnotics to older people: a qualitative study

BACKGROUND

The European guideline for the diagnosis and treatment of insomnia recommends, for all age groups, only restrictive, short-term, and periodic use of potentially addictive hypnotics. As in other European countries, in Norway, actual practice involving older patients differs substantially from this recommendation, as shown by the persistent high frequency of regular prescriptions of addictive hypnotics.

AIM

To explore experienced Norwegian GPs' views of the regular prescription of addictive hypnotics to patients aged >70 years living at home.

DESIGN & SETTING

In-depth individual interviews of a purposive sample of experienced specialists in family medicine at GP offices in Southern Norway.

METHOD

The interviews used a semi-structured interview guide and were performed between June 2022 and January 2023. Reflexive thematic cross-case analysis was used to analyse the data.

RESULTS

Most of the 11 GPs interviewed had more than 10 older patients who were prescribed hypnotics for daily use and the same number for intermittent prescription. Almost all prescriptions were of z-hypnotics. The GPs knew this was contrary to the guideline. Many were at ease with this fact. They emphasised the need to avoid creating new dependencies. The GPs considered these patients a selected minority within this age group with serious sleep problems, for whom few realistic alternatives were available and whose tolerance over time was better than expected. This logic of pragmatic practice reflected a patient-centred approach and respect for the patient's view in a shared decision-making process, combined with challenges of limited alternatives and resources.

CONCLUSION

A 'zero vision' on the prescription of addictive hypnotics to older people may neither be prudent nor realistic in the context of general practice.

Medical encounters with young unaccompanied refugees: a qualitative study among general practitioners and physicians in migrant health clinics in Norway and Denmark

OBJECTIVE

This study examines the experiences of clinical encounters with young unaccompanied refugees in Norway and Denmark among both general practitioners (GPs) and physicians in migrant health clinics (MHC physicians), and it identifies important aspects that should be taken into consideration for improving the quality of healthcare for these patients.

METHODOLOGY

Ten individual in-depth interviews with physicians in Norway and Denmark were conducted and analysed using interpretative phenomenology. Axel Honneth's theory of recognition was our theoretical lens.

RESULTS

The physicians described these patients as vulnerable individuals. They adopted a variety of approaches in their encounters with young unaccompanied refugees spanning from a 'holistic' to an 'instrumental' approach. Those who described an instrumental approach focused on understanding and categorising symptoms from a biomedical perspective, while those describing a holistic approach considered 'the whole person' within their everyday context. Those with a more holistic approach also expressed the importance of interdisciplinary collaboration and defined work-divide. Relationships of trust between physicians and the young unaccompanied refugees were shown to be an important facilitator for adequate healthcare, but this required availability, continuity, and dialogue.

CONCLUSION

Our results highlight how physicians' encounters with vulnerable young refugees actualize previously documented contrasts between holistic and instrumental approaches in clinical work. We argue that recognition in healthcare is conditional on physicians taking a holistic approach. This approach can help build relationships of trust and can support interdisciplinary collaboration. Moreover, such an approach can facilitate the essential components of Honneth's theory of recognition, namely social esteem and emotional support. Barriers to greater interdisciplinary collaboration in healthcare services need to be addressed at the system level.

Exploring organisational support to apply best practice in the sick leave and rehabilitation process from a multiprofessional front-line perspective: a qualitative study

OBJECTIVES

To explore the experiences of organisational support to apply best practices held by front-line employees working with patients in the sick leave and rehabilitation process (SRP).

DESIGN

Qualitative study design. Data were collected with focus group interviews in Region Västra Götaland, Sweden. Participants discussed their perceptions of organisational support to apply the best SRP practice in a primary healthcare context.

PARTICIPANTS

Purposive sampling was conducted to capture a range of experiences among various professionals, including general practitioners (n=6), rehabilitation coordinators, other primary healthcare professionals (n=13) and caseworkers from the Social Insurance Agency, Employment Agency and Social Services (n=12).

RESULTS

Informants perceived that their good intentions to work for the best interests of each patient were not enough to overcome inadequate organisational prerequisites. Identified themes described unequal care due to significant practice variation, conflicting messages, a situation where the patient loses control and mismatch between available support and patient needs. Perceived potential consequences for the patients included legal uncertainty of assessments, harmful passivity of the individual through misapplied sick leave and the risk of overlooking non-medical factors that could be managed in a safer and more well-adapted way.

CONCLUSIONS

Neither guidelines on person-centred approaches, nor laws regulating the right to coordinated individual planning, seem to have fulfilled the intended purpose. The informants depicted an SRP obstructing individualised care, thus risking worsening patients' well-being and abilities. The opportunities to improve the quality of the processes within the SRP, and simultaneously make them more effective, appear to be extensive.

Professionals' experiences of what affects health outcomes in the sick leave and rehabilitation process-A qualitative study from primary care level

OBJECTIVE

To explore frontline employees' experiences of how to create a purposeful sick leave and rehabilitation process (SRP) with the best interest of patients' long-term health in focus.

METHODS

Qualitative design based on focus group interviews in a primary care context in Region Västra Götaland, Sweden. Strategically selected professionals from different SRP organizations discussed sick leave outcomes and the rehabilitation process. Analysis was performed with Systematic text condensation.

SUBJECTS

General practitioners (n = 6), rehabilitation coordinators and/or healthcare professionals from primary healthcare (n = 13), caseworkers from the Social Insurance Agency, the Employment Agency, and Social Services (n = 12).

RESULTS

The outcome of the SRP was described to depend upon the extent to which the process meets patients' bio-psycho-social needs. Aspects considered crucial were: 1) early bio-psycho-social assessments, including medical specialist consultations when needed, 2) long-term realistic planning of sick leave and rehabilitation alongside medical treatment, 3) access to a wide range of early rehabilitative and supportive interventions, including situation-based, non-medical practical problem solving, and 4) trusting relationships over time for all involved professions and roles to maximize process quality and person-centeredness. A gap between the desired scope of the SRP and existing guidelines was identified.

CONCLUSION

Interviewees perceived that successful outcomes from the sick leave and rehabilitation process in a primary care context depend on consensus, person-centeredness, and relationship continuity for all involved professions. An extended process scope and relationship continuity for all involved professionals were suggested to improve process outcomes.

Cultural Competence Interventions in European Healthcare: A Scoping Review

Europe is undergoing rapid social change and is distinguished by its cultural superdiversity. Healthcare is facing an increasing need for professionals to adapt to this environment. Thus, the promotion of cultural competence in healthcare has become a priority. However, the training being developed and their suitability for the European context are not well known. The aim of this qualitative study has been to map the scientific literature in order to comprehend the current state of research on this topic. For this purpose, we conducted a systematic scoping review of the empirical publications focused on cultural competence interventions for healthcare professionals in European countries. The search was conducted in eight thematic (PsycINFO, MedLine, and PubPsych) and multidisciplinary databases (Academic Search Ultimate, E-Journals, Scopus, ProQuest, and Web of Science) to identify relevant publications up to 2023. Results were presented qualitatively. Out of the initial 6506 records screened, a total of 63 publications were included. Although the interventions were implemented in 23 different European countries, cultural competence interventions have not been widely adopted in Europe. Significant heterogeneity was observed in the conception and operacionalización of cultural competence models and in the implementation of the interventions. The interventions have mostly aimed at improving healthcare for minority population groups and have focused on the racial and ethnic dimensions of the individual. Future research is needed to contribute to the conceptual development of cultural competence to design programs tailored to European superdiversity. This scoping review has been registered in OSF and is available for consultation.

Patients as teachers: a within-subjects randomized pilot experiment of patient-led online learning modules for health professionals

PURPOSE

Many health professions education programs involve people with lived experience as expert speakers. Such presentations may help learners better understand the realities of living with chronic illness or experiencing an acute health problem. However, lectures from only one or a small number of people may not adequately illustrate the perspectives and experiences of a diverse patient cohort. Additionally, logistical constraints such as public health restrictions or travel barriers may impede in-person presentations, particularly among people who have more restrictions on their time. Health professions education programs may benefit from understanding the potential effects of online patient-led presentations with a diverse set of speakers. We aimed to explore whether patient-led online learning modules about diabetes care would influence learners' responses to clinical scenarios and to collect learners' feedback about the modules.

METHOD

This within-subjects randomized experiment involved 26 third-year medical students at Université Laval in Quebec, Canada. Participation in the experiment was an optional component within a required course. Prior to the intervention, participating learners responded to three clinical scenarios randomly selected from a set of six such scenarios. Each participant responded to the other three scenarios after the intervention. The intervention consisted of patient-led online learning modules incorporating segments of narratives from 21 patient partners (11 racialized or Indigenous) describing why and how clinicians could provide patient-centered care. Working with clinical teachers and psychometric experts, we developed a scoring grid based on the biopsychosocial model and set 0.6 as a passing score. Independent evaluators, blinded to whether each response was collected before or after the intervention, then scored learners' responses to scenarios using the grid. We used Fisher's Exact test to compare proportions of passing scores before and after the intervention.

RESULTS

Learners' overall percentage of passing scores prior to the intervention was 66%. Following the intervention, the percentage of passing scores was 76% (p = 0.002). Overall, learners expressed appreciation and other positive feedback regarding the patient-led online learning modules.

DISCUSSION

Findings from this experiment suggest that learners can learn to provide better patient-centered care by watching patient-led online learning modules created in collaboration with a diversity of patient partners.

Validating the Effectiveness of the Patient-Centered Cancer Care Framework by Assessing the Impact of Work System Factors on Patient-Centered Care and Quality of Care: Interview Study With Newly Diagnosed Cancer Patients

BACKGROUND

Patients with cancer who have recently been diagnosed have distinct requirements compared to cancer survivors. It is crucial to take into account their unique needs to ensure that they make informed decisions and are receptive to the care provided.

OBJECTIVE

This study suggested a framework titled Effectiveness of Patient-Centered Cancer Care that considers the needs of newly diagnosed patients with cancer and related work system factors. This study investigated how work system factors influence the perceptions of patient-centered care, quality of care, and associated outcomes among newly diagnosed patients with cancer. Patient-centered care is defined in terms of workload and communication considerations, whereas the quality of care is assessed through indicators such as trust in physicians, satisfaction with care, and perceptions of technology.

METHODS

This study used qualitative data collected through interviews with newly diagnosed patients with cancer (N=20) right after their first visits with their physicians. Thematic analysis was conducted to validate the 5 hypotheses of the framework, mapping the interactions among quality of care, patient-centered care, and work system factors.

RESULTS

We found that workload and patient-centered communication impact the quality of care and that the work system elements impact the patient-centeredness (workload and communication) and the quality of care (trust in physicians, satisfaction with care, and perception of technology use).

CONCLUSIONS

Qualitatively validating the proposed Effectiveness of Patient-Centered Cancer Care framework, this study demonstrated its efficacy in elucidating the interplay of various factors. The framework holds promise for informing interventions geared toward enhancing patients' experiences during their initial visits after diagnosis. There is a pressing need for heightened attention to the organizational design, patient processes, and collaborative efforts among diverse stakeholders and providers to optimize the overall patient experience.

Communication in Primary Healthcare: A State-of-the-Art Literature Review of Conversation-Analytic Research

We report the first state-of-the-art review of conversation-analytic (CA) research on communication in primary healthcare. We conducted a systematic search across multiple bibliographic databases and specialist sources and employed backward and forward citation tracking. We included 177 empirical studies spanning four decades of research and 16 different countries/health systems, with data in 17 languages. The majority of studies originated in United States and United Kingdom and focused on medical visits between physicians and adult patients. We generated three broad research themes in order to synthesize the study findings: managing agendas, managing participation, and managing authority. We characterize the state-of-the-art for each theme, illustrating the progression of the work and making comparisons across different languages and health systems, where possible. We consider practical applications of the findings, reflect on the state of current knowledge, and suggest some directions for future research. Data reported are in multiple languages.

Conceptualizing negotiation in the clinical encounter - A scoping review using principles from critical interpretive synthesis

OBJECTIVE

Negotiation as an analytical concept in research about clinical encounters is vague. We aim to provide a conceptual synthesis of key characteristics of the process of negotiation in clinical encounters based on a scoping review.

METHODS

We conducted a scoping review of relevant literature in Embase, Psych Info, Global Health and SCOPUS. We included 25 studies from 1737 citations reviewed.

RESULTS

We found that the process of negotiation is socially situated depending on the individual patient and professional, a dynamic element of the interaction that may occur both tacitly and explicitly at all stages of the encounter and is not necessarily tied to a specific health problem. Hence, negotiation is complex and influenced by both social, biomedical, and temporal contexts.

CONCLUSIONS

We found that negotiation between patient and health professional occurs at all stages of the clinical encounter. Negotiation is influenced by social, temporal, and biomedical contexts that encompass the social meeting between patient and health professional. We suggest that health professionals strive to be attentive to patients' tacit negotiation practices. This will strengthen the recognition of the patients' actual wishes for their course of treatment which can thus guide the health professionals' recommendations and treatment.

A person-centred care transition support for people with stroke/TIA: A study protocol for effect and process evaluation using a non-randomised controlled design

INTRODUCTION

Care transitions following a stroke call for integrated care approaches to reduce death and disability. The proposed research described in this study protocol aims to evaluate the effectiveness of a person-centred multicomponent care transition support and the process in terms of contextual moderators, implementation aspects and mechanisms of impact.

METHODS

A non-randomized controlled trial design will be used. The intervention includes person-centred dialogue intended to permeate all patient-provider communication, various pedagogical modes of information, a person-centred care and rehabilitation plan, and a bridging e-meeting to prepare patients for homecoming. Patients with stroke or TIA who are to be discharged from the participating hospitals to home and referred to a neurorehabilitation team for continued rehabilitation will be included. Follow-ups will be conducted at one week, 3 months and 12 months. Data will be collected on the primary outcome of perceived quality of the care transition, and on the secondary outcomes of health literacy, medication adherence, and perceived person-centeredness. Data for process evaluation will be collected through semi-structured interviews, focus groups, participatory observations, and the Normalisation Measure Development Questionnaire.

DISCUSSION

The study will provide insights on implementation, mechanisms of impact, contextual moderators, and effectiveness of a care transition support, targeting a poorly functioning part of the care trajectory for people with stroke and TIA.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05646589.

Modern medical schools curricula: Necessary innovations and priorities for change

Medical schools' curricula have expanded over the decades to incorporate important new medical breakthroughs and discoveries. Their current focus and overall structures remain, however, stubbornly captive of early 20th-century thinking, with changes having been undertaken in a piecemeal fashion. Indeed, since the notable Flexner reform in 1910, medical schools' study plans have suffered successive and typically always partial adjustments which have failed to keep up with scientific, technological and sociological change. This difficulty may be attributable to the well-known conservatism of medical schools, where updating study plans is a process that invariably encounters numerous barriers to change. These observations were afforded detailed attention some 15 years ago when de Oliveira wrote: 'it is now perfectly demonstrated that public medical schools have not been able to adapt their operation in depth and in due time to the new demands of teaching dictated by an explosive scientific and technological development'. Recent advances in communication and information technologies, as well as the introduction of new pedagogical techniques, have the potential to bring significant benefits to medical practice and healthcare systems, but these have not in the main become properly taught and utilized. The proposition that healthcare is evolving from reactive disease care to care that is predictive, preventive, personalized and participatory was initially regarded as highly speculative, yet systems approaches to biology and medicine are now beginning to provide experience of both health and disease at the molecular, cellular and organ levels. Medicine is a broad scientific field. In contrast to the 19th century, current medical 'sectarianism' is a positive by-product of rapid and gratifying medical progress, and the multiplicity of new models means that the lines of evidence legitimately bearing on practice and health policymaking are already highly diverse and likely to become ever more variegated over time. Put simply, most sound decisions, by definition, will be evidence-informed and not evidence-based, where divergence may be as informative as convergence. Here, the most enduring lesson of history is, perhaps, that clinical medicine is constantly rediscovering its humanistic core. Complexities create opportunities for innovation. In innovative environments, high-performing organizations are finding ways to create a culture that supports a diverse workforce preparing to deliver different models of care, with direct implications for excellence of patient experience and strong repercussions for medical education. The COVID-19 crisis saw major increases in the use of telemedicine, virtual office visits and other forms of online contact, and these are likely to increase considerably. This particular transformation will not be easy or comfortable to make. But reconfiguration of medical education seems inevitable, fuelled by online educational technology and the need to transform clinical training to more outpatient settings with promotion based on competency and person-centeredness, not simply time. As we prepare to enter 2024, this is an exciting time to be working in healthcare. We have more evidence than ever about how to provide high quality, person-centered care, and to keep patients safe. Shame on us if there is any hesitation about applying this knowledge to make the healthcare experience better for patients and providers. Embracing change and making continuous improvements are essential and urgent priorities for medicine and healthcare and, as we describe in the current article, will become more and more indispensably important in our rapidly changing world.

[Design and validation of the ACPAPS questionnaire to assess person-centred care by the family doctor]

OBJECTIVES

Design, construction and validation of a self-completion test that allows the Family Physician (FP) to assess the extent to which he/she integrates person-centred care (PCC) in his/her clinical practice.

DESIGN

Qualitative. Questionnaire design.

LOCATION

Primary care.

PARTICIPANTS

Two hundred and fourteen family and community medicine physicians and residents, from 62 of the 80 health centres in the autonomous community of Murcia (Spain).

METHODS

Construction of a questionnaire from a bank of 873 items from a systematic review and a Delphi study. Review by PCC panel of experts (8). Cognitive pretest with 10 FP. Doctors from 62 health centres were invited to participate. With the responses we measured reliability, validity and feasibility.

RESULTS

The final questionnaire contains 37 items. We measured reliability through internal consistency with a Cronbach's alpha of .915. For construct validity, the appropriate Bartlett's test of sphericity and the Kaiser-Mayer-Olkin measure of .889 allowed us to carry out a factor analysis with the extraction of nine factors (Kaiser's rule) with five main factors (Scree test) whose items coincide with the dimensions proposed by the experts. To assess its feasibility we considered the response rate of 31.15%, the response time of 17minutes 23seconds and only .9% of respondents considered the questionnaire long or complex.

CONCLUSIONS

The ACPAPS questionnaire is a reliable, valid and feasible tool to assess PCC in FM, which has multiple and far-reaching applications.

Reconsidering patient-centred care: Authority, expertise and abandonment

Patient-centred care is commonly framed as a means to guard against the problem of medical paternalism, exemplified in historical attitudes of 'doctor knows best'. In this sense, patient-centred care (PCC) is often regarded as a moral imperative. Reviews of its adoption in healthcare settings do not find any consistent improvement in health outcomes; however, these results are generally interpreted as pointing to the need for more or 'better' training for staff, rather than raising more fundamental questions. Patient autonomy is generally foregrounded in conceptualizations of PCC, to be actualized through the exercising of choice and control. But examining healthcare interaction in practice shows that when professionals attempt to enact these underpinnings, it often results in the sidelining of medical expertise that patients want or need. The outcome is that patients can feel abandoned to make decisions they feel unqualified to make, or even that care standards may not be met. This helps to explain why PCC has not produced the hoped-for improvement in health outcomes. It also suggests that, rather than focusing on scoring individual consultations, we need to consider how medical expertise can be rehabilitated for a 21st century public, and how patient expertise can be better incorporated into co-design and co-production of services and resources rather than being seen as something to be expressed through a binary notion of control. PATIENT AND PUBLIC CONTRIBUTION: This viewpoint draws on research conducted by the author across a range of settings in health and social care, all of which incorporated patient and public involvement when it was conducted.

A contemporary ontology of continuity in general practice: Capturing its multiple essences in a digital age

Continuity is a long-established and fiercely-defended value in primary care. Traditional continuity, based on a one-to-one doctor-patient relationship, has declined in recent years. Contemporary general practice is organisationally and technically complex, with multiple staff roles and technologies supporting patient access (e.g. electronic and telephone triage) and clinical encounters (e.g. telephone, video and electronic consultations). Re-evaluation of continuity's relational, organisational, socio-technical and professional characteristics is therefore timely. We developed theory in parallel with collecting and analysing data from case studies of 11 UK general practices followed from 2021 to 2023 as they introduced (or chose not to introduce) remote and digital services. We used strategic, immersive ethnography, interviews, and material analysis of technologies (e.g. digital walk-throughs). Continuity was almost universally valued but differently defined across practices. It was invariably situated and effortful, influenced by the locality, organisation, technical infrastructure, wider system and the values and ways of working of participating actors, and often requiring articulation and 'tinkering' by staff. Remote and digital modalities provided opportunities for extending continuity across time and space and for achieving-to a greater or lesser extent-continuity of digital records and shared understandings of a patient and illness episode across the clinical team. Delivering continuity for the most vulnerable patients was sometimes labour-intensive and required one-off adaptations. Building on earlier work by Haggerty et al. we propose a novel ontology of four analytically distinct but empirically overlapping kinds of continuity-of the therapeutic relationship (based on psychodynamic and narrative paradigms), of the illness episode (biomedical-interpretive paradigm), of distributed work (sociotechnical paradigm), and of the practice's commitment to a community (political economy and ethics of care paradigm). This ontology allowed us to theorise and critique successes (continuity achieved) and failures (breaches of continuity and fragmentation of care) in our dataset.

Integrating Communication Skills, Awareness of Self and Others, and Reflective Feedback into One Inclusive Anatomical Representation of Relationship-Centered Health Care

The American Veterinary Medical Association Council on Education mandates in standard 11 that all accredited colleges of veterinary medicine must develop and deliver formal processes by which students are observed and assessed in nine competencies. The eighth competency combines clinical communication and sensitivity toward soliciting and understanding individual narratives across a diverse clientele to facilitate health care delivery. Several frameworks have been designed to structure health care consultations for teaching and coaching purposes. The Calgary-Cambridge guide (CCG) provides an evidence-based approach to outlining the flow of consultations, incorporating foundational communication skills and elements of relationship-centered care into a series of sequential tasks. Although the CCG was intended for use as a flexible tool kit, it lacks visible connections between concrete experiences (e.g., the consultation) and reflective observation (e.g., the feedback). This teaching tip describes the development of a novel anatomical representation of the consultation that integrates process elements of the CCG with other core curricular concepts. By combining knowledge, technical skills, critical thinking, reflection, cultural humility, and self-awareness into a skeletal consultation model, linkages are established between communication and intergroup dialogue skills and diversity and inclusion (D&I). This model has been further adapted as feline, caprine, porcine, equine, avian, and reptilian versions for in-class use as strategic visual aids that highlight key areas of focus for Professional Skills class sessions. Future developments by the authors will explore how to link species-specific consultation models to assessment rubrics to reinforce the connection between content (what) and process (how).

Digital technology in medical visits: a critical review of its impact on doctor-patient communication

With the rapid advances of digital technology, computer-mediated medical practices are becoming increasingly dominant in medical visits. However, the question of how to ensure effective, patient-centered communication in this transition remains crucial. In this mini-review, we explore this topic by reviewing quantitative and survey-based studies, as well as discursive-interactional studies that focus on the visit as a communicative event. The review is organized into four sections: the introductory section provides a brief synthesis of the two main models used in medical practice and describes the effects of patient-centered communication practices on patients' health and well-being. The second section presents and discusses qualitative and quantitative studies that assess the effect of technology on medical interaction and its impact on patient-centered communication. The third section focuses on whether and how the digital medical record represents a "potential communication risk" during doctor-patient interactions and explores how certain pen-and-paper literacy practices could help mitigate these challenges. In the concluding section, we outline and analyze three key considerations for utilizing technologies to foster and enhance patient-centered communication during medical visits.

[The new program of the Family and Community Medicine specialty: An opportunity not to be missed]

The training program for the Family and Community Medicine specialty (MFyC), which has been in effect since 2005, is currently undergoing a review and update process. This article proposes contributions to deepen the specific contents of the specialty in order to guide towards a more significant competency development. To carry out values-oriented training, it is suggested to deploy the values function and promote the creation of care spaces where the daily experience of those values is possible. It is proposed to establish a scale of values where the two essential values of the family physician are, in this order, a commitment to the individual person, and a commitment to the group of people under their care. Additionally, it is proposed to reorganize the competency map around five competency integrators or meta-competencies: patient-centered clinical method, population-based clinical governance, primary care oriented to the community, health promotion or community health based on assets, and research in the family and community field.

Measuring students’ ability to identify core elements in a patient-centered consultation with a new tool comprising a questionnaire and a video consultation from general practice. Guidance for the learning process

Introduction: Diverse ways to measure course effectiveness in medical education exist, but it takes time to have the results. The authors have developed a tool consisting of a questionnaire (DanOBS) combined with a test video consultation. The students watched a consultation video and completed a questionnaire about patient-centered elements before and after the course. This study aimed to evaluate the learning process for teachers and students with the DanOBS and a consultation video. Method: Altogether 201 students from autumn 2019 were included in this study, assigned by the university to three general practice courses and six small study groups. After introducing the patient-centered consultation model on the first day of the course, the students watched a video consultation and completed the DanOBS online on their Mobile Phones. They watched the video and completed the questionnaire again on one of the last days of the course. The number of correct answers in each item was compared before and after the course. Furthermore, effect sizes for each item were calculated. Results: The number of students completing the questionnaire before and after the course was 161. The number of correct answers increased after the course. Items where the teaching was a success, as well as items where it needs intensifying, were identified. The DanOBS instrument reflected the effect of strengthening the learning in some elements of the patient-centered mode. Conclusion: A tool for measuring efficacy in teaching patient-centered consultation has been implemented and has given valuable information to teachers about where the students need intensified teaching. The tool can measure the effectiveness of various educational interventions.

Perceptions of the medical relevance of patients` stories of painful and adverse life experiences: a focus group study among Norwegian General Practitioners

Purpose

Adverse life experiences increase the risk of health problems. Little is known about General Practitioners’ (GPs') thoughts, clinical concepts, and work patterns related to eliciting, including, or excluding their patients’ stories of painful and adverse life experiences. We wanted to explore GPs’ perceptions of the medical relevance of stories of painful and adverse life experiences, and to focus on what hinders or facilitates working with such stories.

Method

Eighteen Norwegian GPs participated in three focus group interviews. The interviews were analysed using reflexive thematic analysis.

Results

The participating GPs’ views on the clinical relevance of patients’ painful and adverse experiences varied considerably. Our analysis revealed two distinct stances: a confident-accepting stance, and an ambivalent-conditional stance. GPs encountered barriers to exploring such stories: scepticism on behalf of the medical discipline; scepticism on behalf of the patients; and, uncertainty regarding how to address stories of painful and adverse experiences in consultations. Work with painful stories was best facilitated when GPs manifested personal openness and prepared availability, within the context of a doctor-patient relationship based on trust.

Conclusions

Clearer processes for handling biographical information and life experiences that affect patients’ health are needed to facilitate the work of primary care physicians.

Developing a self-management package for pulmonary fibrosis: an international Delphi study

Rationale

Self-management is considered as an important part of disease management for people with pulmonary fibrosis (PF), but there is a lack of consensus regarding what components should be included. This study aimed to attain consensus from experts in PF and people living with the disease on the essential components and format of a PF self-management package.

Methods

A two-round Delphi process was conducted. In each round, a panel of experts completed an online survey to rate a range of components, formats and delivery methods, followed by an online patient focus group to integrate patient perspectives. Consensus was defined a priori.

Results

45 experts participated in Round 1 and 51 in Round 2. Both focus groups included six people with PF. 12 components were considered essential for self-management in PF: 1) understanding treatment options; 2) understanding and accessing clinical trials; 3) managing medications; 4) role of oxygen therapy; 5) role and importance of pulmonary rehabilitation and regular physical activity; 6) managing shortness of breath; 7) managing fatigue; 8) managing mood; 9) managing comorbidities; 10) smoking cessation advice and support; 11) accessing community support; and 12) how to communicate with others when living with PF. Both groups agreed that self-management in PF required individualisation, goal setting and feedback.

Conclusion

This study identified 12 essential components and highlighted individualisation, goal setting and feedback in self-management of PF. The findings provide a basis for the development of PF self-management interventions.

Application of the DanOBS questionnaire combined with a patient-centered consultation video for measuring teaching efficacy in a general practice course

Introduction: Diverse ways to measure course effectiveness in medical education exist, but it takes time to have the results. The authors have developed a tool consisting of a questionnaire (DanOBS) combined with a test video consultation. The students watched a consultation video and completed a questionnaire about patient-centered elements before and after the course. This study aimed to assess the utility of a new quick tool for measuring efficacy in teaching the patient-centered consultation model. Method: Altogether 201 students from autumn 2019 were included in this study, assigned by the university to three general practice courses and six small study groups. After introducing the patient-centered consultation model on the first day of the course, the students watched a video consultation and completed the DanOBS online on their Mobile Phones. They watched the video and completed the questionnaire again on one of the last days of the course. The number of correct answers in each item was compared before and after the course. Furthermore, effect sizes for each item were calculated.  Results: The number of students completing the questionnaire before and after the course was 161. The number of correct answers increased after the course. Items where the teaching was a success, as well as items where it needs intensifying, were identified. The DanOBS instrument reflected the effect of strengthening the learning in some elements of the patient-centered mode.  Conclusion: A tool for measuring efficacy in teaching patient-centered consultation has been implemented and has given valuable information to teachers about where the students need intensified teaching. The tool can measure the effectiveness of various educational interventions.

Application of the DanOBS questionnaire combined with a patient-centered consultation video for measuring teaching efficacy in a general practice course

Introduction Diverse ways to measure course effectiveness in medical education exist, but it takes time to have the results. The authors have developed a tool consisting of a questionnaire (DanOBS) combined with a test video consultation. The students watched a consultation video and completed a questionnaire about patient-centered elements before and after the course. This study aimed to assess the utility of a new quick tool for measuring efficacy in teaching the patient-centered consultation model. Method Altogether 201 students from autumn 2019 were included in this study, assigned by the university to three general practice courses and six small study groups. After introducing the patient-centered consultation model on the first day of the course, the students watched a video consultation and completed the DanOBS online on their Mobile Phones. They watched the video and completed the questionnaire again on one of the last days of the course. The number of correct answers in each item was compared before and after the course. Furthermore, effect sizes for each item were calculated.  Results The number of students completing the questionnaire before and after the course was 161. The number of correct answers increased after the course. Items where the teaching was a success, as well as items where it needs intensifying, were identified. The DanOBS instrument reflected the effect of strengthening the learning in some elements of the patient-centered mode.  Conclusion A tool for measuring efficacy in teaching patient-centered consultation has been implemented and has given valuable information to teachers about where the students need intensified teaching. The tool can measure the effectiveness of various educational interventions.

Development and implementation of a tool for measuring the training effectiveness of the patient-centered consultation model

Background: The patient-centered consultation model comprises four elements: exploring health, illness and disease experiences, understanding the whole person, finding common ground, and enhancing the patient-doctor relationship. This method is taught at the course in general practice at Copenhagen University. The aim of the study was to develop a simple tool consisting of a questionnaire about the patient-centered elements and a test video consultation. The outcome is the change in the students’ ability to identify these elements. Used as a pre-course and post-course test it can inform the teachers which elements of the patient-centered consultation need intensifying in the teaching. Methods: The students from a course in general practice volunteered to participate in all steps of the development. They took part in individual interviews to select items from an already existing questionnaire (DanSCORE). The preliminary questionnaire was tested for face and content validity, pilot-tested and tested for test-retest reliability. All video consultations were transcribed and assessed for patient-centered elements through a conversation analysis. The videos showed medical students seeing real patients. Results: The preliminary version of the questionnaire (called DanOBS) had 23 items. In the subsequent interviews, items were reduced to 17, each with three response options. After a pilot test, the questionnaire was further reduced to 13 items, all strictly relevant to the model and with two response options. The final questionnaire had acceptable test-retest reliability. The number of test consultation videos underwent a reduction from six videos to one. Conclusions: The DanOBS combined with a test video consultation, used as a pre-and post-course test demonstrates for teachers which elements in the patient-centered consultation need to be intensified in the teaching.

Patient experiences with depression care in general practice: a qualitative questionnaire study

OBJECTIVE

To investigate patient experiences and preferences regarding depression care in general practice.

DESIGN AND SETTING

A qualitative study based on free-text responses in a web-based survey in 2017. Participants were recruited by open invitation on the web page of a Norwegian patient organization for mental health. The survey consisted of four open-ended questions concerning depression care provided by general practitioners (GPs), including positive and negative experiences, and suggestions for improvement. The responses were analysed by Template Analysis.

SUBJECTS

250 persons completed the web-based survey, 86% were women.

RESULTS

The analysis revealed five themes: The informants appreciated help from their GP; they wanted to be met by the GP with a listening, accepting, understanding and respectful attitude; they wanted to be involved in decisions regarding their treatment, including antidepressants which they thought should not be prescribed without follow-up; when referred to secondary mental care they found it wrong to have to find and contact a caregiver themselves; and they thought sickness certification should be individualised to be helpful.

CONCLUSIONS

Patients in Norway appreciate the depression care they receive from their GP. It is important for patients to be involved in decision-making regarding their treatment.KEY POINTSDepression is common, and GPs are often patients' first point of contact when they seek help.  • Patients who feel depressed appreciate help from their GP.  • Patients prefer an empathetic GP who listens attentively and acknowledges their problems.  • Individualised follow-up is essential when prescribing antidepressants, making a referral, or issuing a sickness absence certificate.

Inductive foraging: patients taking the lead in diagnosis, a mixed-methods study

BACKGROUND

Patient involvement in treatment decisions is widely accepted. Making a diagnosis, however, is still seen as a technical task mainly driven by physicians. Patients in this respect are perceived as passive providers of data. But, recent patient-centred concepts highlight the value of an active patient involvement in diagnosis.

OBJECTIVE

We aim to reach a deeper understanding of how patients themselves contribute to the diagnostic process.

METHODS

This is an observational study of patient consultations with their General Practitioner (GP) in 12 German practices. We performed a mixed-method qualitative and quantitative analysis of 134 primary care consultations.

RESULTS

At the beginning of most consultations lies a phase where patients were invited to freely unfold their reason for encounter: This was named "inductive foraging" (IF). While patients actively present their complaints, GPs mainly listen and follow the presentation. This episode was found with every GP participating in this study. Ninety-one percent of consultations with diagnostic episodes were opened by IF. IF had a major contribution to the number of cues (diagnostic information) yielded in the diagnostic process. We illustrate a variety of tactics GPs make use of to invite, support, and terminate their patients in IF.

CONCLUSION

IF was found to be a highly relevant strategy in the diagnostic process. Patient involvement through IF offered a major contribution of diagnostic cues. We hypothesize that a patient-centred approach improves diagnosis.

Development and implementation of a tool for measuring the training effectiveness of the patient-centered consultation model

Background: The patient-centered consultation model comprises four elements: exploring health, illness and disease experiences, understanding the whole person, finding common ground, and enhancing the patient-doctor relationship. This method is taught at the course in general practice at Copenhagen University. The aim of the study was to develop a simple tool consisting of a questionnaire about the patient-centered elements and a test video consultation. The outcome is the change in the students' ability to identify these elements. Used as a pre-course and post-course test it can inform the teachers which elements of the patient-centered consultation need intensifying in the teaching. Methods: The students from a course in general practice volunteered to participate in all steps of the development. They took part in individual interviews to select items from an already existing questionnaire (DanSCORE). The preliminary questionnaire was tested for face and content validity, pilot-tested and tested for test-retest reliability. All video consultations were transcribed and assessed for patient-centered elements through a conversation analysis. The videos showed medical students seeing real patients. Results: The preliminary version of the questionnaire (called DanOBS) had 23 items. In the subsequent interviews, items were reduced to 17, each with three response options. After a pilot test, the questionnaire was further reduced to 13 items, all strictly relevant to the model and with two response options. The final questionnaire had acceptable test-retest reliability. The number of test consultation videos underwent a reduction from six videos to one. Conclusions: The DanOBS combined with a test video consultation, used as a pre-and post-course test demonstrates for teachers which elements in the patient-centered consultation need to be intensified in the teaching.

‘People say it is dangerous’

Introduction: Mild hypertension is a common asymptomatic condition present in people at low risk of future cardiovascular events. These people represent approximately two-thirds of those diagnosed with hypertension. The best available evidence does not support pharmacological treatment for mild hypertension to reduce cardiovascular mortality. Additionally, overdetection of hypertension also occurs, and this practice is supported by public awareness campaigns, screening, easy access to testing, and poor clinical practice, enhancing the overdiagnosis potential. Moreover, sparse qualitative patient-oriented evidence that diagnosing hypertension has harmful consequences is observed. Therefore, evidence regarding the potential for unintended psychosocial effects of diagnosing mild hypertension is required. Objective: The aim of this study was to investigate if diagnosing low-risk people with mild hypertension has unintended psychosocial consequences. Methods: Eleven semi-structured single interviews and four focus groups were conducted in São Paulo, Brazil, among people diagnosed with mild hypertension without comorbidities. Informants were selected among the general population from a list of patients, a primary healthcare clinic, or a social network. The informants had a broad range of characteristics, including sex, age, education level, race/skin colour, and time from diagnosis. Data were subjected to qualitative thematic content analysis by three of the authors independently, followed by discussions, to generate categories and themes. Results: The informants confirmed that the hypertension diagnosis was a label for psychosomatic reactions to stress, medicalised illness experiences, and set a biographical milestone. We observed unintended consequences of the diagnosis in a broad range of psychosocial dimensions, for example, fear of death, disabilities, or ageing; pressure and control from significant others; and guilt, shame, and anxiety regarding work and leisure. Although informants had a broad range of characteristics, they shared similar stories, understandings, and labelling effects of the diagnosis. Conclusion: The diagnosis of hypertension is a significant event and affects daily life. Most of the impact is regarded as negative psychosocial consequences or harm; however, sometimes the impact might be ambiguous. Patients’ explanatory models are key elements in understanding and changing the psychosocial consequences of the diagnosis, and healthcare providers must be aware of explanatory models and psychosocial consequences when evaluating blood pressure elevations.

Development and implementation of a tool for measuring the training effectiveness of the patient-centered consultation model

Background: The patient-centered consultation model comprises four elements: exploring health, illness, and disease experiences, understanding the whole person, finding common ground, and enhancing the patient-doctor relationship. This method is taught at the course in general practice at Copenhagen University. The aim of the study was to develop a simple tool consisting of a questionnaire about the patient-centered elements and a test video consultation. The outcome is the change in the students’ ability to identify these elements. Used as a pre-course and post-course test it can inform the teachers which elements of the patient-centered consultation need intensifying in the teaching. Methods: The students from a course in general practice volunteered to participate in all steps of the development. They took part in individual interviews to select items from an already existing questionnaire (DanSCORE). The preliminary questionnaire was tested for face and content validity, pilot-tested and tested for test-retest reliability. All video consultations were transcribed and assessed for patient-centered elements through a conversation analysis. The videos showed medical students seeing real patients. Results: The preliminary version of the questionnaire (called DanOBS) had 23 items. In the subsequent interviews, items were reduced to 17, each with three response options. After the pilot test, the questionnaire was further reduced to 13 items, all strictly relevant to the model and with two response options. The final questionnaire had acceptable test-retest reliability. The number of test consultation videos underwent a reduction from six videos to one. Conclusions: The DanOBS combined with a test video consultation, used as a pre-and post-course test demonstrates for teachers which elements in the patient-centered consultation need to be intensified in the teaching.

The Association Between Patient-Centered Communication and Primary Care Quality in Urban China: Evidence From a Standardized Patient Study

Background

Effective patient-physician communication has been considered a central clinical function and core value of health system. Currently, there are no studies directly evaluating the association between patient-centered communication (PCC) and primary care quality in urban China. This study aims to investigate the association between PCC and primary care quality.

Methods

The standardized patients were used to measure PCC and the quality of health care. We recruited 12 standardized patients from local communities presenting fixed cases (unstable angina and asthma), including 492 interactions between physicians and standardized patients across 63 CHCs in Xi'an, China. PCC was scored on three dismissions: (1) exploring disease and illness experience, (2) understanding the whole person, and (3) finding common ground. We measured the quality of the primary care by (1) accuracy of diagnosis, (2) consultation time, (3) appropriateness of treatment, (4) unnecessary exams; (5) unnecessary drugs, and (6) medical expenditure. Ordinary least-squares regression models with fixed effects were used for the continuous variables and logistic regression models with fixed effects were used for the categorical variables.

Results

The average score of PCC1, PCC2, and PCC3 was 12.24 ± 4.04 (out of 64), 0.79 ± 0.64 (out of 3), and 10.19 ± 3.60 (out of 17), respectively. The total score of PCC was 23.22 ± 6.24 (out of 84). We found 44.11% of the visits having a correct diagnosis, and 24.19% of the visits having correct treatment. The average number of unnecessary exams and drugs was 0.91 ± 1.05, and 0.45 ± 0.82, respectively. The average total cost was 35.00 ± 41.26 CNY. After controlling for the potential confounding factors and fixed effects, the PCC increased the correct diagnosis by 10 percentage points (P < 0.01), the correct treatment by 7 percentage points (P < 0.01), the consultation time by 0.17 min (P < 0.01), the number of unnecessary drugs by 0.03 items (P < 0.01), and the medical expenditure by 1.46 CNY (P < 0.01).

Conclusions

This study revealed pretty poor communication between primary care providers and patients. The PCC model has not been achieved, which could be one source of the intensified physician-patient relationship. Our findings showed the PCC model in the primary care settings has positive associations with the quality of the primary care. Interactions with a higher score of PCC were more likely to have a correct diagnosis and correct treatment, more consultation time, more unnecessary drugs, and higher medical expenditure. To improve PCC, the clinical capacity and communication skills of primary care providers need to be strengthened. Also, strategies on reforming the pay structure to better reflect the value of physicians and providing a stronger motivation for performance improvement are urgently needed.

Communication skills training in psychiatry

Good communication skills are the basis of all effective doctor–patient relationships, and psychiatrists in particular have to manage many types of complex interaction. Research shows the benefits of communication skills training. This article describes strategies for teaching relevant clinical communication skills to trainee psychiatrists on MRCPsych courses and in local centres. The authors set out a sustainable training framework using higher trainees as tutors. There is a need for more widespread teaching of clinical communication skills in psychiatry and at an early stage of specialist training.

Harnessing Machine Learning to Personalize Web-Based Health Care Content

Web-based health care content has emerged as a primary source for patients to access health information without direct guidance from health care providers. The benefit of this approach is dependent on the ability of patients to access engaging high-quality information, but significant variability in the quality of web-based information often forces patients to navigate large quantities of inaccurate, incomplete, irrelevant, or inaccessible content. Personalization positions the patient at the center of health care models by considering their needs, preferences, goals, and values. However, the traditional methods used thus far in health care to determine the factors of high-quality content for a particular user are insufficient. Machine learning (ML) uses algorithms to process and uncover patterns within large volumes of data to develop predictive models that automatically improve over time. The health care sector has lagged behind other industries in implementing ML to analyze user and content features, which can automate personalized content recommendations on a mass scale. With the advent of big data in health care, which builds comprehensive patient profiles drawn from several disparate sources, ML can be used to integrate structured and unstructured data from users and content to deliver content that is predicted to be effective and engaging for patients. This enables patients to engage in their health and support education, self-management, and positive behavior change as well as to enhance clinical outcomes.

Seeing the Elephant: A Systematic Scoping Review and Comparison of Patient-Centeredness Conceptualizations from Three Seminal Perspectives

"Patient-Centeredness" (PC) is a theoretical construct made up of a diverse constellation of distinct concepts, processes, practices, and outcomes that have been developed, arranged, and prioritized heterogeneously by different communities of professional healthcare practice, research, and policy. It is bound together by a common ethos that puts the holistic individual at the functional and symbolic center of their care, a quality deemed essential for chronic disease management and health promotion. Several important contributions to the PC research space have adeptly integrated seminal PC conceptualizations to improve conceptual clarity, measurement, implementation, and evaluation in research and practice. This systematic scoping review builds on that work, but with a purpose to explicitly identify, compare, and contrast the seminal PC conceptualizations arising from the different healthcare professional groups. The rationale for this work is that a deeper examination of the underlying development and corresponding assumptions from each respective conceptualization will lead to a more informed understanding of and meaningful contributions to PC research and practice, especially for healthcare professional groups newer to the topic area like pharmacy. The literature search identified four seminal conceptualizations from the healthcare professions of Medicine, Nursing, and Health Policy. A compositional comparison across the seminal conceptualizations revealed a shared ethos but also six distinguishing features: (1) organizational structure; (2) predominant level of care; (3) methodological approach; (4) care setting origin; (5) outcomes of interest; and (6) language. The findings illuminate PC's stable theoretical foundations and distinctive nuances needed to appropriately understand, apply, and evaluate the construct's operationalization in contemporary healthcare research and practice. These considerations hold important implications for future research into the fundamental aims of healthcare, how it should look when practiced, and what should reasonably be required of it.

Facing COVID-19 Between Sensory and Psychoemotional Stress, and Instrumental Deprivation: A Qualitative Study of Unmanageable Critical Incidents With Doctors and Nurses in Two Hospitals in Northern Italy

Background: The COVID-19 pandemic severely strained the already unprepared Italian healthcare system. This had repercussions on healthcare workers, stemming, in particular, from a lack of clear guidelines, adequate protective equipment, and professional preparedness. Such conditions were especially prevalent in Northern Italy. Objectives: This study aimed to examine COVID-19-related professional and psychoemotional stress among nurses and doctors in two hospitals in Northern Italy, along with the worst critical incidents affecting healthcare personnel. A parallel objective was to elicit healthcare professionals' opinions about what changes are needed in the healthcare system's operations, as well as about the relational/emotional skills that are needed to better manage relationships with patients in emergency situations. Participants: Snowball sampling was used to recruit participants and yielded 17 hospital professionals: six nurses (five female and one male) and 11 doctors (seven male and four female). Three of these professionals worked in intensive care and the others in different wards. All had close contact with COVID-19 patients. Methods: The study employed a qualitative research design, using in-depth interviews of ~60 min each that were conducted via Skype video calls. The interviews were recorded and transcribed, then analysed. The qualitative analysis employed mixed methods to identify the most relevant and recursive themes from the interviews. Results: Four fundamental themes emerged from our analysis of the interview texts: (1) disorganisation and psychoemotional stress; (2) urgency and critical incidents; (3) everything surreal; and (4) disruptions in empathetic relationships with patients. Conclusions: Through our analysis of the interview narratives, we found that systematic and in-depth psychological training is needed to prepare professionals for (1) altered relationships with patients in emergencies; (2) use of exceptional medical equipment; (3) elaboration of new bioethical models suitable for disasters and pandemics; and (4) engagement with the themes of death and dying.

Palliative care in general practice; a questionnaire study on the GPs role and guideline implementation in Norway

Background

Patients in need of palliative care often want to reside at home. Providing palliative care requires resources and a high level of competence in primary care. The Norwegian guideline for palliative care points to the central role of the regular general practitioner (RGP), specifying a high expected level of competence. Guideline implementation is known to be challenging in primary care. This study investigates adherence to the guideline, the RGPs experience with, and view of their role in palliative care.

Methods

A questionnaire was distributed, by post, to all 246 RGPs in a Norwegian county. Themes of the questionnaire focused on experience with palliative and terminal care, the use of recommended work methods from the guideline, communication with partners, self-reported role in palliative care and confidence in providing palliative care. Data were analyzed descriptively, using SPSS.

Results

Each RGP had few patients needing palliative care, and limited experience with terminal care at home. Limited experience challenged RGPs possibilities to maintain knowledge about palliative care. Their clinical approach was not in agreement with the guideline, but most of them saw themselves as central, and were confident in the provision of palliative care. Rural RGPs saw themselves as more central in this work than their urban colleagues.

Conclusions

This study demonstrated low adherence of the RGPs, to the Norwegian guideline for palliative care. Guideline requirements may not correspond with the methods of general practice, making them difficult to adopt. The RGPs seemed to have too few clinical cases over time to maintain skills at a complex and specialized level. Yet, there seems to be a great potential for the RGP, with the inherent specialist skills of the general practitioner, to be a key worker in the palliative care trajectory.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01426-8.

Implications of a Novel Method for Analyzing Communication in Routine Veterinary Patient Visits for Veterinary Research and Training

The patient-centered clinical method (PCCM), a model developed to characterize communication during patient-physician visits in the 1980s, identifies elements of patient-orientated, physician-orientated, and shared dialogue during the encounter. The model also includes elements that reflect the emotional aspects of these interactions, recognizing expressions of feelings and exchanges related to both personal and medical interests. Fifty-five routine veterinary patient visits in the United Kingdom and United States were analyzed using the novel application of a PCCM adapted for veterinary patient visits. The patient visits were video recorded, transcribed, coded, and analyzed for frequency and proportion of PCCM elements observed. Elements representing the greatest proportion of patient visits were related to gathering information and shared decision making. Those representing the smallest proportion were related to signs of the presenting condition and effects of the condition on the clients' lives. Dialogue during the patient visits flowed iteratively and back and forth between the veterinarian and the client perspective. The findings suggest that patient visits are focused more on gathering information and planning rather than exploring effects of the health problem on the client's life, and that patient visits flow very iteratively and randomly between veterinarian and client perspectives. Both of these topics should be studied further and given emphasis in the way that communication models are developed and taught in order to enhance client-centeredness in veterinary patient visits.

Personalized symptom management: a quality improvement collaborative for implementation of patient reported outcomes (PROs) in 'real-world' oncology multisite practices

Background

Little research has focused on implementation of electronic Patient Reported Outcomes (e-PROs) for meaningful use in patient management in ‘real-world’ oncology practices. Our quality improvement collaborative used multi-faceted implementation strategies including audit and feedback, disease-site champions and practice coaching, core training of clinicians in a person-centered clinical method for use of e-PROs in shared treatment planning and patient activation, ongoing educational outreach and shared collaborative learnings to facilitate integration of e-PROs data in multi-sites in Ontario and Quebec, Canada for personalized management of generic and targeted symptoms of pain, fatigue, and emotional distress (depression, anxiety).

Patients and methods

We used a mixed-methods (qualitative and quantitative data) program evaluation design to assess process/implementation outcomes including e-PROs completion rates, acceptability/use from the perspective of patients/clinicians, and patient experience (surveys, qualitative focus groups). We secondarily explored impact on symptom severity, patient activation and healthcare utilization (Ontario sites only) comparing a pre/post population cohort not exposed/exposed to our implementation intervention using Mann Whitney U tests. We hypothesized that the iPEHOC intervention would result in a reduction in symptom severity, healthcare utilization, and higher patient activation. We also identified key implementation strategies that sites perceived as most valuable to uptake and any barriers.

Results

Over 6000 patients completed e-PROs, with sites reaching 51%–95% population completion rates depending on initial readiness. e-PROs were acceptable to patients for communicating symptoms (76%) and by clinicians for treatment planning (80%). Patient experience was better than the provincial average. Compared to the pre-population, we observed a significant reduction in levels of anxiety (p = 0.008), higher levels of patient activation (p = 0.045), and reduced hospitalization rates (12.3% not exposed vs 10.1% exposed, p = 0.034). A pre/post population trend towards significance for reduced emergency department visit rates (14.8% not exposed vs 12.8% exposed, p = 0.081) was also noted.

Conclusion

This large-scale pragmatic quality improvement project demonstrates the impact of implementation strategies and a collaborative improvement approach on acceptability of using PROs in clinical practice and their potential for reducing anxiety and healthcare utilization; and improving patient experience and patient activation when implemented in ‘real-world’ multi-site oncology practices.

Exploring patient-reported barriers to advance care planning in family practice

BACKGROUND

Although patient-centred care has become increasingly important across all medical specialties, when it comes to end of life care, research has shown that treatments ordered are not often concordant with people's expressed preferences. Patient and family engagement in Advance Care Planning (ACP) in the primary care setting could improve the concordance between patients' wishes and the healthcare received when patients cannot speak for themselves. The aim of this study was to better understand the barriers faced by older patients regarding talking to their family members and family physicians about ACP.

METHODS

In this multi-site cross-sectional study, three free text questions regarding reasons patients found it difficult to discuss ACP with their families or their family physicians were part of a self-administered questionnaire about patients' knowledge of and engagement in ACP. The questionnaire, which included closed ended questions followed by three probing open ended questions, was distributed in 20 family practices across 3 provinces in Canada. The free text responses were analyzed using thematic analysis and form the basis of this paper.

RESULTS

One hundred two participants provided an analyzable response to the survey when asked why they haven't talked to someone about ACP. Two hundred fifty-four answered the question about talking to their physician and 340 answered the question about talking to family members. Eight distinct themes emerged from the free text response analysis: 1. They were too young for ACP; 2. The topic is too emotional; 3. The Medical Doctor (MD) should be responsible for bringing up ACP 4. A fear of negatively impacting the patient-physician relationship; 5. Not enough time in appointments; 6. Concern about family dynamics; 7. It's not a priority; and 8. A lack of knowledge about ACP.

CONCLUSIONS

Patients in our sample described many barriers to ACP discussions, including concerns about the effect these discussions may have on relationships with both family members and family physicians, and issues relating to patients' knowledge and interpretation of the importance, responsibility for, or relevance of ACP itself. Family physicians may be uniquely placed to leverage the longitudinal, person- centred relationship they have with patients to mitigate some of these barriers.

A qualitative study of old patients' experiences of the quality of the health services in hospital and 30 days after hospitalization

Background

The number of people aged 80 years and above is projected to triple over the next 30 years. People in this age group normally have at least two chronic conditions. The impact of multimorbidity is often significantly greater than expected from the sum of the effects of each condition. The World Health Organization has indicated that healthcare systems must prepare for a change in the focus of clinical care for older people. The World Health Organization (WHO) defines healthcare quality as care that is effective, efficient, integrated, patient centered, equitable and safe. The degree to which healthcare quality can be defined as acceptable is determined by services’ ability to meet the needs of users and adapt to patients’ expectations and perceptions.

Method

We took a phenomenological perspective to explore older patients’ subjective experiences and conducted semistructured individual interviews. Eighteen patients (aged from 82 to 100 years) were interviewed twice after discharge from hospital. The interview transcriptions were analyzed thematically.

Results

The patients found their meetings with the health service to be complex and demanding. They reported attempting to restore a sense of security and meaning in everyday life, balancing their own needs against external requirements. Five overarching themes emerged from the interviews: hospital stay and the person behind the diagnosis, poor communication and coordination, life after discharge, relationship with their next of kin, and organizational and systemic determinants.

Conclusion

According to the WHO, to deliver quality healthcare, services must include all six of the dimensions listed above. Our findings show that they do not. Healthcare focused on measurable values and biomedical inquiries. Few opportunities for participation, scant information and suboptimal care coordination left the patients with a feeling of being in limbo, where they struggled to find balance in their everyday life. Further work must be done to ensure that integrated services are provided without a financial burden, centered on the needs and rights of older people.

Informal caregivers' views on the quality of healthcare services provided to older patients aged 80 or more in the hospital and 30 days after discharge

Background

In the European Union (EU), informal caregivers provide 60% of all care. Informal caregiving ranges from assistance with daily activities and provision of direct care to helping care recipients to navigate within complex healthcare and social services systems. While recent caregiver surveys document the impact of informal caregivers, systematic reviews show that they have unmet needs.

Because of the political desire to reduce the length of hospital stays, older patients are discharged from the hospital ‘quicker and sicker’ than before. The transition between different levels of the healthcare system and the period after hospital discharge is critical for elderly patients.

Caregivers’ perspectives on the quality of older patients’ care journeys between levels of the healthcare system may provide valuable information for healthcare providers and policymakers. This study aims to explore older patient’s informal caregivers’ views on healthcare quality in the hospital and in the first 30 days after hospitalisation.

Method

We conducted semi-structured individual interviews with 12 participants to explore and describe informal caregivers’ subjective experiences of providing care to older relatives. The interviews were then transcribed and analysed thematically.

Results

The analysis yielded the overarching theme ‘Informal caregivers – a health service alliance – quality contributor’, which was divided into four main themes: ‘Fast in, fast out’, ‘Scant information’, ‘Disclaimer of responsibility’ and ‘A struggle to secure professional care’. The healthcare system seemed to pay little attention to ensuring mutual understandings between those involved in discharge, treatment and coordination. The participants experienced that the healthcare providers’ main focus was on the patients’ diseases, although the health services are supposed to view patients holistically.

Conclusion

Based on the information given by informal caregivers, health services must take into account each person’s needs and preferences. To deliver quality healthcare, better coordination between inter-professional care teams and the persons they serve is necessary. Health professionals must strengthen the involvement of caregivers in transitions between care and healthcare. Future work should evaluate targeted strategies for formal caregivers to cooperate, support and empower family members as informal caregivers.

Person-Centered Care From a Relational Ethics Perspective for the Delivery of High Quality and Safe Healthcare: A Scoping Review

Background: The aim of this scoping review is to explore whether or not person-centered care (PCC), in its quest to deliver high quality and safe health care, has a relational-ethics perspective. To do so, we first need to relate the extant literature pertaining to PCC and relational ethics. To this extent, the specific features that define PCC and relational ethics were identified. PCC dimensions include: patient and provider concordance, improved health outcomes, improved patient safety, individual expectations, patients' integration within the environment, patient as a person, patient as an active part of society, dialogue and interaction, sharing experience, and documentation of patient's (person's) narrative. Relational ethics framework includes the following actions: mutual respect, engagement, embodied knowledge, environment, and uncertainty. Methods: Data were retrieved through multiple keywords search on PubMed, Medline, and Scopus. Inclusion/exclusion criteria were set, and these were based on year of publication (2008-2018), language, paper focus, research method and document types. A total of 23 articles (N = 23) were selected and reviewed. Content analysis was conducted in order to identify and compare the main features of PCC and relational ethics. Results: The most important relational ethics action referred to in conjunction with PCC features is environment (referred to as person's integration within a social environment/community). This is followed by mutual respect, engagement and embodied knowledge. These were the salient relational ethics actions both directly and indirectly linked to PCC. Uncertainty was the less recurrent relational ethical action mentioned. Conclusions: This paper revealed that while PCC features embrace most of the relational ethics approaches, these are not exploited in their entirety and therefore PCC emerges as a unique ethical stance in healthcare. PCC's ethical approach goes beyond what is explained within provider-patient relational ethics and emphasizes that the patient is an active person and a partner in care with capabilities and resources. This distinction enables us to explain the paradigm shift from "patient-centered" to "person-centered" care. The healthcare provider partnership and co-creation of the healthcare plan contributes to the delivery of high quality, safe and cost-contained healthcare.

Exploring the therapeutic alliance in Belgian family medicine and its association with doctor-patient characteristics: a cross-sectional survey study

OBJECTIVES

Patient-centred care is related to better health outcomes, greater patient satisfaction and reduced healthcare costs. One of the core components of patient-centred care, defined in the patient-centred clinical method, is enhancing the patient-doctor relationship. In this study, we aim to measure the therapeutic alliance in consultations between patients and family doctors in Belgium, and explore which patient, provider and practice characteristics are associated with the strength of the therapeutic alliance.

DESIGN

Cross-sectional cohort study using the Working Alliance Inventory for General Practice (WAI-GP). The patients and family doctors completed a survey after the consultation. The survey consisted of the WAI-GP, demographics, consultation characteristics and variables related to the patient-doctor relationship.

SETTING

Belgian primary care.

PARTICIPANTS

Every third patient (both practice and house call visits) was invited to participate. 170 patient-doctor dyads from four practices were included. Total of 10 doctors (30% men, age range 24-63 years) and 170 patients (35.9% men, age range 18-92 years).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was the WAI-GP score and its correlations with characteristics of the doctor (gender, age) and patients (gender, age, chronic disease, number of annual consultations).

RESULTS

The median WAI-GP score reported after these consultations was 4.5±0.62. Higher WAI-GP scores were reported for consultations with male doctors and by older patients. In the subsample of patients with a chronic illness, higher WAI-GP scores were reported by patients who had more than 10 follow-up consultations per year.

CONCLUSIONS

Consultation quality is an important aspect of healthcare, but attention is needed to understand how the WAI-GP performs in relation to variables that are beyond control, such as gender of the physician, age of the patient and variables related to building continuity of care. This has implications for the measurement of quality of healthcare.

The Impact of Delaying Breast Reconstruction on Patient Expectations and Health-Related Quality of Life: An Analysis Using the BREAST-Q

PURPOSE

An understanding of patient expectations predicts better health outcomes following breast reconstruction. No study to date has examined how patient expectations for breast reconstruction and preoperative health-related quality of life vary with time since breast cancer diagnosis.

METHODS

Women consulting for breast reconstruction to a single surgeon's practice over a 13-month period were enrolled in this cross-sectional study. Patients were asked to prospectively complete the BREAST-Q expectations and preoperative reconstruction modules. A retrospective chart review was then performed on eligible patients, and patient demographics, cancer-related factors, and comorbidities were collected. BREAST-Q scores were transformed using the equivalent Rasch method. Multivariate linear regression models were constructed to assess the association between BREAST-Q scores and time since cancer diagnosis.

RESULTS

Sixty-five patients met inclusion criteria for analysis and are characterized by a mean age of 53 ± 11 (34-79) years and a mean body mass index of 28 ± 6 (19-49). Most patients were treated by mastectomy (58%) or lumpectomy (23%). At the time of retrospective chart review, 29 (43%) patients had undergone reconstruction, most of which were delayed (59%). The mean latency from cancer diagnosis to reconstruction was 685 ± 867 days (range: 28-3322 days). Latency from cancer diagnosis to reconstruction was associated with a greater expectation of pain (β = 0.5; standard error [SE] = 0.005; 95% confidence interval [CI]: 0.003-0.027; P < .05), and a slower expectation for recovery (β = -0.5; SE = 0.004; 95% CI: -0.021 to -0.001; P < .05) after breast reconstruction. Latency from cancer diagnosis to reconstruction was associated with an increase in preoperative psychosocial well-being (β = 0.578; SE 0.009; 95% CI: 0.002-0.046; P < .05).

CONCLUSION

Delaying breast reconstruction may negatively impact patient expectations of postoperative pain and recovery. Educational interventions aimed at understanding and managing patient expectations in the preoperative period may improve health-related quality of life and patient-related outcomes following initial breast cancer surgery.