Attitudes of medical students and primary care physicians regarding input of older and younger patients in medical decisions

Associations of clinical personnel characteristics and telemedicine practices

CONTEXT

The use of telemedicine strategies has been increasing in the United States for more than a decade, with physicians taking advantage of this new tool to reach more patients. Determining the specific demographics of physicians utilizing telemedicine most in their practice can inform recommendations for expanded telemedicine use among all physicians and aid in mitigating the need for local physicians in urban and rural populations.

OBJECTIVES

This study aims to assess the use of telemedicine by physicians in 2021, based on four demographics utilizing the National Electronic Health Record Survey (NEHRS): physician age, sex, specialty, and training.

METHODS

We performed a cross-sectional study of the 2021 NEHRS to determine the relationship between physician characteristics and telemedicine practices. Differences between groups were measured through design-based chi-square tests.

RESULTS

Compared to male physicians, female physicians were more likely to utilize telemedicine services (X 2=8.0; p=0.005). Compared to younger physicians, those over the age of 50 were less likely to utilize telemedicine services (X 2=4.1; p=0.04). Compared to primary care physicians, medical and surgical specialty physicians were less likely to utilize telemedicine services, with surgical specialty physicians being the least likely overall (X 2=11.5; p<0.001). We found no significant differences in telemedicine use based on degree (Osteopathic and Allopathic).

CONCLUSIONS

Our results showed a statistically significant difference between physician's age, sex, and specialty on telemedicine use in practice during 2021. Efforts to increase telemedicine use among physicians may be needed to provide more accessible care to patients. Thus, by increasing physician education on the importance of telemedicine for modern patients, more physicians may decide to utilize telemedicine services in practice.

Use of telemedicine in the outpatient sector during the COVID-19 pandemic: a cross-sectional survey of German physicians

BACKGROUND

In the wake of the coronavirus disease 2019 (COVID-19) pandemic, administrative barriers to the use of telemedicine have been reduced in Germany. The study focused on the analysis of use and assessment of telemedicine by physicians working in the outpatient sector, considering the perspective of different disciplines during the COVID-19 pandemic in Germany.

METHODS

The anonymous cross-sectional online survey within the study COVID-GAMS was conducted from 16 November 2020 to 1 January 2021. General practitioners; cardiologists; gastroenterologists; paediatricians; gynaecologists; ear, nose, and throat (ENT) specialists were randomly selected and invited to participate in the survey. At the same time, open recruitment to the online survey was conducted via the professional societies. Descriptive and regression analyses were performed based on the data of 1521 outpatient responding physicians.

RESULTS

The use of telephone and video consultation increased during the pandemic. Regarding the frequency of use, physicians already using telephone/video consultations in March/April 2020 report an increase in such services. General medicine was associated with an increased use of telephone and video consultations than cardiology, gynaecology or ENT, and in the case of telephone consultations also compared to paediatrics. General practitioners assessed the subjective usefulness higher than gynaecology and ENT. And the self-reported proportion of patients receiving telemedical care was higher correlated with general medicine than all other disciplines. The location of the practice (rural vs. urban), type of practice (individual vs. group) and gender (male vs. female) were also shown to be significant influencing factors on the variables mentioned above. Barriers reported by physicians not using telemedicine were the lack of equivalence to face-to-face contact and perceived low demand from patients.

CONCLUSION

The COVID-19 pandemic has led to a significant increase in the use of telemedicine, to varying degrees in the different specialities. Individual and structural factors lead to a reduced use of telemedicine and there are physician's and patient's barriers that have prevented telephone and video consultations from gaining acceptance by physicians. All these factors must be addressed if telemedicine procedures are to be implemented widely.

Racial Differences in Satisfaction with Physicians

This analysis examines the association between race and satisfaction with physicians among a sample of community-dwelling older adults. It is hypothesized that minority elderly will hold more negative attitudes toward physicians than will their White peers due to the difficulty in establishing rapport in the physician-patient relationship. Using data from the Established Populations for Epidemiologic Studies of the Elderly (Duke), we find that African Americans believe that physicians do not display much compassion for, and respect toward, the elderly. However, African Americans report more positive attitudes about the prudence of physicians. These findings are discussed in the context of improving the physician-patient relationship.

Do Patients Want Control over their Own Health Care? A Review of Measures, Findings, and Research Issues

Across a wide variety of medical settings, patients report that they want detailed information about their condition and their treatment whereas stated desire for input into decision making is skewed more in the direction of physician-only or at least collaborative decision-making. These results, along with the contextual and individual difference factors associated with increased willingness to relinquish control (lower educational level, more serious illness, increasing age), indicate that patients want to assume control if they feel it will be beneficial to them to do so. The findings, however, are based largely on the relationship of patients’ mean scores to arbitrarily determined scale midpoints on measures with little or no criterion-related validity. These measures also show insufficient overlap with better validated measures of desire for health care control, which indicate more normally distributed scores and a broader range of individual differences among respondents. Findings are discussed in terms of the need for further research on the structure (dimensionality) and stability of the construct desire for health care control and issues involved in conducting needed criterion-related validational work.

The Attitude of Physicians toward the Use of Patient Decision Aids in Iran as a Developing Country

Background:

The patient decision aids (PDAs), which can facilitate the decision-making process when choosing the optimal method of treatment, are a challenge to patients. This study tried to determine the attitude of physicians on the barriers of using PDAs in the way of prioritizing and proposing solutions to them.

Methods:

This study was a cross-sectional research carried out on 150 clinical faculty members of research centers and scientific associations affiliated with Tehran University of Medical Sciences. The participants were chosen using the convenience sampling method. The attitude of physicians toward the application of PDAs was interviewed using a self-made questionnaire composed of 23 questions. The association between physicians’ attitude to the use of PDAs and their characteristics was examined using the t-test, analysis of variance, and correlation test.

Results:

The mean score of physicians’ attitude was 76.2 (standard deviation =11.9) and the range was 33–107. There was a significant and direct association between the attitude toward the use of PDA and the respondents’ age (r = 0.237, P = 0.007), years of experience (r = 0.205, P = 0.02), being male (P = 0.04), and working in the private sector (P = 0.009). The attitude score of instructors was significantly lower than that of professors (P = 0.02).

Conclusions:

The general attitude of physicians toward the use of PDAs was positive. However, apparently as a result of problems mentioned in this study for the developing countries such as Iran, it is much easier to employ these tools in centers run by the private sector. Usage of such tools in public centers necessitates systemic infrastructure as well as credits and budgets required for the training of patients and physicians.

Appraisal of Desire for Control over Healthcare: Structure, Stability, and Relation to Health Locus of Control and to the 'Big Five' Personality Traits

This study addressed the question of whether the traditional tripartite distinction between cognitive, decisional and behavioral control is meaningful as applied to desire for healthcare control. Subscales of the Krantz Health Opinion Survey and the Autonomy Preference Index were administered to 680 undergraduates along with the Multidimensional Health Locus of Control Scales and the NEO-FFI Five-Factor Inventory. These measures were readministered to 523 of these subjects approximately seven weeks later. Confirmatory factor analysis of the data indicated that desire for healthcare control is best conceptualized as having three separate components. Desire for information was clearly unrelated to either desire for behavioral or decisional control; however the latter two forms of control, which are indicative of more active engagement by the individual, overlapped to a moderate degree. The three-factor model was stable over time and the component factors (particularly desire for decisional and behavioral control) were also stable. No strong relationships were found between the component factors and measures of health locus of control or the basic personality trait dimensions measured by the NEO, suggesting that the factors represent largely situation-specific traits. Findings were discussed in terms of how they may have been influenced by variability in the instruments that were used to measure the separate desire for healthcare control components, and in terms of the need for criterion-related validational work especially in the crucial area of decisional control.

The role of expectations in preferences of patients for a female or male general practitioner

OBJECTIVE

to determine, for five health problems, whether preference for a male or female general practitioner (GP) is related to patient gender, GP gender and/or patient expectations of GP behaviour.

METHODS

cross-sectional study in 14 health centres in Spain, administering a questionnaire to 360 patients. Outcome variables were: preference for male GP, female GP or no preference in consultations for five hypothetical health problems.

RESULTS

mean age was 47.3 ± 16.5 years, 51% were female. Preference was more frequently expressed by females. Odds ratios (ORs) for a woman preferring a female to male GP ranged from 3 to 508, according to the hypothetical problem, and ORs for a patient with female GP preferring a female GP ranged from 2.8 to 9.1. Patient gender and GP gender had no interactive effect on preferences. Expectations of GP behaviour were related to preferences, except for chest pain. Higher expectations of communication or technical care were associated with greater preference for female or male GP, respectively.

CONCLUSIONS

patient gender and current GP gender are related to preferences in five hypothetical clinical situations and expectations of GP behaviour to preferences in four of them.

PRACTICE IMPLICATIONS

educational strategies are needed to adjust clinical encounters to patients' preferences.

Patient-provider interactions in the management of chronic pain: current findings within the context of shared medical decision making

OBJECTIVE

This article reviews the literature on patient-provider interactions among patients with chronic pain conditions with an emphasis on shared medical decision making.

RESULTS

Key findings suggest that: 1) patients with chronic pain and health care providers are likely to have opposing attitudes and goals, with patients seeking "to be understood as individuals" and struggling to have their pain concerns legitimized while their health care providers may place a greater focus on diagnosis and treatment than quality of life concerns; and 2) female patients may face additional challenges when communicating their pain concerns with providers. Increased emphasis on communication training and efforts to promote a shared decision making process are proposed as possible mechanisms to improve patient-provider interactions.

CONCLUSIONS

Treatment of chronic pain is often complex and may be further complicated when patients and health care providers have differing goals and attitudes concerning treatment. Difficulties in engaging in collaborative treatment decision making may result. Efforts to enhance patient-provider communication as well as to systematically examine nonspecific treatment factors are likely to promote effective management of chronic pain.

Relationship of interpersonal behaviors and health-related control appraisals to patient satisfaction and compliance in a university health center

OBJECTIVE

The authors' aim was to evaluate patient-provider relationships in a college health center.

PARTICIPANTS

Eighty student patients and their health-care providers.

METHODS

Patients completed a measure of perceived health competence before a consultation and measures of provider participatory behavior and interpersonal behavior before and after the consultation. They evaluated their satisfaction with care and compliance after the consultation and again 2 weeks later. Providers completed measures of their participatory behavior and patients' interpersonal behavior after the consultation.

RESULTS

Patients preferred to be well informed and to have their preferences taken into account, and generally felt competent at managing their own health affairs. They indicated they obtained the high level of participation they desired. Patients desired and actually experienced friendly and submissive providers. Degree of match between patients' desired and actual level of involvement in their care was associated with greater satisfaction. A greater match between the extent to which they desired the provider to be affiliative and the provider's actual affiliative behavior was associated with more satisfaction. No variables were predictive of patient compliance.

CONCLUSION

The authors discuss results in terms of the influence of situational factors characteristic of a college health center.

Examining Older Adults’ Perceptions of Health Care Providers: Identifying Important Aspects of Older Adults’ Relationships With Physicians and Nurses

This article describes older adults' conversations about their relationships with health care providers. Focus group participants (N = 23) were from three ethnic groups (Black, White, and Hispanic) and ages 53 to 92. All but three of the participants were women. Content analysis revealed an overarching theme of genuine caring and three sub-themes: interest in patients' well-being, respectful dialogue, and sharing of information. Older adults' perceptions of genuine caring by physicians and nurses did not differ by ethnicity. Older adults want to engage in a caring, respectful, and educational relationship with their health care providers, which is consistent with fundamental professional values.

Optimal matches of patient preferences for information, decision-making and interpersonal behavior: evidence, models and interventions

OBJECTIVE

A comprehensive review was conducted of the theoretical and empirical work that addresses the preference-match strategy in physician-patient communication.

METHODS

Searches were conducted on Medline, PsychINFO, InFoTrac One File Plus, Sociological Abstracts, and Dissertation Abstracts through 2004. The following keywords were used: patient preferred and received information; patient preferred and actualized treatment decision-making; patient-physician beliefs in shared decision-making; patient-physician match, fit, or concordance; reciprocal relationship or mutuality; doctor-patient affiliation, control, relationship; match/fit between patient and physician in affiliation, control, or relationship.

RESULTS

Findings revealed varying degrees of support for the positive effects of matching patients' preferred levels of information, decisional control, and consultative interpersonal behavior.

CONCLUSIONS

Findings justify not only continued but expanded research efforts in this area that would incorporate recommended changes in research design and implementation. PRACTICE AND RESEARCH IMPLICATIONS: Assessment strategies and match interventions are discussed that, if evidence continues to be supportive, might routinely optimize patient-physician encounters toward more positive outcomes. Methodological guidelines are suggested that can improve future preference-match studies of the patient-physician interaction. Practitioners need to consider adoption of patient-match assessment and intervention strategies in addition to recent exclusive concentrations on patient-centered and shared decision-making approaches.

Ethical issues in caring for people with carotid artery rupture

Nurses working in the head and neck oncology field will be conscious of the possible risk of carotid artery rupture in their patients. This complication occurs swiftly and the patient requires the nurse to rapidly change focus from acute care and cure to palliative care and comfort. Prior decisions need to be made as to whether or not active resuscitation is to be undertaken. In this final article, the ethical issues surrounding this decision-making process are discussed, including patient autonomy, advocacy, beneficence and justice. The facts as they relate to each individual patient should be discussed truthfully and openly with them and their significant others. Each person should be assisted to come to his own decision, following discussion of the prognosis and risks that are pertinent to that individual. Respect for the autonomy of patients should be a guiding principle governing the conduct of decisions.

Expectations for Care: Older Adults' Satisfaction With and Trust in Health Care Providers

This study sought to determine whether community-dwelling older adults' expectations for care were met by identifying factors that influence trust in and satisfaction with health care providers. Data were collected using a demographic questionnaire and focus group methodology. A total of 39 older adults participated in 8 focus groups. Three categories of themes were identified: a sense of personal touch, technical proficiency, and environmental factors. These categories related to individual providers or practice environments. When providers and practice settings met expectations for care, then the elderly individual was satisfied. Trust was more complex, as the older adults indicated they could be satisfied but not trust providers or they could trust providers but not be satisfied. Implications for practice include spending quality time with older adults and treating them as individuals.

Development and utilization of vignettes in assessing medical students' support of older and younger patients' medical decisions

Currently no appropriate vignettes exist to examine issues of age-based care among students early in their medical careers. This paper addresses that issue in two parts. First, as the development of vignettes, widely used in medical research, is rarely described, suggestions for developing reliable and valid vignettes are presented. These suggestions are derived from the development of a series of vignettes assessing the support of older and younger patients' medical decisions among first year medical students. Second, the responses to the vignettes were analyzed quantitatively and qualitatively to assess potential age-based biases. Results indicate that students do not differ in their level of support for older and younger patients' medical decisions. However, students are more supportive of patients who desired aggressive treatments than of those who wished to end treatment. Many students did not focus on the age of the patient, but instead on the patient's quality of life.

Older women and the internet

This study was designed to explore the effects that training had on older adults' willingness to use the Internet to manage their health care. The most interesting result was that out of 70 self-volunteers, 58 were women. Results show that highly educated women who either own a computer or have access to one, and have low levels of anxiety toward computers, with strong feelings of self-efficacy toward computers and the Internet, and an internal locus of control, are more willing than men to use the Internet to find medical information to manage a chronic health problem.

Gender differences in health care provider-patient communication: are they due to style, stereotypes, or accommodation?

This article examines gender differences in health care provider-patient communication within the framework of an ecological model of communication in the medical encounter. The ecological perspective posits that, although health care provider-patient interactions are situated within a number of contexts (e.g. organizational, political, cultural), the interpersonal domain is the primary context within which these interactions unfold. Hence, gender may influence provider-patient interaction to the extent that it can be linked to the interactants' goals, skills, perceptions, emotions, and the way the participants adapt to their partner's communication. The evidence reviewed in this essay indicates that gender differences in medical encounters may come from several sources including differences in men's and women's communicative styles, perceptions of their partners, and in the way they accommodate their partner's behavior during the interaction. However, because gender is but one of many personal and partner variables (e.g. age, ethnicity, personal experiences) that can influence these processes, gender differences are often quite modest (if apparent at all) when examined across a population of health care providers and patients. Implications for future research and communicative skill training are discussed.

Should patients have control over their own health care?: empirical evidence and research issues

Available research indicates that purported patient insufficiencies in ability to process information and make rational and reliable decisions have likely been overestimated. Furthermore, data indicate that nonscientific factors often play a role in physician decision-making and that physicians may not value different health outcomes in the same way as patients. Though the data on patient cognitive functioning are limited because of heavy reliance on patient responses in hypothetical versus actual decision-making situations, these findings lend credence to arguments that patients should have increased control over their own health care. Research on the effects of interventions designed to enhance patient control indicates that: (a) patients generally respond positively to increased information, but few studies have evaluated the effects of information as a precursor to decision-making; (b) the few studies using simple behavioral control interventions have shown generally positive effects on a range of patient outcomes; and (c) studies of decisional control (with breast cancer patients) have had experimental confounds which prohibit conclusions regarding effectiveness. Areas in greatest need of research include: (a) further exploration of the utility of noninvasive behavioral control interventions in different settings; (b) measuring the impact of control manipulations on patient perception of control as well as patient control-related behaviors; (c) matching patient differences in desire for control to experimental conditions and to physician differences in receptiveness to patient control; and (d) clinical trials in which patients facing critical decisions in trade-off situations are actually given a choice.

Patients' preferences for participation in clinical decision making: a review of published surveys

Models of doctor-patient relations vary between "paternalistic" and "informative." The paternalistic model emphasizes doctors' authority; alternative models allow patients to exercise their rights to autonomy. Published surveys indicate that most patients want to be informed about their diseases, that a proportion of patients want to participate in planning management of their illnesses, and that some patients would rather be completely passive and would avoid any information. The severity of the patients' conditions, and their being older, less well educated, and male are predictors of a preference for the passive role in the doctor-patient relationship, but demographic and situational characteristics explain only 20% or less of the variability in preferences. The only way a physician can gain insight into an individual patient's desire to participate in decision making is through direct enquiry. The ability to communicate health-related information and to determine the patients' desire to participate in medical decisions should be viewed as a basic clinical skill.

Medical students' attitudes regarding the use of life-sustaining treatments for themselves and for elderly persons

This study investigated students' wishes regarding the use of life-sustaining treatments (LST) in different health conditions compared with their evaluations of the wishes of elderly people, and with reports of a group of elderly people about themselves. Data were collected from two consecutive classes of first year medical students (n = 101), and a random sample of Israeli elderly aged 70+ (n = 987) who responded to fixed-choice questions regarding their will to live and wishes for three kinds of LST in a number of hypothetical illness conditions. The students were also asked to assess elderly's wishes. Students ranked the will to live of elderly persons significantly lower than their own. The elderly ranked their will to live significantly lower than did the students, but higher than the students assumed about them, indicating that although the will to live is weaker among older people, it is stronger than young persons believe. With regard to the use of LST, students believe that old people want less LST than themselves, but the elderly want even less LST than assumed by the students. The best predictors of students' wishes for themselves were fear of dying and religiosity. Fear of dying, the students' self-esteem and religiosity were the best predictors of their evaluations of the elderly's wishes. The results indicate that both the elderly and the students have a relatively strong will to live, but this desire is dependent on quality of life. The implications of this study for medical education are discussed.