Physician responses to ambiguous patient symptoms

Navigating Uncertainty in Clinical Practice: A Structured Approach

The practice of clinical medicine is imbued with uncertainty. The ways in which clinicians and patients think about, communicate about, and act within situations of heightened uncertainty can have significant implications for the therapeutic alliance and for the trajectory and outcomes of clinical care. Despite this, there is limited guidance about the best methods for physicians to recognize, acknowledge, communicate about, and manage uncertainty in clinical settings. In this paper, we propose a structured approach for discussing and managing uncertainty within the context of a clinician-patient relationship. The approach involves four steps: Recognize, Acknowledge, Partner, and Seek Support (i.e., the RAPS framework). The approach is guided by existing literature on uncertainty as well as our own experience as clinicians working at different stages of career. We define each component of the approach and present sample language and actions for how to implement it in practice. Our aim is to empower clinicians to regard situations of high uncertainty as an opportunity to deepen the therapeutic alliance with the patient, and simultaneously to grow and learn as practitioners.

Diagnostic statements: a linguistic analysis of how clinicians communicate diagnosis

OBJECTIVES

To investigate from a linguistic perspective how clinicians deliver diagnosis to patients, and how these statements relate to diagnostic accuracy.

METHODS

To identify temporal and discursive features in diagnostic statements, we analysed 16 video-recorded interactions collected during a practice high-stakes exam for internationally trained clinicians (25% female, n=4) to gain accreditation to practice in Australia. We recorded time spent on history-taking, examination, diagnosis and management. We extracted and deductively analysed types of diagnostic statements informed by literature.

RESULTS

Half of the participants arrived at the correct diagnosis, while the other half misdiagnosed the patient. On average, clinicians who made a diagnostic error took 30 s less in history-taking and 30 s more in providing diagnosis than clinicians with correct diagnosis. The majority of diagnostic statements were evidentialised (describing specific observations (n=24) or alluding to diagnostic processes (n=7)), personal knowledge or judgement (n=8), generalisations (n=6) and assertions (n=4). Clinicians who misdiagnosed provided more specific observations (n=14) than those who diagnosed correctly (n=9).

CONCLUSIONS

Interactions where there is a diagnostic error, had shorter history-taking periods, longer diagnostic statements and featured more evidence. Time spent on history-taking and diagnosis, and use of evidentialised diagnostic statements may be indicators for diagnostic accuracy.

Facing epistemic and complex uncertainty in serious illness: The role of mindfulness and shared mind

BACKGROUND

Epistemic uncertainty refers to situations in which available evidence is insufficient or unreliable, often accompanied by complexity due to novel contexts, multifactorial causation, and emerging options (the "unknowable unknown"). It stands in contrast to aleatory uncertainty where probabilities are known, and potential benefits and harms can be calculated and presented graphically (the "knowable unknown").

DISCUSSION

Epistemic uncertainty is common, and encompasses uncertainty about the nature of the illness, whom to entrust with one's care, and one's ability to adapt and cope. Communication about the "unknowable unknown" occurs infrequently and ineffectively, and there is little research on improving communication in the face of epistemic and complex uncertainty. Terror Management Theory (TMT) predicts that in encountering serious illness, people engage in "worldview defense" - suppressing death-related thoughts, affiliating with like-minded others, and developing cognitive rigidity and intolerance of information that challenges their worldview. Mindfulness is associated with diminished defensive worldview reactions and cognitive rigidity, and greater tolerance of ambiguity. Shared mind encompasses shared understanding and affective attunement.

CONCLUSION

For clinicians and seriously ill patients facing epistemic uncertainty, psychologically-informed interventions that promote mindfulness and shared mind offer promise in promoting open discussions regarding prognostic uncertainty, advance care planning, and treatment decision-making.

Diagnostic uncertainty in primary care: what is known about its communication, and what are the associated ethical issues?

BACKGROUND

Diagnostic uncertainty (DU) in primary care is ubiquitous, yet no review has specifically examined its communication, or the associated ethical issues.

OBJECTIVES

To identify what is known about the communication of DU in primary care and the associated ethical issues.

METHODS

Systematic review, critical interpretive synthesis and ethical analysis of primary research published worldwide. Medline, Embase, Web of Science and SCOPUS were searched for papers from 1988 to 2020 relating to primary care AND diagnostic uncertainty AND [ethics OR behaviours OR communication]. Critical interpretive synthesis and ethical analysis were applied to data extracted.

RESULTS

Sixteen papers met inclusion criteria. Although DU is inherent in primary care, its communication is often limited. Evidence on the effects of communicating DU to patients is mixed; research on patient perspectives of DU is lacking. The empirical literature is significantly limited by inconsistencies in how DU is defined and measured. No primary ethical analysis was identified; secondary analysis of the included papers identified ethical issues relating to maintaining patient autonomy in the face of clinical uncertainty, a gap in considering the direct effects of (not) communicating DU on patients, and considerations regarding over-investigation and justice.

CONCLUSIONS

This review highlights significant gaps in the literature: there is a need for explicit ethical and patient-centred empirical analyses on the effects of communicating DU, and research directly examining patient preferences for this communication. Consensus on how DU should be defined, and greater research into tools for its measurement, would help to strengthen the empirical evidence base.

[Uncertainty management and medical skills: A clinical and educational reflexion]

Uncertainty arises when information is not sufficient to predict the prognosis or the outcome following an intervention. It is omnipresent in medical daily practice, and will follow each practitioner all along his career. The communication or merely even the feeling of uncertainty is frequently perceived as a negative experience. Nevertheless, rather than a sign of weakness, feeling uncertain reflects a dynamic state of self-reassessment which should be experienced by each doctor involved in providing his patients with the best care. Furthermore, uncertainty may lead to disastrous consequences for practitioners who have not been properly prepared to it, involving the sphere of emotions (stress, anxiety, burn-out) as well as the behavioral field (misdiagnosis, excessive testing, impaired communication…). A growing number of observations, clinical or educational studies, supports the idea that learning uncertainty should be a critical prerequisite to a valuable medical practice. Through this literature review, we propose herein a conceptual glance on uncertainty. Then, we expose some sources of uncertainty in daily practice and teaching, its consequences, and the main factors that contribute to the wide variety of the individual relationship with uncertainty. We finally aim to prompt a global reflexion, falling within an uncertainty competency-based education approach, assuming that our obligation to professionalize the students necessitates making them skilled in dealing with uncertainty.

A randomised controlled trial, cost-effectiveness and process evaluation of the implementation of self-management for chronic gastrointestinal disorders in primary care, and linked projects on identification and risk assessment

Background

Chronic gastrointestinal disorders are major burdens in primary care. Although there is some evidence that enhancing self-management can improve outcomes, it is not known if such models of care can be implemented at scale in routine NHS settings and whether or not it is possible to develop effective risk assessment procedures to identify patients who are likely to become chronically ill.

Objectives

What is the clinical effectiveness and cost-effectiveness of an intervention to enhance self-management support for patients with chronic conditions when translated from research settings into routine care? What are the barriers and facilitators that affect the implementation of an intervention to enhance self-management support among patients, clinicians and organisations? Is it possible to develop methods to identify patients at risk of long-term problems with functional gastrointestinal disorders in primary care? Data sources included professional and patient interviews, patient self-report measures and data on service utilisation.

Design

A pragmatic, two-arm, practice-level cluster Phase IV randomised controlled trial evaluating outcomes and costs associated with the intervention, with associated process evaluation using interviews and other methods. Four studies around identification and risk assessment: (1) a general practitioner (GP) database study to describe how clinicians in primary care record consultations with patients who experience functional lower gastrointestinal symptoms; (2) a validation of a risk assessment tool; (3) a qualitative study to explore GPs’ views and experiences; and (4) a second GP database study to investigate patient profiles in irritable bowel syndrome, inflammatory bowel disease and abdominal pain.

Setting

Salford, UK.

Participants

People with long-term conditions and professionals in primary care.

Interventions

A practice-level intervention to train practitioners to assess patient self-management capabilities and involve them in a choice of self-management options.

Main outcome measures

Patient self-management, care experience and quality of life, health-care utilisation and costs.

Results

No statistically significant differences were found between patients attending the trained practices and those attending control practices on any of the primary or secondary outcomes. The intervention had little impact on either costs or effects within the time period of the trial. In the practices, self-management tools failed to be normalised in routine care. Full assessment of the predictive tool was not possible because of variable case definitions used in practices. There was a lack of perceived clinical benefit among GPs.

Limitations

The intervention was not implemented fully in practice. Assessment of the risk assessment tool faced barriers in terms of the quality of codting in GP databases and poor recruitment of patients.

Conclusions

The Whole system Informing Self-management Engagement self-management (WISE) model did not add value to existing care for any of the long-term conditions studied.

Future work

The active components required for effective self-management support need further study. The results highlight the challenge of delivering improvements to quality of care for long-term conditions. There is a need to develop interventions that are feasible to deliver at scale, yet demonstrably clinically effective and cost-effective. This may have implications for the piloting of interventions and linking implementation more clearly to local commissioning strategies.

Trial registration

Current Controlled Trial ISRCTN90940049.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

Managing diagnostic uncertainty in primary care: a systematic critical review

Background

Diagnostic uncertainty is one of the largest contributory factors to the occurrence of diagnostic errors across most specialties in medicine and arguably uncertainty is greatest in primary care due to the undifferentiated symptoms primary care physicians are often presented with. Physicians can respond to diagnostic uncertainty in various ways through the interplay of a series of cognitive, emotional and ethical reactions. The consequences of such uncertainty however can impact negatively upon the primary care practitioner, their patients and the wider healthcare system. Understanding the nature of the existing empirical literature in relation to managing diagnostic uncertainty in primary medical care is a logical and necessary first step in order to understand what solutions are already available and/or to aid the development of any training or feedback aimed at better managing this uncertainty. This review is the first to characterize the existing empirical literature on managing diagnostic uncertainty in primary care.

Methods

Sixteen databases were systematically searched from inception to present with no restrictions. Hand searches of relevant websites and reference lists of included studies were also conducted. Two authors conducted abstract/article screening and data extraction. PRISMA guidelines were adhered to.

Results

Ten studies met the inclusion criteria. A narrative and conceptual synthesis was undertaken under the premises of critical reviews. Results suggest that studies have focused on internal factors (traits, skills and strategies) associated with managing diagnostic uncertainty with only one external intervention identified. Cognitive factors ranged from the influences of epistemological viewpoints to practical approaches such as greater knowledge of the patient, utilizing resources to hand and using appropriate safety netting techniques. Emotional aspects of uncertainty management included clinicians embracing uncertainty and working with provisional diagnoses. Ethical aspects of uncertainty management centered on communicating diagnostic uncertainties with patients. Personality traits and characteristics influenced each of the three domains.

Conclusions

There is little empirical evidence on how uncertainty is managed in general practice. However we highlight how the extant literature can be conceptualised into cognitive, emotional and ethical aspects of uncertainty which may help clinicians be more aware of their own biases as well as provide a platform for future research.

Trial registration

PROSPERO registration: CRD42015027555

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0650-0) contains supplementary material, which is available to authorized users.

Doctors as Makers

Traditional skills and expertise are not enough to prepare future physicians for the complexity, instability, and uncertainty of clinical practice. Responding and making meaning from ill-defined or unusual problems calls for, even demands, creativity. In this article, the author suggests expanding the traditional role of doctor as science-using, evidence-based practitioner to include that of doctor as a "maker" (creator) and artist. Such a reimagining requires a shift in how we view medical knowledge and patients' stories, as well as a new appreciation for "not-knowing" as a generative, creative space in medicine. Creative thinking deserves a central place in the training of doctors, driven by a reconceptualization of the traditional educational model to include medical disciplines, humanities scholars, artists, and designers.

Ambiguity Within Nursing Practice: An Evolutionary Concept Analysis

Purpose:To analyze the concept of ambiguity in a nursing context.Background:Ambiguity is inherent within nursing practice. As health care becomes increasingly complex, nurses must continue to successfully deal with greater amounts of clinical ambiguity. Although ambiguity is discussed in nursing, minimal concept refinement exists to capture the contextual intricacies from a nursing lens. Nurse perception of an ambiguous clinical event, in combination with nurse tolerance level for ambiguity, can impact nurse response. Yet, little is known about what constitutes ambiguity within nursing practice (AWNP).Method:Rodgers evolutionary method was used to explore AWNP, with emphasis on nurse thinking during ambiguous clinical situations. Literature searches across multiple databases yielded 38 articles for analysis.Results:Attributesof AWNP include (a) variations in cues/available information, (b) multiple interpretations, (c) novel/nonroutine presentations, and (d) unpredictable.Antecedentsinclude (a) a context-specific, clinical situation with ambiguous features needing evaluation and (b) an individual to sense a knowledge gap or perceive ambiguity.Consequencesinclude ranges of (a) emotional, (b) behavioral, and (c) cognitive clinician responses.Conclusion:Preliminary findings support AWNP as a distinct concept in which ambiguity perceived by the nurse likely affects judgment, decision making, and clinical interventions. AWNP is a clinically relevant concept requiring continued development.

Transformational leadership in primary care: Clinicians’ patterned approaches to care predict patient satisfaction and health expectations

Clinicians face the complex challenge of motivating their patients to achieve optimal health while also ensuring their satisfaction. Inspired by transformational leadership theory, we proposed that clinicians’ motivational behaviors can be organized into three patient care styles (transformational, transactional, and passive-avoidant) and that these styles differentially predict patient health outcomes. In two studies using patient-reported data and observer ratings, we found that transformational patient care style positively predicted patients’ satisfaction and health expectations above and beyond transactional and passive-avoidant patient care style. These findings provide initial support for the patient care style approach and suggest novel directions for the study of clinicians’ motivational behaviors.

Physicians' anxiety due to uncertainty and use of race in medical decision making

BACKGROUND

The explicit use of race in medical decision making is contested. Researchers have hypothesized that physicians use race in care when they are uncertain.

OBJECTIVES

The aim of this study was to investigate whether physician anxiety due to uncertainty (ADU) is associated with a higher propensity to use race in medical decision making.

RESEARCH DESIGN

This study included a national cross-sectional survey of general internists.

SUBJECTS

A national sample of 1738 clinically active general internists drawn from the SK&A physician database were included in the study.

MEASURES

ADU is a 5-item measure of emotional reactions to clinical uncertainty. Bonham and Sellers Racial Attributes in Clinical Evaluation (RACE) scale includes 7 items that measure self-reported use of race in medical decision making. We used bivariate regression to test for associations between physician characteristics, ADU, and RACE. Multivariate linear regression was performed to test for associations between ADU and RACE while adjusting for potential confounders.

RESULTS

The mean score on ADU was 19.9 (SD=5.6). Mean score on RACE was 13.5 (SD=5.6). After adjusting for physician demographics, physicians with higher levels of ADU scored higher on RACE (+β=0.08 in RACE, P=0.04, for each 1-point increase in ADU), as did physicians who understood "race" to mean biological or genetic ancestral, rather than sociocultural, group. Physicians who graduated from a US medical school, completed fellowship, and had more white patients scored lower on RACE.

CONCLUSIONS

This study demonstrates positive associations between physicians' ADU, meanings attributed to race, and self-reported use of race in medical decision making. Future research should examine the potential impact of these associations on patient outcomes and health care disparities.

Clinician styles of care: Transforming patient care at the intersection of leadership and medicine

A key role of clinicians is to motivate their patients to initiate and maintain beneficial health behaviors. This article integrates research on transformational leadership, clinician–patient communication, and health behavior to introduce a novel approach to understanding and improving clinicians’ effectiveness as motivators. We describe three dominant clinician styles or patterned approaches to patient care that derive from leadership theory (in order of least to most effective): laissez-faire, transactional, and transformational. Additionally, we suggest potential mediators and effects of the transformational style of care. Finally, we discuss future research directions for the study of clinician styles of care.

GPs' decision-making--perceiving the patient as a person or a disease

BACKGROUND

The aim of this study was to analyse the clinical decision making strategies of GPs with regard to the whole range of problems encountered in everyday work.

METHODS

A prospective questionnaire study was carried through, where 16 General practitioners in Sweden registered consecutively 378 problems in 366 patients.

RESULTS

68.3% of the problems were registered as somatic, 5.8% as psychosocial and 25.9% as both somatic and psychosocial. When the problem was characterised as somatic the main emphasis was most often on the symptoms only, and when the problem was psychosocial main emphasis was given to the person. Immediate, inductive, decision-making contrary to gradual, analytical, was used for about half of the problems. Immediate decision-making was less often used when problems were registered as both somatic and psychosocial and focus was on both the symptoms and the person. When immediate decision-making was used the GPs were significantly more often certain of their identification of the problem and significantly more satisfied with their consultation. Rules of thumb in consultations registered as somatic with emphasis on symptoms only did not include any reference to the individual patient. In consultations registered as psychosocial with emphasis on the person, rules of thumb often included reference to the patient as a known person.

CONCLUSIONS

The decision-making (immediate or gradual) registered by the GPs seemed to have been adjusted on the symptom or on the patient as a person. Our results indicate that the GPs seem to recognise immediately both problems and persons, hence the quintessence of the expert skill of the GP as developed through experience.

[Clinical safety in primary care: medical errors (II)]

The first article of this series on Clinical Safety was dedicated to the epidemiology and systemic preventive policies. In the present review we focus on medical errors with special emphasis on diagnostic type errors. These errors sometimes arise from the elusive characteristics of the disease itself, the way in which the patients present their symptoms, and the characteristics of the professionals themselves. If we consider a general practitioner as a diagnostic machine, --paradigm of "physician as a robot"-- it would be easier for us to accept some cognitive limitations and introduce institutional strategies that would humanise the treatment occasionally received. More specifically we will examine three strategies for improving clinical reasoning: recognising dangerous situations, metacognition, and an internal supervisor.

The association of patient's family, leisure time, and work situation with sickness certification in primary care in Sweden

OBJECTIVE

To investigate associations between patients' family, leisure time, and work-related factors and physicians' measure as to whether or not to sickness certify the patient in connection with the consultation.

DESIGN

Questionnaire survey to physicians in general practice and their patients. Setting. General practitioners (GPs) and their patients in Orebro county, Sweden.

SUBJECTS

A total of 474 patient-physician consultations from 65 physicians with up to 10 patients each. Main outcome measure. Whether or not a sickness certificate was issued.

RESULTS

Among work-related factors, high "authority over decisions" and high "social support" correlated with 30% or more reduced sickness certification probability. Worrying about becoming ill or being injured from work correlates with almost doubled sickness certification risk. Among family and leisure-time variables, only living with a common law partner and having no children correlated with increased sickness certification risk. In addition to analyses of the whole group (all diagnoses), the two largest diagnostic subgroups, infectious diseases and musculoskeletal diseases, were examined. For the infectious diseases subgroup, high demands in work correlated with increased sickness certification risk, while in the musculoskeletal diseases subgroup, worry about work-related injury or illness was the main factor correlating with increased risk for sickness certification.

CONCLUSIONS

Work-related factors were the most important factors related to sickness certification in this study. Determinants for sickness certification risk differed between diagnostic subgroups.

Facing uncertainty as a medical student--a qualitative study of their reflective learning diaries and writings on specific themes during the first clinical year

OBJECTIVE

Tolerance of uncertainty related to the complex work is a major dimension of general practitioner's (GP) profession. Strategies for managing uncertainty have been studied among GPs but less is known about how medical students develop tolerance of uncertainty during their studies. The aim of this study was to investigate how the medical students experience uncertainty during their first clinical years and how their feelings develop with time as they progress from the 3rd year to the 4th year.

METHODS

The material consisted of 22 students' reflective learning diaries and writings on specific themes collected during the 3rd and 4th year of their medical studies. The analysis was performed using thematic content analysis. In this article we present the results related to the theme of uncertainty.

RESULTS

Uncertainty is a major cause of mental strain for medical students, particularly fear of making mistakes. Main themes related to facing uncertainty and found in the diaries and writings were insecurity of professional skills, own credibility, facing with the inexactness of medicine, fear of making mistakes, coping with responsibility, and tolerating oneself as incomplete and accepting oneself as a good-enough doctor-to-be. Common steps of development towards tolerance of uncertainty were found in diaries over a one-year time period as the students progressed in their clinical studies.

CONCLUSIONS

Reflective writing showed to be an effective means for the students of both expressing and dealing with uncertainty, both with the difficult and the pleasant feelings and the experiences the students had with their first patient contacts. It also gave some of them the means of self-reflection which they afterwards found worthwhile.

PRACTICE IMPLICATIONS

Reflective writing is powerful tool which medical students could use to facilitate their maturation process what comes to uncertainty during their first clinical year.

Mutual influence in shared decision making: a collaborative study of patients and physicians

OBJECTIVE

To explore how patients and physicians describe attitudes and behaviours that facilitate shared decision making. Background Studies have described physician behaviours in shared decision making, explored decision aids for informing patients and queried whether patients and physicians want to share decisions. Little attention has been paid to patients' behaviors that facilitate shared decision making or to the influence of patients and physicians on each other during this process.

METHODS

Qualitative analysis of data from four research work groups, each composed of patients with chronic conditions and primary care physicians.

RESULTS

Eighty-five patients and physicians identified six categories of paired physician/patient themes, including act in a relational way; explore/express patient's feelings and preferences; discuss information and options; seek information, support and advice; share control and negotiate a decision; and patients act on their own behalf and physicians act on behalf of the patient. Similar attitudes and behaviours were described for both patients and physicians. Participants described a dynamic process in which patients and physicians influence each other throughout shared decision making.

CONCLUSIONS

This study is unique in that clinicians and patients collaboratively defined and described attitudes and behaviours that facilitate shared decision making and expand previous descriptions, particularly of patient attitudes and behaviours that facilitate shared decision making. Study participants described relational, contextual and affective behaviours and attitudes for both patients and physicians, and explicitly discussed sharing control and negotiation. The complementary, interactive behaviours described in the themes for both patients and physicians illustrate mutual influence of patients and physicians on each other.

When doctors disagree: a qualitative study of doctors' and parents' views on the risks of childhood food allergy

OBJECTIVE

To examine the views of doctors which underpin clinical practice variation concerning an uncertain health risk, and the views of parents who had sought advice from these doctors, using the example of childhood food allergy.

STUDY DESIGN

Qualitative study involving in-depth interviews and participant observation over 16 months. Focus groups and consultation audio-recordings provided corroborative data.

SETTING

Three specialist allergy clinics located in one metropolitan area.

PARTICIPANTS

Eighteen medical specialists and trainees in allergy, and 85 parents (from 69 families) with food allergic children.

RESULTS

Doctors expressed a spectrum of views. The most divergent views were characterized by: scientific scepticism rather than precaution in response to uncertainty; emphasis on quantifiable physical evidence rather than parental histories; professional roles as providers of physical diagnosis and treatment rather than of information and advocacy; libertarian rather than communitarian perspectives on responsibility for risk; and values about allergy as a disease and normal childhood. Parents held a similar, but less divergent range of views. The majority of parents preferred more moderate doctors' views, with 43% (30 of 69) of families expressing their dissatisfaction by seeking another specialist opinion. Many were confused by variation in doctors' opinions, preferring relationships with doctors that recognized their concerns, addressed their information needs, and confirmed that they were managing their child's allergy appropriately.

CONCLUSIONS

In uncertain clinical situations, parents do not expect absolute certainty from doctors; inflexible certainty may not allow parental preferences to be acknowledged or accommodated, and is associated with the seeking of second opinions.

Can simulations measure empathy? Considerations on how to assess behavioral empathy via simulations

Standardized patient simulations have been used as an assessment tool, providing teachers an opportunity to observe learner clinical and communication skills while eliminating the fear of harm to patients. Yet the vices and virtues of these simulations in measuring clinical and communication skills have been deliberated. Based on our standardized patient examination experience, we believe standardized patient simulations can be used to assess certain forms of learners' empathic behaviors. We advocate that, in properly designed and conducted simulations, the scores and feedback comments from standardized patients to learners regarding their empathic behaviors can identify learners with important deficiencies. We conclude our discussion by recommending that reflective practice, challenging cases, decision moments, and raters training to provide feedback can supplement and enrich the use of standardized patient simulations in evaluating empathy.

"Could this be something serious?" Reassurance, uncertainty, and empathy in response to patients' expressions of worry

BACKGROUND

Previous work suggests that exploration and validation of patients' concerns is associated with greater patient trust, lower health care costs, improved counseling, and more guideline-concordant care.

OBJECTIVE

To describe physicians' responses to patients' worries, how their responses varied according to clinical context (straightforward versus medically unexplained symptoms [MUS]) and associations between their responses and patients' ratings of interpersonal aspects of care.

DESIGN

Multimethod study. For each physician, we surveyed 50 current patients and covertly audiorecorded 2 unannounced standardized patient (SP) visits. SPs expressed worry about "something serious" in 2 scenarios: straightforward gastroesophageal reflux or poorly characterized chest pain with MUS.

PARTICIPANTS

One hundred primary care physicians and 4,746 patients.

MEASUREMENTS

Patient surveys measuring interpersonal aspects of care (trust, physician knowledge of the patient, satisfaction, and patient activation). Qualitative coding of 189 transcripts followed by descriptive, multivariate, and lag-sequential analyses.

RESULTS

Physicians offered a mean of 3.1 responses to each of 613 SP prompts. Biomedical inquiry and explanations, action, nonspecific acknowledgment, and reassurance were common, whereas empathy, expressions of uncertainty, and exploration of psychosocial factors and emotions were uncommon. Empathy expressed during SP visits was associated with higher patient ratings of interpersonal aspects of care. After adjusting for demographics and comorbidities, the association was only statistically significant for the MUS role. Empathy was most likely to occur if expressed at the beginning of the conversational sequence.

CONCLUSIONS

Empathy is associated with higher patient ratings of interpersonal care, especially when expressed in situations involving ambiguity. Empathy should be expressed early after patient expressions of worry.

Validation and cultural adaptation of a German version of the Physicians' Reactions to Uncertainty scales

BACKGROUND

The aim of the study was to examine the validity of a translated and culturally adapted version of the Physicians' Reaction to Uncertainty scales (PRU) in primary care physicians.

METHODS

In a structured process, the original questionnaire was translated, culturally adapted and assessed after administering it to 93 GPs. Test-retest reliability was tested by sending the questionnaire to the GPs again after two weeks.

RESULTS

The principal factor analysis confirmed the postulated four-factor structure underlying the 15 items. In contrast to the original version, item 5 achieved a higher loading on the 'concern about bad outcomes' scale. Consequently, we rearranged the scales. Good item-scale correlations were obtained, with Pearson's correlation coefficient ranging from 0.56-0.84. As regards the item-discriminant validity between the scales 'anxiety due to uncertainty' and 'concern about bad outcomes', partially high correlations (Pearson's correlation coefficient 0.02-0.69; p < 0.001) were found, indicating an overlap between both constructs. The assessment of internal consistency revealed satisfactory values; Cronbach's alpha of the rearranged version was 0.86 or higher for all scales. Test-retest-reliability, assessed by means of the intraclass-correlation-coefficient (ICC), exceeded 0.84, except for the 'reluctance to disclose mistakes to physicians' scale (ICC = 0.66). In this scale, some substantial floor effects occurred, with 29.3% of answers showing the lowest possible value.

CONCLUSION

Dealing with uncertainty is an important issue in daily practice. The psychometric properties of the rearranged German version of the PRU are satisfying. The revealed floor effects do not limit the significance of the questionnaire. Thus, the German version of the PRU could contribute to the further evaluation of the impact of uncertainty in primary care physicians.

Exploring and validating patient concerns: relation to prescribing for depression

PURPOSE

This study examined moderating effects of physician communication behaviors on relationships between patient requests for antidepressant medications and subsequent prescribing.

METHODS

We conducted a secondary analysis of a randomized trial. Primary care physicians (N = 152) each had 1 or 2 unannounced visits from standardized patients portraying the role of major depression or adjustment disorder. Each standardized patient made brand-specific, general, or no requests for antidepressants. We coded covert visit audio recordings for physicians' exploration and validation of patient concerns (EVC). Effects of communication on prescribing (the main outcome) were evaluated using logistic regression analysis, accounting for clustering and for site, physician, and visit characteristics, and stratified by request type and standardized patient role.

RESULTS

In the absence of requests, high-EVC visits were associated with higher rates of prescribing of antidepressants for major depression. In low-EVC visits, prescribing was driven by patient requests (adjusted odds ratio [AOR] for request vs no request = 43.54, 95% confidence interval [CI], 1.69-1,120.87; P < or = .005), not clinical indications (AOR for depression vs adjustment disorder = 1.82; 95% CI, 0.33-9.89; P = NS). In contrast, in high-EVC visits, prescribing was driven equally by requests (AOR = 4.02; 95% CI, 1.67-9.68; P < or = .005) and clinical indications (AOR = 4.70; 95% CI, 2.18-10.16; P < or = .005). More thorough history taking of depression symptoms did not mediate these results.

CONCLUSIONS

Quality of care for depression is improved when patients participate more actively in the encounter and when physicians explore and validate patient concerns. Communication interventions to improve quality of care should target both physician and patient communication behaviors. Cognitive mechanisms that link patient requests and EVC to quality of care warrant further study.