The effect of physician solicitation approaches on ability to identify patient concerns

Introducing "A Question That Might, Perhaps, Scare you": How Geriatric Physicians Approach the Discussion About Cardiopulmonary Resuscitation with Hospitalized Patients

Decisions about the relevance of life-sustaining treatment, such as cardiopulmonary resuscitation (CPR), are commonly made when a patient is admitted to the hospital. This article aims to refine our understanding of how discussions about CPR are introduced, to identify and classify the components frequently occurring in these introductions, and discuss their implications within the overarching activity (discussing CPR). We recorded 43 discussions about CPR between physicians and patients, taking place during the admission interview. We applied an inductive qualitative content analysis and thematic analysis to all the encounter content from the launch of the conversation on CPR to the point at which the physician formulated a question or the patient an answer. We identified this part of the encounter as the "introduction." This systematic method allowed us to code the material, develop and assign themes and subthemes, and quantify it. We identified four major themes in the introductions: (i) agenda setting; (ii) circumstances leading to CPR (subthemes: types of circumstances, personal prognostics of cardiac arrest); (iii) the activity of addressing CPR with the patient (subthemes: routine, constrain, precedence, sensitivity); and (iv) mentioning advance directives. Our findings reveal the elaborate effort that physicians deploy by appealing to combinations of these themes to account for the need to launch conversations about CPR, and highlight how CPR emerges as a sensitive topic.

Clinician Interruptions and Patient-Rated Clinician Empathy in Specialty Visits

INTRODUCTION

Clinicians tend to interrupt patients when they are describing their problem, which may contribute to feeling unheard or misunderstood. Using transcripts of audio and video recordings from musculoskeletal (MSK) specialty visits, we asked what factors are associated with (1) Perceived clinician empathy, including the time a patient spends describing the problem and time to the first interruption, (2) duration of patient symptom description, and (3) duration between the end of greeting and first nonactive listening interruption.

METHODS

We analyzed transcripts of 194 adult patients seeking MSK specialty care with a median age (Interquartile range [IQR]) of 47 (33 to 59) years. Participants completed postvisit measures of perceived clinician empathy, symptoms of depression, accommodation of pain, and health anxiety. A nonactive listening interruption was defined as the clinician unilaterally redirecting the topic of conversation. Factors associated with patient-rated clinician empathy, patient problem description duration, and time until the first nonactive listening interruption were sought in bivariate and multivariable analyses.

RESULTS

The patient's narrative was interrupted at least one time in 144 visits (74%). The duration of each visit was a median of 12 minutes (IQR 9 to 16 minutes). The median time patients spent describing their symptoms was 139 seconds before the first interruption (IQR 84 to 225 seconds). The median duration between the end of the initial greeting and the first interruption was 60 seconds (IQR 30 to 103 seconds). Clinician interruption was associated with shorter duration of symptom description. Greater perceived clinician empathy was associated with greater accommodation of pain (regression coefficient [95% confidence interval] = 0.015 [0.0005-0.30]; P = 0.04).

DISCUSSION

Clinician interruption was associated with shorter symptom presentation, but not with diminished perception of clinician empathy. Although active listening and avoidance of interruption are important communication tactics, other aspects of the patient-clinician relationship may have more effect on patient experience.

Observational study on the timing and method of interruption by hospital consultants during the opening statement in outpatient consultations

OBJECTIVE

To analyse verbal interruptions by Dutch hospital consultants during the patient's opening statement in medical encounters.

DESIGN

Cross-sectional descriptive study.

SETTING

Isala teaching hospital in Zwolle, the Netherlands.

PARTICIPANTS

94 consultations by 27 consultants, video recorded in 2018 and 2019.

MAIN OUTCOME MEASURES

Physicians' verbal interruptions during patients' opening statements, rate of completion of patients' opening statements, time to first interruption and the effect of gender, age and physician specialty on the rate and type of physicians' verbal interruptions.

RESULTS

Patients were interrupted a median of 9 times per minute during their opening statement, the median time to the first interruption was 6.5 s. Most interruptions (67%) were backchannels (such as 'hm hm' or 'go on'), considered to be encouraging the patient to continue. In 52 consultations (55%), patients could not finish their opening statement due to a floor changing interruption by the consultant. The median time to such an interruption was 31.4 s, on average 20 s shorter than a finished opening statement (p=0.004). Female consultants used more backchannels (median 9, IQR 5-12) than male consultants (median 7, IQR 2-11, p=0.028).

CONCLUSIONS

Hospital-based consultants use various ways to interrupt patients during their opening statements. Most of these interruptions are encouraging backchannels. Still, consultants change the conversational floor in more than half of their patients during their opening statements after a median of 31 s.

Exploring Communication Practices in Italian Physiotherapy: Knowledge and Use of Effective Communication Strategies-A National Descriptive Study

This study aimed to investigate the knowledge and use of effective communication strategies among Italian physiotherapists. We utilized a questionnaire consisting of 19 questions to collect data on the knowledge and use of effective communication strategies among Italian physiotherapists. The results revealed that only 35.8% of the respondents reported being aware of communication strategies related to physiotherapy, with their first exposure occurring during their three-year degree. Despite the majority of respondents agreeing that communication is an effective strategy for improving patient adherence, only about half reported making moderate use of open-ended questions and metaphors during treatment sessions. Furthermore, more than half of the respondents reported being unaware of Motivational Interviewing. The results of this study found that there is a consensus among Italian physiotherapists about the importance of effective communication in clinical practice, though the knowledge and application of some communication strategies remain limited. These findings suggest that there is room for improvement in the training and education of physiotherapists in Italy, with a need for greater emphasis on communication strategies in the university educational curriculum, starting from the bachelor's degree.

Validity and reliability of standardized instruments measuring physician communication and interpersonal skills in video-recorded medical consultations - A systematic review

OBJECTIVE

To identify standardized instruments measuring physician communication and interpersonal skills based on video-recorded consultations.

METHODS

We searched electronic databases for primary studies published from 1950 to 2022. Eligible studies had to report the validation of standardized instruments dedicated to the assessment of physician interpersonal skills based on video-recorded consultations with adult patients.

RESULTS

Of 7155 studies retrieved, 13 primary studies involving nine standardized instruments were included. The median number of physicians and participants was 23 (range, 1-200) and 71 (range, 1-950), respectively. Seven out of nine instruments were multidimensional and comprised a median number of 23 items (range, 7-95). The conceptual framework was reported for two instruments only. Content analysis identified 12 key behaviors with substantial overlap across instruments. The Four Habits Coding Scheme (4-HCS) yielded satisfactory validity and reliability while the evidence on psychometric properties was limited for other instruments.

CONCLUSION

Limited evidence supports the psychometric attributes for most of the published standardized instruments dedicated to assessing physician communication and interpersonal skills.

PRACTICE IMPLICATIONS

Although the decision to use a specific instrument depends on the study aims, the 4-HCS appears to be the most reliable instrument for assessing physician communication and interpersonal skills based on video-recorded consultations.

Predictors of patient satisfaction and perceived quality of healthcare: College healthcare providers and students' communication

Background: Prior research indicates that healthcare provider-patient communication influences health outcomes such as patient satisfaction, compliance with diagnosis or treatment, and general health quality. However, little is known about this type of inquiry in the context of healthcare centers on college and university campuses. Aim: The objective of this study was to examine the influence of students' perception of college healthcare providers' affective and instrumental behaviors on student patient satisfaction and perceived quality of healthcare at a university health center. Methods: 349 participants who were college students took an online survey. Regression analyses were conducted. Results: Affective and instrumental behaviors were important communicative behaviors predicting student patient satisfaction and perceived quality of healthcare. However, directions of these predictions differed between student patient satisfaction and perceived quality of healthcare. Conclusion: Healthcare providers at the university health center are recognizing student patients as partners in the healthcare decision-making processes.

Interrupted opening statements in clinical encounters: A scoping review

OBJECTIVE

To conduct a scoping review of literature on the duration of patients' opening statements in clinical encounters, with or without an interruption.

METHODS

We conducted a scoping review to identify articles based on pre-specified inclusion and exclusion criteria. One reviewer extracted study details and outcomes related to the length of patients' opening statements. A second reviewer verified this data.

RESULTS

We included 14 studies from 1185 citations reviewed. Encounters were in primary care clinics, specialty clinics, and hospitals. Across six studies, the mean time to interruption was 18.2 s. The mean length of uninterrupted opening statements was 45.9 s across nine studies.

CONCLUSION

Clinicians interrupting their patients' opening statements, compared to not interrupting, takes away time from the patient to fully present their concerns. Research has not focused on the nature of clinician interruptions. For instance, an interruption encouraging expansion or more detail facilitates understanding. Therefore, the impact these interruptions have on the clinical encounter remains unknown.

PRACTICE IMPLICATIONS

Interrupting the average patient does not save time, so clinicians may benefit from allowing their patients to complete their opening statements.

"We're All Time Poor": Experienced Clinicians' and Students' Perceptions of Challenges Related to Patient Communication

PHENOMENON

Communication is a complex and essential element of clinical practice. It is widely accepted that communication skills can be taught and learned, but challenges remain for clinicians in achieving effective communication with patients. This study explored the patient-communication challenges faced by both medical students and experienced clinicians.

APPROACH

Semi-structured interviews were conducted with twenty medical students and nineteen experienced clinicians from a range of medical disciplines. Interviews were recorded and transcribed, and transcriptions subjected to thematic analysis and coding to quantify the challenges discussed.

FINDINGS

There was remarkable consistency in the challenges described by both groups of participants, with eight predominant challenges identified: time constraints and chaotic environments, rapport building, patient characteristics, reluctance, omissions, assumptions, decision-making, and keeping conversations focused.

INSIGHTS

Medical curricula often focus on communication challenges associated with complex or sensitive clinical situations, but many of the challenges identified occur in routine consultations. Both pre-service and post-graduate medical training should adopt strategies to help build students' and clinicians' skills in managing these challenges from the outset of training.

Antibiotic Prescribing and Doctor-Patient Communication During Consultations for Respiratory Tract Infections: A Video Observation Study in Out-of-Hours Primary Care

Objective: Communication skills can reduce inappropriate antibiotic prescribing, which could help to tackle antibiotic resistance. General practitioners often overestimate patient expectations for an antibiotic. In this study, we describe how general practitioners and patients with respiratory tract infections (RTI) communicate about their problem, including the reason for encounter and ideas, concerns, and expectations (ICE), and how this relates to (non-)antibiotic prescribing in out-of-hours (OOH) primary care.

Methods: A qualitative descriptive framework analysis of video-recorded consultations during OOH primary care focusing on doctor-patient communication.

Results: We analyzed 77 videos from 19 general practitioners. General practitioners using patient-centered communication skills received more information on the perspective of the patients on the illness period. For some patients, the reason for the encounter was motivated by their belief that a general practitioner (GP) visit will alter the course of their illness. The ideas, concerns, and expectations often remained implicit, but the concerns were expressed by the choice of words, tone of voice, repetition of words, etc. Delayed prescribing was sometimes used to respond to implicit patient expectations for an antibiotic. Patients accepted a non-antibiotic management plan well.

Conclusion: Not addressing the ICE of patients, or their reason to consult the GP OOH, could drive assumptions about patient expectations for antibiotics early on and antibiotic prescribing later in the consultation.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Implementation of Patient Engagement Tools in Electronic Health Records to Enhance Patient-Centered Communication: Protocol for Feasibility Evaluation and Preliminary Results

Background

Patient–physician communication during clinical encounters is essential to ensure quality of care. Many studies have attempted to improve patient–physician communication. Incorporating patient priorities into agenda setting and medical decision-making are fundamental to patient-centered communication. Efficient and scalable approaches are needed to empower patients to speak up and prepare physicians to respond. Leveraging electronic health records (EHRs) in engaging patients and health care teams has the potential to enhance the integration of patient priorities in clinical encounters. A systematic approach to eliciting and documenting patient priorities before encounters could facilitate effective communication in such encounters.

Objective

In this paper, we report the design and implementation of a set of EHR tools built into clinical workflows for facilitating patient–physician joint agenda setting and the documentation of patient concerns in the EHRs for ambulatory encounters.

Methods

We engaged health information technology leaders and users in three health care systems for developing and implementing a set of EHR tools. The goal of these tools is to standardize the elicitation of patient priorities by using a previsit “patient important issue” questionnaire distributed through the patient portal to the EHR. We built additional EHR documentation tools to facilitate patient–staff communication when the staff records the vital signs and the reason for the visit in the EHR while in the examination room, with a simple transmission method for physicians to incorporate patient concerns in EHR notes.

Results

The study is ongoing. The anticipated completion date for survey data collection is November 2021. A total of 34,037 primary care patients from three health systems (n=26,441; n=5136; and n=2460 separately recruited from each system) used the previsit patient important issue questionnaire in 2020. The adoption of the digital previsit questionnaire during the COVID-19 pandemic was much higher in one health care system because it expanded the use of the questionnaire from physicians participating in trials to all primary care providers midway through the year. It also required the use of this previsit questionnaire for eCheck-ins, which are required for telehealth encounters. Physicians and staff suggested anecdotally that this questionnaire helped patient–clinician communication, particularly during the COVID-19 pandemic.

Conclusions

EHR tools have the potential to facilitate the integration of patient priorities into agenda setting and documentation in real-world primary care practices. Early results suggest the feasibility and acceptability of such digital tools in three health systems. EHR tools can support patient engagement and clinicians’ work during in-person and telehealth visits. They could potentially exert a sustained influence on patient and clinician communication behaviors in contrast to prior ad hoc educational efforts targeting patients or clinicians.

Trial Registration

ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/ct2/show/NCT03385512

International Registered Report Identifier (IRRID)

DERR1-10.2196/30431

Agenda setting and visit openings in primary care visits involving patients taking opioids for chronic pain

Background

Agenda setting is associated with more efficient care and better patient experience. This study develops a taxonomy of visit opening styles to assess use of agenda and non-agenda setting visit openings and their effects on participant experience.

Methods

This observational study analyzed 83 video recorded US primary care visits at a single academic medical center in California involving family medicine and internal medicine resident physicians (n = 49) and patients (n = 83) with chronic pain on opioids. Using conversation analysis, we developed a coding scheme that assessed the presence of agenda setting, distinct visit opening styles, and the number of total topics, major topics, surprise patient topics, and returns to prior topics discussed. Exploratory quantitative analyses were conducted to assess the relationship of agenda setting and visit opening styles with post-visit measures of both patient experience and physician perception of visit difficulty.

Results

We identified 2 visit opening styles representing agenda setting (agenda eliciting, agenda reframing) and 3 non-agenda setting opening styles (open-ended question, patient launch, physician launch). Agenda setting was only performed in 11% of visits and was associated with fewer surprise patient topics than visits without agenda setting (mean (SD) 2.67 (1.66) versus 4.28 (3.23), p = 0.03).

Conclusions

In this study of patients with chronic pain, resident physicians rarely performed agenda setting, whether defined in terms of “agenda eliciting” or “agenda re-framing.” Agenda setting was associated with fewer surprise topics. Understanding the communication context and outcomes of agenda setting may inform better use of this communication tool in primary care  practice.

Dynamic brain-to-brain concordance and behavioral mirroring as a mechanism of the patient-clinician interaction

The patient-clinician interaction can powerfully shape treatment outcomes such as pain but is often considered an intangible "art of medicine" and has largely eluded scientific inquiry. Although brain correlates of social processes such as empathy and theory of mind have been studied using single-subject designs, specific behavioral and neural mechanisms underpinning the patient-clinician interaction are unknown. Using a two-person interactive design, we simultaneously recorded functional magnetic resonance imaging (hyperscanning) in patient-clinician dyads, who interacted via live video, while clinicians treated evoked pain in patients with chronic pain. Our results show that patient analgesia is mediated by patient-clinician nonverbal behavioral mirroring and brain-to-brain concordance in circuitry implicated in theory of mind and social mirroring. Dyad-based analyses showed extensive dynamic coupling of these brain nodes with the partners' brain activity, yet only in dyads with pre-established clinical rapport. These findings introduce a putatively key brain-behavioral mechanism for therapeutic alliance and psychosocial analgesia.

Understanding Medical Neglect: When Needed Care Is Delayed or Refused

Though the most common form of child maltreatment, neglect can prove among the hardest to diagnose, and intervention is equally difficult. In considering neglect of a child's medical needs, a number of factors play important roles. Diagnosis should be motivated foremost by the intent of providing the best ongoing care for the patient, supplying what the child has not been able to receive from the caregiver. Characteristics peculiar to the patient, the parents, the pathologic condition, its possible treatments, and the mutual understanding between the child's caregivers and the treating professionals all help determine why the therapeutic relationship has failed and which interventions will be most effective. Religious and cultural considerations may lead a family to refuse medical treatments, occasionally to the child's detriment. The caregivers' wishes must be taken into account, but legal precedent has affirmed that the patient's welfare remains the paramount concern. Sorting through the opinions and providing clarity can be a challenge. Finally, good medical care can help prevent medical neglect in many cases. Clear communication and empathy remain hallmarks of good medical practice.

Trajectories of self-rated health in an older general population and their determinants: the Lifelines Cohort Study

OBJECTIVES

Poor self-rated health (SRH) is a strong predictor of premature mortality in older adults. Trajectories of poor SRH are associated with multimorbidity and unhealthy behaviours. Whether trajectories of SRH are associated with deviating physiological markers is unclear. This study identified trajectories of SRH and investigated the associations of trajectory membership with chronic diseases, health risk behaviours and physiological markers in community-dwelling older adults.

STUDY DESIGN AND SETTING

Prospective general population cohort.

PARTICIPANTS

Trajectories of SRH over 5 years were identified using data of 11 600 participants aged 65 years and older of the Lifelines Cohort Study.

OUTCOME MEASURES

Trajectories of SRH were the main outcome. Covariates included demographics (age, gender, education), chronic diseases, health-risk behaviour (physical activity, smoking, drinking) and physiological markers (body mass index, cardiovascular function, lung function, glucose metabolism, haematological condition, endocrine function, renal function, liver function and cognitive function).

RESULTS

Four stable trajectories were identified, including excellent (n=607, 6%), good (n=2111, 19%), moderate (n=7677, 65%) and poor SRH (n=1205, 10%). Being women (OR: 1.4; 95% CI: 1.0 to 1.9), low education (OR: 2.1; 95% CI: 1.5 to 3.0), one (OR: 10.4; 95% CI: 7.4 to 14.7) or multiple chronic diseases (OR: 37.8; 95% CI: 22.4 to 71.8), smoking (OR: 1.8; 95% CI: 1.0 to 3.2), physical inactivity (OR: 3.1; 95% CI: 1.8 to 5.2), alcohol abstinence (OR: 2.2; 95% CI: 1.4 to 3.2) and deviating physiological markers (OR: 1.5; 95% CI: 1.1 to 2.0) increase the odds for a higher probability of poor SRH trajectory membership compared with excellent SRH trajectory membership.

CONCLUSION

SRH of community-dwelling older adults is stable over time with the majority (65%) having moderate SRH. Older adults with higher probabilities of poor SRH often have unfavourable health status.

Chief complaints and feedback from clinic satisfaction tool: Thematic analysis of a new outpatient communication tool

OBJECTIVES

Up to half of all patients leave their outpatient clinic visit with an uncommunicated need. We designed the clinic satisfaction tool (CST) as a low-cost, highly utilised assessment of the spine clinic experience that improved communication in our multidisciplinary spine practice. The purpose of this study was to qualitatively analyse chief complaints and feedback from the CSTs to determine how spine clinic patients used the form, identify the most prevalent concerns and mark areas for improvement.

METHODS

Institutional retrospective review of CSTs. Chief complaints and feedback were inductively coded to create a framework for patient complaints.

RESULTS

832 patients presented to clinic, and 100 sets of chief complaints coded before reaching thematic saturation. Patients used the chief complaint section of CST to canvas four themes: symptoms, questions about their disease, management and treatment. Twenty-nine patients left mostly positive feedback but also wrote additional concerns about care.

CONCLUSION

Spine patients have a predictable pattern of chief complaints and with the CST were able to have all these complaints addressed. The CST efficiently collects practice-specific chief complaints that can be used to guide physician behaviour and design educational clinical tools that are useful for patients.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN AND PARTICIPANTS

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

MAIN MEASURES

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

KEY RESULTS

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

CONCLUSIONS

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

Assessment of patient concerns: a review

BACKGROUND

Patient-centred communication is the mainstay of the medical consultation. It includes the assessment of patient concerns and is important in building the doctor-patient therapeutic relationship. Our aim was to perform a literature review to identify relevance of patient concern assessment, to identify what concerns are encountered in various clinical settings and to explore the different methodologies used to obtain them.

METHODS

A narrative review was performed.

RESULTS

Addressing patient concerns is associated with increased patient satisfaction. Unvoiced concerns are associated with unresolved health issues and poor doctor-patient relationships. Different specialities have focused on different aspects of concern assessment. Patient concern assessment studies are mostly qualitative in nature. Not all qualitative methods give similar results. Interviews are more reliable sources of information than questionnaires as no one questionnaire captures all patient concerns. The location where interviews take place is also relevant.

CONCLUSIONS

Assessing patient concerns is associated with positive outcomes. Patient concerns are handled differently by different clinical specialties. Various methodologies have been used for concern assessment. Interviews and questionnaires can often yield different results.

Centração no paciente: Contributo para o estudo de adaptação da patient-practitioner orientation scale (PPOS)

Objetivo

Este estudo teve como objetivo traduzir e contribuir para a adaptação para a população portuguesa (Português Europeu) da Patient-Practitioner Orientation Scale (PPOS).

Método

Após o processo de tradução e de pré-teste, a escala foi aplicada a 593 estudantes do 1º ao 6º ano do curso de Medicina em várias Universidades de Portugal Continental. A validade do construto e a fiabilidade do instrumento foram aferidas através da análise fatorial exploratória (ACP) e confirmatória (AFC), e do cálculo do coeficiente alpha de Cronbach.

Resultados

A versão final explica 31.54% da variância total e confirma a estrutura em dois fatores: Caring, (19.56% da variância) e Sharing (11.98% da variância). Os itens 2 e 4 apresentaram inconsistências com os fatores definidos à priori (versão original do instrumento), os itens 9 e 17 obtiveram cargas fatoriais inferiores a .3, e o item 3 registou uma diferença inferior a .1 entre as cargas fatoriais para os dois domínios. Os coeficientes de alpha de Cronbach foram .65, .50 e .56 para a escala total, e subscalas Caring e Sharing, respetivamente. A AFC revelou um bom ajustamento global do modelo de medida (χ²(132, N = 593) = 344.28, p < .001; χ²/gl = 2.61; GFI = .93; AGFI = .92; CFI = .87; NNFI = .81; SRMR = .084; RMSEA = .05, 95% CI [0.045, 0.059], p = .293). As análises exploratórias posteriores sugerem a possibilidade de melhoria dos índices de validade e de fiabilidade da escala total e da sub-escala Caring, com a retirada de itens específicos.

Conclusão

Não obstante as fragilidades encontradas no que concerne à fiabilidade e validade da PPOS-P para uma amostra de estudantes portugueses de Medicina, este estudo representa um contributo científico para a adaptação da escala, que pode ser considerada para efeitos de avaliação de atitudes de centração no paciente nos contextos da educação médica e da investigação.

Addressing unmet needs of patients with chronic diseases: Impact of the VISIT website during consultations

RATIONALE, AIMS, AND OBJECTIVES

Patient concerns are often neglected in consultations, especially for chronic diseases where patients and providers fall into the routine of chronic disease management in consultations. One strategy to elicit patient concerns has been to ask patients to complete agenda lists before the consultation. This study aimed to explore the impact of a preconsultation agenda website in addressing patients' unmet needs during chronic disease consultations.

METHODS

Patients entered their concerns into a website (Values In Shared Interactions Tool (VISIT)). Doctors accessed this information via the electronic medical records before consultations. Individual in-depth interviews were then conducted with patients and doctors on the website's impact on consultations. Interviews were transcribed verbatim and analysed thematically.

RESULTS

The average age (years) was 65.7 for patients (n = 8) and 35.7 for doctors (n = 7). Patients in the study entered between 1 to 6 items in the website. From postconsultation interviews, we found that the website impacted the consultation in 5 ways: (1) It facilitated patients to communicate their full agenda to doctors; (2) it helped address unmet patient needs as it gave them opportunity to raise other issues besides their chronic condition; (3) it facilitated rapport between doctor and patient; (4) it facilitated doctors to organize their consultation around the concerns the patient had listed; and (5) it disrupted the doctor's usual consultation style if the list of concerns was lengthy.

CONCLUSIONS

Integrating patient concerns into electronic health records helped to facilitate patient-centred consultations. Doctors found this information useful but felt uneasy if the agenda list was too long or too complex. Areas for future studies include training doctors to manage complex agendas and formal evaluation of the VISIT tool.

Evaluation of Fourth-Year Veterinary Students' Client Communication Skills: Recommendations for Scaffolded Instruction and Practice

Effective client communication is important for success in veterinary practice. The purpose of this project was to describe one approach to communication training and explore fourth-year veterinary students' communication skills through an evaluation of their interactions with clients during a general practice rotation. Two raters coded 20 random videotaped interactions simultaneously to assess students' communication, including their ability to initiate the session, incorporate open-ended questions, listen reflectively, express empathy, incorporate appropriate nonverbal communication, and attend to organization and sequencing. We provide baseline data that will guide future instruction in client communication. Results showed that students' communication skills require development. Half of the students sampled excelled at open-ended inquiry (n=10), and 40% (n=8) excelled at nonverbal communication. Students needed improvement on greeting clients by name and introducing themselves and their role (n=15), reflective listening (n=18), empathy (n=17), and organization and sequencing (n=18). These findings suggest that more focused instruction and practice is necessary in maintaining an organized structure, reflective listening, and empathy to create a relationship-centered approach to care.

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

Background

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

Methods

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

Results

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

Conclusions

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

Agenda Setting During Follow-Up Encounters in a University Primary Care Outpatient Clinic

At the beginning of the medical encounter, clinicians should elicit patients' agendas several times using open-ended questions. Little is known, however, about how many times physicians really solicit a patient's agenda during follow-up encounters. The objective was to analyze the number of agenda solicitations by physicians, of agendas initiated by physicians, and of patients' spontaneous agendas during the beginning and the entire encounter. We analyzed 68 videotaped follow-up encounters at a university primary care outpatient clinic. The number of different types of agenda setting was searched for and analyzed using negative binomial regression or logistic regression models. Physicians solicited agendas a mean ± SD of 0.8 ± 0.7 times/patient during the first 5 minutes and 1.7 ± 1.2 times/patient during the entire encounter. Physicians in 32.4% of encounters did not solicit the patient agenda, and there were never more than two physician's solicitations during the first 5 minutes. The mean number of physician's solicitations of the patients' agenda was 42% lower among female physicians during the first 5 minutes and 34% lower during the entire encounter. The number of agendas initiated by physicians was 1.2 ± 1.2/patient during the beginning and 3.2 ± 2.3/patient during the entire encounter. In 58.8% of the encounters, patients communicated their agendas spontaneously. There were twice as many patient spontaneous agendas (IRR = 2.12, p = .002) with female physicians than with males. This study showed that agenda solicitation with open-ended questions in follow-up encounters does not occur as often as recommended. There is thus a risk of missing new agendas or agendas that are important to the patient.

Como se estuda o que não se diz: uma revisão sobre demanda oculta

Objetivos: Pessoas com demandas aparentemente bem delimitadas podem, muitas vezes, ter queixas ou preocupações ocultas ou tardiamente apresentadas, chamadas em inglês de hidden agenda, by the way syndrome ou doorknob syndrome (“síndrome da maçaneta”). Poucos trabalhos abordam o fenômeno em contexto clínico discutindo seus aspectos ou consequências sobre o cuidado do ponto de vista sociocultural. Uma pesquisa qualitativa sobre saúde dos homens realizada pelos autores exigiu estudar a produção científica relacionada à hidden agenda de forma descritiva e interpretativa. Métodos: Esta revisão, do tipo estado da questão, abarcou artigos que tratassem da hidden agenda (ou expressões similares) no contexto clínico geral ou especializado, médico ou multiprofissional, em português, inglês ou espanhol, no período de 2000 a 2014. Partindo de 210 resultados iniciais em 3 bases de dados internacionais, foram selecionadas 39 publicações, que foram avaliadas quanto a características objetivas e subjetivas. Resultados: Identificando os temas predominantes nas pesquisas, notamos que hidden agenda é a expressão mais específica, sendo demanda oculta sua melhor tradução. Quase todos os estudos relacionavam a atenção a demandas ocultas a melhores desfechos ou desdobramentos do atendimento, embora nenhum avaliasse essas consequências de forma aprofundada. Conclusão: A revisão deixa claro que a demanda oculta é um elemento problematizador para pensar a prática médica e potencializador para a clínica, especialmente ao buscar-se um cuidado integral e um diálogo efetivo entre profissional e usuário(a). São necessários estudos que articulem o fenômeno a aspectos socioculturais ou tecnoassistenciais e que contemplem alguma discussão sobre construção da demanda, ausente nos artigos revisados.

Soliciting additional concerns in the primary care consultation and the utility of a brief communication intervention to aid solicitation: A qualitative study

OBJECTIVE

To investigate the perspectives of general practitioners (GPs) on the practice of soliciting additional concerns (ACs) and the acceptability and utility of two brief interventions (prompts) designed to aid the solicitation.

METHODS

Eighteen GPs participating in a feasibility randomised controlled trial were interviewed. Interviews were semi-structured and audio-recorded. Data were analysed using a Framework Approach.

RESULTS

Participants perceived eliciting ACs as important for: reducing the need for multiple visits, identifying serious illness early, and increasing patient and GP satisfaction. GPs found the prompts easy to use and some continued their use after the study had ended to aid time management. Others noted similarities between the intervention and their usual practice. Nevertheless, soliciting ACs in every consultation was not unanimously supported.

CONCLUSION

The prompts were acceptable to GPs within a trial context, but there was disagreement as to whether ACs should be solicited routinely. Some GPs considered the intervention to aid their prioritisation efficiency within consultations.

PRACTICE IMPLICATIONS

Some GPs will find prompts which encourage ACs to be solicited early in the consultation enable them to better organise priorities and manage time-limited consultations more effectively.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

Physicians should increase use of optimized forms of agenda setting.

Nurses' Perspectives on Patient Satisfaction and Expectations: An International Cross-Sectional Multicenter Study With Implications for Evidence-Based Practice

BACKGROUND

Addressing patient expectations is necessary to achieve high satisfaction. However, few data are available on nurses' perceptions and performance with respect to patient expectations and satisfaction.

OBJECTIVES

This international multicenter study aimed to: (a) evaluate nurses' attitudes and performance with respect to patient satisfaction and expectations, and (b) identify predictors of nurses' inquiry of patients' satisfaction at the point of discharge.

METHODS

A questionnaire examining attitudes and performance toward patient satisfaction and expectations was developed and validated. Nurses at four academic hospitals in the United States, the United Kingdom, Israel, and Denmark were surveyed.

RESULTS

A total of 536 nurses participated in the study (response rate 85.3%). Nurses expressed positive attitudes toward activities related to patient satisfaction and expectations, endorsing the importance of talking with patients about their satisfaction status (91.6%) and their expectations (93.2%). More than half of the responders (51.8%) claimed to have responded to the status of patient satisfaction or dissatisfaction (Israel: 25%; United States: 54.9%; United Kingdom: 61.7%; Denmark: 69.9%; p < .001). However, only 12.1% stated that they routinely ask patients about their level of satisfaction, with nurses in the United States (18.3%) and Denmark (17.5%) more likely to ask compared to nurses in the United Kingdom (7.4%) and Israel (6.3%; p = .001). Adjusted logistic regression identified four significant predictors (p < .05) of nurses' inquiry about patients' satisfaction: "Responding to patient's satisfaction status" (OR: 3.1; 95% CI: 1.7-5.8); "Documenting patient's satisfaction status" (OR: 2.8; 95% CI: 1.6-5.1); "Asking routinely about expectations" (OR: 5.4; 95% CI: 3-9.7); and "Responded to expectations during the past month" (OR: 4.3; 95% CI: 1.9-9.4).

LINKING EVIDENCE TO ACTION

These findings warrant further investigation, potentially into the nurses' work environments or educational programs, to better understand why nurses' positive attitudes toward patient satisfaction and expectations do not result in actively asking patients about their satisfaction level and what should be done to improve nurses' performance. Healthcare organizations and policy makers should develop and support structured programs to address patient expectations and improve patient satisfaction during hospitalization.

How patients understand physicians' solicitations of additional concerns: implications for up-front agenda setting in primary care

In the more than 1 billion primary-care visits each year in the United States, the majority of patients bring more than one distinct concern, yet many leave with "unmet" concerns (i.e., ones not addressed during visits). Unmet concerns have potentially negative consequences for patients' health, and may pose utilization-based financial burdens to health care systems if patients return to deal with such concerns. One solution to the problem of unmet concerns is the communication skill known as up-front agenda setting, where physicians (after soliciting patients' chief concerns) continue to solicit patients' concerns to "exhaustion" with questions such as "Are there some other issues you'd like to address?" Although this skill is trainable and efficacious, it is not yet a panacea. This article uses conversation analysis to demonstrate that patients understand up-front agenda-setting questions in ways that hamper their effectiveness. Specifically, we demonstrate that up-front agenda-setting questions are understood as making relevant "new problems" (i.e., concerns that are either totally new or "new since last visit," and in need of diagnosis), and consequently bias answers away from "non-new problems" (i.e., issues related to previously diagnosed concerns, including much of chronic care). Suggestions are made for why this might be so, and for improving up-front agenda setting. Data are 144 videotapes of community-based, acute, primary-care, outpatient visits collected in the United States between adult patients and 20 family-practice physicians.

How patients would like to improve medical consultations: Insights from a multicentre European study

OBJECTIVE

In a previous qualitative study (GULiVer-I), a series of lay-people derived recommendations ('tips') was listed for doctor and patient on 'How to make medical consultation more effective from the patient's perspective'. This work (GULiVer-II) aims to find evidence whether these tips can be generally applied, by using a quantitative approach, which is grounded in the previous qualitative study.

METHODS

The study design is based on a sequential mixed method approach. 798 patients, representing United Kingdom, Italy, Belgium and the Netherlands, were invited to assess on four point Likert scales the importance of the GULiVer-I tips listed in the 'Patient Consultation Values questionnaire'.

RESULTS

All tips for the doctor and the patient were considered as (very) important by the majority of the participants. Doctors' and patients' contributions to communicate honestly, treatment and time management were considered as equally important (65, 71 and 58% respectively); whereas the contribution of doctors to the course and content of the consultation was seen as more important than that of patients.

CONCLUSIONS

The relevance of GULiVer-I tips is confirmed, but tips for doctors were assessed as more important than those for patients.

PRACTICE IMPLICATIONS

Doctors and patients should pay attention to these "tips" in order to have an effective medical consultation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

The impacts of job loss and job recovery on self-rated health: testing the mediating role of financial strain and income

BACKGROUND

Is regaining a job sufficient to reverse the harmful impacts on health of job loss during the Great Recession? We tested whether unemployed persons who found work within 1 year of job loss experienced a full recovery of their health. Additionally, we tested the mediating role of financial strain and household income.

METHODS

Linear regression models were used to assess the effects of job loss and recovery on self-rated health using the longitudinal EU-SILC, covering individuals from 27 European countries. We constructed a baseline of employed persons (n = 70 611) in year 2007. We evaluated income and financial strain as potential mediating factors.

RESULTS

Job loss was associated with worse self-rated health in both men (β = 0.12, 95%CI: 0.09-0.15) and women (β = 0.13, 95%CI: 0.10-0.16). Financial strain explains about one-third of the association between job loss and health, but income did not mediate this relation. Women who regained employment within 1 year after job loss were found to be similarly healthy to those who did not lose jobs. In contrast, men whose employment recovered had an enduring health disadvantage compared with those who had not lost jobs (β = 0.11, 95%CI: 0.05-0.16). Unemployment cash benefits mitigated financial strain but were too low to substantially reduce perceived financial strain among men.

CONCLUSIONS

Men and women's health appears to suffer equally from job loss but differs in recovery. For men, employment recovery was insufficient to alleviate financial strain and associated health consequences, whereas in women regaining employment leads to health recovery.

Medical students' agenda-setting abilities during medical interviews

PURPOSE

Identifying patients' agendas is important; however, the extent of Korean medical students' agenda-setting abilities is unknown. The study aim was to investigate the patterns of Korean medical students' agenda solicitation.

METHODS

A total of 94 third-year medical students participated. One scenario involving a female patient with abdominal pain was created. Students were video-recorded as they interviewed the patient. To analyze whether students identify patients' reasons for visiting, a checklist was developed based on a modified version of the Calgary-Cambridge Guide to the Medical Interview: Communication Process checklist. The duration of the patient's initial statement of concerns was measured in seconds. The total number of patient concerns expressed before interruption and the types of interruption effected by the medical students were determined.

RESULTS

The medical students did not explore the patients' concerns and did not negotiate an agenda. Interruption of the patient's opening statement occurred in 4.62±2.20 seconds. The most common type of initial interruption was a recompleter (79.8%). Closed-ended questions were the most common question type in the second and third interruptions.

CONCLUSION

Agenda setting should be emphasized in the communication skills curriculum of medical students. The Korean Clinical Skills Exam must assess medical students' ability to set an agenda.

Solicitations in GP, nurse and pharmacist prescriber consultations: an observational study

BACKGROUND

The opening solicitation is a key element of the primary care consultation as it enables patients to express their ideas, concerns and expectations that can lead to improved patient outcomes. However, in practice, this may not always occur. With nurses and pharmacists now able to prescribe, this research explored the opening solicitation in a multi-professional context.

OBJECTIVE

To compare the nature, frequency and response to opening solicitations used in consultations with nurse prescribers (NPs), pharmacist prescribers (PPs) and GPs.

METHODS

An observational study using audio-recordings of NP, PP and GP patient consultations in 36 primary care practices in southern England. Between 7-13 prescriber-patient consultations were recorded per prescriber. A standardized pro forma based upon previous research was used to assess recordings.

RESULTS

Five hundred and thirty-three patient consultations (213 GPs, 209 NPs, 111 PPs) were audio-recorded with 51 prescribers. Across the prescribing groups, pharmacists asked fewer opening solicitations, while GPs used more open questions than NPs and PPs. The mean number of patient agenda items was 1.3 with more items in GP consultations. Patients completed their opening agenda in 20% of consultations, which was unaffected by professional seen. Redirection of the patient's agenda occurred at 24 seconds (mean).

CONCLUSION

All prescribers should be encouraged to use more open questions and ask multiple solicitations throughout the consultation. This is likely to result in greater expression of patients' concerns and improved patient outcomes.

Learning to listen: effects of using conversational transcripts to help medical students improve their use of open questions in soliciting patient problems

OBJECTIVE

This study reports effects of a 'bottom-up' pedagogy using doctor-patient conversation transcripts to improve medical students' use of open questions in soliciting patient problems.

METHODS

We implemented an innovative approach involving students reviewing transcripts of medical interviews, skills practice using role-play and standardized patients (SPs), and reflection on these practices. We analyzed three open question categories (general, biomedical, and psychosocial) used by 27 Taiwanese medical students from two SP interviews, conducted before and after training.

RESULTS

Across the full encounter, use of general and psychosocial open questions increased significantly after training (from 27 to 92 general questions and 15 to 33 psychosocial questions). The high rates of narrowly focused opening questions (52% of initial position questions, 74% of second position questions, and 85% of third position questions) prior to training were reduced to 11%, 15%, and 15% respectively after training. Students also shifted from a micro (narrow) to a macro (broad) pattern of questioning.

CONCLUSION

The 'bottom-up' approach facilitated by using conversation transcripts is effective in improving communication skills.

PRACTICE IMPLICATIONS

By carefully reviewing transcripts of their own performance as part of an overall communication training package, beginning medical students can become more patient-centered in soliciting patient problems.

Evidence-based competencies for improving communication skills in graduate medical education: a review with suggestions for implementation

Communicating with patients is arguably the most common and important activity in medical practice, but this activity receives relatively little emphasis in graduate medical education. We propose 12 evidence-based communication competencies that program directors can adopt as a framework for teaching and evaluating residents' communication skills. We review supporting evidence for these competencies and argue that communication should be treated like a procedural skill that must be taught and evaluated by observing real resident-patient interactions. We make practical suggestions for implementing these competencies by addressing three critical components of a competency-based approach to communication skills: patient safety, faculty development, and direct observation of residents. This approach to teaching and assessing communication skills provides a rationale for incorporating routine direct observation into graduate medical education programs and also for designing communication skills training that ensures graduating residents develop the skills needed to provide safe, effective patient care.

Effectiveness of intensive physician training in upfront agenda setting

BACKGROUND

Patients want all their concerns heard, but physicians fear losing control of time and interrupt patients before all concerns are raised.

OBJECTIVE

We hypothesized that when physicians were trained to use collaborative upfront agenda setting, visits would be no longer, more concerns would be identified, fewer concerns would surface late in the visit, and patients would report greater satisfaction and improved functional status.

DESIGN AND PARTICIPANTS

Post-only randomized controlled trial using qualitative and quantitative methods. Six months after training (March 2004-March 2005) physician-patient encounters in two large primary care organizations were audio taped and patients (1460) and physicians (48) were surveyed.

INTERVENTION

Experimental physicians received training in upfront agenda setting through the Establishing Focus Protocol, including two hours of training and two hours of coaching per week for four consecutive weeks.

MAIN MEASURES

Outcomes included agenda setting behaviors demonstrated during the early, middle, and late encounter phases, visit length, number of raised concerns, patient and physician satisfaction, trust and functional status.

KEY RESULTS

Experimental physicians were more likely to make additional elicitations (p < 0.01) and their patients were more likely to indicate agenda completion in the early phase of the encounter (p < 0.01). Experimental group patients and physicians raised fewer concerns in the late encounter phase (p < 0.01). There were no significant differences in visit length, total concerns addressed, patient or provider satisfaction, or patient trust and functional status

CONCLUSION

Collaborative upfront agenda setting did not increase visit length or the number of problems addressed per visit but may reduce the likelihood of "oh by the way" concerns surfacing late in the encounter. However, upfront agenda setting is not sufficient to enhance patient satisfaction, trust or functional status. Training focused on physicians instead of teams and without regular reinforcement may have limited impact in changing visit content and time use.

Is referral to a spine surgeon a double-edged sword?: patient concerns before consultation

OBJECTIVE

To assess the concerns of adult patients with spine-related complaints during the period between referral to and consultation with a spine surgeon.

DESIGN

Prospective survey.

SETTING

Toronto, Ont.

PARTICIPANTS

A total of 338 consecutive, nonemergent patients before consultation with a single spine surgeon over a 5-month period.

MAIN OUTCOME MEASURES

Patient concerns, effect of referral to a spine surgeon, and effect of waiting to see a spine surgeon.

RESULTS

The issues patients reported to be most concerning were ongoing pain (45.6% rated this as most concerning), loss of function (23.4%), need for surgery (12.1%), and permanence of the condition (9.6%). Regression analysis demonstrated that older age was an independent predictor of increased level of concern regarding pain (P=.01) and disability (P=.04). Forty-seven percent of all patients listed the need for surgery among their top 3 concerns. Mere referral to a spine surgeon (P=.03) was an independent predictor of increased concern regarding the need for surgery. Sex, diagnosis, surgical candidacy, and actual wait time were not predictive of increased concerns. Patients reported family physicians to be their most influential information source regarding spinal conditions.

CONCLUSION

Timely provision of more specific information regarding the benign and non-surgical nature of most degenerative spinal conditions might substantially reduce patients' exaggerated concerns regarding the probability of surgery for a considerable number of patients referred to spine surgeons.

Deficits and Variations in Patients’ Experience with Making 9 Common Medical Decisions: The DECISIONS Survey

Background

Although many researchers have examined patient involvement and patient-provider interactions within specific clinical environments, no nationally representative data exist to characterize patient perceptions of decision making and patient-provider communications across multiple common medical decisions.

Objective

To identify deficits and variations in the patient experience of making common medical decisions about initiation of prescription medications for hypertension, hypercholesterolemia, or depression; screening tests for colorectal, breast, or prostate cancer; and surgeries for knee or hip replacement, cataracts, or lower back pain, as well as to identify factors associated with patient confidence in the decisions.

Setting

National sample of US adults identified by random-digit dialing.

Design

Cross-sectional survey conducted from November 2006 to May 2007.

Participants

Included 2473 English-speaking adults age 40 and older who reported undertaking 1 or more of the above 9 medical actions or discussing doing so with a health care provider within the past 2 years.

Measurements

Patients reported who initiated discussions and made the final decisions, how much discussion of pros and cons occurred, whether they were asked about their preferences, and their confidence that the decision “was the right one.”

Results

The proportion of patient-driven decisions varied significantly across decisions (range: blood pressure: 16% to knee/hip replacement: 48%). Most patients (78%–85%) reported that providers made a recommendation, and such recommendations generally favored taking medical action. Fewer patients reported that providers asked them about their preferences (range: colon cancer screening: 34% to knee/hip replacement: 80%) or discussed reasons not to take action (range: breast cancer screening: 20% to lower back surgery: 80%). Decision confidence was higher among patients who reported primarily making the decision themselves (odds ratio [OR] = 14.6, P < 0.001) or having been asked for their preference (OR = 1.32, P < 0.01) and was lower among patients whose patient provider discussions included cons (OR = 0.74, P = 0.008).

Limitations

Recall biases may affect patients’ memories of their decision-making processes.

Conclusions

Decisions participants reported wide variations in the proportion of discussions that included a conversation about reasons not to take action or a conversation about patients’ preferences about what they would like to do. These factors appear directly related to patients’ confidence that the decision was “right.”

Treating and precepting with RESPECT: a relational model addressing race, ethnicity, and culture in medical training

BACKGROUND

In 2000 a diverse group of clinicians/educators at an inner-city safety-net hospital identified relational skills to reduce disparities at the point of care.

DESCRIPTION

The resulting interviewing and precepting model helps build trust with patients as well as with learners. RESPECT adds attention to the relational dimension, addressing documented disparities in respect, empathy, power-sharing, and trust while incorporating prior cross-cultural models. Specific behavioral descriptions for each component make RESPECT a concrete, practical, integrated model for teaching patient care.

CONCLUSIONS

Precepting with RESPECT fosters a safe climate for residents to partner with faculty, address challenges with patients at risk, and improve outcomes.

Older adults' pain communication: the effect of interruption

The effect of interrupting older adults as they talk about their osteoarthritis pain was examined in a secondary analysis using a nonrandomized two-group design. Participants were part of a study in which older adults orally responded to a series of three pain questions asked by a videotaped practitioner presented on a computer screen. The initial 96 participants were given visual and auditory cues to touch the computer screen to continue to the next question. The remaining 216 participants received only the visual cue after the auditory cue was noted to interrupt participant responses. Older adults' pain communication was audiotaped, transcribed, and content analyzed using 16 a priori criteria from the American Pain Society's (2002)Guidelines for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis. Older adults in the uninterrupted group responded with significantly more pain information, M=6.3 (SD=3.69), than the interrupted group, M=5.3 (SD=3.22); F(1,300)=4.49, p=.04, chi(2)=0.004. Adjusting for sample size differences, older adults in the interrupted group described 56% less information about the source of their pain, 41% less about the quality of their pain, 29% less about their pain treatments, 24% less about the timing of their pain, and 15% less about their pain intensity. The brief, innocuous interruption diminished the amount of important pain information communicated by the older adults. Deliberate interruptions by practitioners might further reduce communication of important pain information.

Elements of effective communication--rediscoveries from homeopathy

OBJECTIVE

Patients are increasingly attracted to homeopathy despite the unproven effectiveness of homeopathic remedies. Clinical benefit of homeopathy may be due to communication. This review aims to identify and assess effective communication patterns in homeopathy.

METHODS

Narrative review and synthesis of published communication patterns, patient narratives and the author's professional experience as a homeopathic practitioner.

RESULTS

In the biomedical model, where the focus is on disease, communication is physician-centered with early redirection of patients' concerns, and associated with reduced compliance, increasing risk of malpractice claims and low professional fulfillment. The biopsychosocial and the developing integrative medicine models are based on biomedicine but aim to include the whole person. Patient-centeredness is a behavior that elicits, respects and incorporates patients' wishes, allows active patient participation and is related to improved outcomes. The homeopathic model is based on holism and comprehension of the totality of the patient and uses patient-centered communication with a high degree of physician co-operation, empathy, hopefulness, enablement and narrative competence, all of which can improve outcomes.

CONCLUSION

Both biopsychosocial and homeopathic models rely on patient-centered communication. Regardless of conceptual differences, they overlap in their common respect for the totality and individuality of the patient. The study of the homeopathic model shows that respect for the whole person is a basic requirement to entrench patient-centeredness more firmly in medicine.

PRACTICE IMPLICATIONS

Medical education should include values such as individual coping strategies, the benefits of a sound and healthy life-style and the necessity of hope and enablement. Health care should be redesigned to honor physicians who practice these values.