Assessing communication quality of consultations in primary care: initial reliability of the Global Consultation Rating Scale, based on the Calgary-Cambridge Guide to the Medical Interview

Patient-Clinician Communication During Cardiology Telemedicine Consultations: A Feasibility Study

While studies have evaluated the utility of telehealth in replacing in-person clinical encounters, there is a dearth of literature examining the quality of patient-physician communication with telehealth encounters. Accordingly, this study assessed the feasibility of using virtual cardiology clinical encounters to examine patient-physician interaction, communication, and perceptions of the clinical encounter. Telemedicine cardiology clinical encounters were audio- and video-recorded following the encounter, patients, and cardiologists completed an electronic survey to assess perceptions of the encounter. Qualitative analysis of the communication and statistical analysis of the survey data was conducted, providing descriptive data. The study included 11 patient-physician dyads; all patients were non-Hispanic White. Cardiologists were more racially and ethnically diverse (63% Asian). Most patients agreed telemedicine was comparable to in-person encounters (85.7%), with all cardiologists reporting that patients appeared satisfied with the encounter. We utilized an assessment tool to examine patient-physician communication in the recorded virtual encounters. This study suggests examining patient-physician communication using virtual clinical encounters is feasible, although there are barriers that need addressing for larger studies.

Exploring the dynamics of physician-patient relationships: Factors affecting patient satisfaction and complaints

This review identifes the factors influencing the relationship between physicians and patients that can lead to patients' dissatisfaction and medical complaints. Utilizing a systemic approach 92 studies were retrieved which included quantitative, qualitative, and mixed method studies. Through a thematic analysis of the literature, we identified three interrelated main themes that can influence the relationship between physicians and patients, patients' satisfaction, and the decision to file a medico-legal complaint. The main themes include patient and physician characteristics; the interpersonal relationship between physicians and patients; and the health care system and policies, with relevant subthemes. These themes are demonstrated in a descriptive model. The review suggests areas of focus for physicians who may wish to increase their awareness around the potential sources of relational problems with their patients. Identifying these issues may assist in improvements in the therapeutic relationship with patients, can reduce their medico-legal risk, and enhance the quality of their clinical practice. The findings can also be utilized to support andragogical principles for medical learners. The article can serve as a structured framework to identify potential problems and gaps to design and test effective interventions to mitigate these potential relational problems between physician-patient.

Exploring the value of structured narrative feedback within the Serious Illness Conversation-Evaluation Exercise (SIC-Ex): a qualitative analysis

OBJECTIVES

The Serious Illness Conversation Guide (SICG) has emerged as a framework for conversations with patients with a serious illness diagnosis. This study reports on narratives generated from open-ended questions of a novel assessment tool, the Serious Illness Conversation-Evaluation Exercise (SIC-Ex), to assess resident-led conversations with patients in oncology outpatient clinics.

DESIGN

Qualitative study using template analysis.

SETTING

Three academic cancer centres in Canada.

PARTICIPANTS

7 resident physicians (trainees), 7 patients from outpatient cancer clinics, 10 preceptors (raters) consisting of medical oncologists, palliative care physicians and radiation oncologists.

INTERVENTIONS

Each trainee conducted an SIC with a patient, which was videotaped. The raters watched the videos and evaluated each trainee using the novel SIC-Ex and the reference Calgary-Cambridge Guide (CCG) initially and again 3 months later. Two independent coders used template analysis to code the raters' narrative comments and identify themes/subthemes.

OUTCOME MEASURES

How narrative comments aligned with elements of the CCG and SICG.

RESULTS

Template analysis yielded four themes: adhering to SICG, engaging patients and family members, conversation management and being mindful of demeanour. Narrative comments identified numerous verbal and non-verbal elements essential to SICG. Some comments addressing general skills in engaging patients/families and managing the conversation (eg, setting agenda, introduction, planning, exploring, non-verbal communication) related to both the CCG and SICG, whereas other comments such as identifying substitute decision maker(s), affirming commitment and introducing Advance Care Planning were specific to the SICG.

CONCLUSIONS

Narrative comments generated by SIC-Ex provided detailed and nuanced insights into trainees' competence in SIC, beyond the numerical ratings of SIC-Ex and the general communication skills outlined in the CCG, and may contribute to a more fulsome assessment of SIC skills.

'Doing Questioning' in the Emergency Department (ED)

Eliciting information from patients is fundamental to medical professionals' capacity to deliver good healthcare outcomes in Emergency Departments (EDs). There are different kinds of utterances that "do questioning", and health professionals can variously attend to the medical agenda and the interpersonal aspects of their interactions with those attending the ED in the way that they construct these utterances. We investigate a corpus of ED interactions to determine the prevalence and range of utterances produced by doctors and directed at patients that "do questioning." We developed a questioning utterance typology, informed by previous research on the formulation of such utterances and extended according to observations of our data. We subsequently manually coded 4,355 questioning utterances and report the variety of forms that such utterances can take, considering how these are distributed across doctors at different levels of seniority. We found that doctors at different seniority levels favored similar questioning utterance types and the most frequently used appeared to restrict the contributions of patients. We conclude that our extended typology of questioning utterances has value for understanding the ways in which doctors may encourage patients to provide more extensive responses.

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

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

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.

A simulation-based OSCE with case presentation and remote rating - development of a prototype

Simulation-based examination formats improve the possibility to assess medical students' competences during their performance. Additionally, videotaping of simulations allows for remote rating, providing advantages for raters, students, and exam organizers. We describe a simulation-based OSCE prototype with remote rating of students' competences, developed to replace a conventional OSCE at Hamburg Medical Faculty. The assessment consists of two phases: a consultation phase with four simulated patient encounters and a case presentation phase where four students present two cases each. All encounters from the consultation and the presentation phase are to be videotaped and remotely rated by clinical raters. Advanced medical students (year 4) are to be assessed regarding their clinical knowledge as well as physician-patient-communication, clinical reasoning competence, and patient management competence. We provide detailed schedules for the simulation-based OSCE procedure and a roster for organization. When piloting the assessment, we encountered two major obstacles with respect to legal obligations regarding examination time and videotaping which allowed us to provide tips on how to successfully implement this assessment prototype. Remote rating will, when successfully implemented, help students to concentrate on their consultation or presentation tasks, reduce raters' time constraints and also allow for randomized rating. Using established instruments for competence-rating rather than OSCE checklists provides an additional feature for this simulation-based OSCE prototype. Legal issues can be avoided by using the prototype for formative assessment but should be addressed in advance when it is planned to be used as summative assessment.

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

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

The role of the emotive, moral, and cognitive components for the prediction of medical students' empathic behavior in an Objective Structured Clinical Examination (OSCE)

OBJECTIVES

Investigate whether medical students' emotive abilities, attitudes, and cognitive empathic professional abilities predict empathic behavior in an Objective Structured Clinical Examination (OSCE).

METHODS

Linear and multiple regressions were used to test concurrent validity between Interpersonal Reactivity Index (IRI), Jefferson Scale of Physician Empathy (JSPE-S), Situational Judgement Test (SJT-expert-based score (SJT-ES), SJT-theory-based score (SJT-TS)) and empathic behavior in an OSCE measured by Berlin Global Rating (BGR) and Verona Coding Definitions for Emotion Sequences (VR-CoDES).

RESULTS

Highest amounts of explained variance of empathic behavior measured by VR-CoDES were found for the SJT-ES (R2 = 0.125) and SJT-TS (R2 = 0.131). JSPE-S (R2 = 0.11) and SJT-ES (R2 = 0.10) explained the highest amount of variance in empathic behavior as measured by BGR. Stepwise multiple regression improved the model for BGR by including SJT-ES and JSPE-S, explaining 16.2% of variance.

CONCLUSIONS

The instrument measuring the emotive component (IRI) did not significantly predict empathic behavior, whereas instruments measuring moral (JSPE-S) and cognitive components (SJT) significantly predicted empathic behavior. However, the explained variance was small.

PRACTICE IMPLICATIONS

The instrument measuring the emotive component (IRI) did not significantly predict empathic behavior, whereas instruments measuring moral (JSPE-S) and cognitive components (SJT) significantly predicted empathic behavior. However, the explained variance was small. In a longitudinal assessment program, triangulation of different instruments assessing empathy offers a rich perspective of learner's empathic abilities. Empathy training should include the acquisition of knowledge, attitudes, and behavior to support learner's empathic behaviors.

Barriers and Facilitators to the Initiation of Injectable Therapies for Type 2 Diabetes Mellitus: A Mixed Methods Study

INTRODUCTION

Initiation of injectable therapies in type 2 diabetes (T2D) is often delayed, however the reasons why are not fully understood.

METHODS

A mixed methods study performed in sequential phases. Phase 1: focus groups with people with T2D (injectable naïve [n = 12] and experienced [n = 5]) and healthcare professionals (HCPs; nurses [n = 5] and general practitioners (GPs) [n = 7]) to understand their perceptions of factors affecting initiation of injectables. Phase 2: video-captured GP consultations (n = 18) with actor-portrayed patient scenarios requiring T2D treatment escalation to observe the initiation in the clinical setting. Phase 3: HCP surveys (n = 87) to explore external validity of the themes identified in a larger sample.

RESULTS

Focus groups identified patients' barriers to initiation; fear, lack of knowledge and misconceptions about diabetes and treatment aims, concerns regarding lifestyle restrictions and social stigma, and feelings of failure. Facilitators included education, good communication, clinician support and competence. HCP barriers included concerns about weight gain and hypoglycaemia, and limited consultation time. In simulated consultations, GPs performed high-quality consultations and recognised the need for injectable initiation in 9/12 consultations where this was the expert recommended option but did not provide support for initiation themselves. Survey results demonstrated HCPs believe injectable initiation should be performed in primary care, although many practitioners reported inability to do so or difficulty in maintaining skills.

CONCLUSION

People with T2D have varied concerns and educational needs regarding injectables. GPs recognise the need to initiate injectables but lack practical skills and time to address patient concerns and provide education. Primary care nurses also report difficulties in maintaining these skills. Primary care HCPs initiating injectables require additional training to provide practical demonstrations, patient education and how to identify and address concerns. These skills should be concentrated in the hands of a small number of primary care providers to ensure they can maintain their skills.

Quality in Clinical Consultations: A Cross-Sectional Study

The coronavirus disease 2019 pandemic may have affected the quality of clinical consultations. The objective was to use 10 proposed quality indicator questions to assess outpatient consultation quality; to assess whether the recent shift to telemedicine during the pandemic has affected consultation quality; and to determine whether consultation quality is associated with satisfaction and consultation outcome. A cross-sectional study was used to survey clinicians and patients after outpatient consultations (1 February to 31 March 2021). The consultation quality score (CQS) was the sum of ‘yes’ responses to the survey questions. In total, 78% (538/690) of consultations conducted were assessed by a patient, clinician, or both. Patient survey response rate was 60% (415/690) and clinician 42% (291/690). Face-to-face consultations had a greater CQS than telephone (patients and clinicians < 0.001). A greater CQS was associated with higher overall satisfaction (clinicians log-odds: 0.77 ± 0.52, p = 0.004; patients log-odds: 1.35 ± 0.57, p < 0.001) and with definitive consultation outcomes (clinician log-odds: 0.44 ± 0.36, p = 0.03). In conclusion, consultation quality is assessable; the shift to telemedicine has negatively impacted consultation quality; and high-quality consultations are associated with greater satisfaction and definitive consultation outcome decisions.

A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures

Introduction: Dental operative procedures, by their interventive nature, impede the opportunity for peri-intervention verbal communication between patients and clinicians. This can impair trust, consent, and shared decision making with the potential of adversely affecting patient dignity, and potentially resulting in suboptimal clinical outcomes. This scoping review aims to interrogate the literature concerning non-verbal communication methods used in dental and medical practices during peri-interventive procedures, in aiding communication between clinician and patient. We will also ascertain how these align with the Limited Capacity Model of Motivated Mediated Message Processing (LC4MP) communication theory. Methods: The framework proposed by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews, will be used to guide this scoping review and reporting methodology. Selected electronic databases (Medline, Embase, Cochrane Library and Scopus), PsychInfo, CINAHL and grey literature sources will be searched. Inclusion criteria are: articles written in the English language, publications between 2000 and 2020, peer-reviewed empirical studies, with either qualitative or quantitative data, mixed methods, reviews, book chapters and grey literature with a principal focus on non-verbal communication in the healthcare setting. A narrative synthesis will be conducted, with results reported according to elements of LCM4P theory: cognitive load, motivated messaging, message processing and memory. Conclusion: This scoping review will contribute to our methodological and theoretical understanding of the use of non-verbal communication strategies in clinical settings.

General practitioners' communication skills in Nairobi, Kenya: A descriptive observational study

BACKGROUND

High quality primary care is associated with person-centeredness and effective communication that also supports continuity and coordination of care. In Kenya, there is little knowledge about the quality of communication in consultations by general practitioners (GPs).

AIM

To evaluate the quality of communication by GPs.

DESIGN & SETTING

Descriptive, observational study of 23 GPs consultations in 13 private sector primary care facilities in Nairobi, Kenya.

METHOD

One consultation with a randomly selected adult patient was recorded per GP, and 16 communication skills evaluated with the Stellenbosch University Observation Tool. A total percentage score was calculated per consultation, and compared with the GPs' demographics, consultations' complexity and duration using the Statistical Package for Social Sciences.

RESULTS

The GPs' median age was 30.0 years (IQR: 29-32) and median consultation time was 7.0 minutes (IQR =3-9). Median overall score was 64.3% (IQR: 48.4-75.7). They demonstrated skills in gathering information, making and explaining the diagnosis and suggesting appropriate management. They did not make an appropriate introduction, explore the context or patient's perspective, allow shared decision making or provide adequate safety netting. There was a positive correlation between the scores and duration of the consultations (r=0.680, P=0.001). The score was higher in consultations of moderate complexity (78.1; IQR =57.1-86.7) versus low complexity (52.2; IQR =45.1-66.6) (P=0.012).

CONCLUSION

Consultations were brief and biomedical by young and inexperienced GPs. GPs needed further training in communication skills, particularly with regard to person-centredness. Deploying family physicians to the primary care setting would also improve the overall quality of service delivery.

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

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

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

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

Evaluating the Global Rating scale's psychometric properties to assess communication skills of undergraduate medical students in video-recorded simulated patient encounters

OBJECTIVES

To evaluate the psychometric properties of the Global Rating scale (GR) as an observer-based tool to assess communication skills of undergraduate medical students in video-recorded patient encounters.

METHODS

Seventy advanced undergraduate medical students participated in a simulation-based assessment including patient consultations. Simulated patients rated these encounters with the Consultation and Relational Empathy (CARE) scale. Two independent, blinded raters assessed the videos of the encounters with the GR and another blinded rater with the Clinical Reasoning Indicators Scale (CRI-HT-S). To assess the GR's psychometric properties, we analysed reliability by means of a G-study, interrater reliability by ICC, convergent validity (correlation of GR and CARE), and divergent validity (correlation of GR and CRI-HT-S).

RESULTS

We analysed 325 videos of 65 students (56.9% female, mean age 26.1 ± 2.2 years). The G-coefficient was.90. Interrater reliability of the GR was ICC = .95, 95% CI [.91,.97]. CARE and GR correlated moderately (ρ = .47, 95% CI [.25,.65]). GR and CRI-HT-S did not correlate (ρ = .09, 95% CI [-.16,.34]).

CONCLUSIONS

With excellent reliability and adequate validity, the quality of the GR as assessment instrument for communication skills could be demonstrated.

PRACTICE IMPLICATIONS

The GR is a suitable instrument for video-based rating of communication skills.

Teaching and assessing communication skills in the postgraduate medical setting: a systematic scoping review

BACKGROUND

Poor communication skills can potentially compromise patient care. However, as communication skills training (CST) programs are not seen as a priority to many clinical departments, there is a discernible absence of a standardised, recommended framework for these programs to be built upon. This systematic scoping review (SSR) aims to gather prevailing data on existing CSTs to identify key factors in teaching and assessing communication skills in the postgraduate medical setting.

METHODS

Independent searches across seven bibliographic databases (PubMed, PsycINFO, EMBASE, ERIC, CINAHL, Scopus and Google Scholar) were carried out. Krishna's Systematic Evidence-Based Approach (SEBA) was used to guide concurrent thematic and content analysis of the data. The themes and categories identified were compared and combined where possible in keeping with this approach and then compared with the tabulated summaries of the included articles.

RESULTS

Twenty-five thousand eight hundred ninety-four abstracts were identified, and 151 articles were included and analysed. The Split Approach revealed similar categories and themes: curriculum design, teaching methods, curriculum content, assessment methods, integration into curriculum, and facilitators and barriers to CST. Amidst a wide variety of curricula designs, efforts to develop the requisite knowledge, skills and attitudes set out by the ACGME current teaching and assessment methods in CST maybe categorised into didactic and interactive methods and assessed along Kirkpatrick's Four Levels of Learning Evaluation.

CONCLUSIONS

A major flaw in existing CSTs is a lack of curriculum structure, focus and standardisation. Based upon the findings and current design principles identified in this SSR in SEBA, we forward a stepwise approach to designing CST programs. These involve 1) defining goals and learning objectives, 2) identifying target population and ideal characteristics, 3) determining curriculum structure, 4) ensuring adequate resources and mitigating barriers, 5) determining curriculum content, and 6) assessing learners and adopting quality improvement processes.

[Quality of health worker-patient communication: What are the benefits of integrating mental health into front-line services in Guinea?]

BACKGROUND

Patient-centred care presupposes communication based on empathy, active listening and dialogue. Our study examines the effects of integrating mental health in multi-purpose health centres on health workers' communication with patients who consult for problems unrelated to mental health. The objective is to compare the quality of communication in health centres where staff have received specific training in the management of mental disorders (SM+) compared to those without such training (SM-).

METHODS

The study was conducted among 18 health workers in charge of primary curative consultations in 12 non-governmental health centers in Guinea: 7 health workers in 4 SM+ health centers and 11 health workers in 8 SM- health centres. The study is based on mixed methods: observation, semi-structured and group interviews. The Global Consultation Rating Scale (GCRS) was applied to assess patient-centered communication.

RESULTS

The SM+ GCRS scores obtained by SM+s during observations are generally higher than the SM- scores. The odds of having a "good quality" consultation are almost 3 times higher in SM+ than in SM- for some steps in the consultation process. The SM+ discourse is more patient-centered, and differs from the more biomedical discourse of SM-. SM- health workers do not consider all of the stages of a patient-centred consultation to be applicable and recommend "leapfrogging". On the contrary, SM+ health workers consider all stages to be important and are convinced that the integration of mental health has improved their communication through the training they have received and the practice of caring for persons with mental disorders.

CONCLUSION

The integration of mental health into primary care provision represents an opportunity to improve the quality of care in its "patient-centred care" dimension. That said, optimal development of patient-centred care presupposes favorable structural conditions.

Development of a Scale for Assessing Basic Psychotherapeutic Skills

Abstract. Background: Well-established scales for the observation-based assessment of psychotherapy competence encompass multiple domains, require extensive rater training, and are rather cost-intensive. Objective: To develop a comprehensive but easy-to-administer instrument for the observation-based assessment of basic communication and counseling skills in both real and simulated patient encounters, the Clinical Communication Skills Scale (CCSS). Methods: We investigated the content validity and applicability of this scale. We then presented videos of simulated therapy sessions conducted by a competent vs. noncompetent therapist online to N = 209 laypersons and psychology students. Results: Results suggested a one-factorial solution. Internal consistency was excellent ( α = .94). For most aspects, convergent validity with established scales was moderate to high. The CCSS effectively differentiated between both levels of skill. Conclusions: The CCSS appears to be a feasible, reliable, and valid instrument. Nonetheless, its psychometric criteria should be investigated further in clinical samples, with licensed therapists, and in other languages.

Doctor-patient communication skills: a survey on knowledge and practice of Iranian family physicians

Background

Communication skills are fundamental to successful medical practice and can greatly impact patient satisfaction, compliance and outcomes. This study evaluated knowledge and practice of doctor- patient communication among the urban family physicians based on main items of Calgary Cambridge Observation Guides.

Method

This cross-sectional study was conducted from July to September, 2019, in a 400 randomly selected sample of family physicians of Shiraz, Fars province. The data collection tool was a self-administered, second-part questionnaire developed by the researchers. Participants were asked about their age, gender, practice setting, and years of work experience and if they received any formal training in doctor- patient communication. Data were analyzed using SPSS (Version 16, SPSS Inc., Chicago, IL, USA). A p-value of less than 0.05 was considered statistically significant.

Results

The study participants included 204 male and 196 female family physicians with a mean age of 46.7 ± 7.7 years. The mean communication skills knowledge score was 41.5 (SD: ± 2.8) indicating a high level of knowledge. The mean score for practices was 38.7 (SD: ± 3.4), implying a moderate level of practice. Based on Bloom’s scale, nearly 80% of family physicians had good knowledge about doctor-patient communication skills, however, 55% of participants reported moderate to poor level of practice in this regard. Results of multivariate regression analysis suggest that higher levels of related knowledge, having higher age or longer work experience, and working in the public sector can predict better practice scores (P < 0.005).

Conclusion

There is a potential gap between knowledge and self-reported practices toward communication skills among a sample of Iranian family physicians. They have fundamental weakness in the most important evidence-based items of doctor- patient communication. Considering significant role of family physicians in prevention and control of non-communicable diseases (NCDs) as an emerging challenge of our country, the topic of communication skills should be inserted as a top educational priority of family physicians.

Undertaking consultations and clinical assessments at advanced level

Once deemed the reserve of doctors, 'the medical interview' has since transitioned across professional boundaries and is now a key part of the advanced clinical practitioner (ACP) role. Much of the literature surrounding this topic focuses on a purely medical model; however, the ACPs' use of consultation and clinical assessment of complex patient caseloads with undifferentiated and undiagnosed diseases is now a regular feature in healthcare practice. This article explores how knowledge of the fundamental principles surrounding ACP-patient communications, along with the use of appropriate consultation frameworks and examination skills, can provide a deeper insight and enhance the existing skills of the ACP. A comprehensive guide to undertaking patient consultations, physical examination and diagnostic reasoning on a body systems basis is explored in future issues of this Advanced Clinical Practice series.

Upscaling communication skills training - lessons learned from international initiatives

OBJECTIVE

To collect experiences and to identify the main facilitators and barriers for the implementation process of large scale communication training programs.

METHODS

Using a multiple case study design, data was collected from leaders of the individual programs in Australia, Ireland, Austria and Denmark. The RE-AIM framework was used to evaluate the components: Reach, Effectiveness, Adoption, Implementation, and Maintenance of the programs.

RESULTS

The programs, all based on the Calgary-Cambridge Guide, succeeded in reaching the intended target groups corresponding to between 446 and 3000 healthcare workers. New courses are planned and so far the outcome of the intervention has been investigated in two countries. The fact that implementation, including educating trainers, relies on a few individuals was identified as the main challenge.

CONCLUSION

Large scale communication training programs based on the Calgary-Cambridge Guide can be implemented and adopted in multiple different healthcare settings across a national health system culture. The importance of standardized trainer education and adaption of the programs to clinical practice was highlighted.

PRACTICE IMPLICATIONS

In order to address the sustainability of the programs and to allow the intervention to scale up, it is important to prioritise and allocate resources at the political and organizational level.

Patients' Expectations of Physiotherapeutic Treatment for Long-Term Side Effects After Cancer: A Qualitative Study

OBJECTIVE

This study aims to explore the expectations of physiotherapeutic treatment of long-term side effects (LTSEs) after cancer among patients treated in physiotherapy clinics.

METHODS

This a qualitative interview study based on a phenomenological approach. Adult patients with LTSEs after cancer were recruited through The Danish Cancer Society and a private physiotherapy clinic in Denmark. Individual semi-structured interviews were carried out using Microsoft Teams based on an interview guide piloted before the interviews. Interviews were audiotaped and transcribed verbatim. Sampling was conducted with a focus on variation in LTSE. The data were analyzed using Malterud's principles of systematic text condensation and coded in NVivo 12.

RESULTS

2 males and 8 females with an average age of 55.8 years were interviewed for between 40 and 60 minutes from October to November 2020. Four main themes emerged from the interviews1: The importance of the physiotherapist's approach,2 the benefits of meeting patients with similar symptoms,3 the importance of receiving knowledge, and4 patients seeking to maintain their current state more often than aiming to improve their condition.

CONCLUSIONS

Patients consulting a physiotherapy clinic with LTSE after cancer prefer the physiotherapist to have knowledge about cancer and to be emphatic. Furthermore, patients prefer to meet like-minded people and expect support to maintain their current condition rather than improve their condition.

Implementation of national antenatal hypertension guidelines: a multicentre multiple methods study

OBJECTIVE

To evaluate the implementation of National Institute for Health and Care Excellence antenatal hypertension guidelines, to identify strategies to reduce incidences of severe hypertension and associated maternal and perinatal morbidity and mortality in pregnant women with chronic hypertension.

METHODS

We used a multiple method multisite approach to establish implementation of guidelines and the associated barriers and facilitators. We used a national survey of healthcare professionals (n=97), case notes review (n=55) and structured observations (n=42) to assess implementation. The barriers and facilitators to implementation were identified from semistructured qualitative interviews with healthcare professionals (n=13) and pregnant women (n=18) using inductive thematic analysis. The findings were integrated and evaluated using the Consolidated Framework for Implementation Research.

SETTING AND PARTICIPANTS

Pregnant women with chronic hypertension and their principal carers (obstetricians, midwives and physicians), at three National Health Service hospital trusts with different models of care.

RESULTS

We found severe hypertension to be prevalent (46% of case notes reviewed) and target blood pressure practices to be suboptimal (56% of women had an antenatal blood pressure target documented). Women were infrequently given information (52%) or offered choice (19%) regarding antihypertensives. Women (14/18) reported internal conflict in taking antihypertensives and non-adherence was prevalent (8/18). Women who were concordant with treatment recommendations described having mutual trust with professionals mediated through appropriate information, side effect management and involvement in decision making. Professionals reported needing updates and tools for target blood pressure setting and shared decision making underpinned by antihypertensive safety and effectiveness research.

CONCLUSIONS

Women's non-adherence to antihypertensives is higher than anticipated. Suboptimal information provision around treatment, choice of antihypertensives and target setting practices by healthcare professionals may be contributory. Understanding the reasons for non-adherence will inform education and decision-making strategies needed to address both clinician and women's behaviour. Further research into the effectiveness and long-term safety of common antihypertensives is also required.

Evaluating provider communication in pediatric chronic kidney disease care using a global coding system

OBJECTIVE

Among adolescents and young adults (AYAs) with chronic illness, effective provider communication is essential for patient-centered care during a sensitive developmental period. However, communication in chronic illness care for AYAs is not well studied. Our objectives were to describe the provider communication skills in pediatric chronic kidney disease (CKD) care visits; and determine if communication skills differ by AYA characteristics.

METHODS

We adapted a global consultation rating system for pediatric subspecialty care using audiotaped clinic encounters of 18 pediatric nephrologists with 99 AYAs (age M(SD) = 14.9(2.6)) with CKD stages 1-5 and 96 caregivers. We hypothesized that provider communication skills would differ by AYA characteristics (age, gender, and race).

RESULTS

The strongest provider skills included initiating the session and developing rapport; lowest rated skills were asking patient's perspective and checking understanding. Communication scores did not consistently differ by AYA age or race, but were rated higher with female AYAs in several domains (ps<0.05).

CONCLUSIONS

Pediatric providers generally had adequate or good communication scores with AYAs, but improvement in certain skills, particularly with male AYAs, may further support patient-centered care.

PRACTICE IMPLICATIONS

To achieve consistent, patient-centered communication with AYAs, an observation-based global assessment may identify areas for provider improvement.

Codebook for rating clinical communication skills based on the Calgary-Cambridge Guide

BACKGROUND

The aim of the study was to confirm the validity and reliability of the Observation Scheme-12, a measurement tool for rating clinical communication skills.

METHODS

The study is a sub-study of an intervention study using audio recordings to assess the outcome of communication skills training. This paper describes the methods used to validate the assessment tool Observation Scheme-12 by operationalizing the crude 5-point scale into specific elements described in a codebook. Reliability was tested by calculating the intraclass correlation coefficients for interrater and intrarater reliability.

RESULTS

The validation of the Observation Scheme-12 produced a rating tool with 12 items. Each item has 0 to 5 described micro-skills. For each item, the codebook described the criteria for delivering a rating from 0 to 4 depending on how successful the different micro-skills (or number of used jargon words) was accomplished. Testing reliability for the overall score intraclass correlation coefficients was 0.74 for interrater reliability and 0.86 for intrarater reliability. An intraclass correlation coefficient greater than 0.5 was observed for 10 of 12 items.

CONCLUSION

The development of a codebook as a supplement to the assessment tool Observation Scheme-12 enables an objective rating of audiotaped clinical communication with acceptable reliability. The Observation Scheme-12 can be used to assess communication skills based on the Calgary-Cambridge Guide.

Evaluation of Communication Skills Among Physicians: A Systematic Review of Existing Assessment Tools

OBJECTIVE

The importance of physician training in communication skills for motivating patients to adopt a healthy life-style and optimize clinical outcomes is increasingly recognized. This study inventoried and systematically reviewed the psychometric properties of, and the skills assessed by, existing assessment tools used to evaluate communication skills among physicians.

METHODS

This review was conducted in accordance with the PRISMA guidelines (PROSPERO: CRD42018091932). Four databases (PUBMED, EMBASE, PsychINFO, and SCOPUS) were searched up to December 2018, generating 3902 unique articles, which were screened by two authors. A total of 57 articles met the inclusion criteria and underwent full data extraction.

RESULTS

Forty-five different assessment tools were identified. Only 47% of the studies mentioned underlying theories or models for designing the tool. Fifteen communication skills were assessed across the tools, the five most prevalent were information giving (46%) or gathering (40%), eliciting patients' perspectives (44%), planning/goal setting (37%), and closing the session (32%). Most tools (93%) assessed communication skills using in-person role play exercises with standardized (61%) or real (32%) patients, but only 54% described the expertise of the raters who performed the evaluations. Overall, reporting of the psychometric properties of the assessment tools was poor-moderate (4.5 ± 1.3 out of 9).

CONCLUSIONS

Despite identifying several existing physician communication assessment tools, a high degree of heterogeneity between these tools, in terms of skills assessed and study quality, was observed, and most have been poorly validated. Research is needed to rigorously develop and validate accessible, convenient, "user-friendly," and easy to administer and score communication assessment tools.

Standardized patients in psychotherapy training and clinical supervision: study protocol for a randomized controlled trial

Background

Psychotherapy is highly effective and widely acknowledged for treating various mental disorders. Nevertheless, in terms of methods for teaching effective psychotherapeutic approaches and competencies, there has been a lack of investigation. Training and supervision are the main strategies for teaching therapist competencies, and standardized role-plays with simulated patients (i.e., trained individuals playing someone with a mental disorder) seem useful for evaluating training approaches. In medical education, this procedure is now internationally established. However, so far, little use has been made of standardized role-playing to evaluate training and supervision in the area of clinical psychology and psychotherapy.

Methods

In this study, standardized role-plays are used to evaluate methods for training and supervision. Central cognitive behavioral approaches for treating depression are taught in the training. The first experiment compares an active training approach (i.e., model learning) with a passive one (i.e., reading manual-based instructions). The second experiment compares a direct supervision technique (i.e., supervision based on video analysis) with an indirect one (i.e., supervision based on verbal reporting). In each experiment, 68 bachelor’s and master’s students of psychology will be randomly assigned to the experimental and control groups. Each student takes part in three role-plays (baseline, post and 3-month follow-up), which are all videotaped. Two independent raters assess therapist competencies in each role-play on the basis of a standardized competence scale.

Discussion

The research project aims to contribute to the development of specific training and supervision methods in order to improve psychotherapy training and patient care.

Trial registration

ISRCTN Registry, ISRCTN19173895. Registered on 10 December 2019.

Evaluation of a virtual agent to train medical students conducting psychiatric interviews for diagnosing major depressive disorders

BACKGROUND

A psychiatric diagnosis involves the physician's ability to create an empathic interaction with the patient in order to accurately extract semiology (i.e., clinical manifestations). Virtual patients (VPs) can be used to train these skills but need to be evaluated in terms of accuracy, and to be perceived positively by users.

METHODS

We recruited 35 medical students who interacted in a 35-min psychiatric interview with a VP simulating major depressive disorders. Semiology extraction, verbal and non-verbal empathy were measured objectively during the interaction. The students were then debriefed to collect their experience with the VP.

RESULTS

The VP was able to simulate the conduction of a psychiatric interview realistically, and was effective to discriminate students depending on their psychiatric knowledge. Results suggest that students managed to keep an emotional distance during the interview and show the added value of emotion recognition software to measure empathy in psychiatry training. Students provided positive feedback regarding pedagogic usefulness, realism and enjoyment in the interaction.

LIMITATIONS

Our sample was relatively small. As a first prototype, the measures taken by the VP would need improvement (subtler empathic questions, levels of difficulty). The face-tracking technique might induce errors in detecting non-verbal empathy.

CONCLUSION

This study is the first to simulate a realistic psychiatric interview and to measure both skills needed by future psychiatrists: semiology extraction and empathic communication. Results provide evidence that VPs are acceptable by medical students, and highlight their relevance to complement existing training and evaluation tools in the field of affective disorders.

Interactions between women with rheumatoid arthritis and nurses during outpatient consultations: A qualitative study

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory disease, and patients with RA receive services in various settings-for example, in nurse-led follow-up consultations. The present study aimed to investigate how the management of RA in everyday life is expressed in interactions between nurses and women with RA during nursing consultations.

METHODS

The study was conducted in accordance with constructivist grounded theory, with data based on participant observations and subsequent interviews with 10 women with RA.

RESULTS

A core category was developed, "Collaboration through mutual acknowledgement", which documented how the women and nurses confirmed their shared understanding of the content and the structure of the consultation. Three subcategories were identified: (i) "On safe ground", which illustrated that biomedical factors, such as blood test results and pharmacological treatment, structured the basis of the dialogue; (ii) "Venturing forward", which documented how both parties were aware of each other's reactions when the dialogue dealt with women's perspectives of illness in their everyday lives; and (iii) "Gentle steering", which showed that the nurses gently steered the dialogue if the women strayed from the planned content.

CONCLUSIONS

Both parties agreed that a disease perspective consistent with biomedical factors formed the basis for further dialogue. Subsequently, the women's perspectives on illness were included, and the women felt acknowledged. Therefore, the recommendation is that the consultations start by all parties agreeing on a shared agenda to facilitate the inclusion of the women's perspectives on illness.

A narrative review on the consultation tools available for pharmacists in the United Kingdom: do they facilitate person-centred care?

OBJECTIVES

To identify consultation tools cited in the published literature and undertake a narrative review which establishes their scope to support the delivery of person-centred medicine-focused consultations between community pharmacists and patients in the United Kingdom (UK).

KEY FINDINGS

Nine consultation tools used in a pharmacy context were identified. Four tools (Calgary-Cambridge guide, MRCF, MUR and NMS advanced services and PaCT) were selected for further appraisal. None of the tools identified provided a suitable format or sufficient guidance to address all components required for the delivery of a person-centred patient consultation in practice.

SUMMARY

Tools available to UK pharmacists are inadequate for fully supporting delivery of a person-centred consultation in practice. Revision of existing tools or creation of more pharmacy-specific tools will support UK pharmacists' delivery of person-centred consultations in practice.

Intensification to injectable therapy in type 2 diabetes: mixed methods study (protocol)

BACKGROUND

In the UK, type 2 diabetes mellitus (T2D) is largely managed in primary care. Delay in the intensification to injectable therapy, a form of clinical inertia, is associated with worse glycaemic control. UK general practice is highly computerised, with care being recorded on computerised medical record systems; this allows for quantitative analysis of clinical care but not of the underpinning decision-making process. The aim of this study is to investigate perceptions of patients and clinicians in primary care on the initiation of injectable therapies in T2D, and the context within which those decisions are made.

METHODS

This is a mixed methods study, taking a "realist evaluation" approach. The qualitative components comprise focus groups, interviews, and video recordings of simulated surgeries; the quantitative analysis: an overview of participating practices, elements of the video recording, and an online survey. We will recruit primary care clinicians (general practitioners and nurses) and patients from a representative sample of practices within the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network. Participants will be patients with T2D, and primary care clinicians. Focus groups and semi-structured interviews will be recorded, transcribed verbatim and analysed using Framework Analysis. The simulated surgeries will include cases that might be escalated to injectable therapy. The consultation will be reviewed using the Calgary-Cambridge model to assess communication and determination of adherence to national prescribing guidelines. We will conduct multi-channel video recording including screen capture, clinician and patient facial expressions, wide angle view of the consultation, and the computerised medical record screen. This allows annotation and qualitative analysis of the video recordings, and statistical analyses for the quantitative data. We will also conduct an online survey of primary care clinicians' attitudes to, and perceptions of, initiation of injectable therapies, which will be analysed using summary statistics.

DISCUSSION

Results aim to provide a detailed insight into the dynamic two-way decision-making process underpinning use of injectable therapy for T2D. The study will provide insights into clinical practice and enable the development of training, interventions and guidelines that may facilitate, where appropriate, the intensification to injectable therapy.

Controlled, Constrained, or Flexible? How Self-Management Goals Are Shaped By Patient-Provider Interactions

A person-centered approach to goal-setting, involving collaboration between patients and health professionals, is advocated in policy to support self-management. However, this is difficult to achieve in practice, reducing the potential effectiveness of self-management support. Drawing on observations of consultations between patients and health professionals, we examined how goal-setting is shaped in patient-provider interactions. Analysis revealed three distinct interactional styles. In controlled interactions, health professionals determine patients' goals based on biomedical reference points and present these goals as something patients should do. In constrained interactions, patients are invited to present goals, yet health professionals' language and questions orientate goals toward biomedical issues. In flexible interactions, patients and professionals both contribute to goal-setting, as health professionals use less directive language, create openings, and allow patients to decide on their goals. Findings suggest that interactional style of health professionals could be the focus of interventions when aiming to increase the effectiveness of goal-setting.

An exploration of the experiences of rheumatology nurses counselling patients on methotrexate therapy

OBJECTIVES

Methotrexate is commonly used to treat patients with inflammatory arthritis. A key role of a rheumatology nurse is to educate patients on how to take this drug safely prior to the commencement of treatment. The objective of the present study was to explore the experiences of rheumatology nurses conducting this role, focusing on the content of the consultation and training received to perform the role.

METHODS

A qualitative phenomenological approach was used. Six semi-structured interviews were performed with nurses from two hospitals who regularly counsel patients prior to starting methotrexate. The interviews were thematically analysed by two researchers and themes extracted.

RESULTS

Four main themes were identified: (a) using written information to structure the content of the consultation; (b) patients have different information needs; (c) time pressures; and (d) training and evolution of practice. All participants described a lack of confidence when they first started counselling patients commencing methotrexate, with a wide variation in training. Participants reported that patients required different information depending on whether they were commencing this agent on its own or in combination with other drugs. All participants experienced some time pressure.

CONCLUSIONS

Participants reported that the majority of the consultation focused on conveying information, with little opportunity for patient interaction and questions. We suggest that there is a clear need for further exploration of these consultations, to identify possible training needs. Participants also used standard written information to guide both the structure and content of the consultation limiting patients'; opportunities to ask questions.

How well do public sector primary care providers function as medical generalists in Cape Town: a descriptive survey

BACKGROUND

Effective primary health care requires a workforce of competent medical generalists. In South Africa nurses are the main primary care providers, supported by doctors. Medical generalists should practice person-centred care for patients of all ages, with a wide variety of undifferentiated conditions and should support continuity and co-ordination of care. The aim of this study was to assess the ability of primary care providers to function as medical generalists in the Tygerberg sub-district of the Cape Town Metropole.

METHODS

A randomly selected adult consultation was audio-recorded from each primary care provider in the sub-district. A validated local assessment tool based on the Calgary-Cambridge guide was used to score 16 skills from each consultation. Consultations were also coded for reasons for encounter, diagnoses and complexity. The coders inter- and intra-rater reliability was evaluated. Analysis described the consultation skills and compared doctors with nurses.

RESULTS

45 practitioners participated (response rate 85%) with 20 nurses and 25 doctors. Nurses were older and more experienced than the doctors. Doctors saw more complicated patients. Good inter- and intra-rater reliability was shown for the coder with an intra-class correlation coefficient of 0.84 (95% CI 0.045-0.996) and 0.99 (95% CI 0.984-0.998) respectively. The overall median consultation score was 25.0% (IQR 18.8-34.4). The median consultation score for nurses was 21.6% (95% CL 16.7-28.1) and for doctors was 26.7% (95% CL 23.3-34.4) (p = 0.17). There was no difference in score with the complexity of the consultation. Ten of the 16 skills were not performed in more than half of the consultations. Six of the 16 skills were partly or fully performed in more than half of the consultations and these included the more biomedical skills.

CONCLUSION

Practitioners did not demonstrate a person-centred approach to the consultation and lacked many of the skills required of a medical generalist. Doctors and nurses were not significantly different. Improving medical generalism may require attention to how access to care is organised as well as to training programmes.

The Evaluation of Physicians' Communication Skills From Multiple Perspectives

PURPOSE

To examine how family physicians', patients', and trained clinical raters' assessments of physician-patient communication compare by analysis of individual appointments.

METHODS

Analysis of survey data from patients attending face-to-face appointments with 45 family physicians at 13 practices in England. Immediately post-appointment, patients and physicians independently completed a questionnaire including 7 items assessing communication quality. A sample of videotaped appointments was assessed by trained clinical raters, using the same 7 communication items. Patient, physician, and rater communication scores were compared using correlation coefficients.

RESULTS

Included were 503 physician-patient pairs; of those, 55 appointments were also evaluated by trained clinical raters. Physicians scored themselves, on average, lower than patients (mean physician score 74.5; mean patient score 94.4); 63.4% (319) of patient-reported scores were the maximum of 100. The mean of rater scores from 55 appointments was 57.3. There was a near-zero correlation coefficient between physician-reported and patient-reported communication scores (0.009, P = .854), and between physician-reported and trained rater-reported communication scores (-0.006, P = .69). There was a moderate and statistically significant association, however, between patient and trained-rater scores (0.35, P = .042).

CONCLUSIONS

The lack of correlation between physician scores and those of others indicates that physicians' perceptions of good communication during their appointments may differ from those of external peer raters and patients. Physicians may not be aware of how patients experience their communication practices; peer assessment of communication skills is an important approach in identifying areas for improvement.

A scale assessing doctor-patient communication in a context of acute conditions based on a systematic review

BACKGROUND

There is no validated generic tool to measure Doctor-Patient-Communication (DPC) in a context of acute conditions.

OBJECTIVE

To create and validate such a scale in a real population.

MATERIALS AND METHOD

We performed a systematic review of validated DPC scales available in English. From these, using a theoretical model based on a multidisciplinary approach, we selected pertinent items that met the inclusion criteria and included them in a simple questionnaire. This tool based on a synthesis of the literature was then validated in a prospective study in two hospital emergency departments.

RESULTS

We found 22 pertinent questionnaires and scoring systems. From these, we extracted items and built a scale based on 15 questions with graded responses (Likert from 1 to 4). The mean time for questionnaire completion was 3 minutes. We included 189 adults and adolescents in the study and analyzed complete responses to the questionnaire by 149 patients, gathered over the phone one week after their consultation. The scale had high internal consistency (Cronbach's alpha = 0.89) and good external validity. Two questions were removed due to redundancy giving a scale based on 13 questions.

CONCLUSIONS

We have created an easy-to-use and validated generic questionnaire to assess DPC in a context of acute conditions, usable both in clinical research and in routine practice.

Assessment of motivational interviewing: a qualitative study of response process validity, content validity and feasibility of the motivational interviewing target scheme (MITS) in general practice

BACKGROUND

The Motivational Interviewing target Scheme (MITS) is an instrument to assess competency in Motivational Interviewing (MI) and can be used to assess MI in long and brief consultations. In this qualitative study we examined two sources of the Unified Model of Validity, the current standard of assessment validation, in the context of General Practice. We collected evidence concerning response process validity and content validity of the MITS in general practice. Furthermore, we investigated its feasibility.

METHODS

Assessing consultations of General Practitioners and GP-trainees (GPs), the assessors systematically noted down their considerations concerning the scoring process and the content of the MITS in a semi-structured questionnaire. Sampling of the GPs was based on maximum variation and data saturation was used as a stopping criterion. An inductive approach was used to analyse the data. In response to scoring problems the score options were adjusted and all consultations were assessed using the original and the adjusted score options.

RESULTS

Twenty seven assessments were needed to reach data saturation. In most consultations, the health behaviour was not the reason for encounter but was discussed on top of discussing physical problems. The topic that was most discussed in the consultations was smoking cigarettes. The adjusted score options increased the response process validity; they were more in agreement with theoretical constructs and the observed quality of MI in the consultations. Concerning content validity, we found that the MITS represents the broad spectrum and the current understanding of MI. Furthermore, the MITS proved to be feasible to assess MI in brief consultations in general practice.

CONCLUSIONS

Based on the collected evidence the MITS seems a promising instrument to measure MI interviewing in brief consultations. The evidence gathered in this study lays the foundation for research into other aspects of validation.

Selecting graduates for the interns' award by using multisource feedback process: does it work?

Background

The purpose of this study is to find a reliable method for choosing graduates for a higher-education award. One such method that has achieved notable popularity is known as multisource feedback. Multisource feedback is assessment tool that uses evaluations of different groups and includes both physicians and non-physicians. It is useful for assessing several domains, including professionalism, communication and collaboration, and therefore is a valuable tool for providing a well-rounded selection of the top interns for postsecondary awards. 16 graduates in Royal College of Surgeons in Ireland-Medical University of Bahrain (RCSI Bahrain) responded to an invitation to participate in the student award, which was conducted by the using the multisource feedback process. 5 individuals from different categories (physicians, nurses, and fellow students), rated each participant in this study. A total of 15 individuals were the proposed number for rating. The ratings were calculated using mean and standard deviation, and the award went to the one of the top score out of the 16 participants. Reliability and internal consistency was calculated using Cronbach’s coefficient, and construct validity was evaluated using factor analysis.

Results

16 graduates participated in the Royal College of Surgeons in Ireland-Bahrain interns’ award based on the multisource feedback process, giving us a 16.5% response rate. The instrument was found to be suitable for factor analysis and showed 3 factor solutions representing 79.3% of the total variance. Reliability analysis using Cronbach’s α reliability of internal consistency indicated that the full scale of the instrument had high internal consistency (Cronbach’s α 0.98).

Conclusion

This study confirmed our hypothesis, finding multisource feedback to be a process for choosing the most suitable graduates for interns’ awards that is both reliable and valid. Unfortunately, there were low response rate, which could mean that multisource feedback is not a realistic way to bring most students into the process.

The potential of a self-assessment tool to identify healthcare professionals' strengths and areas in need of professional development to aid effective facilitation of group-based, person-centered diabetes education

BACKGROUND

Healthcare professionals' person-centered communication skills are pivotal for successful group-based diabetes education. However, healthcare professionals are often insufficiently equipped to facilitate person-centeredness and many have never received post-graduate training. Currently, assessing professionals' skills in conducting group-based, person-centered diabetes education primarily focus on experts measuring and coding skills on various scales. However, learner-centered approaches such as adequate self-reflective tools have been shown to emphasize professional autonomy and promote engagement. The aim of this study was to explore the potential of a self-assessment tool to identify healthcare professionals' strengths and areas in need of professional development to aid effective facilitation of group-based, person-centered diabetes education.

METHODS

The study entails of two components: 1) Field observations of five different educational settings including 49 persons with diabetes and 13 healthcare professionals, followed by interviews with 5 healthcare professionals and 28 persons with type 2 diabetes. 2) One professional development workshop involving 14 healthcare professionals. Healthcare professionals were asked to assess their person-centered communication skills using a self-assessment tool based on challenges and skills related to four educator roles: Embracer, Facilitator, Translator, and Initiator. Data were analyzed by hermeneutic analysis. Theories derived from theoretical model 'The Health Education Juggler' and techniques from 'Motivational Interviewing in Groups' were used as a framework to analyze data. Subsequently, the analysis from the field notes and interview transcript were compared with healthcare professionals' self-assessments of strengths and areas in need to effectively facilitate group-based, person-centered diabetes education.

RESULTS

Healthcare professionals self-assessed the Translator and the Embracer to be the two most skilled roles whereas the Facilitator and the Initiator were identified to be the most challenged roles. Self-assessments corresponded to observations of professional skills in educational programs and were confirmed in the interviews.

CONCLUSION

Healthcare professionals self-assessed the same professional skills as observed in practice. Thus, a tool to self-assess professional skills in facilitating group-based diabetes education seems to be useful as a starting point to promote self-reflections and identification of healthcare professionals' strengths and areas of need of professional development.

The suffering of chronic pain patients on a wait list: Are they amenable to narrative therapy?

Background: Chronic pain affects one in five Canadians. People with chronic pain frequently experience loss in their lives related to work, relationships, and their independence. They may be referred to a chronic pain program, which aims to strengthen coping through medical intervention and self-management skills. Data suggest that, even when individuals begin their pain program, many feel overwhelmed and do not continue.

Aims: The aim of this study was to conduct a needs assessment to explore the acceptability and feasibility of developing a psychosocial intervention, narrative therapy (NT), to address loss for chronic pain patients on the wait list of a chronic pain program.

Methods: Two focus groups were conducted with ten patients who had experienced being on a wait list for a provincial chronic pain management program (CPMP). Transcribed interviews were subjected to thematic and interpretive analysis.

Results: Two major themes emerged from the analysis: loss of identity and sharing a story of chronic pain. All patients were enthusiastic toward an NT intervention, although individual preferences differed regarding mode of delivery.

Conclusions: Loss is a significant part of the chronic pain experience. NT seems to be an acceptable intervention to address loss for patients on the wait list for a chronic pain program.

Improving patient experience in primary care: a multimethod programme of research on the measurement and improvement of patient experience

Background

There has been an increased focus towards improving quality of care within the NHS in the last 15 years; as part of this, there has been an emphasis on the importance of patient feedback within policy, through National Service Frameworks and the Quality and Outcomes Framework. The development and administration of large-scale national patient surveys to gather representative data on patient experience, such as the national GP Patient Survey in primary care, has been one such initiative. However, it remains unclear how the survey is used by patients and what impact the data may have on practice.

Objectives

Our research aimed to gain insight into how different patients use surveys to record experiences of general practice; how primary care staff respond to feedback; and how to engage primary care staff in responding to feedback.

Methods

We used methods including quantitative survey analyses, focus groups, interviews, an exploratory trial and an experimental vignette study.

Results

(1)Understanding patient experience data. Patients readily criticised their care when reviewing consultations on video, although they were reluctant to be critical when completing questionnaires. When trained raters judged communication during a consultation to be poor, a substantial proportion of patients rated the doctor as ‘good’ or ‘very good’. Absolute scores on questionnaire surveys should be treated with caution; they may present an overoptimistic view of general practitioner (GP) care. However, relative rankings to identify GPs who are better or poorer at communicating may be acceptable, as long as statistically reliable figures are obtained. Most patients have a particular GP whom they prefer to see; however, up to 40% of people who have such a preference are unable regularly to see the doctor of their choice. Users of out-of-hours care reported worse experiences when the service was run by a commercial provider than when it was run by a not-for profit or NHS provider. (2)Understanding patient experience in minority ethnic groups. Asian respondents to the GP Patient Survey tend to be registered with practices with generally low scores, explaining about half of the difference in the poorer reported experiences of South Asian patients than white British patients. We found no evidence that South Asian patients used response scales differently. When viewing the same consultation in an experimental vignette study, South Asian respondents gave higher scores than white British respondents. This suggests that the low scores given by South Asian respondents in patient experience surveys reflect care that is genuinely worse than that experienced by their white British counterparts. We also found that service users of mixed or Asian ethnicity reported lower scores than white respondents when rating out-of-hours services. (3)Using patient experience data. We found that measuring GP–patient communication at practice level masks variation between how good individual doctors are within a practice. In general practices and in out-of-hours centres, staff were sceptical about the value of patient surveys and their ability to support service reconfiguration and quality improvement. In both settings, surveys were deemed necessary but not sufficient. Staff expressed a preference for free-text comments, as these provided more tangible, actionable data. An exploratory trial of real-time feedback (RTF) found that only 2.5% of consulting patients left feedback using touch screens in the waiting room, although more did so when reminded by staff. The representativeness of responding patients remains to be evaluated. Staff were broadly positive about using RTF, and practices valued the ability to include their own questions. Staff benefited from having a facilitated session and protected time to discuss patient feedback.

Conclusions

Our findings demonstrate the importance of patient experience feedback as a means of informing NHS care, and confirm that surveys are a valuable resource for monitoring national trends in quality of care. However, surveys may be insufficient in themselves to fully capture patient feedback, and in practice GPs rarely used the results of surveys for quality improvement. The impact of patient surveys appears to be limited and effort should be invested in making the results of surveys more meaningful to practice staff. There were several limitations of this programme of research. Practice recruitment for our in-hours studies took place in two broad geographical areas, which may not be fully representative of practices nationally. Our focus was on patient experience in primary care; secondary care settings may face different challenges in implementing quality improvement initiatives driven by patient feedback. Recommendations for future research include consideration of alternative feedback methods to better support patients to identify poor care; investigation into the factors driving poorer experiences of communication in South Asian patient groups; further investigation of how best to deliver patient feedback to clinicians to engage them and to foster quality improvement; and further research to support the development and implementation of interventions aiming to improve care when deficiencies in patient experience of care are identified.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Rating Communication in GP Consultations: The Association Between Ratings Made by Patients and Trained Clinical Raters

Patient evaluations of physician communication are widely used, but we know little about how these relate to professionally agreed norms of communication quality. We report an investigation into the association between patient assessments of communication quality and an observer-rated measure of communication competence. Consent was obtained to video record consultations with Family Practitioners in England, following which patients rated the physician’s communication skills. A sample of consultation videos was subsequently evaluated by trained clinical raters using an instrument derived from the Calgary-Cambridge guide to the medical interview. Consultations scored highly for communication by clinical raters were also scored highly by patients. However, when clinical raters judged communication to be of lower quality, patient scores ranged from “poor” to “very good.” Some patients may be inhibited from rating poor communication negatively. Patient evaluations can be useful for measuring relative performance of physicians’ communication skills, but absolute scores should be interpreted with caution.

Understanding negative feedback from South Asian patients: an experimental vignette study

OBJECTIVES

In many countries, minority ethnic groups report poorer care in patient surveys. This could be because they get worse care or because they respond differently to such surveys. We conducted an experiment to determine whether South Asian people in England rate simulated GP consultations the same or differently from White British people. If these groups rate consultations similarly when viewing identical simulated consultations, it would be more likely that the lower scores reported by minority ethnic groups in real surveys reflect real differences in quality of care.

DESIGN

Experimental vignette study. Trained fieldworkers completed computer-assisted personal interviews during which participants rated 3 video recordings of simulated GP-patient consultations, using 5 communication items from the English GP Patient Survey. Consultations were shown in a random order, selected from a pool of 16.

SETTING

Geographically confined areas of ∼130 households (output areas) in England, selected using proportional systematic sampling.

PARTICIPANTS

564 White British and 564 Pakistani adults recruited using an in-home face-to-face approach.

MAIN OUTCOME MEASURE

Mean differences in communication score (on a scale of 0-100) between White British and Pakistani participants, estimated from linear regression.

RESULTS

Pakistani participants, on average, scored consultations 9.8 points higher than White British participants (95% CI 8.0 to 11.7, p<0.001) when viewing the same consultations. When adjusted for age, gender, deprivation, self-rated health and video, the difference increased to 11.0 points (95% CI 8.5 to 13.6, p<0.001). The largest differences were seen when participants were older (>55) and where communication was scripted to be poor.

CONCLUSIONS

Substantial differences in ratings were found between groups, with Pakistani respondents giving higher scores than White British respondents to videos showing the same care. Our findings suggest that the lower scores reported by Pakistani patients in national surveys represent genuinely worse experiences of communication compared to the White British majority.

Impact of focused training on communication skills of final-year medical students in a medical school in India

BACKGROUND

Although communication skills are important for a good physician-patient relationship, Indian medical curricula give very little emphasis on training medical students in this aspect.

AIMS

To determine the change in communication skills of final-year medical students following focused training.

METHODS

This was an educational interventional study done at Pondicherry Institute of Medical Sciences, a tertiary care teaching hospital in South India, to assess communication skills among final-year MBBS students. Fifty-two students (24 males and 28 females) participated in the study. A pre-test was conducted in the form of an objectively structured clinical examination (OSCE), followed by focused training for four hours. The same OSCE was administered as post-test. A comparison between the pre-test and post-test scores was done using Wilcoxon Signed Ranks Test.

RESULTS

Ninety-six per cent of participants (50 out of 52) showed improvement in their performance after the focused training. The mean marks of the pre-test and post-test were 10.77± 3 and 18.04±2, respectively, out of a maximum mark of 20 (p<0.05). One out of 52 participants did not show any improvement, and one participant scored less in the post-test compared to the pre-test. There was no significant difference in the performance between male and female students.

CONCLUSION

Focused training can enhance the communication skills of medical students. Hence, it may be included in the curriculum of undergraduate medical teaching programmes in India.

Measurement of physician-patient communication--a systematic review

BACKGROUND

Effective communication with health care providers has been found as relevant for physical and psychological health outcomes as well as the patients' adherence. However, the validity of the findings depends on the quality of the applied measures. This study aimed to provide an overview of measures of physician-patient communication and to evaluate the methodological quality of psychometric studies and the quality of psychometric properties of the identified measures.

METHODS

A systematic review was performed to identify psychometrically tested instruments which measure physician-patient communication. The search strategy included three databases (EMBASE, PsycINFO, PubMed), reference and citation tracking and personal knowledge. Studies that report the psychometric properties of physician-patient communication measures were included. Two independent raters assessed the methodological quality of the selected studies with the COSMIN (COnsensus based Standards for the selection of health status Measurement INtruments) checklist. The quality of psychometric properties was evaluated with the quality criteria of Terwee and colleagues.

RESULTS

Data of 25 studies on 20 measures of physician-patient communication were extracted, mainly from primary care samples in Europe and the USA. Included studies reported a median of 3 out of the nine COSMIN criteria. Scores for internal consistency and content validity were mainly fair or poor. Reliability and structural validity were rated mainly of fair quality. Hypothesis testing scored mostly poor. The quality of psychometric properties of measures evaluated with Terwee et al.'s criteria was rated mainly intermediate or positive.

DISCUSSION

This systematic review identified a number of measures of physician-patient communication. However, further psychometric evaluation of the measures is strongly recommended. The application of quality criteria like the COSMIN checklist could improve the methodological quality of psychometric property studies as well as the comparability of the studies' results.

Measuring patient experience: concepts and methods

Providing a good patient experience is a key part of providing high-quality medical care. This paper explains why patient experience is important in its own right, and its relationship to other domains of quality. We describe methods of measuring patient experience, including issues relating to validity, reliability and response bias. Differences in reported patient experience may sometimes reflect differences in expectations of different population groups and we describe the arguments for and against adjusting patient experience data for population characteristics. As with other quality improvement strategies, feeding back patient experience data on its own is unlikely to improve quality: sustained and multiple interventions are usually required to deliver sustained improvements in care.