Studies of doctor-patient interaction

Patient-provider communication during consultations for elective dental procedures: A scoping review

INTRODUCTION

Patient-provider communication (PPC) is a critical component of patient-centered care. Original studies have examined specific factors related to PPC during consultations for elective dental procedures, but this evidence has yet to be comprehensively summarized. This scoping review aimed to understand better the extent and depth of the available literature regarding factors that influence PPC during consultations for elective dental procedures.

METHODS

The authors considered electronically available, English-language, original research published since 1990 assessing communication during consultations for elective dental procedures. Four electronic databases, Google Scholar, and reference lists of inclusions were searched until August 2023. No quality assessment was completed. Two independent researchers assessed article eligibility. Data were charted with a narrative review approach.

RESULTS

A total of 37 studies were included. The most popular discipline studied was orthodontics. Prospective cohorts and cross-sectional were the most common study designs. Information recall, patient satisfaction, and patient comprehension were the most common outcome measures. Most studies employed questionnaires, surveys, or interviews for data collection. Nineteen factors related to PPC during elective dental consultations were identified and categorized into information delivery (4), patient-related (9), and provider-related factors (6).

CONCLUSIONS

This scoping review is the first to present a list of evidence-supported factors related to PPC in elective dental consultations. Identifying these factors is an important first step to better understanding their influence on PPC and designing interventions targeting those that may be modifiable. PPC during elective dental consultations is a dynamic, ongoing process. Several recommendations emerged that may help improve PPC, including appropriate information delivery, patient engagement, providing adequate time, and educating ourselves on approaches to PPC.

Antecedents of rapport and its mediating role on relational cohesion in patient-physician interaction

Increasing competition in healthcare services, it is imperative that physicians and family-care practitioners seek ways to attract and retain patients. Building relationships with existing patients is one sure way to continued patronage and increased clientele. The purpose of this paper is to examine antecedents of rapport and its influence on perceived relationships in the context of patient-physician interaction. Study using cross-sectional survey method with structured questionnaire was used for data collection. Structural Equation Modeling was used for analyzing the data collected from 326 patients residing in Karnataka, India. The finding suggests that respect, responsibility and understanding have significant influence on relational cohesion with rapport acting as mediating variable. The results add to the empirical validity of the relationship among rapport, respect & relationship, as it is required to understand studied in Indian context. The finding provides new directions for both healthcare professionals and institutions in their endeavor of building relationships with their customers (Patients) by emphasizing the need for developing 'rapport' as an integral part of service interaction. Future research like longitudinal and experimental studies can provide more conclusive evidence regarding the influence of service behaviour on rapport.

Viewpoint: Patient safety in primary care - patients are not just a beneficiary but a critical component in its achievement

Promoting and maintaining patient safety in primary care requires different strategies and monitoring than utilized in large healthcare delivery systems. Maintenance of a culture of safety is key to providing patient safety but has been difficult to measure in primary care. This is particularly true in rural settings where practice size is a major barrier to measurement reliability. Primary care evaluates a wide range of patients, including those who are immunocompromised and others who have infectious diseases. Providing a safe environment with proper wearing of N95 masks, clean examination rooms, and adequate ventilation is important. Patients with infectious diseases should be separated from other patient populations. Primary care is often less bureaucratic than hospitals, but also has fewer resources to implement patient safety initiatives, along with detecting safety lapses and adverse events. However, monitoring the practice's safety practices and the culture of safety is of utmost importance and should be performed using both outcome and process measures. Because of the small size of many rural practices, effective monitoring of adverse events and maintenance of safety protocols should include patients. Patients are an important resource for reporting of adverse events and medical treatment outcomes. The aim of this manuscript is to underscore the importance of patient safety in primary care and to stimulate future research in developing a metric for the culture of safety in primary care, which also incorporates the patient perspective. Patients should be viewed not only as beneficiaries of patient safety but also as a critical component of its maintenance.

A new paradigm for investigating real-world social behavior and its neural underpinnings

Eye tracking and other behavioral measurements collected from patient-participants in their hospital rooms afford a unique opportunity to study natural behavior for basic and clinical translational research. We describe an immersive social and behavioral paradigm implemented in patients undergoing evaluation for surgical treatment of epilepsy, with electrodes implanted in the brain to determine the source of their seizures. Our studies entail collecting eye tracking with other behavioral and psychophysiological measurements from patient-participants during unscripted behavior, including social interactions with clinical staff, friends, and family in the hospital room. This approach affords a unique opportunity to study the neurobiology of natural social behavior, though it requires carefully addressing distinct logistical, technical, and ethical challenges. Collecting neurophysiological data synchronized to behavioral and psychophysiological measures helps us to study the relationship between behavior and physiology. Combining across these rich data sources while participants eat, read, converse with friends and family, etc., enables clinical-translational research aimed at understanding the participants' disorders and clinician-patient interactions, as well as basic research into natural, real-world behavior. We discuss data acquisition, quality control, annotation, and analysis pipelines that are required for our studies. We also discuss the clinical, logistical, and ethical and privacy considerations critical to working in the hospital setting.

Patient accounts for nonadherence: A critical window into the patient experience

OBJECTIVES

This paper explores patient use of excuses to better understand the patient experience during clinical interactions.

METHODS

A content analysis of 32 residents treating 99 different patients was used to reveal accounts of nonadherence. Using grounded theory, these accounts were coded into types and then reduced using a Q-sort.

RESULTS

Analysis revealed 163 accounts of nonadherence. When questioned about their adherence to treatment, 68% of patients offered at least one account for nonadherence during the visit. These accounts were coded into fourteen types and then the Q-sort identified four types of accounts: healthcare system failures, treatment failure, situational exigencies, and self-directed. Of the accounts offered, 7% of the patients provided 6 or more accounts and 25% provided between 3 and 5 accounts.

CONCLUSIONS

The examination of excuses provides a unique way to gain insight into how patients communicate with their physicians. Patient accounts ranged from those where patients indicated adherence was within their control (self-directed) and accounts outside their control (healthcare system failure, treatment failure, and situational exigency).

PRACTICE IMPLICATIONS

The types of accounts of nonadherence patients could provide doctors insight into the patient experience. Recognizing these types could allow opportunities for doctors to develop communication strategies for encouraging patient adherence.

Empathy experiences of Japanese certified genetic counselors: A qualitative investigation and proposed framework

Empathy is an important element of genetic counseling. Most genetic counselors acknowledge the significance of empathically engaging clients. However, few empirical studies have focused on the empathy experience of genetic counselors, especially in non-Western countries. This study aimed to investigate Japanese genetic counselors' perspectives on the concept of empathy in clinical practice. The study conducted semi-structured interviews with Japanese certified genetic counselors who had approximately 10 years of clinical experience. Fourteen participants were interviewed about their thoughts on empathy and their experiences wherein they had deeply understood clients or felt closer to them. The interview data were analyzed using grounded theory. As a result, 17 categories were extracted, of which 13 were integrated into three themes of empathy: the empathic cycle in the relationships between genetic counselors and clients (cycling), the process of forming a deeper understanding of a client's perspectives (feeling), and the process of developing skills to understand clients with empathy (developing). The remaining four categories were grouped into the theme of "challenges of empathy." The categories included in the first three themes were similar to previous findings in Western countries, whereas some categories of challenges of empathy were unique to this study, which was conducted in a non-Western country. This might be attributed to the influence of Japanese culture, in which people emphasize self-regulation and an interdependent-self model. To our knowledge, this study is the first to report on Japanese certified genetic counselors' experiences of empathy. This study concludes with some suggestions for future research, including focusing on ways to overcome challenges of empathy in countries or healthcare systems.

Effectiveness of a multifaceted intervention to improve interpersonal skills of physicians in medical consultations (EPECREM): protocol for a randomised controlled trial

INTRODUCTION

Interpersonal skills, encompassing communication and empathy, are key components of effective medical consultations. Although many organisations have implemented structured training programmes, limited evidence exists on their effectiveness in improving physician interpersonal skills. This study aims to evaluate the effectiveness of a standardised, multifaceted, interpersonal skills development programme for hospital physicians.

METHODS AND ANALYSIS

This study is a prospective, randomised (with a 1:1 allocation ratio), controlled, open-label, two parallel arm, superiority trial conducted at a single university hospital. Physicians will be randomised to receive either a multifaceted training programme or no intervention. The experimental intervention combines two 4-hour training sessions, dissemination of interactive educational materials, review of video-recorded consultations and individual feedback. The primary outcome measure is the overall 4-Habits Coding Scheme score assessed by two independent raters blinded to the study arm, based on video-recorded consultations, before and after intervention. The secondary outcomes include patient satisfaction, therapeutic alliance, physician self-actualisation and the length of medical consultation.

ETHICS AND DISSEMINATION

The study protocol was approved on 21 October 2020 by the CECIC Rhône-Alpes Auvergne, Clermont-Ferrand, France (IRB 5891). All participants will provide written informed consent. Efforts will be made to release the primary results within 6 to 9 months of study completion, regardless of whether they confirm or deny the research hypothesis.

TRIAL REGISTRATION NUMBER

NCT04703816.

Missed Empathic Opportunities During Hand Surgery Office Visits

Background: Empathy (conveyance of an understanding of a patient's situation, perspective, and feelings) deepens the therapeutic alliance and leads to better health outcomes. We studied the frequency and nature of empathic opportunities and physician responses in patients visiting a hand surgeon. We also sought patient characteristics associated with the number of patient-initiated-clues and missed opportunities by surgeons. Methods: For this prospective cohort study, we enrolled 83 new, adult patients visiting 1 of 3 hand surgeons during a period of 4 months. All visits were audio-recorded, and empathic opportunities (patient-initiated emotional or social clues) and physician responses were categorized using the model of Levenson et al. Before the visit, patients completed the Newest Vital Sign health literacy test; 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper-Extremity function, Pain Interference, and Depression questionnaires; and a sociodemographic survey. Results: Empathic opportunities were present in 70% of hand surgery office visits. Surgeons responded empathically to about half of the opportunities. Patients with limited health literacy and greater symptoms of depression (small correlation; r = -0.29) were less likely to receive a positive response. Response to an empathic opportunity did not affect visit duration. Conclusions: Hand surgeons often miss empathic opportunities. Future research might address the influence of training physicians to address empathic opportunities on trust, adherence, satisfaction, and outcomes.

What is empathy? Oncology patient perspectives on empathic clinician behaviors

BACKGROUND

Oncology patients and physicians value empathy because of its association with improved health outcomes. Common measures of empathy lack consistency and were developed without direct input from patients. Because of their intense engagement with health care systems, oncology patients may have unique perspectives on what behaviors signal empathy in a clinical setting.

METHODS

As part of a cross-sectional study of patient perspectives on clinician empathy at an academic cancer center in the northeastern United States, the authors solicited up to 10 free-text responses to an open-ended question about what clinician behaviors define empathy.

RESULTS

The authors categorized open-ended responses from 89 oncology patients into 5 categories representing 14 themes. These categories were relationship sensitivity, focus on the whole person, communication, clinician attributes, and institutional resources and care processes. Frequently represented themes, including listening, understanding, and attention to emotions and what matters most, aligned with existing measures of empathy; behaviors that were not well represented among existing measures included qualities of information sharing and other communication elements. Patients also associated clinician demeanor, accessibility, and competence with empathy.

CONCLUSIONS

Oncology patients' perspectives on empathy highlight clinician behaviors and attributes that may help to refine patient experience measures and may be adopted by clinicians and cancer centers to enhance patient care and outcomes. High-quality communication skills training can promote active listening and paying attention to the whole person. A system-level focus on delivering empathic care may improve patients' experiences and outcomes.

LAY SUMMARY

Oncology patients' responses to an open-ended question about empathic clinician behavior have revealed insights into a variety of behaviors that are perceived as demonstrative of empathy. These include behaviors that imply sensitivity to the clinician-patient relationship, such as listening and understanding and attention to the whole person. Participants valued caring communication and demeanor and clinician accessibility. Perspective taking was not common among answers. Many existing measures of clinical care quality do not include the behaviors cited by patients as empathic. These results can inform efforts to refine quality measures of empathy-associated behaviors in clinical practice. Cancer centers can use skills training to improve elements of communication.

Care Team Integration in Primary Care Improves One-Year Clinical and Financial Outcomes in Diabetes: A Case for Value-Based Care

Despite significant treatment advances, diabetes outcomes remain suboptimal and health care costs continue to rise. There are limited data on the feasibility and financial implications of integrating a diabetes-specific care team in the primary care setting (ie, where the majority of diabetes is treated). This pragmatic quality improvement project investigated whether a cardiometabolic care team intervention (CMC-TI) could achieve greater improvements in clinical, behavioral, and cost outcomes compared to usual diabetes care in a large primary care group in Southern California. Over 12 months, n = 236 CMC-TI and n = 239 usual care patients with type 1 or 2 diabetes were identified using the electronic medical record. In the CMC-TI group, a registered nurse (RN)/certified diabetes educator care manager, medical assistant health coach, and RN depression care manager utilized electronic medical record-based risk stratification reports, standardized decision-support tools, live and remote tailored treatments, and coaching to manage care. Results indicated that the CMC-TI group achieved greater improvements in glycemic and lipid control, diabetes self-management behaviors, and emotional distress over 1 year compared with the usual care group (all P < .05). The CMC-TI group also had a significant 12.6% reduction in total health care costs compared to a 51.7% increase in the usual care group during the same period and inclusive of CMC-TI program costs. Patients and providers reported high satisfaction with CMC-TI. These findings highlight that team-based care management interventions that utilize nurses, medical assistant health coaches, and behavioral specialists to support diabetes patients can help primary care practices achieve value-based targets of improved health, cost, and patient experience.

Medical assistant health coaching ("MAC") for type 2 diabetes in diverse primary care settings: A pragmatic, cluster-randomized controlled trial protocol

In the US, nearly 11% of adults were living with diagnosed diabetes in 2017, and significant type 2 diabetes (T2D) disparities are experienced by socioeconomically disadvantaged, racial/ethnic minority populations, including Hispanics. The standard 15-min primary care visit does not allow for the ongoing self-management support that is needed to meet the complex needs of individuals with diabetes. "Team-based" chronic care delivery is an alternative approach that supplements physician care with contact from allied health personnel in the primary care setting (e.g., medical assistants; MAs) who are specially trained to provide ongoing self-management support or "health coaching." While rigorous trials have shown MA health coaching to improve diabetes outcomes, less is known about if and how such a model can be integrated within real world, primary care clinic workflows. Medical Assistant Health Coaching for Type 2 Diabetes in Diverse Primary Care Settings - A Pragmatic, Cluster-Randomized Controlled Trial will address this gap. Specifically, this study compares MA health coaching versus usual care in improving diabetes clinical control among N = 600 at-risk adults with T2D, and is being conducted at four primary care clinics that are part of two health systems that serve large, ethnically/racially, and socioeconomically diverse populations in Southern California. Electronic medical records are used to identify eligible patients at both health systems, and to examine change in clinical control over one year in the overall sample. Changes in behavioral and psychosocial outcomes are being evaluated by telephone assessment in a subset (n = 300) of participants, and rigorous process and cost evaluations will assess potential for sustainability and scalability.

Diet and Oral Health Coaching Methods and Models for the Independent Elderly

Health-related behavior based on diet is an important determinant of oral health in independent elderly. Aging impairs senses, mastication, oral status, and function, causing nutritional needs and diet insufficiencies that contribute to a vicious circle of impairment. But the present needs of independent older adults suggest that health research and oral health care should shift from disease management and therapy to integral customized and personal treatment plans, including lifestyle, psychological, nutritional, and oral health coaching approaches. In this paper health coaching approaches in medical and dental settings are valued as to their effectiveness for older adults. Furthermore, coaching approaches for seniors are discussed and coaching models for better senior patient-dentist cooperation on the diet issue are suggested. Diet and oral health coaching is proven to be a modern senior patient-centered approach that needs to be incorporated at all relevant settings. It should aim to empower older adults in co-management of their oral diseases or bad diet habits affecting their oral health. This can be carried out through an incorporated educational plan for dentists either at the postgraduate or professional level since advantages seem to enhance the quality of life of the independent elderly.

Creating Middle Stage: Finding a New Space for Reflection within a Residency Program

While communication is essential to effective clinical outcomes, training programs that employ synchronous feedback systems are expensive and time consuming. Using a secure web blog as an asynchronous alternative for enhancing communication skills, we created a unique middle stage learning opportunity within a residency training program. Each resident was recorded interacting with a patient and that digital record was posted to a secure blog. By the end of year three, the residents (N = 6) interacted with 20 patients and wrote a blog post discussing each interaction. The other residents watched these interactions and responded to their peers' digitized interactions in the form of a blog post (N = 95). Transcripts were created and analyzed using the constant comparative method and yielded five categories of resident message types. They were: Narrative of the visit, visit issues, communication strategies, social support, and reflections on the experience and provided a unique opportunity to examine interaction among the residents.

Resident reflections on resident-patient communication during family medicine clinic visits

OBJECTIVE

Residency programs emphasize effective doctor and patient interaction. However, training can be time intensive and logistically challenging. This paper examines a blog providing resident peer feedback and an opportunity to explore how residents think about patient communication.

METHODS

A grounded theory approach examined peer commenting on doctor patient interactions. Between 2012-2015, at a U.S. East Coast Family Medicine Clinic, 35 family medicine residents were recorded interacting with patients, producing a total of 84 videos which were posted to a blog. Residents reflected on these videos resulting in 356 responses, 3162 meaning units and 211 codes. Codes were grouped into 10 themes. Further analysis explored how residents signaled positive and negative doctor communications-related behavior.

RESULTS

Most common themes identified were Rapport/Relationship building skills, Negotiating the appointment, and Peer interaction. Most common themes discussed in light of both positive and negative behavior were Education, Use of technology, and Negotiating the appointment.

CONCLUSIONS

Residents view their communication with patients as more of a transmission of critical information than an opportunity for dialogue.

PRACTICE IMPLICATIONS

Findings support how online tools can be used for resident reflections. These tools can reveal resident perceptions of salient communication information in a clinical encounter.

How Do Smart Device Apps for Diabetes Self-Management Correspond with Theoretical Indicators of Empowerment? An Analysis of App Features

OBJECTIVES

Smart device apps for diabetes have the potential to support patients in their daily disease management. However, uncertainty exists regarding their suitability for empowering patients to improve self-management behaviors. This paper addresses a general research gap regarding theoretically based examinations of empowerment in diabetes research, by examining how diabetes app features correspond with conceptual indicators of empowerment.

METHODS

We examined features of 121 apps for diabetes self-management available in Singapore, with the second highest proportion of diabetes among developed nations, for psychological empowerment (feeling of empowerment) and for behavioral empowerment (social support).

RESULTS

Diabetes apps studied offered a narrow range of features, with limited feature-sets corresponding to indicators of empowerment. Customization as a strategy to improve perceived relevance of diabetes self-management as an indicator of psychological empowerment was especially limited. Moreover, there was a lack of features supporting patients' communication with healthcare professionals and within their private social networks.

CONCLUSIONS

Mobile apps for diabetes self-management failed to provide relevant features for empowering patients. Specific practical recommendations target improved adoption, sustained usage, and effectiveness of diabetes self-management apps.

When Your Doctor "Gets It" and "Gets You": The Critical Role of Competence and Warmth in the Patient-Provider Interaction

Background: Research demonstrates that the placebo effect can influence the effectiveness of medical treatments and accounts for a significant proportion of healing in many conditions. However, providers may differ in the degree to which they consciously or unconsciously leverage the forces that produce placebo effects in clinical practice. Some studies suggest that the manner in which providers interact with patients shapes the magnitude of placebo effects, but this research has yet to distill the specific dimensions of patient-provider interactions that are most likely to influence placebo response and the mechanisms through which aspects of patient-provider interactions impact placebo response. Methods: We offer a simplifying and unifying framework in which interactions that boost placebo response can be dissected into two key dimensions: patients' perceptions of competence, or whether a doctor "gets it" (i.e., displays of efficiency, knowledge, and skill), and patients' perceptions of warmth, or whether a doctor "gets me" (i.e., displays of personal engagement, connection, and care for the patient). Results: First, we discuss how this framework builds on past research in psychology on social perception of competence and warmth and in medical literature on models of effective medical care, patient satisfaction, and patient-provider interactions. Then we consider possible mechanisms through which competence and warmth may affect the placebo response in healthcare. Finally, we share original data from patients and providers highlighting how this framework applies to healthcare. Both patient and provider data illustrate actionable ways providers can demonstrate competence and warmth to patients. Discussion: We conclude with recommendations for how researchers and practitioners alike can more systematically consider the role of provider competence and warmth in patient-provider interactions to deepen our understanding of placebo effects and, ultimately, enable providers to boost placebo effects alongside active medications (i.e., with known medical ingredients) and treatment in clinical care.

Patient-centered communication, patient satisfaction, and retention in care in assisted reproductive technology visits

PURPOSE

To explore the association between patient-centered communication, patients' satisfaction, and retention in care in assisted reproductive technology (ART) visits.

METHODS

ART visits at eight Italian clinics were videotaped and coded using the Roter Interaction Analysis System, which includes a Patient-Centered Index (PCI), a summary "patient-centered communication" ratio. After the visit, patients completed a satisfaction questionnaire (SATQ). After 3 months, patients were asked about their retention in care. Spearman correlations and Mann-Whitney tests were used to test associations between the study variables; the open-ended item of SATQ was analyzed through content analysis.

RESULTS

Eighty-five visits were videotaped (involving 28 gynecologists and 160 patients). PCI score (μ = 0.51 ± 0.28) revealed a more disease-oriented communication during the visit. Patients reported high levels of satisfaction with the visit and identified in the information provision or in the doctor's humanity or kindness the main reasons of satisfaction. At the follow-up, the majority of the couples declared to have followed the clinicians' recommendations and to have remained related to the ART center. No associations were found among the study variables, except for a lower male satisfaction among couples who declared to have changed ART clinic.

CONCLUSIONS

Contrary to what was expected, the style of physician-patient communication was not found to be associated with patient satisfaction and retention in care. However, patients were highly satisfied and engaged. The actual meaning of a communication that is "patient-centered" in the ART context might be wider, including the couples' need for information, as suggested by qualitative findings.

After-visit summaries in primary care: mixed methods results from a literature review and stakeholder interviews

BACKGROUND

After-visit summary (AVS) documents presenting key information from each medical encounter have become standard in the USA due to federal health care reform. Little is known about how they are used or whether they improve patient care.

METHODS

First, we completed a literature review and described the totality of the literature on AVS by article type and major outcome measures. Next, we used reputational sampling from large-scale US studies on primary care to identify and interview nine stakeholders on their perceptions of AVS across high-performing primary care practices. Interviews were transcribed and coded for AVS use in practice, perceptions of the best/worst features and recommendations for improving AVS utility in routine care.

RESULTS

The literature review resulted in 17 studies; patients reported higher perceived value of AVS compared with providers, despite poor recall of specific AVS content and varied post-visit use. In key informant interviews, key informants expressed enthusiasm for the potential of using AVS to reinforce key information with patients, especially if AVS were customizable. Despite this potential, key informants found that AVS included incorrect information and did not feel that patients or their practices were using AVS to enhance care.

CONCLUSIONS

There is a gap between the potential of AVS and how providers and patients are using it in routine care. Suggestions for improved use of AVS include increasing customization, establishing care team responsibilities and workflows and ensuring patients with communication barriers have dedicated support to review AVS during visits.

Cross-cultural adaptation of the Patient-Doctor Relationship Questionnaire (PDRQ-9) in Brazil

OBJECTIVE

To describe the process of cross-cultural adaptation of the Patient-Doctor Relationship Questionnaire (PDRQ-9), as well as compare the agreement between two different types of application.

METHODS

This is a cross-sectional study with 133 adult users of a Primary Health Service in Porto Alegre, State of Rio Grande do Sul, Brazil. The PDRQ-9 was answered by the participants as a self-administered questionnaire and in an interview. The instrument was also validated by interview, using data from 628 participants of the Mais Médicos Program Evaluation Research, which is a cross-sectional study with a systematic sample of Primary Care Services in all regions of Brazil. We evaluated the semantic, conceptual, and item equivalence, as well as factor analysis and reliability.

RESULTS

All items presented factor loading > 0.5 in the different methods of application and populations in the factor analysis. We found Cronbach's alpha of 0.94 in the self-administered method. We found Cronbach's alpha of 0.95 and 0.94 in the two different samples in the interview application. The use of PDRQ-9 with an interview or self-administered was considered equivalent.

CONCLUSIONS

The cross-cultural adaptation of the PDRQ-9 in Brazil replicated the factorial structure found in the original study, with high internal consistency. The instrument can be used as a new dimension in the evaluation of the quality of health care in clinical research, in the evaluation of services and public health, in health management, and in professional training. Further studies can evaluate other properties of the instrument, as well as its behavior in different populations and contexts.

Exploring patient-centeredness: The relationship between self-reported empathy and patient-centered communication in medical trainees

OBJECTIVE

To explore the relationships between self-reported Empathy and the patient-centered communication patterns of physician trainees.

METHODS

"Eighty-four 3rd year medical students completed the Jefferson Scale of Empathy (JSE - student version) and had recordings of a single OSCE analyzed using the Roter Interactional Analysis System (RIAS). Correlation and regression were employed to explore the relationships among JSE total score, 3 JSE subscales, 10 composite codes of provider communication, and a summary 'patient centered communication' ratio, reflecting the balance of psychosocial and emotional to biomedical communication of the simulated patient and student.

RESULTS

Results indicate that controlling for other elements of student communication, the RIAS composite of codes reflecting 'emotional responsiveness' (characterized by empathy statements, legitimization, showing concern, partnership statements and medically relevant provider self-disclosure) was positively related to the JSE Total Score while student 'question asking' and 'biomedical counseling' were negatively related to the JSE Score. RIAS-coded communication variables accounted for 32.4% of the JSE Total score.

CONCLUSION

The relationship between student expressions of emotional responsiveness and predicted self-reported empathy provides concurrent validation evidence for the JSE.

PRACTICE IMPLICATIONS

Further research is needed in order to elaborate and further explore a Patient-Centeredness latent variable.

Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study

Background

There is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.

Objective(s)

To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.

Design

Multilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).

Setting

Three contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.

Data collection and analysis

Macro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.

Results

Policy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.

Conclusions

Virtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.

Limitations

The focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.

Future research

Further studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Resonance and dissonance asymmetry in effective physician-patient relationships

This paper examines the proposed asymmetry that should occur between resonance and dissonance in physician-patient relationships in favour of resonance to facilitate an effective relationship. Resonance is represented by the positive emotional attractor, which comprises patients' conscious preferred future or ideal self, and dissonance is expressed by the negative emotional attractor and consists of the gaps between patients' ideal and real self or their fears, problems, and shortfalls. Intentional change theory is reviewed to optimise the physician-patient relationship. Concepts from complexity theory and recent research on emotions are used to explain positive and negative emotional attractors. The role of resonance and dissonance in physician-patient relationships is discussed along with how behaviour can be changed with positive and negative emotional attractors. This paper focuses on the quality and effectiveness of physician-patient relationships for physicians who create high versus low positive emotional attractor/negative emotional attractor ratios. Two theoretical propositions are offered and the research and practice implications are explained.

Managing Breast Cancer: Echoes from Patients in Lagos, Nigeria

Breast cancer is ranked second as the cause of cancer death among women. Of importance to the management of breast cancer is the interaction processes between the patients and their professional caregivers or healthcare providers. Against this background, this study explores the experiences of Nigerian women as breast cancer patients and their interaction with their caregivers in the management of their condition. The study was cross-sectional in design. Twenty diagnosed breast cancer patients participated in the study and were purposively selected using convenience and snow balling sampling technique. Patients affirmed that they were initially afraid when diagnosed but overcame their fear based on caregivers' supports. Physical interactions and the use of mobile phones were common means of communication while the fear of death and financial burden of the disease were of major concerns to the patients. The majority of the patients were satisfied with the quality of care and treatment received in the private hospitals as they were encouraged and supported. It was discovered that professional caregivers are germane to patients' survival from shock and adequate information on how to manage their condition and live a normal life.

Diabetes and the Motivated Patient: Understanding Perlocutionary Effect in Health Communication

Health care providers (HCP) understand the importance of keeping patients motivated but may be unaware how their words may have unintended negative effects upon their patient's lives. People with diabetes report being told by their HCP that they are "cured" or that they are praised for strides made in weight loss and/or lowered blood glucose, and interpret these messages in unexpected ways. For this paper, we focus upon one case to illustrate the depth and nuance of the patient-provider communication as it emerged within a larger interview-based ethnographic study. Audio-recorded interviews and transcriptions were analyzed discursively. Discourse analysis reveals the ways ideology affects how the patient responds to HCP's utterances and how this affects diabetes self-care. Findings indicate significant perlocutionary effects upon health outcomes, varying both positively and/or negatively. This study points to the importance of carefully considering the power of words and whenever possible knowing the patient's ideological orientation to their world. HCPs should be explicit and deliberate with their communication. Sensitization to the various ways patients hear and react to messages in a clinical setting may lead to improved health outcomes, especially for those with chronic health conditions such as diabetes mellitus.

Using a computer simulation for teaching communication skills: A blinded multisite mixed methods randomized controlled trial

OBJECTIVES

To assess advanced communication skills among second-year medical students exposed either to a computer simulation (MPathic-VR) featuring virtual humans, or to a multimedia computer-based learning module, and to understand each group's experiences and learning preferences.

METHODS

A single-blinded, mixed methods, randomized, multisite trial compared MPathic-VR (N=210) to computer-based learning (N=211). Primary outcomes: communication scores during repeat interactions with MPathic-VR's intercultural and interprofessional communication scenarios and scores on a subsequent advanced communication skills objective structured clinical examination (OSCE). Multivariate analysis of variance was used to compare outcomes.

SECONDARY OUTCOMES

student attitude surveys and qualitative assessments of their experiences with MPathic-VR or computer-based learning.

RESULTS

MPathic-VR-trained students improved their intercultural and interprofessional communication performance between their first and second interactions with each scenario. They also achieved significantly higher composite scores on the OSCE than computer-based learning-trained students. Attitudes and experiences were more positive among students trained with MPathic-VR, who valued its providing immediate feedback, teaching nonverbal communication skills, and preparing them for emotion-charged patient encounters.

CONCLUSIONS

MPathic-VR was effective in training advanced communication skills and in enabling knowledge transfer into a more realistic clinical situation.

PRACTICE IMPLICATIONS

MPathic-VR's virtual human simulation offers an effective and engaging means of advanced communication training.

Older Persons 'Medical Encounters and their Outcomes

This article reviews research on older patients and their doctors, with particular attention to the medical encounter between an elderly patient and his or her physician. Major categories of variables affecting the medical encounter include provider and patient characteristics (age, gender, ethnicity, education, values) and the context or setting of the encounter (site, presence of a patient's companion, and whether the visit is an initial one for the physician-patient pair). The process and content of medical encounters are affected by participant characteristics and context variables, and these in turn affect outcome variables such as participant satisfaction, adherence to treatment regimens, and medical outcome. Process issues include transfer of information, medical decision making, and interpersonal relations. Methodological issues are discussed, including problems with theory generation, lack of standardized methodology, gaps in research knowledge, and prior emphasis on descriptive studies as opposed to testing of interventions to improve elderly patient-physician communication.

The role of patient narratives in healthcare innovation: supporting translation and meaning making

Purpose

– The purpose of this paper is to investigate the process and impact of patient involvement in locally defined improvement projects in two hospital clinics. The paper particularly aims to examine how patient narratives, in the form of diaries and radio montage, help to create new insights into patient experience for healthcare professionals, and support professionals’ enrolment and mobilisation in innovation projects.

Design/methodology/approach

– Two case studies were undertaken. These drew upon qualitative interviews with staff and participant observation during innovation workshops. Patient diaries and a recorded montage of patient voices were also collected.

Findings

– The findings illuminate translation processes in healthcare innovation and the emergence of meaning making process for staff through the active use of patient narratives. The paper highlights the critical role of meaning making as an enabler of patient-centred change processes in healthcare via: local clinic mangers defining problems and ideas; collecting and sharing patient narratives in innovation workshops; and healthcare professionals’ interpretation of patient narratives supporting new insights into patient experience.

Practical implications

– This study demonstrates how healthcare professionals’ meaning making can be supported by articulating, constructing, listening and interpreting patient narratives. The two cases demonstrate how patient narratives serve as reflective devices for healthcare professionals.

Originality/value

– This study presents a novel demonstration of the importance of patient narratives for translating healthcare innovation in a clinical practice setting.

Keep it going: maintaining health conversations using relational and instrumental approaches

The initial moments of conversations, particularly discussions addressing difficult or unexpected health topics, establish the context and tone of the entire discussion. We examined how elements of relational and instrumental communication occurring within the first five minutes of the request impacted the length of the discussion. A sample of 16 U.S. tissue banking organizations and their staff (n = 226) making telephone requests for donation to families of tissue-donation eligible patients (n = 1,465) agreed to participate in the research. The first five minutes of 430 (29.4%) audiorecorded request conversations were qualitatively coded and analyzed. The primary outcome measure was whether the conversation continued beyond the first five minutes (yes/no). Aspects of both relational and instrumental communication were associated with discussion length. A logistic regression analysis found that the total number of distinct topics disclosed and requesters' vocal affect during the discussion as well as characteristics of the family member approached about donation predicted conversational maintenance. This research demonstrates that "thin slices" of effective relational and instrumental communication can have a significant, positive impact on conversation length.

Predictors of nurses' intention and behavior in using health literacy strategies in patient education based on the theory of planned behavior

BACKGROUND

Health literacy is one of the most important priorities for improving health care quality through enhancing patient-provider communication. Implementing health literacy strategies enable nurses to provide information and instructions for patients in a manner that is more commensurate and understandable. The purpose of this study was to investigate the factors affecting nurses' intention to implement health literacy strategies in patient education based on theory of planned behavior.

METHODS

A cross-sectional study was done on 148 nurse practitioners of AL-Zahra educational hospital in Isfahan, Iran, using a descriptive-analytic method. Data collected via a standardized questionnaire based on theory of planned behavior constructed and analyzed by SPSS v.17 using ANOVA, Independent T-test, Pearson correlation and linear regression.

RESULTS

There was statistically significant correlation between using health literacy strategies and marriage status, attending in retraining courses, employment type, job history, and job status. Perceived behavioral control was the most powerful predictor of intention (β=0.417) and use health literacy strategies in patient education and behavior of nurses (β=0.33).

CONCLUSION

According to the findings of this study, perceived behavioral control is a powerful determinant of nurses' intention and behavior of using health literacy strategies in patient education. Hence we recommend nurse educators to pay special attention to the constructs of this theory mainly perceived behavioral control in retrain courses about patient education and health literacy strategies.

"…still waiting for chloroquine": the challenge of communicating changes in first-line treatment policy for uncomplicated malaria in a remote Kenyan district

Background

Widespread parasite resistance to first-line treatment for uncomplicated malaria leads to introduction of new drug interventions. Introducing such interventions is complex and sensitive because of stakeholder interests and public resistance. To enhance take up of such interventions, health policy communication strategies need to deliver accurate and accessible information to empower communities with necessary information and address problems of cultural acceptance of new interventions.

Objectives

To explore community understanding of policy changes in first-line treatment for uncomplicated malaria in Kenya; to evaluate the potential role of policy communication in influencing responses to changes in first-line treatment policy.

Methods

Data collection involved qualitative strategies in a remote district in the Kenyan Coast: in-depth interviews (n = 29), focus group discussions (n = 14), informal conversations (n = 11) and patient narratives (n = 8). Constant comparative method was used in the analysis. Being malaria-prone and remotely located, the district offered an ideal area to investigate whether or not and how policy communication about a matter as critical as change of treatment policy reaches vulnerable populations.

Results

Three years after initial implementation (2009), there was limited knowledge or understanding regarding change of first-line treatment from sulphadoxine-pyrimethamine (SP) to artemether-lumefantrine (AL) for treatment of uncomplicated malaria in the study district. The print and electronic media used to create awareness about the drug change appeared to have had little impact. Although respondents were aware of the existence of AL, the drug was known neither by name nor as the official first-line treatment. Depending on individuals or groups, AL was largely viewed negatively. The weaknesses in communication strategy surrounding the change to AL included poor choice of communication tools, confusing advertisements of other drugs and conflicts between patients and providers.

Conclusion

Effective health policy communication is important for the uptake of new drug interventions and adherence to treatment regimens. Besides, prompt access to effective treatment may not be achieved if beneficiaries are not adequately informed about treatment policy changes. Future changes in treatment policy should ensure that the communication strategy is designed to pass sustained, accurate and effective messages that account for local contexts.

Challenges to implementing expanded team models: lessons from a centralised nurse-led cholesterol-lowering programme

BACKGROUND

Lowering low-density lipoprotein (LDL) cholesterol in patients with diabetes mellitus (DM) and cardiovascular disease (CVD) is critical to lowering morbidity and mortality. To increase the percentage of patients with DM and CVD at target LDL (<100 mg/dL), we launched an expanded team-based quality improvement programme in which centralised registered nurses (RNs) followed a detailed protocol to adjust cholesterol-lowering medications. Despite the growing use of team-based approaches to improve quality of care, little remains known about how best to implement them.

PROGRAM EVALUATION

To share our experiences and lessons from operating a team-based programme, we conducted a retrospective observational analysis of administrative and clinical data on programme performance. We measured: primary care physician (PCP) and patient acceptance of the programme, number of medication adjustments, change in LDL, per cent of patients achieving target, time to LDL target and the efforts required to achieve these goals.

RESULTS

Using administrative data, we initially identified 374 potential patients for enrolment. Chart review revealed that 203 (54%) were clinically eligible. PCPs agreed to enrol 74% (150/203) of these patients. Thirty-six per cent of PCP-approved patients (54/150) could not be reached via phone and 5.3% (8/150) declined enrolment. Of patients enrolled (n=64), 50% did not complete the programme. Of those enrolled, median LDL decreased by 21 mg/dL and 52% (33/64) achieved the LDL target. Programme RNs spent 12 023 min on programme activities, of which 44.4% (5539) was related to non-enrolled patients.

CONCLUSIONS

Our adoption of a centralised expanded team-based programme for the management of LDL cholesterol uncovered many barriers to efficiency and success. Even though expanded team programmes may be supported by PCPs, the administrative efforts required to identify, enrol and continually engage eligible patients raise many concerns regarding efficiency and highlight infrastructure changes needed for successful team-based approaches.

Consumers' perceptions of patient-accessible electronic medical records

Background

Electronic health information (eHealth) tools for patients, including patient-accessible electronic medical records (patient portals), are proliferating in health care delivery systems nationally. However, there has been very limited study of the perceived utility and functionality of portals, as well as limited assessment of these systems by vulnerable (low education level, racial/ethnic minority) consumers.

Objective

The objective of the study was to identify vulnerable consumers’ response to patient portals, their perceived utility and value, as well as their reactions to specific portal functions.

Methods

This qualitative study used 4 focus groups with 28 low education level, English-speaking consumers in June and July 2010, in New York City.

Results

Participants included 10 males and 18 females, ranging in age from 21-63 years; 19 non-Hispanic black, 7 Hispanic, 1 non-Hispanic White and 1 Other. None of the participants had higher than a high school level education, and 13 had less than a high school education. All participants had experience with computers and 26 used the Internet. Major themes were enhanced consumer engagement/patient empowerment, extending the doctor’s visit/enhancing communication with health care providers, literacy and health literacy factors, improved prevention and health maintenance, and privacy and security concerns. Consumers were also asked to comment on a number of key portal features. Consumers were most positive about features that increased convenience, such as making appointments and refilling prescriptions. Consumers raised concerns about a number of potential barriers to usage, such as complex language, complex visual layouts, and poor usability features.

Conclusions

Most consumers were enthusiastic about patient portals and perceived that they had great utility and value. Study findings suggest that for patient portals to be effective for all consumers, portals must be designed to be easy to read, visually engaging, and have user-friendly navigation.

Transforming primary care: from past practice to the practice of the future

The gap between the supply of primary care physicians and the demand for primary care continues to grow. Primary care practices must find a way to increase their patient capacity without sacrificing quality of care or adding more work to already overburdened physicians. A transformed primary care practice addressing these issues must redefine the physician role such that the physician no longer sees all patients assigned to the practice but acts as a leader for a well-trained, highly functioning primary care team. The team's overall goal would be to advance the health of an entire patient panel. New payment models are among changes that will be central to this transformation.

Development of the patient approach and views toward healthcare communication (PAV-COM) measure among older adults

Background

This study examines the psychometric properties of 9 items on the Patient Activation component of the Medicare Current Beneficiary Survey (MCBS) that assess how patients approach and communicate with their physicians. The MCBS is a nationally representative, cross-sectional survey of Medicare beneficiaries.

Methods

We analyzed MCBS data collected in 2002 and 2005 from 15,165 adults aged 65 and older. Exploratory factor analysis was conducted using maximum likelihood to estimate a polychoric correlation matrix on the 2002 data, and confirmatory factor analysis was performed using the 2005 data.

Results

Exploratory factor analysis of the 2002 data showed a 2-factor solution: approach to interactions (5 items) and views about physician’s healthcare communication (6 items). Findings were confirmed using the 2005 data. Items were combined to form the Patient Approach and Views toward Healthcare Communication (PAV-COM) scale (range 1 to 100; Cronbach’s alpha of 0.75, and item-rest correlations between 0.33 and 0.54). Higher PAV-COM scores were associated with greater fulfillment of preventive health behaviors such as vaccinations and cancer screenings.

Conclusions

The PAV-COM measure is a valid tool for assessing patient approaches and views toward communication with physicians. This measure can be used to evaluate interventions to improve patient participation during healthcare encounters.

Introducing the "teamlet": initiating a primary care innovation at san francisco general hospital

CONTEXT

The 15-minute office visit to primary care clinicians cannot meet the health care needs of patients. Innovation is needed to address this limitation, but practice redesign is challenging in clinical settings.

OBJECTIVE

Here we describe the implementation of a practice innovation, the teamlet model, in a San Francisco safety-net clinic. The teamlet consists of a clinician and "health coach" who expand the traditional medical visit into previsit, visit, postvisit, and between-visit care.

DESIGN

Teamlet implementation is occurring in phases. Phase 1 is evaluated using plan-do-study-act improvement cycles and interviews with a few patients, clinicians, and coaches. Phase 2 is evaluated using a pre- and postevent questionnaire, focused interviews, and focus groups with patients, faculty, clinicians, and coaches.

MAIN OUTCOME MEASURES

Phase 1: Plan-do-study-act cycles generate ideas to improve implementation. Phase 2 evaluation will query demographics, satisfaction, knowledge of self-management support, access, teamwork, and benefits/challenges of the teamlet model. Future research would measure objective clinical outcomes.

RESULTS

Phase 1 of the teamlet project led to useful adaptations, with anecdotal evidence that patients and clinicians were satisfied overall with practice improvements. Logistic problems made implementation of the innovation challenging. Phase 2 is currently underway, with results expected in 2008.

CONCLUSIONS

Primary care innovation requires multiple perspectives and constant revision. Traditional randomized controlled trials and quantitative evaluation designs are not appropriate for assessing practice-improvement pilot projects because projects must change and develop in their early stages. Despite numerous challenges, the teamlet practice redesign has the potential for improving on the traditional 15-minute physician's office visit.

Identifying transparency in physician communication

OBJECTIVE

To categorize physician communication demonstrating understanding of what patients want to know and skill in conveying that information. Physicians underestimate how much information patients want and patients rarely seek information during clinic visits. Transparent communication is advocated to facilitate patient understanding and support autonomy, informed decision-making and relationship development.

METHODS

Analysis and coding of 263 audiotaped interactions between 33 primary care physicians and their patients in eight community-based, primary care clinics in Washington State, USA.

RESULTS

Physicians proactively used five types of process transparency to preview speech and actions. Four types of content transparency were used to explicate diagnosis and treatment, demystify medical language and concepts, and interpret biomedical information. Physicians spent the greatest proportion of clinic time explicating medical content.

CONCLUSION

The primacy of information exchange over process-oriented, relational communication was demonstrated. Proactive transparency appears promising to increase understanding and collaboration.

PRACTICE IMPLICATIONS

In patient-centered care where collaboration is the ideal, transparency in its various forms is a critical ingredient. Without much communicative effort, physicians who proactively communicated that an examination was over, that they were leaving the exam room briefly so patients could dress provided information that appeared to address patient uncertainty and demonstrated empathy and respect.

The continuing need to investigate the nature and content of teleconsultation communication using interaction analysis techniques

The lack of systematically collected and analysed data about the effect of telemedicine on patient-provider communication is a frequently cited barrier for why video communication has yet to reach its full potential. Existing research provides little information about the subtle and detailed changes in communication that take place over video. Comprehensive investigations of actual medical encounter behaviour are therefore required, including verbal content analysis, which uses interaction analysis systems (IAS) to describe and categorize the communication that has taken place. Ten IAS studies were identified in the literature. Although it is difficult to generalize due to differences in methodology and context, some tentative conclusions can be drawn. First, on-site providers tend to be substantially less active than off-site providers, suggesting that the former typically serve as facilitators and observers, rather than active participants. Second, just as in the conventional face-to-face setting, providers' utterances tend to predominate in telemedicine. Third, conventional patterns of more task-focused than socio-emotional utterances tend to persist in telemedicine. However, some studies found telemedicine to be more patient-centred than conventional medicine, and others found it less so. We do not yet have a full understanding of the subtractive and enhancing effects of telemedicine on provider-patient relations and outcomes.

Implications of reassigning patients for the medical home: a case study

PURPOSE

Improving patient-doctor continuity is one goal of the medical home, but achieving this goal may require physicians to reduce panel size. This article examines the impact on patient experience and utilization of Group Health Cooperative's process of reassigning patients to new physicians as part of their medical home demonstration project.

METHODS

This work represents a subanalysis of the Group Health medical home pilot evaluation. Study participants include 8,005 adults who received primary care in 2006 and 2007 at an urban practice owned and operated by a not-for-profit integrated delivery system. Approximately one-quarter of patients were selected to be reassigned to a new physician. Primary care, emergency department, secure messaging, and telephone utilization were captured through automated sources. Patients' experience was measured before and after implementation of the medical home for a subset of 1,098 patients.

RESULTS

Patients who were retained by their existing physicians were older, sicker, and had longer preexisting patient-doctor relationships. After reassignment, reassigned patients were less likely to use primary care services but equally likely to use the emergency department. They were no less satisfied with their care experience.

CONCLUSIONS

Informational and managerial continuity may mitigate deleterious effects of reassignment, but more must be done to actively bind reassigned patients to the medical home to improve relational continuity with younger, healthier patients.

Shared decision-making in cardiology: do patients want it and do doctors provide it?

OBJECTIVE

Doctors should involve their patients in making decisions about their care. We studied patients with heart disease to assess if shared decision-making occurs and to study factors that predict patients' choices or influence cardiologists' behaviour.

METHODS

85 patients attending for arteriography were assessed to elicit preferred involvement in decision-making, perception of involvement, and confidence in the decision.

RESULTS

40% of patients wished to be involved in decisions. Preferences were unrelated to demographic factors. Cardiologists involved patients more in decisions concerning severe disease (p=0.056). Involvement varied between cardiologists (p=0.001). The mean duration of consultations was 5.5 min. Patients' confidence in decisions correlated with duration (p=0.001), explicit reference to a decision that needed to be made (p=0.0026), and perceived, but not observed, involvement in decision-making (p=0.05).

CONCLUSION

This study highlighted the complexity of doctor-patient communication. Irrespective of preferences for involvement, patients were more confident in decisions in which they perceived more involvement or which were the products of longer consultations.

PRACTICE IMPLICATIONS

Patients' confidence in clinical decisions can be increased by increasing consultation length and increasing their perception of involvement. Patients perceive more involvement in decisions when doctors specifically identify the need for treatment decisions early in the consultation.

Working with interpreters: how student behavior affects quality of patient interaction when using interpreters

BACKGROUND

Despite the prevalence of medical interpreting in the clinical environment, few medical professionals receive training in best practices when using an interpreter. We designed and implemented an educational workshop on using interpreters as part of the cultural competency curriculum for second year medical students (MSIIs) at David Geffen School of Medicine at UCLA. The purpose of this study is two-fold: first, to evaluate the effectiveness of the workshop and second, if deficiencies are found, to investigate whether the deficiencies affected the quality of the patient encounter when using an interpreter.

METHODS

A total of 152 MSIIs completed the 3-hour workshop and a 1-station objective-structured clinical examination, 8 weeks later to assess skills. Descriptive statistics and independent sample t-tests were used to assess workshop effectiveness.

RESULTS

Based on a passing score of 70%, 39.4% of the class failed. Two skills seemed particularly problematic: assuring confidentiality (missed by 50%) and positioning the interpreter (missed by 70%). While addressing confidentiality did not have a significant impact on standardized patient satisfaction, interpreter position did.

CONCLUSION

Instructing the interpreter to sit behind the patient helps sustain eye contact between clinician and patient, while assuring confidentiality is a tenet of quality clinical encounters. Teaching students and faculty to emphasize both is warranted to improve cross-language clinical encounters.

Improving parent satisfaction: an intervention to increase neonatal parent-provider communication

OBJECTIVE

The objective of the study was to assess whether a targeted intervention improved the satisfaction of neonatal parents with primary medical provider communication.

STUDY DESIGN

The study design was a survey assessment of parents in a neonatal intensive care unit regarding their satisfaction with physician and nurse practitioner communication. Serial cohorts were surveyed before and after an intervention, including educating providers about family communication, distributing contact cards to families and showing a poster of providers in the unit.

RESULT

More subjects in the post-intervention cohort (n=33) were satisfied (95%) with provider communication than in the pre-intervention cohort (n=50, 74%; P<0.01). Parents who reported talking with a provider in the previous 7 days were more satisfied than parents who did not (P<0.001). After the intervention, fewer families (36 versus 65%) reported a desire for more frequent provider contact (P<0.01).

CONCLUSION

A targeted intervention improved parent satisfaction with provider communication. Improving the quality and quantity of parent-provider communication increased parent satisfaction with communication with their baby's medical providers.

Reactions to cancer: communicating with patients, family and carers

Effective communication has benefits for both patients and members of the health care team. Five main communication tasks in head and neck cancer are identified: Screening for head and neck cancer and communicating risk; Communicating the diagnosis of head and neck cancer; Providing information about treatment and pre-treatment; Communicating following treatment and dealing with fear of recurrence; Discussing the end of life. For each specific aspects of the communication situation are discussed. Underpinning each is the use of core communication skills.

Patients' question-asking behavior during primary care visits: a report from the AAFP National Research Network

PURPOSE

The Ask Me 3 (AM3) health communication program encourages patients to ask specific questions during office visits with the intention of improving understanding of their health conditions and adherence to treatment recommendations. This study evaluated whether implementing AM3 improves patients' question-asking behavior and increases adherence to prescription medications and lifestyle recommendations.

METHODS

This randomized trial involved 20 practices from the American Academy of Family Physicians National Research Network that were assigned to an AM3 intervention group or a control group. Forty-one physicians in the practices were each asked to enroll at least 20 patients. The patients' visits were audio recorded, and recordings were reviewed to determine whether patients asked questions and which questions they asked. Patients were interviewed 1 to 3 weeks after the visit to assess their recall of physicians' recommendations, rates of prescription filling and taking, and attempts at complying with lifestyle recommendations.

RESULTS

The study enrolled 834 eligible patients in 20 practices. There were no significant difference between the AM3 and control patients in the rate of asking questions, but this rate was high (92%) in both groups. There also were no differences in rates of either filling or taking prescriptions, although rates of these outcomes were fairly high, too. Control patients were more likely to recall that their physician recommended a lifestyle change, however (68% vs 59%, P = .04).

CONCLUSIONS

In a patient population in which asking questions already occurs at a high rate and levels of adherence are fairly high, we found no evidence that the AM3 intervention results in patients asking specific questions or more questions in general, or in better adherence to prescription medications or lifestyle recommendations.