Evidence on patient-doctor communication

The interconnection between social media addiction, alexithymia and empathy in medical students

Introduction

This study explores whether high alexithymia values correlate with low levels of empathy, while also trying to identify potential connections with social media addiction.

Methods

We hypothesized that alexithymia mediates the relationship between social media addiction and empathy levels in a sample of undergraduate students. The study population consisted of 649 medical students in the 4th/5th/6th University year, recruited between March and May 2021. For this assessment, we employed three psychometric instruments: the Toronto Empathy Questionnaire (TEQ), the Social Media Addiction Scale-Student Form (SMAS-SF), and the Toronto Alexithymia Scale (TAS-20). A pathway analysis investigated alexithymia as a mediator between social media addiction and the degree of empathy in medical undergraduates. Sobel's test and the Baron and Kenny approach were used for testing mediation.

Results

The TEQ total mean score was 48.76 ± 5.65, while the TAS-20 total mean score was 47.71 ± 11.49. Further analysis of the TAS-20 scale scores showed that 21.42% of students had possible alexithymia, while 14.02% had clear alexithymia. The SMAS-SF total mean score was 73.20 ± 14.59. None of the students reported levels consistent with major social media addiction. The mediated effect of the TAS-20 is about 1.3 times larger than the direct effect of the SMAS-SF on TEQ.

Discussion

We found a significant negative correlation between empathy and alexithymia in medical students. Alexithymia was a mediator between social media addiction and empathy. Therefore, we recommend further efforts to identify potential levels of alexithymia in medical students, in order to successfully develop tailored interventions aimed at increasing their emotional awareness.

The imperative for cross-cultural medical education in globalized healthcare

Current healthcare systems are like living creatures. They are highly complex, multi-faceted, and dynamic. They must constantly change and adapt; they are like a melting pot, brimming with both rich and diverse cultures from all corners of the world. Beyond just nationality, these systems can include many languages, religious beliefs, socioeconomic backgrounds, and unique health practices. The tides of globalization, multicultural societies, migration, and international collaboration are continuously reshaping how healthcare providers are educated and how healthcare is delivered in an equitable, inclusive, and fair manner. To keep pace with, and within, these highly vibrant socio-cultural frameworks, Cross-Cultural Medical Education is needed to educate healthcare professionals. This education is essential to create professionals who are not just skilled, but who are also culturally savvy and able provide fair and equal care to patients from all sorts of backgrounds. It provides professionals with foundational knowledge to navigate the complex landscape of diverse patient populations. Cross-Cultural Medical Education is thus of paramount importance to satisfy the need for effective cross-cultural communication and understanding in patient care preferences, ultimately leading to improved health outcomes.

The role of cultural competency training to address health disparities in surgical settings

BACKGROUND

Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities.

SOURCES OF DATA

In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities.

AREAS OF AGREEMENT

The unjustness of health care disparities is universally accepted.

AREAS OF CONTROVERSY

Whether the outcome of CCT justifies the cost has not been effectively answered.

GROWING POINTS

These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting.

AREAS TIMELY FOR DEVELOPING RESEARCH

Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.

Clinician Interruptions and Patient-Rated Clinician Empathy in Specialty Visits

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Conversation Analysis of Clients' Active Resistance to Veterinarians' Proposals for Long-Term Dietary Change in Companion Animal Practice in Ontario, Canada

The impact of nutrition on animal health requires effective diet-related treatment recommendations in veterinary medicine. Despite low reported rates of veterinary clients' adherence with dietary recommendations, little is known about how clients' resistance to nutritional proposals is managed in the talk of veterinary consultations. This conversation-analytic study investigated clients' active resistance to veterinarians' proposals for long-term changes to cats' and dogs' diets in 23 segments from 21 videotaped appointments in Ontario, Canada. Clients' accounts suggested the proposals themselves or nutritional modifications were unnecessary, inappropriate, or unfeasible, most often based on patients' food preferences, multi-pet feeding issues, current use of equivalent strategies, or current enactment of the proposed changes. Resistance arose when veterinarians constructed proposals without first gathering relevant diet- and patient-related information, soliciting clients' perspectives, or educating them about the benefits of recommended changes. Veterinarians subsequently accommodated clients' concerns more often when resistance involved patient- or client-related issues rather than clients' lack of medical knowledge. The design of subsequent proposals accepted by clients frequently replaced dietary changes in the initial proposals with nutritional or non-nutritional alternatives and oriented to uncertainty about adherence. This study provides evidence-based findings for developing effective communication training and practice guidelines in nutritional assessment and shared decision-making.

The Influence of Stereotypes on Trust in Doctors from Patients' Perspective: The Mediating Role of Communication

Purpose

To investigate the relationship among patients' stereotypes of doctors, effectiveness of doctors' communication skills evaluated by patients, and patients' trust in doctors.

Patients and Methods

A cross-sectional survey with a total of 3289 patients from 103 hospitals in eastern, central and western China was conducted.

Results

There were strong correlations among patients' stereotypes, patients' evaluation on doctors' communication skills, and patients' trust (r = 0.50-0.67, p < 0.01 for all). Patients' trust was predicted by patients' stereotypes directly (β = 0.32, 95% CI: 0.27-0.37) and indirectly (β = 0.19, 95% CI: 0.16-0.23) through patients' evaluation on doctors' communication skills.

Conclusion

Both patients' stereotypes and patients' evaluation on doctors' communication skills have predictive effects on patients' trust. Patients' stereotypes are not only a direct predictor of patients' trust but also an indirect predictor via doctors' communication skills as a mediator. This national survey underlines the significance of patients' stereotypes, and emphasizes the importance of developing doctors' communication skills on patients' trust. In order to build a more trustful doctor-patient relationship, there should be a joint effort at social and individual level to reinforce positive impression and suppress negative stereotypes of doctors. As far as communication skills are concerned, doctors are encouraged to use helpful verbal and nonverbal techniques that benefit their profession impression management.

Development and validation in Ecuador of the EPD Questionnaire, a diabetes-specific patient-reported experience and outcome measure: A mixed-methods study

Introduction

The global prevalence of diabetes in 2019 in adults was estimated to be 9.3%. This study developed in Ecuador, for the first time, instruments to assess patient‐reported outcomes and experiences.

Methods

The Experiences of the Person with Diabetes (EPD) Questionnaire is a diabetes‐specific instrument. A mixed‐methods study was conducted. First, a qualitative item development phase that included four focus groups and six semi‐structured interviews with patients was conducted in different rural and urban areas of Ecuador to obtain information on culture, beliefs, demographics, diet and social perspectives. A second quantitative phase for psychometric validation was carried out in primary care settings of rural and urban areas of Ecuador.

Results

Forty‐two and four hundred and eighty‐nine participants were included in each phase, respectively. The item development phase resulted in a questionnaire of 44 items (23 for perceived outcomes and 21 for experiences). In the validation study, most participants were women (58%) and from urban areas (57%). Exploratory factor analysis revealed three dimensions for each instrument. Outcomes instrument dimensions were symptoms and burnout, worries and fears and social limitations. Experiences instrument dimensions were information, patient‐centred care and care delivery. Cronbach's α values of the total score and dimensions were high, ranging between .81 and .93 in both instruments. Confirmatory factor analysis showed an acceptable fit of the data.

Conclusion

The EPD Questionnaire is probably the first instrument developed to assess patient‐reported experiences and perceived outcomes in a middle‐income country that included patients to capture all dimensions relevant for the intended population. Its psychometric properties are robust and could provide valuable information for clinicians and policymakers in the region.

Patient or Public Contribution

The development of these instruments has taken into consideration patients and the public since their conception. A qualitative approach gathered relevant information related to the cultural, social and economic burden of different populations in Ecuador. Before validation, a pilot test was carried out with users of the National Health Services to obtain their perspectives and insights of the developed instrument. Finally, during the data analysis, we have given special consideration to social variables such as rural and urban populations.

Cultural Competency Interventions During Medical School: a Scoping Review and Narrative Synthesis

Many medical accreditation bodies agree that medical students should be trained to care for diverse patient populations. However, the teaching methods that medical schools employ to accomplish this goal vary widely. The purpose of this work is to summarize current cultural competency teaching for medical students and their evaluation methods. A scoping review was completed by searching the databases PubMed, Scopus, MedEdPORTAL, and MEDLINE for the search terms "medical education" and "cultural competency" or "cultural competence." Results were summarized using a narrative synthesis technique. One hundred fifty-four articles on cultural competency interventions for medical students were systematically identified from the literature and categorized by teaching methods, length of intervention, and content. Fifty-six articles had a general focus, and ninety-eight articles were focused on specific populations including race/ethnicity, global health, socioeconomic status, language, immigration status, disability, spirituality at the end of life, rurality, and lesbian, gay, bisexual, transgender, and queer. About 54% of interventions used lectures as a teaching modality, 45% of the interventions described were mandatory, and 9.7% of interventions were not formally evaluated. The authors advocate for expansion and more rigorous analysis of teaching methods, teaching philosophies, and outcome evaluations with randomized controlled trials that compare the relative effectiveness of general and population-specific cultural competency interventions.

Informing patients on planned consultation time - a randomised controlled intervention study of consultation time in primary care

Objective: To investigate whether patients' pre-consultation knowledge of the time frames for the consultation influences the actual consultation time and/or patient and physician related outcomes; satisfaction and enablement.Design: Randomised controlled blinded intervention study.Setting: Four strategically chosen Primary Health Care Centres (PHCC:s) in Kronoberg county in Sweden participated.Intervention: Pre-consultation information on planned consultation time. During one week in each PHCC consecutive patients were randomised to intervention group or control group, when booking an appointment with a physician.Subjects: Patients >18 years of age.Main outcome measures: Consultation time, patient satisfaction, patient enablement and physician satisfaction.Results: No significant difference in consultation time was found between the intervention group and control group. No differences were seen between intervention group and control group regarding any of the other measures. Stratified data showed significantly shorter consultation time for the intervention group in one of the PHCC:s and for employed physicians. Employed physicians also rated consultations as being easier and were more satisfied with their consultations compared to non-employed physicians.Conclusion: Information on the planned consultation time has a potential to decrease consultation time in certain settings. No negative side effects were found in this study. Key pointsPatients prepare before their consultation but to influence its contents and length is difficult.Informing patients on estimated consultation time can influence actual consultation time.Informing patients on planned consultation time has no adverse effects in this study.

Provider-patient communication about prescription drug abuse: A qualitative analysis of the perspective of prescribers

Background: Provider-patient communication underpins many initiatives aimed at reducing the public health burden associated with prescription drug abuse in the United States. The purpose of this qualitative analysis was to examine the characteristics of provider-patient communication about prescription drug abuse from the perspective of prescribers. Methods: From 2014 to 2015, 10 semi-structured interviews were conducted with a purposive sample of prescribers from multiple professions and medical fields in Central and South Central Appalachia. The interviews were conducted using a guide informed by Social Cognitive Theory and community theory research, audio-recorded, and transcribed verbatim. Thematic analysis, facilitated by NVivo 10 software, was used to generate themes. Results: Prescribers described 3 primary communication patterns with patients related to prescription drug abuse-informative, counteractive, and supportive. Prescribers also reported multiple factors-personal (e.g., education, experiences, and feelings of tension) and environmental (e.g., relationship with a patient, clinical resources, and policies on controlled prescription drugs)-that affect provider-patient communication and, by association, delivery of patient care related to prescription drug abuse. Conclusions: The findings suggest that provider-patient communication about prescription drug abuse is multidimensional and dynamic, characterized by multiple communication patterns and contributory factors. They have implications for (1) research aimed at advancing theoretical understanding of prescriber prescription drug abuse communication behaviors with patients and (2) interventions aimed at strengthening prescriber prescription drug abuse communication behaviors with patients.

The Development and Evaluation of Personalized Training in Shared Decision-making Skills for Rheumatologists

OBJECTIVE

Many factors influence a patient's preference in engaging in shared decision making (SDM). Several training programs have been developed for teaching SDM to physicians, but none of them focused on the patients' preferences. We developed an SDM training program for rheumatologists with a specific focus on patients' preferences and assessed its effects.

METHODS

A training program was developed, pilot tested, and given to 30 rheumatologists. Immediately after the training and 10 weeks later, rheumatologists were asked to complete a questionnaire to evaluate the training. Patients were asked before and after the training to complete a questionnaire on patient satisfaction.

RESULTS

Ten weeks after the training, 57% of the rheumatologists felt they were capable of estimating the need of patients to engage in SDM, 62% felt their communication skills had improved, and 33% reported they engaged more in SDM. Up to 268 patients were included. Overall, patient satisfaction was high, but there were no statistically significant differences in patient satisfaction before and after the training.

CONCLUSION

The training was received well by the participating rheumatologists. Even in a population of rheumatologists that communicates well, 62% reported improvement. The training program increased awareness about the principles of SDM in patients and physicians, and improved physicians' communicative skills, but did not lead to further improvement in patients' satisfaction, which was already high.

Patient-rated physician empathy and patient satisfaction during pain clinic consultations

BACKGROUND

Little is known about the influence of patient-perceived healthcare provider empathy on patient satisfaction in the setting of a hospital pain clinic consultation. The objective of this research was to examine the relationship between patient-rated physician empathy and patient satisfaction after a single new pain clinic consultation.

METHODS

After institutional ethics committee approval, a sample of 140 adult patients completed a two-page questionnaire, directly after a pain clinic consultation. This included a brief sociodemographic questionnaire, the Consultation and Relational Empathy (CARE) measure and an overall satisfaction rating.

RESULTS

The sample, N = 140 patients, was balanced for gender and 80% of participants ranged in age from 30 to 70. Of these patients, 80.7% had been living with chronic pain between 1 and 5 years. The data were deemed to be non-parametric and a Spearman's ranked order correlation analysis yielded a strong positive correlation between patient-rated physician empathy and patient consultation satisfaction.

CONCLUSION

Patient-rated physician empathy was strongly correlated with patient satisfaction in a pain clinic consultation. Patient satisfaction plays a significant role in adherence to treatment and contributes to a positive working patient-physician therapeutic relationship. This research supports the growing body of research citing the importance of investing in, promoting and developing educational programs for physicians and medical trainees to enhance empathic communication skills within the clinical setting.

Cultural awareness workshops: limitations and practical consequences

Cultural awareness training for health professionals is now commonplace across a variety of sectors. Its popularity has spawned several alternatives (i.e., cultural competence, cultural safety, cultural humility, cultural intelligence) and overlapping derivatives (diversity training, anti-racism training, micro-aggression training). The ever-increasing reach of cultural awareness initiatives in health settings has generally been well intentioned - to improve cross-cultural clinical encounters and patient outcomes with the broader expectation of reducing health disparities. Yet the capacity of cultural awareness training to accomplish or even impact such outcomes is seldom comprehensively scrutinized. In response, this paper applies a much needed critical lens to cultural awareness training and its derivatives by examining their underpinning philosophies, assumptions and most importantly, verification of their effectiveness. The paper finds cultural awareness approaches to be over-generalizing, simplistic and impractical. They may even induce unintended negative consequences. Decades of research point to their failure to realize meaningful outcomes in health care settings and beyond. Broader expectations of their capacity to reduce health disparities are almost certainly unachievable. Alternative suggestions for improving cross-cultural health care interactions and research are discussed within.

Differences in Attitudes Toward Online Interventions in Psychiatry and Psychotherapy Between Health Care Professionals and Nonprofessionals: A Survey

Background: Although the use of e-mental health interventions and their evaluation is already well advanced in countries such as the United States and Australia, research in this area is still in the early stages in Germany. Moreover, existing programs are used only to a small extent by patients, although physicians and therapists generally have a positive attitude toward their use. To help promote the use of online interventions in the future, an analysis of the differences in opinions and attitudes toward e-mental health interventions between health care professionals and nonprofessionals is necessary. Objective: This study aimed to examine the differences in attitudes toward online interventions between health care professionals and nonprofessionals. Methods: This study examined 92 physicians, 36 psychotherapists, and 1,353 randomly recruited nonprofessionals with the eight-item questionnaire entitled "Attitudes on telemedicine in psychiatry and psychotherapy (ATiPP)." Results: The questionnaires of n = 62 physicians, n = 37 psychotherapists, and n = 1,353 nonprofessionals were included in the analysis. Overall, nonprofessionals rate the use of telemedicine more critically than professionals. The itemwise t tests show significant differences between health care professionals and nonprofessionals on six out of eight items. The analyses of variance with post hoc tests for each single item also found differences between the groups (physicians vs. therapists vs. telephone participants vs. practice sample). Conclusion: There are significant differences in attitudes toward online interventions between professionals and nonprofessionals.

Healthcare Users' Experiences of Communicating with Healthcare Professionals About Children Who Have Life-Limiting Conditions: A Qualitative Systematic Review

BACKGROUND

Globally, an estimated eight million children could benefit from palliative care each year. Effective communication about children with life-limiting conditions is well recognized as a critical component of high-quality pediatric palliative care.

OBJECTIVE

To synthesize existing qualitative research exploring healthcare users' experiences of communicating with healthcare professionals about children with life-limiting conditions.

DESIGN

The results of a systematic literature search were screened independently by two reviewers. Raw data and analytic claims were extracted from included studies and were synthesized using thematic analysis methods for systematic reviews.

DATA SOURCES

MEDLINE, PubMed, CINAHL, Embase, PsycINFO, Scopus, Web of Science, ProQuest, and ScienceDirect were searched for articles published in English between 1990 and May 2017.

RESULTS

This review included 29 studies conducted across 11 countries and involving at least 979 healthcare users (adults [n = 914], patients [n = 25], and siblings [n = 40]). The four domains of communication experience identified through thematic synthesis are: Information, Emotion, Collaboration, and Relationship. Although included studies were from a range of settings and diverse populations, further research is needed to explore whether and how domains of communication experience differ across settings and populations. In particular, further research about children's palliative care experiences is needed.

CONCLUSIONS

Healthcare users typically value communication with healthcare professionals: that (1) is open and honest, (2) acknowledges emotion, (3) actively involves healthcare users, and (4) occurs within established and trusting relationships.

Role of Kindness in Cancer Care

The wonders of high-tech cancer care are best complemented by the humanity of high-touch care. Simple kindnesses can help to diffuse negative emotions that are associated with cancer diagnosis and treatment—and may even help to improve patients’ outcomes. On the basis of our experience in cancer care and research, we propose six types of kindness in cancer care: deep listening , whereby clinicians take the time to truly understand the needs and concerns of patients and their families; empathy for the patient with cancer, expressed by both individual clinicians and the care culture, that seeks to prevent avoidable suffering; generous acts of discretionary effort that go beyond what patients and families expect from a care team; timely care that is delivered by using a variety of tools and systems that reduce stress and anxiety; gentle honesty, whereby the truth is conveyed directly in well-chosen, guiding words; and support for family caregivers, whose physical and mental well-being are vital components of the care their loved ones receive. These mutually reinforcing manifestations of kindness—exhibited by self-aware clinicians who understand that how care is delivered matters—constitute a powerful and practical way to temper the emotional turmoil of cancer for patients, their families, and clinicians themselves.

Health Disparities in Patients with Pulmonary Arterial Hypertension: A Blueprint for Action. An Official American Thoracic Society Statement

BACKGROUND

Health disparities have a major impact in the quality of life and clinical care received by minorities in the United States. Pulmonary arterial hypertension (PAH) is a rare cardiopulmonary disorder that affects children and adults and that, if untreated, results in premature death. The impact of health disparities in the diagnosis, treatment, and clinical outcome of patients with PAH has not been systematically investigated.

OBJECTIVES

The specific goals of this research statement were to conduct a critical review of the literature concerning health disparities in PAH, identify major research gaps and prioritize direction for future research.

METHODS

Literature searches from multiple reference databases were performed using medical subject headings and text words for pulmonary hypertension and health disparities. Members of the committee discussed the evidence and provided recommendations for future research.

RESULTS

Few studies were found discussing the impact of health disparities in PAH. Using recent research statements focused on health disparities, the group identified six major study topics that would help address the contribution of health disparities to PAH. Representative studies in each topic were discussed and specific recommendations were made by the group concerning the most urgent questions to address in future research studies.

CONCLUSIONS

At present, there are few studies that address health disparities in PAH. Given the potential adverse impact of health disparities, we recommend that research efforts be undertaken to address the topics discussed in the document. Awareness of health disparities will likely improve advocacy efforts, public health policy and the quality of care of vulnerable populations with PAH.

Patient-provider communication, maternal anxiety, and self-care in pregnancy

RATIONALE

Favorable relationships with health care providers predict greater patient satisfaction and adherence to provider recommendations. However, the specific components of patient-provider relationships that account for these benefits have not been identified. The potential benefits of strong patient-provider relationships in pregnancy may be especially important, as care providers have frequent, intimate interactions with pregnant women that can affect their emotions and behaviors. In turn, prenatal emotions and health behaviors have potent effects on birth outcomes.

OBJECTIVE

This study investigated whether pregnant women's relationships with their midwives predicted better self-care. Specific components of the patient-provider relationship (communication, integration, collaboration, and empowerment) were examined. We also investigated a mechanism through which these relationship components may be associated with salutary health behaviors: by alleviating women's anxiety.

METHODS

In total, 139 low-risk patients of a university-affiliated midwifery practice in the northeastern United States completed well-validated measures assessing their relationship with midwives, state anxiety, and prenatal health behaviors in late pregnancy; state anxiety was also assessed in mid-pregnancy.

RESULTS

Women's perceptions of better communication, collaboration, and empowerment from their midwives were associated with more frequent salutary health behavior practices in late pregnancy. Controlling for mid-pregnancy anxiety, lower anxiety in late pregnancy mediated associations of communication and collaboration with health behavior practices, indicating that these associations were attributable to reductions in anxiety from mid- to late pregnancy.

CONCLUSION

Results substantiate that benefits of patient-provider relationships in pregnancy may extend beyond providing medical expertise. Some aspects of patient-provider relationships may offer direct benefits to pregnant women in promoting better health practices; other aspects of these relationships may indirectly contribute to better health practices by alleviating negative emotions. The benefits of strong midwife relationships may derive from the reassurance, comfort, and warmth these relationships offer, as well as the information and education that midwives provide to their patients.

Promoting empathy using video-based teaching

BACKGROUND

Empathy is fundamental to patient-centred care. It has been shown to improve patient satisfaction and therapeutic outcomes. The success of educational interventions in enhancing students' empathy has been mixed, however, and a consensus on the most effective approach is lacking.

METHODS

Patients were videoed discussing their hospital experiences and interactions with clinicians. These videos were shown to groups of medical students, who then took part in a facilitated discussion around themes of health care communication and patient experience. The session was delivered to 48 students over seven sessions and evaluated by way of serial attitude questionnaires (the Patient-Practitioner Orientation Scale, PPOS) and written feedback.

RESULTS

There was an improvement in PPOS scores amongst participants, with pre- and post-intervention means of 78.8 and 82.0, respectively, indicating an improvement in patient-centred attitudes. Written feedback highlighted the emotional impact of hearing patients' stories, and that the discussion explored issues not covered in previous teaching. Students reported changes in their approach to patients, including introducing themselves more often, and taking measures to make patients feel more at ease on ward rounds. Empathy is fundamentalto patient-centred care DISCUSSION: This study describes the use of patient video interviews to promote empathy in medical students, by stimulating reflective discussion on themes of health care communication and patient experience. Future use of these methods are recommended, although further research would benefit from larger student numbers and the use of objective clinical examination scores to assess behaviour change.

Association Between Dentist-Dental Hygienist Communication and Dental Treatment Outcomes

Communication between physician and patient is critical in all fields of medicine, and various types of communication exist in healthcare settings. Cooperation among healthcare professionals is thought to be essential in providing high-quality services. Dental hygienists are key team members in the provision of dental care, and are known to play an important role in the health of their patients. This study aimed to determine the effect of communication between dentists and hygienists on patient satisfaction. Study subjects were dentists, patients, and dental hygienists, and we examined how dentist-dental hygienist communication affected patient outcome indices. A significant difference was observed only for satisfaction in terms of meeting expectations (p = 0.035). Results for patient satisfaction indicated significant differences in explanatory behavior in dentist-dental hygienist evaluations (p = 0.001). The results showed improved health and reduced fear, indicating significant differences for the dentist-dental hygienist evaluations in explanation behavior (p = 0.016). Our evaluation of the effects of dentist-dental hygienist communication on patient outcomes indicated a significant correlation, suggesting that inter-professional communication in the field of dentistry affects patient satisfaction.

African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients

OBJECTIVES

We sought to characterize the relationship between hospital inpatient racial diversity and outcomes for African-American patients including rates of major complications or mortality during hospitalization for five common gastrointestinal diagnoses.

METHODS

Using the 2012 National Inpatient Sample database, hospital inpatient racial diversity was defined as the percentage of African-American patients discharged from each hospital. Logistic regression was used to predict major complication rates or death, long length of stay, and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of African Americans with patient race.

RESULTS

There were 848,395 discharges across 3,392 hospitals. The patient population was on average 27% minority (s.d.±21%) with African Americans accounting for 14% of all patients. Overall, African-American patients had higher rates of major complications or death relative to white patients (adjusted odds ratio (aOR) 1.19; 95% confidence interval (CI) 1.16-1.23). However, when treated in hospitals with higher patient racial diversity, African-American patients experienced significantly lower rates of major complications or mortality (aOR 0.80; 95% CI 0.74-0.86).

CONCLUSIONS

African Americans have better outcomes for five common gastrointestinal diagnoses when treated in hospitals with higher inpatient racial diversity. This has major ramifications on total hospital charges.

Disparities in perceived patient-provider communication quality in the United States: Trends and correlates

OBJECTIVE

This study aimed to describe disparities and temporal trends in the level of perceived patient-provider communication quality (PPPCQ) in the United States, and to identify sociodemographic and health-related factors associated with elements of PPPCQ.

METHODS

A cross-sectional analysis was conducted using nationally-representative data from the 2011-2013 iterations of the Health Information National Trends Survey (HINTS). Descriptive statistics, multivariable linear and logistic regression analyses were conducted to examine associations.

RESULTS

PPPCQ scores, the composite measure of patients' ratings of communication quality, were positive overall (82.8; 95% CI: 82.1-83.5). However, less than half (42-46%) of respondents perceived that providers always addressed their feelings, spent enough time with them, or helped with feelings of uncertainty about their health. Older adults and those with a regular provider consistently had higher PPPCQ scores, while those with poorer perceived general health were consistently less likely to have positive perceptions of their providers' communication behaviors.

CONCLUSIONS

Disparities in PPPCQ can be attributed to patients' age, race/ethnicity, educational attainment, employment status, income, healthcare access and general health.

PRACTICE IMPLICATIONS

These findings may inform educational and policy efforts which aim to improve patient-provider communication, enhance the quality of care, and reduce health disparities.

Symptoms as the main problem: a cross- sectional study of patient experience in primary care

Background

Symptoms are common in primary care. Besides providing thorough assessment of possible severe disease, the general practitioner (GP) must ensure good health care to all patients, irrespective of diagnoses. We aimed to explore patient satisfaction with the provided care and how well expectations in patients were met when no diagnosis was made during the consultation.

Method

Cross-sectional study based on a questionnaire survey conducted in 2008–2009 among 377 GPs and their patients in the Central Denmark Region. A total of 2286 patients completed a questionnaire after the consultation (response rate: 54 %). The questionnaire included four satisfaction items from the EUROPEP instrument and a question about unmet expectations. For each patient, the GP answered a one-page registration form including information about the main problem in the consultation, chronic disorders and assessment of prognosis. Statistical analyses were adjusted for patient characteristics and GP clustering.

Results

A higher proportion of patients reported illness worry (20 vs. 17 %, p-value: 0.005), unmet expectations (17 vs. 13 %, p-value: 0.019) and dissatisfaction with their GP after the consultation when no diagnosis was made. Dissatisfaction was primarily related to the medical examination (adjusted OR 1.30; 95 % CI: 1.06–1.60) and GP explanations (adjusted OR 1.40; 95 % CI: 1.14–1.71). Exploratory analyses revealed an association between dissatisfaction with examination and the GP assessment that symptoms were unrelated to biomedical disease. This association was found both in patients with ‘symptoms only’ and patients given a specific diagnosis.

Conclusion

GPs are challenged by patients presenting symptoms that do not fit the patterns of biomedical diagnoses. The current study demonstrates more illness worry, unmet expectations and dissatisfaction with the consultation in these patients compared to patients receiving a diagnosis. This trend is true for all patients assessed as having ‘symptoms only’ at the end of a consultation and not only for the minority group with ‘medically unexplained symptoms’. As primary care is the frontline of the health-care system, symptoms are managed as the main problem in almost one in three consultations. It is about time that we take the same professional approach to symptoms as we have done for years to biomedical disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0429-8) contains supplementary material, which is available to authorized users.

Factors influencing intercultural doctor-patient communication: a realist review

OBJECTIVE

Due to migration, doctors see patients from different ethnic backgrounds. This causes challenges for the communication. To develop training programs for doctors in intercultural communication (ICC), it is important to know which barriers and facilitators determine the quality of ICC. This study aimed to provide an overview of the literature and to explore how ICC works.

METHODS

A systematic search was performed to find literature published before October 2012. The search terms used were cultural, communication, healthcare worker. A realist synthesis allowed us to use an explanatory focus to understand the interplay of communication.

RESULTS

In total, 145 articles met the inclusion criteria. We found ICC challenges due to language, cultural and social differences, and doctors' assumptions. The mechanisms were described as factors influencing the process of ICC and divided into objectives, core skills and specific skills. The results were synthesized in a framework for the development of training.

CONCLUSION

The quality of ICC is influenced by the context and by the mechanisms. These mechanisms translate into practical points for training, which seem to have similarities with patient-centered communication.

PRACTICE IMPLICATIONS

Training for improving ICC can be developed as an extension of the existing training for patient-centered communication.

The Language of Recovery: How Effective Communication of Information Is Crucial to Restructuring Post-Stroke Life

BACKGROUND

Providing appropriate and effective information to people with stroke and their families has been identified as a key component to successful practice. Researchers continue to focus on "lack of information" as being the lack of specific technical medical information rather than the communication of practical knowledge and how people use that knowledge to restructure life after stroke. To meet patients' expectations and achieve better outcomes in stroke, professionals need access to communication theory, research, and training.

OBJECTIVES

Improve stroke communication systematically.

METHOD

This article will examine stroke communication using a three-part framework: 1. Utilize theory to clearly conceptualize how communication influences stroke outcome. 2. Identify components and mechanisms of communication content to positively influence stroke outcome. 3. Develop goals and strategies for putting content skills into stroke communication practice.

CONCLUSION

Relatively little is known about the content and structure of informal communication transactions between stroke survivors, families, and health care professionals and how they accommodate (or resist) realignment of identity after stroke. The professional discourse attempts to ensure realistic expectations of recovery whereas stroke survivors and families complain about the negative discourses, how possibilities for life after stroke are presented, and the hopelessness that this creates. More research is required into how these different discourses affect outcomes.

A Preliminary Investigation of Barriers to Achieving Patient-Centered Communication with Patients Who Have Stroke-Related Communication Disorders

This article reports on research investigating barriers to achieving patient-centered communication (PCC) with patients who have stroke-related communication disorders. A focus group, including people who had strokes and their family members, identified PCC issues they encounter when communicating with health care providers. The two key themes that emerged from this research were the desire to be treated with respect and the importance of allowing adequate time for a person with a speech disorder to communicate. Suggestions are given for improving PCC with people who have stroke-related communication disorders.

Weight's up? Predictors of weight-related communication during primary care visits with overweight adolescents

OBJECTIVE

Physicians' use of Motivational Interviewing (MI) techniques when discussing weight with adolescent patients is unknown.

METHODS

We coded audio-recorded encounters between 49 primary care physicians and 180 overweight adolescent patients. During weight discussions, we used the MITI 3.0 to assess: Empathy, MI Spirit, open-ended questions, reflections, MI consistent behaviors (e.g., praising) and MI inconsistent behaviors (e.g., confronting). We examined associations of patient and physician characteristics with (1) MI techniques, (2) time discussing weight, and (3) encounter time.

RESULTS

Physicians used more MI consistent techniques with female patients (p=0.06) and with heavier patients (p=0.02). Physicians with prior MI training also used more MI consistent techniques (p=0.04) and asked more open-ended questions (p=0.05). Pediatricians had a higher MI Spirit score than family physicians (p=0.03). Older patient age was associated with physicians spending less time discussing weight-related topics (p=0.04) and higher BMI percentile was associated with physicians spending more time discussing weight-related topics (p=0.01). Increased use of MI inconsistent techniques was associated with longer encounters (p=0.02).

CONCLUSION

Physicians' weight discussions vary based on adolescent and physician characteristics. Importantly, not using MI lengthened encounter time.

PRACTICE IMPLICATIONS

Physicians might consider using MI techniques more and attempt to use these equally with all adolescents.

Residents' and standardized patients' perspectives on empathy: issues of agreement

OBJECTIVE

We investigated correlations between residents' scores on the Jefferson Scale of Empathy (JSE), residents' perceptions of their empathy during standardized-patient encounters, and the perceptions of standardized patients.

METHODS

Participants were 214 first-year residents in internal medicine or family medicine from 13 residency programs taking standardized patient-based clinical skills assessment in 2011. We analyzed correlations between residents' JSE scores; standardized patients' perspectives on residents' empathy during OSCE encounters, using the Jefferson Scale of Patient Perceptions of Physician Empathy; and residents' perspectives on their own empathy, using a modified version of this scale.

RESULTS

Residents' JSE scores correlated with their perceptions of their own empathy during encounters but correlated poorly with patients' assessments of resident empathy.

CONCLUSION

The poor correlation between residents' and standardized patients' assessments of residents' empathy raises questions about residents' abilities to gauge the effectiveness of their empathic communications. The study also points to a lack of congruence between the assessment of empathy by standardized patients and residents as receivers and conveyors of empathy, respectively.

PRACTICE IMPLICATIONS

This study adds to the literature on empathy as a teachable skill set and raises questions about use of OSCEs to assess trainee empathy.

The influence of patient-centered communication during radiotherapy education sessions on post-consultation patient outcomes

OBJECTIVE

To adapt an observational tool for assessing patient-centeredness of radiotherapy consultations and to assess whether scores for this tool and an existing tool assessing patient-perceived patient-centeredness predict patient outcomes.

METHODS

The Measure of Patient-Centered Communication (MPCC), an observational coding system that assesses depth of discussion during a consultation, was adapted to the radiotherapy context. Fifty-six radiotherapy patients (from 10 radiation therapists) had their psycho-education sessions recorded and coded using the MPCC. Patients also completed instruments assessing their perception of patient-centeredness, trust in the radiation therapist, satisfaction with the consultation, authentic self-representation (ASR) and state anxiety.

RESULTS

The MPCC correlated weakly with patient-perceived patient-centeredness. The Feelings subcomponent of the MPCC predicted one aspect of ASR and trust, and interacted with level of therapist experience to predict trust. Patient-perceived patient-centeredness, which exhibited a ceiling effect, predicted satisfaction.

CONCLUSION

Patient-centered communication is an important predictor of patient outcomes in radiotherapy and obviates some negative aspects of radiation therapists' experience on patient trust. As in other studies, there is a weak association between self-reported and observational coding of PCC.

PRACTICE IMPLICATIONS

Radiation therapists have both technical and supportive roles to play in patient care, and may benefit from training in their supportive role.

Triptan education and improving knowledge for optimal migraine treatment: an observational study

BACKGROUND

It is generally felt that patient education and patient knowledge regarding triptan use for acute migraine management are important for successful and safe treatment. It is unclear how knowledgeable triptan users are regarding their triptan, how much education occurs when triptans are prescribed, and the impact patient education has on actual patient knowledge regarding triptan use.

OBJECTIVE

The primary objective was to compare triptan users' self-perceived knowledge and actual knowledge about triptans in patients who report having received triptan education vs patients who report not having received triptan education.

METHODS

This was a multicenter prospective observational study of 207 migraine patients who were using triptans for abortive therapy and who were being evaluated as new patients at academic headache specialty clinics in the United States. Patients completed standardized questionnaires regarding their self-perceived knowledge about triptans, their actual knowledge regarding triptans, and the perceived education about the triptan that they had received at the time of prescription.

RESULTS

Although greater than 80% of the subjects reported receiving education about when to take the triptan and the number of doses they could take for headache, only 71.5% reported receiving education about triptan side effects, 64% for the number of triptan doses they could take each week/month, 64% for taking other medications with the triptan, and 49% for medical contraindications to triptan use. Compared with subjects who did not recall receiving education about when to take their triptan, subjects who recalled such education had a statistically significant greater actual knowledge for taking the triptan immediately after a headache begins (91% vs 77%, P = .049; confidence interval [CI]: 0.00-0.33), treating when pain is mild (75% vs 50%, P = .009; CI: 0.04-0.45), understanding that they do not need to fail treatment with over-the-counter medications before taking a triptan (74% vs 42%, P = .001; CI: 0.11-0.51), and recognizing that coronary artery disease is a contraindication to triptan use (40% vs 19%, P = .001; CI: 0.09-0.34).

CONCLUSION

This study provides evidence that patients who recall having received education at the time of triptan prescribing have greater knowledge regarding optimal triptan use. Triptan users who recalled having received this education had greater recognition of the importance of taking the triptan immediately at the onset of a headache, treating when pain is mild, not needing to fail treatment with over-the-counter medications before taking a triptan, and understanding that coronary artery disease is a contraindication to triptan use.

Integrating the 3Ds--social determinants, health disparities, and health-care workforce diversity

The established relationships among social determinants of health (SDH), health disparities, and race/ethnicity highlight the need for health-care professionals to adequately address SDH in their encounters with patients. The ethnic demographic transition slated to occur during the next several decades in the United States will have numerous effects on the health-care sector, particularly as it pertains to the need for a more diverse and culturally aware workforce. In recent years, a substantial body of literature has developed, exploring the extent to which diversity in the health-care workforce may be used as a tool to eliminate racial/ethnic disparities in health and health care in the U.S. We explore existing literature on this topic, propose a conceptual framework, and identify next steps in health-care policy for reducing and eliminating health disparities by addressing SDH and diversification of the health-care workforce.

The Impact of Pharmaceutical Care Intervention on the Quality of Life of Nigerian Patients Receiving Treatment for Type 2 Diabetes

OBJECTIVES

To evaluate the impact of pharmaceutical care (PC) intervention on health-related quality of life (HRQOL) of patients with type 2 diabetes.

METHODS

This study was a randomized, controlled study with a 12-month patient follow-up. The study protocol was approved by the Research Ethical Committees of the institutions in which this study was conducted. A total of 110 patients were randomly assigned to each of the "intervention" (PC) and "control" (usual care [UC]) groups. Patients in the UC group received the usual/conventional care offered by the hospitals. Patients in the PC group received UC and additional PC for 12 months. The HUI23S4EN.40Q (developed by HUInc - Mark index 2&3) questionnaire was used to assess the HRQOL of the patients at baseline, 6 months, and 12 months. Two-sample comparisons were made by using Student's t tests for normally distributed variables or Mann-Whitney U tests for nonnormally distributed data at baseline, 6 months, and 12 months. Comparisons of proportions were done by using the chi-square test.

RESULTS

The overall HRQOL (0.86 ± 0.12 vs. 0.64 ± 0.10; P < 0.0001) and single attributes except "hearing" functioning of the patients were significantly improved at 12 months in the PC intervention arm when compared with the UC arm. The HRQOL utility score was highly negatively (deficit ≥10%) associated with increasing age (≥52 years), diabetes duration (>4 years), emergency room visits, comorbidity of hypertension, and stroke in both PC and UC groups.

CONCLUSION

Addition of PC to UC improved the quality of life in patients with type 2 diabetes.

The Nuka System of Care: improving health through ownership and relationships

Southcentral Foundation’s Nuka System of Care, based in Anchorage, Alaska, is a result of a customer-driven overhaul of what was previously a bureaucratic system centrally controlled by the Indian Health Service. Alaska Native people are in control as the “customer-owners” of this health care system. The vision and mission focus on physical, mental, emotional, and spiritual wellness and working together as a Native Community. Coupled with operational principles based on relationships, core concepts and key points, this framework has fostered an environment for creativity, innovation and continuous quality improvement. Alaska Native people have received national and international recognition for their work and have set high standards for performance excellence, community engagement, and overall impact on population health. In this article, the health care transformation led by Alaska Native people is described and the benefits and results of customer ownership and the relationship-based Nuka System of Care are discussed.

Understanding patient-provider conversations: what are we talking about?

OBJECTIVES

Effective patient-provider communication is a critical aspect of the delivery of high-quality patient care; however, research regarding the conversational dynamics of an overall emergency department (ED) visit remains unexplored. Identifying both patterns and relative frequency of utterances within these interactions will help guide future efforts to improve the communication between patients and providers within the ED setting. The objective of this study was to analyze complete audio recordings of ED visits to characterize these conversations and to determine the proportion of the conversation spent on different functional categories of communication.

METHODS

Patients at an urban academic ED with four diagnoses (ankle sprain, back pain, head injury, and laceration) were recruited to have their ED visits audio recorded from the time of room placement until discharge. Patients were excluded if they were age < 18 years, were non-English-speaking, had significant history of psychiatric disease or cognitive impairment, or were medically unstable. Audio editing was performed to remove all silent downtime and non-patient-provider conversations. Audiotapes were analyzed using the Roter Interaction Analysis System (RIAS). RIAS is the most widely used medical interaction analysis system; coders assign each "utterance" (or complete thought) spoken by the patient or provider to one of 41 mutually exclusive and exhaustive categories. Descriptive statistics were calculated for all 41 categories and then grouped according to RIAS standards for "functional groupings." The percentage of total utterances in each functional grouping is reported.

RESULTS

Twenty-six audio recordings were analyzed. Patient participants had a mean (±SD) age of 38.8 (±16.0) years, and 30.8% were male. Intercoder reliability was good, with mean intercoder correlations of 0.76 and 0.67 for all categories of provider and patient talk, respectively. Providers accounted for the majority of the conversation in the tapes (median = 239 utterances, interquartile range [IQR] = 168 to 308) compared to patients (median = 145 utterances, IQR = 80 to 198). Providers' utterances focused most on patient education and counseling (34%), followed by patient facilitation and activation (e.g., orienting the patient to the next steps in the ED or asking if the patient understood; 30%). Approximately 15% of the provider talk was spent on data gathering, with the majority (86%) focusing on biomedical topics rather than psychosocial topics (14%). Building a relationship with the patient (e.g., social talk, jokes/laughter, showing approval, or empathetic statements) constituted 22% of providers' talk. Patients' conversation was mainly focused in two areas: information giving (47% of patient utterances: 83% biomedical, 17% psychosocial) and building a relationship (45% of patient utterances). Only 5% of patients' utterances were devoted to question asking. Patient-centeredness scores were low.

CONCLUSIONS

In this sample, both providers and patients spent a significant portion of their talk time providing information to one another, as might be expected in the fast-paced ED setting. Less expected was the result that a large percentage of both provider and patient utterances focused on relationship building, despite the lack of traditional, longitudinal provider-patient relationships.

Comparison of the medical students' perceived self-efficacy and the evaluation of the observers and patients

BACKGROUND

The accuracy of self-assessment has been questioned in studies comparing physicians' self-assessments to observed assessments; however, none of these studies used self-efficacy as a method for self-assessment. The aim of the study was to investigate how medical students' perceived self-efficacy of specific communication skills corresponds to the evaluation of simulated patients and observers.

METHODS

All of the medical students who signed up for an Objective Structured Clinical Examination (OSCE) were included. As a part of the OSCE, the student performance in the "parent-physician interaction" was evaluated by a simulated patient and an observer at one of the stations. After the examination the students were asked to assess their self-efficacy according to the same specific communication skills. The Calgary Cambridge Observation Guide formed the basis for the outcome measures used in the questionnaires. A total of 12 items was rated on a Likert scale from 1-5 (strongly disagree to strongly agree). We used extended Rasch models for comparisons between the groups of responses of the questionnaires. Comparisons of groups were conducted on dichotomized responses.

RESULTS

Eighty-four students participated in the examination, 87% (73/84) of whom responded to the questionnaire. The response rate for the simulated patients and the observers was 100%. Significantly more items were scored in the highest categories (4 and 5) by the observers and simulated patients compared to the students (observers versus students: -0.23; SE:0.112; p=0.002 and patients versus students:0.177; SE:0.109; p=0.037). When analysing the items individually, a statistically significant difference only existed for two items.

CONCLUSION

This study showed that students scored their communication skills lower compared to observers or simulated patients. The differences were driven by only 2 of 12 items. The results in this study indicate that self-efficacy based on the Calgary Cambridge Observation guide seems to be a reliable tool.

Exploring the relationships among attachment, emotional intelligence and communication

OBJECTIVES

Attachment style has been shown to influence both emotional intelligence (EI) and the clinical communication of medical students and doctors. No research has assessed the relationships among attachment, EI and clinical communication in medical students. This study was conducted to evaluate the effect of EI on the relationship between medical students' attachment style and clinical communication.

METHODS

Medical students were invited to complete measures of attachment (using the Experiences in Close Relationships-Short Form [ECR-SF], a 12-item measure that provides attachment avoidance and attachment anxiety dimensional scores) and EI (using the Mayer-Salovey-Caruso Emotional Intelligence Test [MSCEIT], a 141-item measure of the perception, use, understanding and management of emotions) at the end of Year 1, prior to a summative objective structured clinical examination (OSCE). Clinical communication was assessed using OSCE scores. Structural equation modelling (SEM) was used to analyse a hypothetical model of the relationships among attachment style, EI and clinical communication.

RESULTS

A total of 200 of 358 (55.9%) students participated. Attachment avoidance was significantly negatively correlated with total EI scores (r=-0.28, p<0.01); total EI was significantly positively correlated with OSCE scores (r = 0.23, p < 0.01). A parsimonious SEM revealed that attachment avoidance accounted for 13% of the variance in students' total EI scores but did not directly predict OSCE scores, whereas total EI significantly predicted 7% of the variance in OSCE scores.

CONCLUSIONS

Attachment is perceived to be stable from early adulthood, whereas the literature suggests that EI can be developed through the use of targeted interventions. This has potential implications for the training of medical students in clinical communication.

A qualitative study of breast cancer treatment decisions: evidence for five decision-making styles

Being diagnosed with breast cancer requires that women make a number of decisions about their medical treatments. To gain insight into the variety of forces that shape a woman's breast cancer treatment decisions, we conducted semistructured interviews with 44 breast cancer survivors. Through an interpretive analysis, we identified five treatment decision-making styles: (a) medical expert, (b) self-efficacy, (c) relationship embedded, (d) inhibition, and (e) constellation of information, which are differentiated by two dimensions: (a) low versus high information needs and (b) self versus other preferences.