Two words to improve physician-patient communication: what else?

Identifying personalized barriers for hypertension self-management from TASKS framework

OBJECTIVE

Effective management of hypertension requires not only medical intervention but also significant patient self-management. The challenge, however, lies in the diversity of patients' personal barriers to managing their condition. The objective of this research is to identify and categorize personalized barriers to hypertension self-management using the TASKS framework (Task, Affect, Skills, Knowledge, Stress). This study aims to enhance patient-centered strategies by aligning support with each patient's specific needs, recognizing the diversity in their unique circumstances, beliefs, emotional states, knowledge levels, and access to resources. This research is based on observations from a single study focused on eight patients, which may have been a part of a larger project.

RESULTS

The analysis of transcripts from eight patients and the Global Hypertension Practice Guidelines revealed 69 personalized barriers. These barriers were distributed as follows: emotional barriers (49%), knowledge barriers (24%), logical barriers (17%), and resource barriers (10%). The findings highlight the significant impact of emotional and knowledge-related challenges on hypertension self-management, including difficulties in home blood pressure monitoring and the use of monitoring tools. This study emphasizes the need for tailored interventions to address these prevalent barriers and improve hypertension management outcomes.

Analysis of Closed Claims Among All Medical Specialties: Importance of Communication and Other Non-Clinical Contributing Factors

Objective

Medical malpractice claims represent patient dissatisfaction of care delivered by their healthcare provider. Evaluation of contributing factors (CFs) associated with claims provides important information to optimize the patient-provider relationship.

Study Design

A total of 21,101 closed claims with 54,479 CFs (2.2 contributing factors per claim) from a large medical professional liability coverage provider were analyzed from 2010 to 2019.

Results

Four clinical CFs (technical performance, management of therapy, patient assessment, and patient factors) and four nonclinical CFs (communication between providers and patient, communication among providers, failure or delay in obtaining a consult, and insufficient documentation) were identified >1,500 times. Nonclinical CFs increased as a percentage from 50% in the first part of the study period to 54% in the second part of the study period (p < 0.01), and were more frequent in cases associated with indemnity when compared to clinical CFs (Nonclinical: 57% vs 43%; p < 0.001). Poor communication as a CF increased steadily during the study period (3-year average; 2010-2012: 777 CF/year vs 2017-2019: 1207 CF/year; p < 0.001). In claims associated with high severity injury, poor communication among providers was more significant than poor communication between the provider and patient (63% vs 29%; p < 0.001), mainly due to failure to convey the severity of the patient's condition. For non-surgical specialties except psychiatry, communication was the highest CF and the second or third CF for psychiatry or surgical specialties.

Discussion

Clinical and nonclinical CFs are equally important for malpractice claims. Communications issues are particularly important regardless of specialty. While focusing on clinical quality is important, implementing strategies that account for nonclinical issues, with a particular focus on communication, would have significant benefits particularly in an environment of increased consolidation of healthcare delivery systems.

Clinical Interviewing: An Essential but Neglected Method of Medicine

Clinical interviewing is the basic method to understand how a person feels and what are the presenting complaints, obtain medical history, evaluate personal attitudes and behavior related to health and disease, give the patient information about diagnosis, prognosis, and treatment, and establish a bond between patient and physician that is crucial for shared decision making and self-management. However, the value of this basic skill is threatened by time pressures and emphasis on technology. Current health care trends privilege expensive tests and procedures and tag the time devoted to interaction with the patient as lacking cost-effectiveness. Instead, the time spent to inquire about problems and life setting may actually help to avoid further testing, procedures, and referrals. Moreover, the dialogue between patient and physician is an essential instrument to increase patient's motivation to engage in healthy behavior. The aim of this paper was to provide an overview of clinical interviewing and its optimal use in relation to style, flow and hypothesis testing, clinical domains, modifications according to settings and goals, and teaching. This review points to the primacy of interviewing in the clinical process. The quality of interviewing determines the quality of data that are collected and, eventually, of assessment and treatment. Thus, interviewing deserves more attention in educational training and more space in clinical encounters than it is currently receiving.

Large language models: Are artificial intelligence-based chatbots a reliable source of patient information for spinal surgery?

PURPOSE

Large language models (LLM) have recently attracted attention because of their enormous performance. Based on artificial intelligence, LLM enable dialogic communication using quasi-natural language that approximates the quality of human communication. Thus, LLM could play an important role for patients to become informed. To evaluate the validity of an LLM in providing medical information, we used one of the first high-performance LLM (ChatGPT) on the clinical example of acute lumbar disc herniation (LDH).

METHODS

Twenty-four spinal surgeons experienced in LDH surgery directed questions to ChatGPT about the clinical picture of LDH from a patient's perspective. They evaluated the quality of ChatGPT responses and its potential use in medical communication. The responses were compared with the information content of a standard informed consent form.

RESULTS

ChatGPT provided good results in terms of comprehensibility, specificity, and satisfaction of responses and in terms of medical accuracy and completeness. ChatGPT was not able to provide all the information that was provided in the informed consent form, but did communicate information that was not listed there. In some cases, albeit minor, ChatGPT made medically inaccurate claims, such as listing kyphoplasty and vertebroplasty as surgical options for LDH.

CONCLUSION

With the incipient use of artificial intelligence in communication, LLM will certainly become increasingly important to patients. Even if LLM are unlikely to play a role in clinical communication between physicians and patients at the moment, the opportunities-but also the risks-of this novel technology should be alertly monitored.

Preparing Patients to Communicate with Their Doctors About Clinical Trials as a Treatment Option: Impact of a Novel Video Intervention for Patients with a Blood Cancer and Their Caregivers

Cancer clinical trials (CCTs) are imperative for advancing cancer treatment and providing treatment options for patients; however, many barriers exist to offering and enrolling interested and eligible patients. It is crucial to equip patients and caregivers with communication skills that help them initiate and navigate conversations about the option of receiving treatment within a CCT. The aim was to assess the acceptability and impact of a novel video training for patients and caregivers that models strategies for patient-provider communication using the PACES method of healthcare communication and provides information about CCTs. The three-module training was implemented among blood cancer patients and caregivers. Using a single-arm pre-post study design, self-report surveys assessed changes in knowledge, confidence in using the PACES method, and perceived importance of, confidence in, and behavioral intention related to talking with doctors about CCTs. The Patient Report of Communication Behavior (PRCB) scale was administered. Among 192 participants, post-intervention knowledge gains were evident (p < 0.001). Confidence, importance, and likelihood to communicate about CCTs and confidence about using PACES also increased (p < 0.001); females who had never previously spoken to a provider about CCTs demonstrated greater impact (p = 0.045) than other genders. PRCB mean scores increased among patients 65+ who had never spoken to a provider about CCTs, with greater change than patients <65 (p = 0.001). This educational intervention for patients and caregivers increased knowledge about CCTs, skills in communicating with doctors about care and CCTs, and readiness to initiate conversations about CCTs as a potential treatment option.

Fear of childbirth and its determinants in pregnant women in the third trimester: a cross-sectional study

BACKGROUND

Fear of childbirth (FOC) is a prevalent issue among pregnant women and significantly relates to adverse outcomes for the mother and child. However, it is not clear the prevalence and risk factors of FOC among pregnant women in a region with a moderate level of economic development in China. The aim of this study was to investigate the prevalence and risk factors of FOC among pregnant women in the third trimester of pregnancy in Lianyungang city, Eastern China.

METHODS

A cross-sectional survey was conducted from December 2022 to February 2023 among pregnant women in the third trimester who met the inclusion criteria and visited Lianyungang Maternal and Child Health Hospital in Jiangsu Province, Eastern China. A structured questionnaire including sociodemographic characteristics, clinical characteristics, FOC, family function, doctor-patient communication, social support, general self-efficacy, anxiety, depression, insomnia symptoms, and quality of life was used to collect data. A multiple linear regression model was used to identify predictors of FOC.

RESULTS

This study included 535 pregnant women in the third trimester. The mean score of FOC was 30.67 ± 10.18, and the median score was 29.00. The prevalence of FOC was 56.64%. Multiple linear regression analysis revealed that pregnant women with electronic screen exposure time more than 5 h per day (β = 2.02, 95%CI: 0.50-3.53, P < 0.05), no history of cesarean section (β = 2.66, 95%CI: 0.61-4.71, P < 0.05), likes sour food or hates greasy food (β = 1.75, 95%CI: 0.00-3.50, P < 0.05), anxiety (β = 0.50, 95%CI: 0.21-0.80, P < 0.05) and depression (β = 0.30, 95%CI: 0.04-0.57, P < 0.05) were more likely to have a greater level of FOC than their counterparts. However, a significantly lower level of FOC was observed in pregnant women who were multipara (β=-1.64, 95%CI: -3.27-0.01, P < 0.05), not worrying about delivery without family members (β=-3.75, 95%CI: -5.26-2.25, P < 0.001), had good family function (β=-0.32, 95%CI: -0.64-0.00, P < 0.05) and doctor-patient communication (β=-0.33, 95%CI: -0.64-0.02, P < 0.05).

CONCLUSIONS

The prevalence of FOC was high in Lianyungang city, Eastern China. FOC is influenced by multiple factors. There is an urgent need to develop interventions to reduce the prevalence of FOC in the third trimester of pregnancy, and to pay attention to pregnant women with risk factors for FOC.

Qualitatively exploring the impact of a relationship-centered communication skills training program in improving patient perceptions of care

Objective

To explore qualitative patient experience comments before and after a relationship-centered communication skills training to understand patient experience, program impact, and opportunities for improvement.

Methods

Qualitative patient experience evaluation data was captured from January 2016 to December 2018 for 483 health care clinicians who participated in the skills training. A random sampling of available open-ended patient comments (N = 33,223) were selected pre-training (n = 668) and post-training (n = 566). Comments were coded for valence (negative/neutral/positive), generality versus specificity, and based on 12 communication behaviors reflective of training objectives.

Results

No significant difference was found in the valence of comments, or generality versus specificity of comments before and after the training. A significant decrease was present in perceived clinician concern. "Confidence in care provider" was the communication skill most frequently identified in comments both pre- and post-training.

Conclusion

Perceptions of interactions largely remained the same following training. Key relationship-centered communication skills require further attention in future training efforts. Measurements of patient satisfaction and engagement may not adequately represent patient experience.

Innovation

This study identified areas for improvement in the training program and offers a model for utilizing patient experience qualitative data in understanding communication training impact.

The Direct to Consumer Stem Cell Market and the Role of Primary Care Providers in Correcting Misinformation

INTRODUCTION

Direct to consumer stem cell and regenerative interventions (SCRIs) for various medical conditions have increased in popularity due to unmet medical needs and the promise of SCRIs to meet those needs. These interventions may have varying levels of safety and efficacy data and many lack sufficient scientific data to be marketed. The direct to consumer SCRI industry has received significant attention due to potential physical, economic, and emotional harms to patients. Patients may seek the counsel of their primary care providers when considering stem cell therapy for their condition.

METHODS

Here we describe strategies primary care providers can utilize when counseling patients.

RESULTS

Although we recommend constructing these discussions around individual patients' needs, one can utilize a general approach consisting of 4 parts. First, providers should recognize what information the patient is seeking and what is their understanding of stem cell and regenerative medicine. Next, providers should convey evidence-based information at the level of patients understanding so that they are aware of the risks, benefits, and descriptions of possible procedures. Throughout the conversations, attempts should be made to guide patients to a trusted resource that can provide additional information. Finally, providers should make an effort to address misinformation in a way that is nonjudgmental and patient-centered to make the patient feel safe and comfortable.

CONCLUSION

Effectively communicating risk information by primary care providers to patients is important given the harms reported from direct-to-consumer SCRIs. Correcting misinformation remains a priority when discussing SCRI's. Providers should strive to offer patients with additional resources such as the opportunity for consultation with a specialist or a consultation service dedicated to informing patients about regenerative medicine.

Use of Tactile Contact Accompanying Health Prmotion Messages During Routine Health & Physical Examinations: A Technique for Improving Compliance

A daunting challenge for health providers and medical practitioners is communicating the vital importance of health promotion and medical treatment adherence and compliance. This article is an evidence-based, best-practices commentary advocating the use of touch-accompanied verbal suggestions during the touching portions of routine, near-universal Health & Physical examinations. Notional case examples are presented; based on the professional literature, underlying Behavioral Mechanics are discussed. Touch-accompanied verbal health promotion messages skillfully deployed in routine Health & Physical examinations offer a non-harmful and efficient technique to synergistically and substantially enhance the probability of patient compliance with health improvement and medical treatment regimens. Though it is not a magic panacea, the public health applications, extensions and benefits are incalculable in terms of healthy behavior adoption. Additionally, if deftly conducted in accordance with best practices, it has the potential to greatly improve practitioner-patient relations and increase patient satisfaction. Further avenues of research inquiry are considered.

Dental EHR-infused Persona Ontologies to Enrich Dental Dialogue Interaction of Agents

The quality of patient-provider communication can predict the healthcare outcomes in patients, and therefore, training dental providers to handle the communication effort with patients is crucial. In our previous work, we developed an ontology model that can standardize and represent patient-provider communication, which can later be integrated in conversational agents as tools for dental communication training. In this study, we embark on enriching our previous model with an ontology of patient personas to portray and express types of dental patient archetypes. The Ontology of Patient Personas that we developed was rooted in terminologies from an OBO Foundry ontology and dental electronic health record data elements. We discuss how this ontology aims to enhance the aforementioned dialogue ontology and future direction in executing our model in software agents to train dental students.

'There's nothing you can do … it's like that in Chinatown': Chinese immigrant women's perceptions of experiences in Chicago Chinatown healthcare settings

Objectives: Chinese American women living in linguistically isolated communities are among the least likely to utilize healthcare services. Qualitative research methods can help identify health system vulnerability points to improve local healthcare delivery for this population.Design: We conducted 6 focus groups among 56 Chinese-speaking adult women in Chicago's Chinatown between July and August 2014 to explore their perceptions of experiences receiving medical care and interacting with healthcare providers in Chinatown healthcare settings.Results: Health system/clinic infrastructure and patient-provider communications were perceived barriers to care at Chinatown healthcare settings. Chinese participants reported long wait times, difficulty scheduling appointments, and poor front desk customer service. Communication difficulties at Chinatown healthcare settings involved language barriers with non-Chinese-speaking providers, but consideration for healthcare providers, provider demeanor, and reliance on provider recommendation also hindered patient-provider communications.Conclusions: Findings improve understanding of barriers to care experienced by Chinese immigrant women in one urban Chinatown community.

Clinician-Patient Movement Synchrony Mediates Social Group Effects on Interpersonal Trust and Perceived Pain

Pain is an unfortunate consequence of many medical procedures, which in some patients becomes chronic and debilitating. Among the factors affecting medical pain, clinician-patient (C-P) similarity and nonverbal communication are particularly important for pain diagnosis and treatment. Participants (N = 66) were randomly assigned to clinician and patient roles and were grouped into C-P dyads. Clinicians administered painful stimuli to patients as an analogue of a painful medical procedure. We manipulated the perceived C-P similarity of each dyad using groups ostensibly based on shared beliefs and values, and each patient was tested twice: Once with a same group clinician (concordant, CC) and once with a clinician from the other group (discordant, DC). Movement synchrony was calculated as a marker of nonverbal communication. We tested whether movement synchrony mediated the effects of group concordance on patients' pain and trust in the clinician. Movement synchrony was higher in CC than DC dyads. Higher movement synchrony predicted reduced pain and increased trust in the clinician. Movement synchrony also formally mediated the group concordance effects on pain and trust. These findings increase our understanding of the role of nonverbal C-P communication on pain and related outcomes. Interpersonal synchrony may be associated with better pain outcomes, independent of the specific treatment provided. PERSPECTIVE: This article demonstrates that movement synchrony in C-P interactions is an unobtrusive measure related to their relationship quality, trust toward the clinician, and pain. These findings suggest that interpersonal synchrony may be associated with better patient outcomes, independent of the specific treatment provided.

Improving Medical Communication in Migraine Management: A Modified Delphi Study to Develop a Digital Migraine Tracker

OBJECTIVE

This study aimed to identify the essential content and amount of information to be collected from people with migraine via a patient-facing smartphone-based migraine tracker for them to share with clinicians during live discussions to assist in optimizing migraine management. The proposed tracker is intended for use in non-interventional research to evaluate disease burden in episodic migraine and chronic migraine patients as assessed by demographic and clinical characteristics and health resource utilization in an integrated delivery network setting. The proposed tracker is not intended for commercial purposes.

BACKGROUND

Epidemiological studies suggest migraine is underdiagnosed and undertreated. Studies of patient-clinician interactions suggest that effective medical communication may help address these issues.

METHODS

Four migraine practice leaders, an epidemiologist with extensive migraine experience, and a measurement expert took part in a modified Delphi panel process to identify data elements that could be collected from people with migraine through a smartphone-based migraine tracker. Importantly, the proposed tracker would not be intended to replace the patient-clinician encounter but to support the encounter through enabling the patient to document migraine symptoms and experiences in a timely and accurate manner for sharing with a clinician as part of a broader face-to-face discussion. The panel reviewed questions derived from the existing migraine diaries in the public domain, those used in clinical trials, and patient-centric surveys assessing the impact of migraine on physical function and other related concepts. Key considerations included identification of the most clinically useful data elements for a shared communication tool for people with migraine under the care of a clinician. The panel also identified numerous functionality requirements for such a tool and provided recommendations on the most effective way to present results to a clinician.

RESULTS

The expert panel opined that people with migraine may value the ability to capture a relatively broad range of information for their own migraine-tracking purposes, while clinicians will likely find greater value in a small set of data relevant to the management of migraine. The panel identified the 3 most essential concepts in categories of data for a clinician, for which they coined the term "The 3 Fs": Frequency of days with headache; Frequency of acute medication usage; and Functional impairment. Information on the frequency of days with headache was felt to combine with the information on the frequency of acute medication usage to provide essential insights into current migraine management strategy and its outcomes, and to assist considerations of preventive measures. Functional impairment was treated as an effective surrogate for headache severity and was assessed based on the following: degree of difficulty in performing activities of daily living, impact on absenteeism (taking leave from work or cancelling/avoiding other activities) and presenteeism (performing work or other daily activities, with reduced productivity/capability), and amount of rest required as a result of a migraine attack. The modified Delphi panel process resulted in the selection of 13 questions in 8 categories to elicit sufficient and meaningful data comprising headache occurrence, symptoms, daily/preventive and as-needed/acute medication usage, triggers, ability to concentrate, and functional impairment. The panel also agreed that the tracker should generate 2 distinct reports: one for people with migraine that would include a wider range of data about symptoms and perceived triggers, and a targeted report for the clinician that would place prime emphasis on the 3 Fs for aggregating the results of each headache occurrence and the trend over time.

CONCLUSIONS

A system that easily captures critical data elements about migraine, with specific feedback displays for patients to share with clinicians during live discussions, may offer some benefit to people with migraine and their clinicians by facilitating more objective communication and optimizing management. The tracker's output may enable people with migraine to track a wide range of data for their own purposes, allowing them to better understand their condition, while a synthesized view of the selected data may support more informed clinical decision-making for the clinician and individualized, evidence-based discussion with the patient. As a result, this shared decision-making tool may enable patients to more accurately convey essential migraine information during live patient-clinician discussions to drive improved management and patient outcomes.

Older Hypertensive Patients’ Adherence to Healthy Lifestyle Behaviors

Non-pharmacological treatment including diet, body weight reduction, smoking cessation and physical activity, is very important part of hypertension treatment. The objective of this study was to investigate the adherence to healthy lifestyle behavior in the representative sample of the older hypertensive patients, and to investigate factors associated with adherence in the studied older population. The study was conducted on random sample of 362 long term hypertensive (> five years) patients older than 65 years of age, at Health Care Center of Kragujevac. Adherence was assessed using the structured questionnaire for the analysis of the implementation of both hypertension and diabetes guidelines in the primary care. Both bivariate and multivariate analyses were conducted. Nearly 35% of examined patients were highly adherent; they exercised regularly, avoided smoking for at least five years and consumed special healthy diet prescribed for hypertension. Another 35.6% of the cases reported exercising regularly, 39.5% followed the recommended diet for the hypertension, while 23.4% of the patients have still consumed cigarettes. Multivariate logistic regression demonstrated that received counseling on healthy lifestyle behaviors by physicians and lack of education predicted high adherence to healthy lifestyle behavior. In order to improve adherence of elderly hypertensive patients to healthy lifestyle, strengthening patient-physician relationships through efforts to enhance communication may be a promising strategy to enhance patients’ engagement in healthy lifestyle behaviors for hypertension. Such an improvement could be achieved through the education of both the physicians and patients.

Physician verbal compliance-gaining strategies and patient satisfaction

Purpose

The patient healthcare experience is a complex phenomenon, as is encouraging patient compliance with medical advice. To address this multifaceted relationship, the purpose of this paper is to explore the ways resident physicians verbally encourage patient compliance and the relationship between these compliance-seeking strategies and patient satisfaction.

Design/methodology/approach

A total of 40 medical interviews between resident physicians and patients were audio-recorded, transcribed, coded, and analysed. Patient questionnaires were also administered and analysed.

Findings

It was found that resident physicians used indirect orders most frequently, followed by motivation, persuasion, scheduling, and direct orders. It was also found that female patients received (marginally) more messages than male patients; female residents used more messages with female patients than with male patients; female residents used more persuasion messages with female patients than with male patients; male residents were less likely than female residents to use motivational messages with female patients; and compliance was significantly correlated with expertise satisfaction, overall satisfaction, and communication satisfaction.

Originality/value

This study advances existing research by examining various ways in which residents verbally encourage patient compliance and the relationship between these messages and patient satisfaction. Findings can be used to inform physicians on strategies to encourage patient adherence to medication regimen, appointments, and lifestyle changes.

Veterans' Preferences for Remote Management of Chronic Conditions

BACKGROUND

The Veterans Health Administration (VA) is investing considerable resources into providing remote management care to patients for disease prevention and management. Remote management includes online patient portals, e-mails between patients and providers, follow-up phone calls, and home health devices to monitor health status. However, little is known about patients' attitudes and preferences for this type of care. This qualitative study was conducted to better understand patient preferences for receiving remote care.

METHODS

Ten focus groups were held comprising 77 patients with hypertension or tobacco use history at two VA medical centers. Discussion questions focused on experience with current VA remote management efforts and preferences for receiving additional care between outpatient visits.

RESULTS

Most participants were receptive to remote management for referrals, appointment reminders, resource information, and motivational and emotional support between visits, but described challenges with some technological tools. Participants reported that remote management should be personalized and tailored to individual needs. They expressed preferences for frequency, scope, continuity of provider, and mode of communication between visits. Most participants were open to nonclinicians contacting them as long as they had direct connection to their medical team. Some participants expressed a preference for a licensed medical professional. All groups raised concerns around confidentiality and privacy of healthcare information. Female Veterans expressed a desire for gender-sensitive care and an interest in complementary and alternative medicine.

CONCLUSIONS

The findings and specific recommendations from this study can improve existing remote management programs and inform the design of future efforts.

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

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

Patient-Provider Engagement and Chronic Pain in Drug-Using, Primarily African American Persons Living with HIV/AIDS

Among disadvantaged persons living with HIV/AIDS (PLHIV), patient-provider engagement, which has been defined as patient-provider relationships that promote the use of health care services and are characterized by active listening and supportive decision making, has been associated with antiretroviral therapy (ART) maintenance and viral suppression. However, chronic pain, depression, and substance use, all of which are prevalent in this population, can reduce the quality of patient-provider engagement. We hypothesized a model in which chronic pain, depression, and substance use would be associated with poorer patient-provider engagement, which would be positively associated with adherence, with the latter associated positively with viral suppression. We analyzed data from the BEACON study, which included surveys from 383 PLHIV who were primarily African American, on ART, and had histories of drug use. Due to six missing cases on the chronic pain variable, we used data from 377 respondents in a structural equation model. Chronic pain and depressive symptoms were significantly associated with poorer patient-provider engagement, while substance use was associated with better engagement. Patient-provider engagement in turn was associated with better ART adherence, which was associated with higher viral suppression. Results suggest the role of chronic pain in poor patient-physician engagement in this population, which has potential implications for quality of HIV patient care and health outcomes. Findings suggest the need for attention to patient-provider engagement in PLHIV.

Simplistic and complex thought in medicine: the rationale for a person-centered care model as a medical revolution

According to the concept developed by Thomas Kuhn, a scientific revolution occurs when scientists encounter a crisis due to the observation of anomalies that cannot be explained by the generally accepted paradigm within which scientific progress has thereto been made: a scientific revolution can therefore be described as a change in paradigm aimed at solving a crisis. Described herein is an application of this concept to the medical realm, starting from the reflection that during the past decades, the medical community has encountered two anomalies that, by their frequency and consequences, represent a crisis in the system, as they deeply jeopardize the efficiency of care: nonadherence of patients who do not follow the prescriptions of their doctors, and clinical inertia of doctors who do not comply with good practice guidelines. It is proposed that these phenomena are caused by a contrast between, on the one hand, the complex thought of patients and doctors that sometimes escapes rationalization, and on the other hand, the simplification imposed by the current paradigm of medicine dominated by the technical rationality of evidence-based medicine. It is suggested therefore that this crisis must provoke a change in paradigm, inventing a new model of care defined by an ability to take again into account, on an individual basis, the complex thought of patients and doctors. If this overall analysis is correct, such a person-centered care model should represent a solution to the two problems of patients' nonadherence and doctors' clinical inertia, as it tackles their cause. These considerations may have important implications for the teaching and the practice of medicine.

Teaching and assessing professionalism in medical learners and practicing physicians

Professionalism is a core competency of physicians. Clinical knowledge and skills (and their maintenance and improvement), good communication skills, and sound understanding of ethics constitute the foundation of professionalism. Rising from this foundation are behaviors and attributes of professionalism: accountability, altruism, excellence, and humanism, the capstone of which is professionalism. Patients, medical societies, and accrediting organizations expect physicians to be professional. Furthermore, professionalism is associated with better clinical outcomes. Hence, medical learners and practicing physicians should be taught and assessed for professionalism. A number of methods can be used to teach professionalism (e.g. didactic lectures, web-based modules, role modeling, reflection, interactive methods, etc.). Because of the nature of professionalism, no single tool for assessing it among medical learners and practicing physicians exists. Instead, multiple assessment tools must be used (e.g. multi-source feedback using 360-degree reviews, patient feedback, critical incident reports, etc.). Data should be gathered continuously throughout an individual's career. For the individual learner or practicing physician, data generated by these tools can be used to create a "professionalism portfolio," the totality of which represents a picture of the individual's professionalism. This portfolio in turn can be used for formative and summative feedback. Data from professionalism assessments can also be used for developing professionalism curricula and generating research hypotheses. Health care leaders should support teaching and assessing professionalism at all levels of learning and practice and promote learning environments and institutional cultures that are consistent with professionalism precepts.

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.

How can Doctors Improve their Communication Skills?

The process of curing a patient requires a holistic approach which involves considerations beyond treating a disease. It warrants several skills in a doctor along with technical expertise. Studies have shown that good communication skill in a doctor improve patient's compliance and overall satisfaction. There are certain basic principles of practicing good communication. Patient listening, empathy, and paying attention to the paraverbal and non verbal components of the communication are the important ones that are frequently neglected. Proper information about the nature, course and prognosis of the disease is important. Besides, patients and attendants should always be explained about the necessity and yield of expensive investigations and risks/benefits involved in invasive procedures. One should be extremely cautious while managing difficult encounters and breaking bad news. Formal training of the doctors in improving communication skills is necessary and has proven to improve overall outcome. The authors recommend inclusion of formal training in communication skills in medical curriculum and training of practising doctors in the form of CMEs and CPEs.

Empathy and integrative thinking: Talmudic paradigms for the essentials of a medical interview

Intentional empathy and integrative thinking are essential elements of a medical interview. Yet the repetitive, sometimes monotonous, nature of medical practice can compromise their achievement. Emotional and intellectual fatigue may lead to clouded observation with diagnostic errors resulting. In spite of a long extant pedagogy of teaching interviewing techniques and creative mnemonics, hurdles remain and significant miscues continue. The challenge is one of surmounting these obstacles and of finding 'new' ways to perform 'old' tasks. It is to do what we already know to do but somehow do not. In the essay which follows, two Talmudic legends are identified and discussed as paradigms for empathy and integrative thinking. They are offered as 'literary mnemonics' for potential use in physician-patient encounters. The legends are linked to the insights of contemporary scholars including Jerome Groopman, Danielle Ofri, Roger Martin and others who have considered concepts of cognition, emotion, empathy, 'opposable mind' and integrative thinking in medical and non-medical settings.

A “boca amarga" para o paciente: competência comunicativa intercultural

Objetivo: demonstrar a compreensão dos usuários da Unidade de Saúde da Família (USF) Castelo Branco II da cidade de Rio Grande/RS-Brasil em relação à queixa “boca amarga” e discutir a competência comunicativa intercultural necessária à equipe de saúde para a abordagem desses usuários. Métodos: trata-se de um estudo descritivo exploratório de abordagem qualitativa. Os participantes da pesquisa foram agentes comunitários de saúde e usuários atendidos na USF Castelo Branco II. Resultados: a explicação da queixa “boca amarga” faz parte da linguagem do ideário popular e médico. Os tratamentos populares para a queixa envolvem: cura espontânea; uso de chás; medicamentos; e cuidados nutricionais. A maioria dos participantes da pesquisa nunca havia comentado com o seu médico ou outro profissional de saúde sobre a “boca amarga”, sendo que um dos participantes referiu que a “boca amarga” era um “tabu” e citou o constrangimento que existe em discutir o assunto. Conclusões: a população possui uma compreensão cultural própria da queixa “boca amarga”. No entanto, são necessários mais estudos sobre as doenças populares e uma abordagem mais aprofundada das mesmas. Este estudo constitui-se apenas em um enfoque inicial, indispensável para a compreensão da expressão “boca amarga” e da competência comunicativa cultural necessária para os profissionais de saúde. 

Challenges of recognition of the psychiatric aspects of intimate partner violence

Background:

Even though intimate partner violence represents a major public health problem in Nigeria, much of its associated burden of psychiatric morbidity presenting in the clinical setting goes unrecognized and untreated.

Objectives:

The purpose of this paper is to clarify the psychiatric perspectives on intimate partner violence and highlight the barriers that militate against the detection of these problems in clinical contexts.

Method:

This paper utilized the framework of relevant case series and a focused review of the relevant literature to describe and annotate the psychiatric problems of the victims and perpetrators of intimate partner violence in southeast Nigeria.

Results:

The major barriers to detection of the psychiatric disorders occurring in the context of intimate partner violence include patients’ feelings of shame, reticence about the abuse experiences in the clinical encounter, and cloaking of their emotional distress in somatic complaints. Also, the poor interviewing skills of many doctors and their difficulty in processing psychosocial matters contributes to the non-detection of psychiatric problems occurring in the context of partner violence.

Conclusion:

Concerted efforts directed towards the improved detection, treatment and/or referral of patients presenting with these difficulties will enhance their wellbeing and quality of life.

Hypertensive chronic kidney disease in African Americans: strategies for improving care

African Americans have a disproportionate burden of chronic kidney disease (CKD), which tends to have an earlier onset and a more rapid progression in this population. Many of the factors responsible for the rapid progression of CKD in African Americans are detectable by screening and are modifiable with prompt therapy.

Changes in herb and dietary supplement use in the U.S. adult population: a comparison of the 2002 and 2007 National Health Interview Surveys

BACKGROUND

Past national surveys indicate that use of herbs and dietary supplements rose rapidly in the United States during the 1990s and early 2000s. Additional research is needed to determine whether this growth rate and associated patterns of use have persisted over time.

OBJECTIVES

The objectives of this study were: (1) to assess population and subpopulation changes in rates of herb and supplement use; and (2) to assess changes in rates of disclosure of herb and supplement use to conventional medical providers.

METHODS

This study used data from the 2002 (n = 30,427) and 2007 (n = 22,657) Adult Complementary and Alternative Medicine File to the National Health Interview Survey (NHIS). Weighted group and subgroup comparisons used the Wald χ(2) tests to compare differences in herb and supplement use between 2002 and 2007.

RESULTS

The number of adults in the United States that ever used herbs or supplements grew slightly, from 50.6 million in 2002 to 55.1 million in 2007. However, the proportion of adults who reported use of herbs or supplements in the past 12 months dropped significantly: from 18.9% in 2002 to 17.9% in 2007 (P < 0.05). Subpopulation comparisons revealed that younger adults were less likely to use herbs and supplements in 2007 (17.6%) than in 2002 (20.0%), whereas older adults (ie, those aged ≥65 years) were more likely to do so (19.5% in 2007 vs. 13.2% in 2002). Racial and ethnic minorities also reported a significant decline in recent use. The proportion of respondents that disclosed herb or supplement use to their physician or another conventional medical professional rose, from 33.4% in 2002 to 45.4% in 2007. However, <1% of recent herb and supplement users disclosed this use to their pharmacist. Limitations of this research are that the 2 national data sets were not directly comparable and that questionnaires in the 2 surveys assessed were not identical.

CONCLUSIONS

Herbal preparations and dietary supplements remain popular in the United States, but the user population and patterns of use are changing. Ongoing surveillance of this health behavior is a public health priority.

Examining the validity of the unitary theory of clinical relationships: comparison of observed and experienced parent-doctor interaction

OBJECTIVE

We explored parent-doctor relationships in the care of children with leukaemia from three perspectives simultaneously: parents', doctors' and observers'. Our aim was to investigate convergence and divergence between these perspectives and thereby examine the validity of unitary theory of emotionality and authority in clinical relationships.

METHODS

33 audiorecorded parent-doctor consultations and separate interviews with parents and doctors, which we analysed qualitatively and from which we selected three prototype cases.

RESULTS

Across the whole sample doctors' sense of relationship generally converged with our observations of consultation, but parents' sense of relationship diverged strongly from each. Contrary to current assumptions, parents' sense of emotional connection with doctors did not depend on doctors' emotional behaviour, and parents did not feel disempowered by doctors' authority. Moreover, authority and emotionality were not conceptually distinct for parents, who gained emotional support from doctors' exercise of authority.

CONCLUSIONS

The relationships looked very different from the three perspectives. These divergences indicate weaknesses in current ideas of emotionality and authority in clinical relationships and the necessity of multisource datasets to develop these ideas in a way that characterises clinical relationships from all perspectives.

PRACTICE IMPLICATIONS

Methodological development will be needed to address the challenges posed by multisource datasets.

Narratives in hand therapy

This article reviews literature on Narrative Medicine and applies this knowledge to hand therapy using brief case examples in which the narrative message of each example is illustrated. The value of narratives in hand therapy is thereby described.

LEVEL OF EVIDENCE

5.

Integrative qualitative communication analysis of consultation and patient and practitioner perspectives: towards a theory of authentic caring in clinical relationships

OBJECTIVE

We developed a method whereby relationships can be studied simultaneously from the perspectives of each party and researchers' observations of their dialogue. Then we used this method to study how to recognise authentic, caring clinical relationships.

METHODS

Participants were 20 patients who had recently received surgery for breast cancer and nine surgeons with whom they had a post-operative consultation. We audiorecorded consultations, before interviewing patients and surgeons about their perceptions of the consultation and each other. Cross-case qualitative analyses (analysing consultations and surgeon and patient interviews, respectively) were supplemented by integrative, within-case analysis.

RESULTS

Surgeons and patients described their relationship as personal and emotional, but emotional talk was absent from consultations. For patients and surgeons, their relationship depended, instead, on surgeons' expertise and character.

CONCLUSION

Our integrative approach suggested that authentic caring in these relationships lay in practitioners' conscientious execution of their role and, contrary to currently influential views, not in an explicit emotional engagement.

PRACTICE IMPLICATIONS

Relationships between patients and practitioners cannot be described adequately using analyses of interactions between them. Researchers will need to triangulate between these observations and the patient and practitioner perspectives in order to understand what makes for authentically caring relationships.

Patient Satisfaction in Obstetrics and Gynecology: Individualized Patient-centered Communication

Background

Patient satisfaction is becoming an increasingly prevalent topic in medicine, but little is known about patient satisfaction in women's health and other specialties. We review current methods of improving patient satisfaction in the field of obstetrics and gynecology with the intent to increase patient satisfaction even further by enhancing and combining previously used strategies.

Methods

A search from inception to June 2010 for electronic literature was performed using Medline. The search strategy used the medical subject heading terms “patient satisfaction”, “obstetrics”, “gynecology”, “patient-centered communication”, “communication training”, and “malpractice”. The company websites for Press Ganey Associates, Inc and Integrated Health Associates' were also reviewed. Studies in both general medicine and the field of obstetrics and gynecology were reviewed to emphasize disparities between patients' satisfaction in diverse medical specialties.

Results

Studies indicating the importance of patient satisfaction, the factors contributing to patient satisfaction, and an evaluation of current, evidence-based methods of increasing patient satisfaction were reviewed. The studies included suggest that current methods of assessing/improving patient satisfaction are effective, but may not be the most productive.

Conclusions

We expect that the combination of previously successful methods of improving patient satisfaction to allow physicians to employ individualized patient-centered communication may improve patient satisfaction even further. Studying the use of our proposed enhancements in physician-patient communication may be worthwhile tools to increase patient satisfaction and optimize the quality of women's healthcare.

Cost-effectiveness analysis of interventions to prevent cardiovascular disease in Vietnam

BACKGROUND

Vietnam is in the process of an epidemiological transition, with cardiovascular disease (CVD) now ranked as the leading cause of death. The burden of CVD will continue to rise unless effective interventions for addressing its underlying risk factors are put in place.

OBJECTIVES

To assess the costs, health effects and cost-effectiveness of a set of personal and non-personal prevention strategies to reduce CVD in Vietnam, including mass media campaigns for reducing consumption of salt and tobacco, drugs for lowering blood pressure or cholesterol, and combined pharmacotherapy for people at varying levels of absolute risk of a cardiovascular event.

METHODS

WHO-CHOICE methods and analytical models were employed, using local data to estimate the costs, effects and cost-effectiveness of 12 population and individual interventions implemented singly or in combination. Costs were measured in Vietnamese Dong for the year 2007 (discounted at a rate of 3% per year), while health effects were expressed in age-weighted and discounted disability-adjusted life years (DALYs) averted.

RESULTS

A health education programme to reduce salt intake (VND 1 945 002 or US$118 per DALY averted) and individual treatment of systolic blood pressure above 160 mmHg (VND 1 281 596 or US$78 per DALY averted) were found to be the most cost-effective measures for population- and individual-based approaches, respectively. Where budget is very limited, a mass media education programme on salt intake and a combination mass media programme addressing salt intake, cholesterol and tobacco should be selected first. If more resources become available, greatest population health gains can be achieved via individual treatment of systolic blood pressure and the absolute risk approach to CVD prevention.

CONCLUSIONS

Contextualization of WHO-CHOICE using local data provides health decision-makers with more sound economic evidence for policy debates on prioritizing health interventions to reduce cardiovascular diseases in Vietnam. When used, cost-effectiveness analysis could increase efficiency in allocating scare resources.

"Practicing medicine": patient perceptions of physician communication and the process of prescription

OBJECTIVE

This study explores patient perceptions of physician communication regarding prescription medications and develops a theory of the effects of perceived physician communication on the patient decision-making process of medication taking.

METHODS

Using a grounded theory approach, this study systematically analyzed patient narratives of communication with physicians regarding prescription medications and the patient's resulting medication taking and adherence behavior.

RESULTS

Participants described concern about side effects, lack of perceived need for medications, and healthcare system factors as barriers to medication adherence. Overall, participants seemed to assess the utility of communication about these issues based on their perceptions of their physician as the source of the message.

CONCLUSION

The theory generated here includes patient assessments of their physician's credibility (trustworthiness and expertise) as a critical influence in how chronically-ill patients process information about the need for prescribed therapy. Trial and error to find appropriate medications seemed to deteriorate patients' perceptions of their physicians' credibility.

PRACTICE IMPLICATIONS

A practical application of this theory is the recommendation for physicians to increase perceived expertise by clearly outlining treatment processes at the outset of treatment, presenting efficacy and timeline expectations for finding appropriate medications.

Communicating with parents of children with autism about vaccines and complementary and alternative approaches

Despite incontrovertible evidence that vaccines do not cause autism, some parents continue to refuse them and many parents of children with autism seek hope in unproven and potentially harmful complementary and alternative (CAM) approaches. This commentary explores the reasons for such behaviors and proposes that pediatricians may support parents in their pursuit of hope in unproven treatments as long as these are not potentially harmful to the child or prohibitively expensive. While respecting parental autonomy and hope the pediatricians should share with parents their concerns about lack of scientific evidence about CAM and potential for harm by some approaches.