"Do You Smoke?" Physician-Patient Conversations About Smoking and Lung Cancer

This study examined how physicians initiated and navigated conversations about smoking with patients with lung cancer. While there are numerous health benefits associated with smoking cessation in patients with advanced lung cancer, conversations about smoking cessation are infrequent and often lack tangible cessation support. We conducted a qualitative inductive content analysis on transcripts of conversations (n = 58) recorded during an initial appointment between a physician and a standardized patient (SP). SPs portrayed a 62-year-old male with lung cancer completing an initial visit with a new physician. Qualitative analysis focused on examining how physicians discussed smoking with a new patient. We found that a majority of physicians initiated conversations about smoking, often during the medical history charting process or during conversations about the lung cancer diagnosis. The content of conversations about smoking generally fits within six categories: assesses smoking status, builds smoking history profile, praises smoking cessation, connects smoking behaviors to diagnosis or treatment, provides empathy or understanding, and presents a negative bias about smoking. We found that while a majority of physicians asked patients about smoking, most physicians aimed for these conversations to be short, routine, and medically driven. Conversations about smoking were not tailored to meet the specific needs of patients with lung cancer, which might include additional provision of support for smoking cessation and recognition of smoking-related stigma.

Empowering patients with the PREPARE advance care planning program results in reciprocal clinician communication

BACKGROUND

The patient-directed PREPAREforYourCare.org program empowers patients to participate in advance care planning (ACP) discussions with clinicians. Our goal was to determine whether PREPARE could reciprocally increase clinician ACP communication.

METHODS

In a secondary analysis of two trials evaluating the efficacy of PREPARE plus an easy-to-read advance directive (AD) versus an AD alone, patients were included if they were ≥55 years old, English- or Spanish-speaking, and had ≥2 chronic conditions. We audio-recorded postintervention primary care visits and used the validated clinician-patient participation coding scheme to calculate the number of clinician ACP utterances concerning information-giving, recommendations, or supportive talk. We examined differences by study arm using mixed effects negative binomial models, stratifying by language. To assess possible mediation, we adjusted for active patient participation (e.g., asking questions or stating preferences).

RESULTS

Three hundred ninety-three visits were audio-recorded (177 in PREPARE arm and 216 in AD-only arm). Recordings included 179 clinicians (mean 2.2 [SD 1.9] patients each). Patients' mean age was 66 ± 8 years, 31% had limited health literacy, and 25% were Spanish-speaking. Exactly 67% of recordings included information-giving, 85% recommendations, and 62% supportive talk. PREPARE resulted in 51% more clinician supportive talk versus the AD alone (mean 4.5 [8.9] vs. 2.9 [6.0] utterances; incidence rate ratio 1.51 [95% CI 1.02-2.24]). Effects were most pronounced among Spanish speakers. There were no differences in information-giving or recommendations. After adjusting for active patient participation, no differences in supportive talk remained.

CONCLUSIONS

The patient-directed PREPARE program was associated with greater clinician supportive ACP communication with older adults compared with an AD alone; the effect was most pronounced among Spanish speakers and was mediated by active patient participation. Thus, PREPARE helps patients be more engaged communicators, which in turn encourages clinicians to be more supportive of patients. Enhanced patient-clinician communication represents an important mechanism by which PREPARE may decrease disparities in ACP.

The Influence of Emotions on Treatment Decisions About Low-Risk Thyroid Cancer: A Qualitative Study

Background: Little is known about the role of emotions in treatment decisions for thyroid cancer. We aimed to characterize the emotional content of patient-surgeon communication during decision-making about low-risk thyroid cancer treatment. Methods: We audio-recorded conversations about treatment for clinically low-risk thyroid cancer or biopsy suspicious for thyroid cancer between patients (n = 30) and surgeons (n = 9) in two diverse, academic hospitals in the United States. Inductive and deductive content analyses were used to characterize the emotional content in verbatim transcripts. Results: Patients' expression of emotion focused on primarily on their diagnosis and treatment outcomes. Patients commonly expressed negative emotions like fear and anxiety about "the C-word" and worried about the cancer growing or spreading. In response, most surgeons used education, as opposed to empathy or validation, to reassure patients, often highlighting low probabilities of adverse events. Surgeons emphasized the "slow-growing" nature and excellent prognosis of thyroid cancer compared with other malignancies. When discussing treatment options, surgeons often described alternatives in terms of their emotional outcomes. Some described total thyroidectomy as providing "peace of mind" or a "sense of completeness," warning that cancer or thyroid tissue remaining in the body with active surveillance or lobectomy might "worry" or "bother" patients. Surgeons supported deliberation by reassuring patients that there are "two right answers" and "no rush" to decide. Conclusions: Patients express negative emotions during treatment decision-making. In response, surgeons often miss opportunities to provide empathy in addition to education. Surgeons and patients both acknowledge patient fear and anxiety as a reason to choose thyroidectomy instead of active surveillance. Peace of mind gained by patients and surgeons as a result of thyroidectomy may lead to overtreatment of patients with low-risk thyroid cancer.

Head to head randomized trial of two decision aids for prostate cancer

Background

While many studies have tested the impact of a decision aid (DA) compared to not receiving any DA, far fewer have tested how different types of DAs affect key outcomes such as treatment choice, patient–provider communication, or decision process/satisfaction. This study tested the impact of a complex medical oriented DA compared to a more simplistic decision aid designed to encourage shared decision making in men with clinically localized prostate cancer.

Methods

1028 men at 4 VA hospitals were recruited after a scheduled prostate biopsy. Participants completed baseline measures and were randomized to receive either a simple or complex DA. Participants were men with clinically localized cancer (N = 285) by biopsy and who completed a baseline survey. Survey measures: baseline (biopsy); immediately prior to seeing the physician for biopsy results (pre- encounter); one week following the physician visit (post-encounter). Outcome measures included treatment preference and treatment received, knowledge, preference for shared decision making, decision making process, and patients’ use and satisfaction with the DA.

Results

Participants who received the simple DA had greater interest in shared decision making after reading the DA (p = 0.03), found the DA more helpful (p’s < 0.01) and were more likely to be considering watchful waiting (p = 0.03) compared to those receiving the complex DA at Time 2. While these differences were present before patients saw their urologists, there was no difference between groups in the treatment patients received.

Conclusions

The simple DA led to increased desire for shared decision making and for less aggressive treatment. However, these differences disappeared following the physician visit, which appeared to change patients’ treatment preferences.

Trial registration This trial was pre-registered prior to recruitment of participants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01505-x.

Epidemiology of Fear, Sadness, and Anger Expression in Palliative Care Conversations

CONTEXT

Advancing the science of serious illness communication requires methods for measuring characteristics of conversations in large studies. Understanding which characteristics predict clinically important outcomes can help prioritize attention to scalable measure development.

OBJECTIVES

To understand whether audibly recognizable expressions of distressing emotion during palliative care serious illness conversations are associated with ratings of patient experience or six-month enrollment in hospice.

METHODS

We audiorecorded initial palliative care consultations involving 231 hospitalized people with advanced cancer at two large academic medical centers. We coded conversations for expressions of fear, anger, and sadness. We examined the distribution of these expressions and their association with pre/post ratings of feeling heard and understood and six-month hospice enrollment after the consultation.

RESULTS

Nearly six in 10 conversations included at least one audible expression of distressing emotion (59%; 137 of 231). Among conversations with such an expression, fear was the most prevalent (72%; 98 of 137) followed by sadness (50%; 69 of 137) and anger (45%; 62 of 137). Anger expression was associated with more disease-focused end-of-life treatment preferences, pre/post consultation improvement in feeling heard and understood and lower six-month hospice enrollment. Fear was strongly associated with preconsultation patient ratings of shorter survival expectations. Sadness did not exhibit strong association with patient descriptors or outcomes.

CONCLUSION

Fear, anger, and sadness are commonly expressed in hospital-based palliative care consultations with people who have advanced cancer. Anger is an epidemiologically useful predictor of important clinical outcomes.

Examining dual method contraceptive use among midwestern parenting Latinx teens: Perspectives from adolescent parents, caretakers, and nurses

BACKGROUND

Despite dual method (DM) contraception being effective in reducing repeat-births and sexually transmitted infections (STIs), Latinx adolescent parents who live in non-traditional migration areas remain vulnerable for both outcomes.

OBJECTIVE

This study applied the Unified Theory of Behavior (UTB) and drew upon Bronfenbrenner's social ecological model to explore multiple stakeholders' (adolescent parents, caregivers, and nurses) perceptions of factors that influence DM intentions and use among Latinx adolescent parents.

METHODS

Semi-structured interviews with Latinx adolescent parent-caregiver dyads and nurses were analyzed using thematic analysis.

RESULTS

Study findings revealed that while all participant groups considered medical providers as DM influencers, contradicting views related to caregivers' as DM influencers emerged among adolescent parents and caregivers. Findings suggest that DM is deemed both acceptable and effective; and adolescent parents' reported DM self-efficacy. DM obstacles included negative emotions, environmental constraints, and poor knowledge and skills.

CONCLUSIONS

Study results suggest that constructs from the UTB framework are useful in identifying individual and social factors that can potentially influence DM intentions and use among Latinx adolescent parents.

IMPLICATIONS FOR PUBLIC HEALTH NURSING

This study's findings have potential implications for public health nurses interested in designing community-based interventions to reduce repeat-births and STIs among Latinx adolescent parents.

Empowering Older Adults to Discuss Advance Care Planning During Clinical Visits: The PREPARE Randomized Trial

BACKGROUND/OBJECTIVES

A patient-directed, online program (PREPARE for Your Care [PREPARE]; prepareforyourcare.org) has been shown to increase advance care planning (ACP) documentation. However, the mechanisms underlying PREPARE are unknown. Our objectives were to compare the efficacy of PREPARE plus an easy-to-read advance directive (AD) vs an AD alone to increase active patient participation in ACP discussions during clinic visits and to examine effects of active patient participation on ACP documentation.

DESIGN

Audio recordings of postintervention primary care visits from two randomized trials (2013-2016).

SETTING

Seven primary care clinics at a veterans affair and safety-net hospital in San Francisco, CA.

PARTICIPANTS

English- and Spanish-speaking adults, aged 55 years and older, with two or more chronic/serious conditions.

INTERVENTION

PREPARE plus an easy-to-read AD or an AD alone.

MEASUREMENTS

The primary outcome was the number of active patient participation utterances about ACP (eg, asking questions, stating preferences) measured by the validated Active Patient Participation Coding Scheme. We examined differences in utterances by study arm using mixed effects negative binomial models and utterances as a mediator of PREPARE's effect on documentation using adjusted logistic regression. Models were adjusted for health literacy, prior care planning, and clinician.

RESULTS

Among 393 participants, the mean (SD) age was 66 (8.1) years, 120 (30.5%) had limited health literacy, and 99 (25.2%) were Spanish speaking. PREPARE plus the AD resulted in 41% more active patient participation in ACP discussions compared with the AD alone (mean [SD] = 10.1 [16.8] vs 6.6 [13.4] utterances; incidence rate ratio = 1.41; 95% confidence interval = 1.00-1.98). For every additional utterance, participants had 15% higher odds of ACP documentation, and active patient participation accounted for 16% of PREPARE's effect on documentation.

CONCLUSIONS

The PREPARE program and easy-to-read AD empowered patients to actively participate in ACP discussions during clinical visits more than the AD alone. Increased activation was associated with increased ACP documentation. Therefore, PREPARE may mitigate barriers to ACP among English- and Spanish-speaking older adults.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941. J Am Geriatr Soc 68:1210-1217, 2020.

Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer

OBJECTIVE

We examined whether conversations involving Black or Latino patients with advanced cancer differ in the presence or characteristics of prognosis communication.

METHODS

We audio-recorded initial consultations between 54 palliative care clinicians and 231 hospitalized people with advanced cancer. We coded for the presence and characteristics of prognosis communication. We examined whether the presence or characteristics of prognosis communication differed by patients' self-reported race/ethnicity.

RESULTS

In 231 consultations, 75.7% contained prognosis communication. Prognosis communication was less than half as likely to occur during conversations with Black or Latino patients (N = 48) compared to others. Among consultations in which prognosis was addressed, those involving Black or Latino patients were more than 8 times less likely to contain optimistically cued prognoses compared to others.

CONCLUSION

Prognosis communication occurred less frequently for Black and Latino patients and included fewer optimistic cues than conversations with other patients. More work is needed to better understand these observed patterns of prognosis communication that vary by race and ethnicity.

PRACTICE IMPLICATIONS

Growing evidence supports prognosis communication being important for end-of-life decision-making and disproportionately rare among non-White populations. Therefore, our findings identify a potentially salient target for clinical interventions that are focused on ameliorating disparities in end-of-life care.

The contagion of optimism: The relationship between patient optimism and palliative care clinician overestimation of survival among hospitalized patients with advanced cancer

OBJECTIVE

Clinicians frequently overestimate survival time among seriously ill patients, and this can result in medical treatment at end of life that does not reflect the patient's preferences. Little is known, however, about the sources of clinicians' optimistic bias in survival estimation. Related work in social networks and experimental psychology demonstrates that psychological states-such as optimism-can transfer from one person to another.

METHODS

We directly observed and audio recorded 189 initial inpatient palliative care consultations among hospitalized patients with advanced cancer. Patients self-reported their level of trait optimism and expectations for survival prognosis prior to the palliative care consultation, and the palliative care clinicians rated their expectations for the patient's survival time following the initial conversation with the patient. We followed patient mortality for 6 months.

RESULTS

Patient optimism was associated with clinician overestimation of their survival in a dose-response relationship. Clinicians were approximately three times as likely to overestimate the survival of patients endorsing both high trait optimism and optimistic ratings of their survival time compared with neither (OR: 2.95; 95% CI: 1.24-7.02). This association was not attenuated by adjustment for age, gender, race, ethnicity, education, income, cancer type, functional status, quality of life, or white blood cell count (OR_adj : 3.45; 95% CI: 1.24-9.66).

CONCLUSION

Patients' optimism may have some influence over their clinicians' prognostic judgments.

Palliative Care Clinician Overestimation of Survival in Advanced Cancer: Disparities and Association With End-of-Life Care

CONTEXT

Clinicians frequently overestimate survival time in serious illness.

OBJECTIVE

The objective of this study was to understand the frequency of overestimation in palliative care (PC) and the relation with end-of-life (EOL) treatment.

METHODS

This is a multisite cohort study of 230 hospitalized patients with advanced cancer who consulted with PC between 2013 and 2016. We asked the consulting PC clinician to make their "best guess" about the patients' "most likely survival time, assuming that their illnesses are allowed to take their natural course" (<24 hours; 24 hours to less than two weeks; two weeks to less than three months; three months to less than six months; six months or longer). We followed patients for up to six month for mortality and EOL treatment utilization. Patients completed a brief interviewer-facilitated questionnaire at study enrollment.

RESULTS

Median survival was 37 days (interquartile range: 12 days, 97 days) and 186/230 (81%) died during the follow-up period. Forty-one percent of clinicians' predictions were accurate. Among inaccurate prognoses, 85% were overestimates. Among those who died, overestimates were substantially associated with less hospice use (OR_adj: 0.40; 95% CI: 0.16-0.99) and later hospice enrollment (within 72 hours of death OR_adj: 0.33; 95% CI: 0.15-0.74). PC clinicians were substantially more likely to overestimate survival for patients who identified as Black or Latino compared to others (OR_adj: 3.89; 95% CI: 1.64-9.22). EOL treatment preferences did not explain either of these findings.

CONCLUSION

Overestimation is common in PC, associated with lower hospice use and a potentially mutable source of racial/ethnic disparity in EOL care.

End-of-Life Preferences, Length-of-Life Conversations, and Hospice Enrollment in Palliative Care: A Direct Observation Cohort Study among People with Advanced Cancer

CONTEXT

Prognosis communication is one hypothesized mechanism by which effective palliative care (PC) promotes preference-concordant treatment near end of life (EOL), but little is known about this relationship.

METHODS

This is a multisite cohort study of 231 hospitalized patients with advanced cancer who consulted with PC. We audio-recorded the initial consultation with the PC team and coded conversations for all statements regarding expectations for how long the patient will live. We refer to these statements as length-of-life talk. We followed patients for up to six months to determine EOL treatment utilization, including hospice enrollment. Patients completed a brief interviewer-facilitated questionnaire at study enrollment.

RESULTS

Forty-four percent (101/231) of observed conversations contained at least one statement about expectations for length of life, and 60% of patients (139/231) enrolled in hospice during the six months following these conversations. The association between length-of-life talk and hospice enrollment was strong among those (155/231) who endorsed treatment preferences favoring comfort over longevity in the last weeks to months of life (odds ratio [OR]_adj = 2.98; 95% confidence interval [CI] = 1.34-6.65) and weak/absent among others (69/231; OR_adj = 0.70; 95% CI = 0.16-3.04).

CONCLUSIONS

Talking about expectations for remaining length of life during PC consultations is associated with six-month hospice enrollment among people with advanced cancer who endorse preferences for EOL treatment that favor comfort over longevity.

Accuracy and congruence of physician and adolescent patient weight-related discussions: Teen CHAT (Communicating health: Analyzing talk)

OBJECTIVE

We assessed the accuracy and congruence of recall of weight topics during clinical encounters between adolescent patients with overweight/obesity and physicians (randomized to Motivational Interviewing education vs. control arm).

METHODS

We audio recorded 357 clinic encounters and coded topics of weight, physical activity (PA), breakfast, and fast food. We assessed recall accuracy/congruence. Generalized estimation equation modeling assessed associations between selected factors and recall accuracy.

RESULTS

Accuracy for physicians was: weight (90%), PA (88%), breakfast (77%) and fast food (70%). Patient accuracy was: weight (94%), PA (94%), breakfast (73%) and fast food (61%). Physician/patient congruence was: weight (89%), PA (90%), breakfast (71%) and fast food (67%). Use of a reminder report indicating adolescent's weight behaviors in the physician control group resulted in increased adolescent (p = 0.02) and physician accuracy (p = 0.05) for fast food. Adolescents were more likely to recall discussions of fast food (odds ratio, 0.87; 95% CI, 0.77-0.97) as encounter time decreased; male adolescents were less likely to recall breakfast than females (odds ratio, 0.52; 95% CI, 0.28-0.95).

CONCLUSION

Adolescents and physicians recall weight and PA more often, perhaps indicating greater engagement in these topics.

PRACTICE IMPLICATIONS

Reminder reports might possibly enhance discussion and recall of diet related messages.

Identifying Connectional Silence in Palliative Care Consultations: A Tandem Machine-Learning and Human Coding Method

Background: Systematic measurement of conversational features in the natural clinical setting is essential to better understand, disseminate, and incentivize high quality serious illness communication. Advances in machine-learning (ML) classification of human speech offer exceptional opportunity to complement human coding (HC) methods for measurement in large scale studies. Objectives: To test the reliability, efficiency, and sensitivity of a tandem ML-HC method for identifying one feature of clinical importance in serious illness conversations: Connectional Silence. Design: This was a cross-sectional analysis of 354 audio-recorded inpatient palliative care consultations from the Palliative Care Communication Research Initiative multisite cohort study. Setting/Subjects: Hospitalized people with advanced cancer. Measurements: We created 1000 brief audio "clips" of randomly selected moments predicted by a screening ML algorithm to be two-second or longer pauses in conversation. Each clip included 10 seconds of speaking before and 5 seconds after each pause. Two HCs independently evaluated each clip for Connectional Silence as operationalized from conceptual taxonomies of silence in serious illness conversations. HCs also evaluated 100 minutes from 10 additional conversations having unique speakers to identify how frequently the ML screening algorithm missed episodes of Connectional Silence. Results: Connectional Silences were rare (5.5%) among all two-second or longer pauses in palliative care conversations. Tandem ML-HC demonstrated strong reliability (kappa 0.62; 95% confidence interval: 0.47-0.76). HC alone required 61% more time than the Tandem ML-HC method. No Connectional Silences were missed by the ML screening algorithm. Conclusions: Tandem ML-HC methods are reliable, efficient, and sensitive for identifying Connectional Silence in serious illness conversations.

Identifying types of sex conversations in adolescent health maintenance visits

Background Physician-adolescent sexuality discussions are a recommended element in health maintenance visits, but such discussions - if they occur at all - probably vary by adolescents' characteristics and situations, and physicians' personal beliefs and training. However, little is known about the form and content of physician-adolescent sexuality discussions during health maintenance visits.

METHODS

We evaluated 245 physician-adolescent sexuality conversations. Using latent class analysis, we identified conversation types based on 13 sexually related topics, which occurred in at least 10% of all conversations.

RESULTS

We found four discrete types of sexuality conversations, which differed in terms of emphasis, topics addressed as part of the sexual history and risk assessment, and topics addressed in anticipatory guidance. Inquiry about partnered sexual experience was typical across all conversation types, as well as over half including discussions about body development and protective behaviours. In all four types of conversation, sexuality discussions were typically embedded in a sequence of psychosocial and behavioural topics recommended for health maintenance visits.

CONCLUSIONS

The presence of sexuality conversations in the majority of these visits suggests that physicians consider sexuality to be an important issue and part of their responsibility in caring for their adolescent patients. However, the substantial variability in the types of sexuality conversations, particularly the notable omissions of many key topics, supports the importance of teaching sexual health interview skills in medical school and residency, and as part of continuing medical education and quality improvement.

Feeling Heard and Understood in the Hospital Environment: Benchmarking Communication Quality Among Patients With Advanced Cancer Before and After Palliative Care Consultation

CONTEXT

Maximizing value in palliative care requires continued development and standardization of communication quality indicators.

OBJECTIVES

To describe the basic epidemiology of a newly adopted patient-centered communication quality indicator for hospitalized palliative care patients with advanced cancer.

METHODS

Cross-sectional analysis of 207 advanced cancer patients who received palliative care consultation at two medical centers in the U.S. Participants completed the Heard & Understood quality indicator immediately before and the day after the initial palliative care consultation: Over the past two days ["24 hours" for the post-consultation version], how much have you felt heard and understood by the doctors, nurses, and hospital staff?-completely/quite a bit/moderately/slightly/not at all. We categorized completely as indicating ideal quality.

RESULTS

Approximately one-third indicated ideal Heard & Understood quality before palliative care consultation. Age, financial security, emotional distress, preferences for comfort-longevity tradeoffs at the end of life, and prognosis expectations were associated with preconsultation quality. Among those with less-than-ideal quality at baseline, 56% rated feeling more Heard & Understood the day after palliative care consultation. The greatest prepost improvement was among people who had unformed end-of-life treatment preferences or who reported having no idea about their prognosis at baseline.

CONCLUSION

Most patients felt incompletely heard and understood at the time of referral to palliative care consultation, and more than half of the patients improved after consultation. Feeling heard and understood is an important quality indicator sensitive to interventions to improve care and key variations in the patient experience.

Physician Weight-Related Counseling Is Unrelated to Extreme Weight Loss Behaviors Among Overweight and Obese Adolescents

Some physicians may be hesitant to counsel overweight and obese adolescents about weight because of concerns that such counseling may result in extreme weight loss behaviors and the subsequent development of eating disorders. We compared self-reported extreme weight loss behaviors in 535 overweight/obese adolescents prior to receiving weight-related counseling during primary care visits, and again after 3 months. We found no change in fasting (7.7% vs 6.3%, P = .45), and decreases in diet pill use (4.1% vs 1.7%, P = .003) and laxative use/vomiting (2.6% vs 1.0%, P = .02). Three months following their medical appointment, patients were also less likely to report trying to lose weight in general (80.0% vs 75.6%, P = .04). Physicians should be reassured that providing weight-related counseling to their obese adolescents is unlikely to induce extreme weight loss behaviors. Frequent counseling may be required in order to help patients maintain motivation to attain a healthy weight.

"I'm Not Gonna Pull the Rug out From Under You": Patient-Provider Communication About Opioid Tapering

In response to increases in harms associated with prescription opioids, opioid prescribing has come under greater scrutiny, leading many health care organizations and providers to consider or mandate opioid dose reductions (tapering) for patients with chronic pain. Communicating about tapering can be difficult, particularly for patients receiving long-term opioids who perceive benefits and are using their medications as prescribed. Because of the importance of effective patient-provider communication for pain management and recent health system-level initiatives and provider practices to taper opioids, this study used qualitative methods to understand communication processes related to opioid tapering, to identify best practices and opportunities for improvement. Up to 3 clinic visits per patient were audio-recorded, and individual interviews were conducted with patients and their providers. Four major themes emerged: 1) explaining-patients needed to understand individualized reasons for tapering, beyond general, population-level concerns such as addiction potential, 2) negotiating-patients needed to have input, even if it was simply the rate of tapering, 3) managing difficult conversations-when patients and providers did not reach a shared understanding, difficulties and misunderstandings arose, and 4) nonabandonment-patients needed to know that their providers would not abandon them throughout the tapering process.

PERSPECTIVE

Although opioid tapering can be challenging, helping patients to understand individualized reasons for tapering, encouraging patients to have input into the process, and assuring patients they would not be abandoned all appear to facilitate optimal communication about tapering.

Physicians Talking About Sex, Sexuality, and Protection With Adolescents

Adolescent-physician communication about sexual behaviors, sexuality, and protective behaviors is vital for the support of sexual minorities and the prevention of sexually transmitted infections and unintended pregnancies. The objective of this review is to identify sexual topics that physicians and adolescents discuss during medical encounters and examine the quantity and quality of that communication. We performed a systematic literature review of major databases through May 2016. We identified 33 papers that focused on adolescent-physician communication about three major sexual health topics: coital or noncoital sexual behaviors, sexual orientation or attractions, and sexually protective or preventative behaviors. Communication between adolescents and physicians about these sexual topics is infrequent and coincides with calls for improvement in clinical sex communication. Communication about sexual attractions, sexual orientation, and noncoital sexual behaviors were the rarest in practice, whereas mentions of contraception were more frequent. The review also highlights substantial limitations with this body of research, and more advanced research designs are warranted. Associations between clinical sexual communication and sexual health outcomes (e.g., contraceptive use and sexually transmitted infection occurrence) would improve knowledge of the effectiveness of communication in practice.

Teaching primary care physicians the 5 A's for discussing weight with overweight and obese adolescents

OBJECTIVE

We developed an online intervention to teach physicians both MI (addressed in outcomes paper) and the 5 A's (Ask, Advise, Assess, Assist, and Arrange) when discussing weight with overweight/obese adolescents.

METHODS

We audio recorded 527 encounters between adolescents and physicians and coded the 5 A's during weight/BMI discussions. Half of physicians were randomized to receive a tailored, intervention that included their own audio-recorded clips. To examine arm differences, we used multilevel linear mixed-effects models for sum of 5 A's and generalized estimating equations (GEE) models with a logit link for each of the A's separately.

RESULTS

Intervention arm physicians used more A's than control physicians (estimated difference=0.6; 95%CI(0.2,1.0);p=0.001). Intervention physicians used Assess (p=0.004), Assist (p=0.001) and Arrange (p=0.02) more when compared to control arm physicians.

CONCLUSION

An online intervention increased physicians' use of the 5 A's when discussing weight with overweight adolescents. These results are promising as the online intervention improved performance for the three A's that are infrequently used (Assess, Assist, and Arrange) yet have the most impact.

PRACTICE IMPLICATIONS

A tailored online program can increase physicians' use of the 5 A's behavioral counseling approach in clinical practice with adolescents.

"I just think that doctors need to ask more questions": Sexual minority and majority adolescents' experiences talking about sexuality with healthcare providers

OBJECTIVE

To examine adolescent and young adults' experiences of sexuality communication with physicians, and gain advice for improving interactions.

METHODS

Semi-structured interviews were conducted with questions focusing on: puberty, romantic attractions, sexual orientation, dating, sexual behavior, clinical environment, and role of parents. Interviews were transcribed and analyzed using thematic analysis with both open and axial coding.

RESULTS

Five themes emerged from interviews: 1) need for increased quantity of sexual communication, 2) issues of confidentiality/privacy, 3) comfort (physician discomfort, physical space), 4) inclusivity (language use, gender-fluid patients, office environment), 5) need for increased quality of sexual communication.

CONCLUSIONS

Sexual minority and majority adolescents and young adults indicate sexuality discussions with physicians are infrequent and need improvement. They indicate language use and clinical physical environment are important places where physicians can show inclusiveness and increase comfort.

PRACTICE IMPLICATIONS

Physicians should make an effort to include sexual communication at every visit. They should consider using indirect questions to assess sexual topics, provide other outlets for sexual health information, and ask parents to leave the exam room to improve confidentiality. Clinic staff should participate in Safe Zone trainings, and practices can promote inclusion with signs that indicate safe and accepting environments.

Differences in Physicians' Verbal and Nonverbal Communication With Black and White Patients at the End of Life

CONTEXT

Black patients are more likely than white patients to die in the intensive care unit with life-sustaining treatments. Differences in patient- and/or surrogate-provider communication may contribute to this phenomenon.

OBJECTIVES

To test whether hospital-based physicians use different verbal and/or nonverbal communication with black and white simulated patients and their surrogates.

METHODS

We conducted a randomized factorial trial of the relationship between patient race and physician communication using high-fidelity simulation. Using a combination of probabilistic and convenience sampling, we recruited 33 hospital-based physicians in western Pennsylvania who completed two encounters with prognostically similar, critically and terminally ill black and white elders with identical treatment preferences. We then conducted detailed content analysis of audio and video recordings of the encounters, coding verbal emotion-handling and shared decision-making behaviors, and nonverbal behaviors (time interacting with the patient and/or surrogate, with open vs. closed posture, and touching the patient and physical proximity). We used a paired t-test to compare each subjects' summed verbal and nonverbal communication scores with the black patient compared to the white patient.

RESULTS

Subject physicians' verbal communication scores did not differ by patient race (black vs. white: 8.4 vs. 8.4, P-value = 0.958). However, their nonverbal communication scores were significantly lower with the black patient than with the white patient (black vs. white: 2.7 vs. 2.9, P-value 0.014).

CONCLUSION

In this small regional sample, hospital-based physicians have similar verbal communication behaviors when discussing end-of-life care for otherwise similar black and white patients but exhibit significantly fewer positive, rapport-building nonverbal cues with black patients.

Studying physician-adolescent patient communication in community-based practices: recruitment challenges and solutions

BACKGROUND

Practice-based studies are needed to assess how physicians communicate health messages about weight to overweight/obese adolescent patients, but successful recruitment to such studies is challenging. This paper describes challenges, solutions, and lessons learned to recruit physicians and adolescents to the Teen Communicating Health Analyzing Talk (CHAT) study, a randomized controlled trial of a communication skills intervention for primary care physicians to enhance communication about weight with overweight/obese adolescents.

MATERIALS AND METHODS

A "peer-to-peer" approach was used to recruit physicians, including the use of "clinic champions" who liaised between study leaders and physicians. Consistent rapport and cooperative working relationships with physicians and clinic staff were developed and maintained. Adolescent clinic files were reviewed (HIPAA waiver) to assess eligibility. Parents could elect to opt-out for their children. To encourage enrollment, confidentiality of audio recordings was emphasized, and financial incentives were offered to all participants.

RESULTS

We recruited 49 physicians and audio-recorded 391 of their overweight/obese adolescents' visits. Recruitment challenges included 1) physician reticence to participate; 2) variability in clinic operating procedures; 3) variability in adolescent accrual rates; 4) clinic open access scheduling; and 5) establishing communication with parents and adolescents. Key solutions included the use of a "clinic champion" to help recruit physicians, pro-active, consistent communication with clinic staff, and adapting calling times to reach parents and adolescents.

CONCLUSION

Recruiting physicians and adolescents to audio-recorded, practice-based health communication studies can be successful. Anticipated challenges to recruiting can be met with advanced planning; however, optimal solutions to challenges evolve as recruitment progresses.

Goal Communication in Palliative Care Decision-Making Consultations

CONTEXT

Palliative care (PC) promotes patient-centered outcomes, but the mechanisms underlying these effects remain poorly understood. Identifying, clarifying, and prioritizing patients' goals are conceptually fundamental to the process of patient-centeredness and are the main reasons for PC referral. However, very little is empirically known about the content or process of goal expression in the natural setting of PC.

OBJECTIVES

To describe the frequency, types, and determinants of goal expression in PC consultations.

METHODS

This was a cross-sectional direct observational study of 72 audiorecorded PC consultations with hospitalized patients (and families) referred for PC goals of care clarification or end-of-life decision making. We coded digital audio files using reliable methods and linked conversation codes to clinical record and brief clinician interview data.

RESULTS

Goal expressions occurred frequently in PC consultations and addressed both length-of-life and quality-of-life domains. The presence of existential suffering in the conversation was associated with substantially more expressions and types of goals.

CONCLUSION

Goal communication is common in PC decision-making settings and strongly influenced by existential suffering.

Using music[al] knowledge to represent expressions of emotions

OBJECTIVE

Being able to identify expressions of emotion is crucial to effective clinical communication research. However, traditional linguistic coding systems often cannot represent emotions that are expressed nonlexically or phonologically (i.e., not through words themselves but through vocal pitch, speed/rhythm/tempo, and volume).

METHODS

Using audio recording of a palliative care consultation in the natural hospital setting, two experienced music scholars employed Western musical notation, as well as the graphic realization of a digital audio program (Piano roll visualization), to visually represent the sonic features of conversation where a patient has an emotional "choke" moment.

RESULTS

Western musical notation showed the ways that changes in pitch and rate correspond to the patient's emotion: rising sharply in intensity before slowly fading away. Piano roll visualization is a helpful supplement.

CONCLUSIONS

Using musical notation to illustrate palliative care conversations in the hospital setting can render visible for analysis several aspects of emotional expression that researchers otherwise experience as intuitive or subjective. Various forms and formats of musical notation techniques and sonic visualization technologies should be considered as fruitful and complementary alternatives to traditional coding tools in clinical communications research.

PRACTICE IMPLICATIONS

Musical notation offers opportunity for both researchers and learners to "see" how communication evolves in clinical encounters, particularly where the lexical and phonological features of interpersonal communication are concordant and discordant with one another.

Patient-physician communication about early stage prostate cancer: analysis of overall visit structure

BACKGROUND

We know little about patient-physician communication during visits to discuss diagnosis and treatment of prostate cancer.

OBJECTIVE

To examine the overall visit structure and how patients and physicians transition between communication activities during visits in which patients received new prostate cancer diagnoses.

PARTICIPANTS

Forty veterans and 18 urologists at one VA medical centre.

METHODS

We coded 40 transcripts to identify major communication activities during visits and used empiric discourse analysis to analyse transitions between activities.

RESULTS

We identified five communication activities that occurred in the following typical sequence: 'diagnosis delivery', 'risk classification', 'options talk', 'decision talk' and 'next steps'. The first two activities were typically brief and involved minimal patient participation. Options talk was typically the longest activity; physicians explicitly announced the beginning of options talk and framed it as their professional responsibility. Some patients were unsure of the purpose of visit and/or who should make treatment decisions.

CONCLUSION

Visits to deliver the diagnosis of early stage prostate cancer follow a regular sequence of communication activities. Physicians focus on discussing treatment options and devote comparatively little time and attention to discussing the new cancer diagnosis. Towards the goal of promoting patient-centred communication, physicians should consider eliciting patient reactions after diagnosis delivery and explaining the decision-making process before describing treatment options.

The Language of End-of-Life Decision Making: A Simulation Study

BACKGROUND

Framing is known to influence decision making.

OBJECTIVE

The study objective was to describe language used by physicians when discussing treatment options with a critically and terminally ill elder.

METHODS

High-fidelity simulation was used, involving an elder with end-stage cancer and life-threatening hypoxia, followed by a debriefing interview. Subjects were hospitalist, emergency medicine, and critical care physicians from three academic medical centers. Measures were observation of encounters in real time followed by content analysis of simulation and debriefing interview transcripts. During the simulation we identified the first mention ("broaching") of principal treatment options--intubation and mechanical ventilation (life-sustaining treatment [LST]) and palliation in anticipation of death (palliation)--and used constant comparative methods to identify language used. We identified physician opinions about the use of LST in this clinical context during the debriefing interviews, and compared language used with opinions.

RESULTS

Among 114 physician subjects, 106 discussed LST, 86 discussed palliation, and 84 discussed both. We identified five frames: will (decided), must (necessary), should (convention), could (option), and ask (elicitation of preferences). Physicians broached LST differently than palliation (p<0.01), most commonly framing LST as necessary (53%), while framing palliation as optional (49%). Among physicians who framed LST as imperative (will or must), 16 (30%) felt intubation would be inappropriate in this clinical situation.

CONCLUSIONS

In this high-fidelity simulation experiment involving a critically and terminally ill elder, the majority of physicians framed the available options in ways implying LST was the expected or preferred choice. Framing of treatment options could influence ultimate treatment decisions.

Disclosure of Sexual Intercourse by Teenagers: Agreement Between Telephone Survey Responses and Annual Visit Disclosures

BACKGROUND

Physicians can help guide teenagers in their emerging sexuality; however, teens rarely inform physicians about their sexual activity.

METHODS

We audio-recorded annual visits between 365 teenagers and 49 physicians. Before the recorded visit, the teens were asked in a confidential telephone survey whether they had ever engaged in sexual intercourse. Recordings were coded for teenage disclosures about previous sexual intercourse. We measured agreement between telephone survey responses and annual visit disclosures, and examined factors associated with agreement between the two.

RESULTS

Fifty-six teenagers (15%) reported previous sexual intercourse in either the telephone survey or to their physician. Among those who reported sexual intercourse, 57% shared this information to both the telephone survey and their physician (κ = .72, confidence interval = 0.63-0.82).

CONCLUSIONS

Although a slight majority of teenagers disclosed their sexual activity to both the telephone survey and their doctor, a significant number disclosed to just one source.

Weight-related SMS texts promoting appropriate pregnancy weight gain: a pilot study

OBJECTIVES

Excessive gestational weight gain (GWG) puts women and children at risk of obesity. We piloted an SMS-texting intervention to promote healthy GWG among overweight and obese women.

METHODS

We recruited 35 women and randomized them in a 2:1 fashion to: a tailored SMS-texting intervention (Preg CHAT) vs. a generic texting intervention (Txt4baby). Preg CHAT texts provided personalized feedback based on women's intake of sweetened beverages, fruits and vegetables, fast food, daily steps taken, and weight. We abstracted women's weights from charts and surveyed women at baseline and 32 weeks gestation.

RESULTS

Few women refused the study; many (30%) did not complete the study, however. Of those in the Preg CHAT arm, 86% responded to texts, and 80% said they would recommend this program to a friend. For women who completed the surveys (n=23), those in the Preg CHAT arm had a mean gain of 6 less pounds than women in the Txt4Baby arm (95% CI -15.9, 4.0; p=0.24).

CONCLUSIONS

This pilot study shows feasibility, acceptability, and potential efficacy of a low-intensity and disseminable intervention to help overweight and obese women reduce GWG.

PRACTICE IMPLICATIONS

An SMS texting program might help overweight women reduce excessive GWG.

Physicians Use of Inclusive Sexual Orientation Language During Teenage Annual Visits

PURPOSE

Physicians are encouraged to use inclusive language regarding sexuality in order to help all adolescent patients feel accepted. Non-inclusive language by physicians may influence relationships with adolescent patients, especially those with still-developing sexual identities. The aim of this study was to identify patterns of physicians' use of inclusive and non-inclusive language when discussing sexuality.

METHOD

A total of 393 conversations between 393 adolescents and 49 physicians from 11 clinics located throughout the Raleigh-Durham, North Carolina, area were audio recorded. Conversations were coded for the use of inclusive talk (language use that avoids the use of specific gender, sex, or sexual orientation language), direct non-inclusive talk (language use that assumes the teenager is heterosexual or exclusively engages in heterosexual sexual activity), and indirect non-inclusive talk (language use that frames talk heterosexually but does not pre-identify the adolescent as heterosexual).

RESULTS

Nearly two-thirds (63%, 245) of the visits contained some sexuality talk. Inclusive talk rarely occurred (3.3%) while non-inclusive language was predominant (48.1% direct and 48.6% indirect). There were no significant differences in language use by gender, age, adolescent race, or visit length. These non-significant findings suggest that all adolescents regardless of race, gender, or age are receiving non-inclusive sexuality talk from their providers.

CONCLUSION

Physicians are missing opportunities to create safe environments for teenagers to discuss sexuality. The examples of inclusive talk from this study may provide potentially useful ways to teach providers how to begin sexuality discussions, focusing on sexual attraction or asking about friends' sexual behavior, and maintain these discussions.

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.

Emotional distress and compassionate responses in palliative care decision-making consultations

BACKGROUND

Seriously ill hospitalized patients and their loved ones are frequently faced with complex treatment decisions laden with expressions of emotional distress during palliative care (PC) consultations. Little is known about these emotional expressions or the compassionate responses providers make and how common these are in PC decision-making conversations.

OBJECTIVES

To describe the types and frequency of emotional distress that patients and loved ones express and how providers respond to these emotions during PC decision-making consultations with seriously ill hospitalized patients.

METHODS

We used a quantitative descriptive approach to analyze 71 audio-recorded inpatient PC decision-making consultations for emotional distress and clinicians' responses to those emotions using reliable and established methods.

RESULTS

A total of 69% of conversations contained at least one expression of emotional distress. The per-conversation frequency of expressions of emotional distress ranged from 1 to 10. Anxiety/fear were the most frequently encountered emotions (48.4%) followed by sadness (35.5%) and anger/frustration (16.1%). More than half of the emotions related to the patient's feelings (53.6%) and 41.9% were related to the loved ones' own emotions. The majority of emotions were moderate in intensity (65.8%) followed by strong (20.7%) and mild (13.5%). Clinicians responded to a majority of emotions with a compassionate response (75.7%) followed by those with medical content (21.9%) and very few were ignored (1.3%).

CONCLUSIONS

Expressions of emotional distress are common during PC consultations and are usually met with compassionate responses by the clinician.

Sexuality talk during adolescent health maintenance visits

IMPORTANCE

Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality.

OBJECTIVE

To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area.

MAIN OUTCOMES AND MEASURES

Total time per visit during which sexuality issues were discussed. RESULTS One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥ 36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥ 36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation.

CONCLUSIONS AND RELEVANCE

Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01040975.

Teen CHAT: Development and utilization of a web-based intervention to improve physician communication with adolescents about healthy weight

OBJECTIVE

To describe the theoretical basis, use, and satisfaction with Teen CHAT, an online educational intervention designed to improve physician-adolescent communication about healthy weight.

METHODS

Routine health maintenance encounters between pediatricians and family practitioners and their overweight adolescent patients were audio recorded, and content was coded to summarize adherence with motivational interviewing techniques. An online educational intervention was developed using constructs from social cognitive theory and using personalized audio recordings. Physicians were randomized to the online intervention or not, and completed post-intervention surveys.

RESULTS

Forty-six physicians were recruited, and 22 physicians were randomized to view the intervention website. The educational intervention took an average of 54min to complete, and most physicians thought it was useful, that they would use newly acquired skills with their patients, and would recommend it to others. Fewer physicians thought it helped them address confidentiality issues with their adolescent patients.

CONCLUSION

The Teen CHAT online intervention shows potential for enhancing physician motivational interviewing skills in an acceptable and time-efficient manner.

PRACTICE IMPLICATIONS

If found to be effective in enhancing motivational interviewing skills and changing adolescent weight-related behaviors, wide dissemination will be feasible and indicated.

Interprofessional communication skills training for serious illness: evaluation of a small-group, simulated patient intervention

BACKGROUND

Communication with patients and families is an essential component of high-quality care in serious illness. Small-group skills training can result in new communication behaviors, but past studies have used facilitators with extensive experience, raising concerns this is not scalable.

OBJECTIVE

The objective was to investigate the effect of an experiential communication skills building workshop (Codetalk), led by newly trained facilitators, on internal medicine trainees' and nurse practitioner students' ability to communicate bad news and express empathy.

DESIGN

Trainees participated in Codetalk; skill improvement was evaluated through pre- and post- standardized patient (SP) encounters.

SETTING AND SUBJECTS

The subjects were internal medicine residents and nurse practitioner students at two universities.

INTERVENTION AND MEASUREMENTS

The study was carried out in anywhere from five to eight half-day sessions over a month. The first and last sessions included audiotaped trainee SP encounters coded for effective communication behaviors. The primary outcome was change in communication scores from pre-intervention to post-intervention. We also measured trainee characteristics to identify predictors of performance and change in performance over time.

RESULTS

We enrolled 145 trainees who completed pre- and post-intervention SP interviews-with participation rates of 52% for physicians and 14% for nurse practitioners. Trainees' scores improved in 8 of 11 coded behaviors (p<0.05). The only significant predictors of performance were having participated in the intervention (p<0.001) and study site (p<0.003). The only predictor of improvement in performance over time was participating in the intervention (p<0.001).

CONCLUSIONS

A communication skills intervention using newly trained facilitators was associated with improvement in trainees' skills in giving bad news and expressing empathy. Improvement in communication skills did not vary by trainee characteristics.

Palliative care communication: linking patients' prognoses, values, and goals of care

Prognostic communication is a primary component of goals of care conversations in palliative care (PC) practice. Little is known about these conversations in the natural setting. This study's aim was to describe the processes of prognostic communication in PC goals of care consultations. Using line-by-line qualitative analysis, we examined prognostic conversation in 66 audio-taped PC consultations. We identified five processes by which clinicians link prognoses, values, and goals of care: (1) signposting the crossroads; (2) closing off a goal; (3) clarifying current path; (4) linking paths and patients' values; and (5) choosing among paths. The findings add to our understanding of PC consultation by describing how prognoses link with patients' values and choices in goals of care conversations.

Smoking is bad for babies: obstetric care providers' use of best practice smoking cessation counseling techniques

PURPOSE

To use direct observations of first prenatal visits to describe obstetric providers' adherence to the evidence-based clinical practice guideline for smoking cessation counseling recommended by the American College of Obstetricians and Gynecologists, the 5 A's (Ask, Advice, Assess, Assist, and Arrange).

DESIGN

Observational study using audio recordings of first obstetric visits.

SETTING

An urban academic hospital-based clinic.

PARTICIPANTS

Obstetric care providers and pregnant women attending their first obstetric visit.

METHOD

First obstetric visits were audio recorded. Visits were identified in which patients reported smoking, and discussions were analyzed for obstetric providers' use of the 5 A's in smoking cessation counseling.

RESULTS

Obstetric providers asked about smoking in 98% of the 116 visits analyzed, but used 3 or more of the 5 A's in only 21% (24) of visits. In no visits did providers use all 5 A's. In 54% of the visits, providers gave patients information about smoking, most commonly about risks associated with perinatal smoking.

CONCLUSION

Few obstetric care providers performed the recommended 5 A's smoking cessation counseling with their pregnant smokers. Effective and innovative methods are needed to improve obstetric providers' use of the 5 A's.

Communicating and understanding the purpose of pediatric phase I cancer trials

PURPOSE

Quality informed consent should provide a clear understanding of the purpose of the research. Given the ethical challenges of pediatric phase I cancer trials, it is important to investigate physician-parent communication during informed consent conferences (ICCs) and parental understanding of the purpose of these studies.

METHODS

In the multisite Informed Consent in Pediatric Phase I Cancer Trials study, 85 ICCs for phase I research between June 2008 and May 2011 were directly observed, and 60 parents were subsequently interviewed. The scientific purpose was defined as composite understanding of drug safety, dose finding, and dose escalation. We determined the frequency with which physicians explained these and other phase I-related concepts during the ICC. Parent interviews were analyzed to determine understanding.

RESULTS

The child was present at 83 of 85 ICCs. Only 32% of parents demonstrated substantial understanding of the scientific purpose of phase I cancer trials; 35% demonstrated little or no understanding. Parents of higher socioeconomic status and racial majority status were more likely to understand the scientific purpose. Factors associated with understanding included physician explanation of the goal of the applicable phase I protocol offered (explained in 85% of ICCs) and explanation of the dose cohorts (explained in 43% of ICCs). Physicians explained drug safety in 23% of ICCs, dose finding in 52% of ICCs, and dose escalation in 53% of ICCs.

CONCLUSION

Many parents of children participating in phase I trials do not understand the purpose of these trials. Physician-parent communication about the purpose of phase I research is lacking during ICCs.

Can physicians accurately predict which patients will lose weight, improve nutrition and increase physical activity?

BACKGROUND

Physician counselling may help patients increase physical activity, improve nutrition and lose weight. However, physicians have low outcome expectations that patients will change. The aims are to describe the accuracy of physicians' outcome expectations about whether patients will follow weight loss, nutrition and physical activity recommendations. The relationships between physician outcome expectations and patient motivation and confidence also are assessed.

METHODS

This was an observational study that audio recorded encounters between 40 primary care physicians and 461 of their overweight or obese patients. We surveyed physicians to assess outcome expectations that patients will lose weight, improve nutrition and increase physical activity after counselling. We assessed actual patient change in behaviours from baseline to 3 months after the encounter and changes in motivation and confidence from baseline to immediately post-encounter.

RESULTS

Right after the visit, ~55% of the time physicians were optimistic that their individual patients would improve. Physicians were not very accurate about which patients actually would improve weight, nutrition and physical activity. More patients had higher confidence to lose weight when physicians thought that patients would be likely to follow their weight loss recommendations.

CONCLUSIONS

Physicians are moderately optimistic that patients will follow their weight loss, nutrition and physical activity recommendations. Patients might perceive physicians' confidence in them and thus feel more confident themselves. Physicians, however, are not very accurate in predicting which patients will or will not change behaviours. Their optimism, although helpful for patient confidence, might make physicians less receptive to learning effective counselling techniques.

The influence of physician communication style on overweight patients' perceptions of length of encounter and physician being rushed

BACKGROUND AND OBJECTIVES

Little is known about how patients and physicians perceive time and the extent to which they perceive the physician being rushed during encounters. One aim of this paper is to examine whether patient and physician characteristics and physician communication influence patient perception of the duration of the encounter and their perception of physicians being rushed. Another aim is to examine the relationship between patient and physician perceptions of physicians feeling rushed.

METHODS

We audiorecorded 461 encounters of overweight or obese patients with 40 primary care physicians and included 320 encounters in which weight was discussed. We calculated time spent with physician and coded all communication about weight using the Motivational Interview Treatment Integrity scale (MITI). Patients completed post-visit questionnaires in which they reported the estimated duration of the encounter and how rushed they thought the physician was during the encounter. Physicians reported how rushed they felt.

RESULTS

Patients estimated encounters to be longer than they actually were by an average of 2.6 minutes (SD=11.0). When physicians used reflective statements when discussing weight, patients estimated the encounter to be shorter than when physicians did not use reflective statements (1.17 versus 4.56 minutes more than actual duration). Whites perceived the encounter as shorter than African Americans (1.45 versus 4.28 minutes more than actual duration). Physicians felt rushed in 66% of visits; however, most patients did not perceive this. Internists were perceived to be more rushed than family physicians.

CONCLUSIONS

There is wide variation in patients' ability to estimate the length of time they spend with their physician. Some physician and patient characteristics were related to patient perceptions of the length of the encounter. Reflective statements might lead patients to perceive encounters as shorter. Physicians, especially family physicians, appear able to conceal that they are feeling rushed.

Predictors of weight loss communication in primary care encounters

OBJECTIVE

Evidence suggests that physicians' use of motivational interviewing (MI) techniques helps patients lose weight. We assessed patient, physician, relationship, and systems predictors of length of weight-loss discussions and whether physicians' used MI techniques.

METHODS

Forty primary care physicians and 461 of their overweight or obese patients were audio recorded and surveyed.

RESULTS

Weight-related topics were commonly discussed (nutrition 78%, physical activity 82%, and BMI/weight 72%). Use of MI techniques was low. A multivariable linear mixed model was fit to time spent discussing weight, adjusting for patient clustering within physician. More time was spent with obese patients (p=.0002), by African American physicians (p=.03), family physicians (p=.02), and physicians who believed patients were embarrassed to discuss weight (p=.05). Female physicians were more likely to use MI techniques (p=.02); African American physicians were more likely to use MI-inconsistent techniques (p<.001).

CONCLUSION

Primary care physicians routinely counsel about weight and are likely to spend more time with obese than with overweight patients. Internists spend less time on weight. Patient and systems factors do not seem to influence physicians' use MI techniques.

PRACTICE IMPLICATIONS

All physicians, particularly, male and African American physicians, could increase their use of MI techniques to promote more weight loss among patients.

Effects of counseling techniques on patients' weight-related attitudes and behaviors in a primary care clinic

OBJECTIVE

Examine primary care physicians' use of counseling techniques when treating overweight and obese patients and the association with mediators of behavior change as well as change in nutrition, exercise, and weight loss attempts.

METHODS

We audio recorded office encounters between 40 physicians and 461 patients. Encounters were coded for physician use of selected counseling techniques using the Motivational Interviewing Treatment Integrity (MITI) scale. Patient motivation and confidence as well as Fat and Fiber Diet score (1-4), Framingham physical activity questionnaire (MET-minutes), and weight loss attempts (yes/no) were assessed by surveys. Generalized linear models were fit, including physician, patient, and visit level covariates.

RESULTS

Patients whose physicians were rated higher in empathy improved their Fat and Fiber intake 0.18 units (95% CI 0, 0.4). When physicians used "MI consistent" techniques, patients reported higher confidence to improve nutrition (OR 2.57, 95% CI 1.2, 5.7).

CONCLUSION

When physicians used counseling techniques consistent with MI principles, some of their patients' weight-related attitudes and behaviors improved.

PRACTICE IMPLICATIONS

Physicians may not be able to employ formal MI during a clinic visit. However, use of counseling techniques consistent with MI principles, such as expression of empathy, may improve patients' weight-related attitudes and behaviors.

Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial

BACKGROUND

Quality cancer care requires addressing patients' emotions, which oncologists infrequently do. Multiday courses can teach oncologists skills to handle emotion; however, such workshops are long and costly.

OBJECTIVE

To test whether a brief, computerized intervention improves oncologist responses to patient expressions of negative emotion.

DESIGN

Randomized, controlled, parallel-group trial stratified by site, sex, and oncologic specialty. Oncologists were randomly assigned to receive a communication lecture or the lecture plus a tailored CD-ROM. (ClinicalTrials.gov registration number: NCT00276627)

SETTING

Oncology clinics at a comprehensive cancer center and Veterans Affairs Medical Center in Durham, North Carolina, and a comprehensive cancer center in Pittsburgh, Pennsylvania.

PARTICIPANTS

48 medical, gynecologic, and radiation oncologists and 264 patients with advanced cancer.

INTERVENTION

Oncologists were randomly assigned in a 1:1 ratio to receive an interactive CD-ROM about responding to patients' negative emotions. The CD-ROM included tailored feedback on the oncologists' own recorded conversations.

MEASUREMENTS

Postintervention audio recordings were used to identify the number of empathic statements and responses to patients' expressions of negative emotion. Surveys evaluated patients' trust in their oncologists and perceptions of their oncologists' communication skills.

RESULTS

Oncologists in the intervention group used more empathic statements (relative risk, 1.9 [95% CI, 1.1 to 3.3]; P = 0.024) and were more likely to respond to negative emotions empathically (odds ratio, 2.1 [CI, 1.1 to 4.2]; P = 0.028) than control oncologists. Patients of intervention oncologists reported greater trust in their oncologists than did patients of control oncologists (estimated mean difference, 0.1 [CI, 0.0 to 0.2]; P = 0.036). There was no significant difference in perceptions of communication skills.

LIMITATIONS

Long-term effects were not examined. The findings may not be generalizable outside of academic medical centers.

CONCLUSION

A brief computerized intervention improves how oncologists respond to patients' expressions of negative emotions.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial

BACKGROUND

Quality cancer care requires addressing patients' emotions, which oncologists infrequently do. Multiday courses can teach oncologists skills to handle emotion; however, such workshops are long and costly.

OBJECTIVE

To test whether a brief, computerized intervention improves oncologist responses to patient expressions of negative emotion.

DESIGN

Randomized, controlled, parallel-group trial stratified by site, sex, and oncologic specialty. Oncologists were randomly assigned to receive a communication lecture or the lecture plus a tailored CD-ROM. (ClinicalTrials.gov registration number: NCT00276627)

SETTING

Oncology clinics at a comprehensive cancer center and Veterans Affairs Medical Center in Durham, North Carolina, and a comprehensive cancer center in Pittsburgh, Pennsylvania.

PARTICIPANTS

48 medical, gynecologic, and radiation oncologists and 264 patients with advanced cancer.

INTERVENTION

Oncologists were randomly assigned in a 1:1 ratio to receive an interactive CD-ROM about responding to patients' negative emotions. The CD-ROM included tailored feedback on the oncologists' own recorded conversations.

MEASUREMENTS

Postintervention audio recordings were used to identify the number of empathic statements and responses to patients' expressions of negative emotion. Surveys evaluated patients' trust in their oncologists and perceptions of their oncologists' communication skills.

RESULTS

Oncologists in the intervention group used more empathic statements (relative risk, 1.9 [95% CI, 1.1 to 3.3]; P = 0.024) and were more likely to respond to negative emotions empathically (odds ratio, 2.1 [CI, 1.1 to 4.2]; P = 0.028) than control oncologists. Patients of intervention oncologists reported greater trust in their oncologists than did patients of control oncologists (estimated mean difference, 0.1 [CI, 0.0 to 0.2]; P = 0.036). There was no significant difference in perceptions of communication skills.

LIMITATIONS

Long-term effects were not examined. The findings may not be generalizable outside of academic medical centers.

CONCLUSION

A brief computerized intervention improves how oncologists respond to patients' expressions of negative emotions.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Weight-loss talks: what works (and what doesn't)

BACKGROUND

In primary care encounters, it is unknown whether physician advice on weight-related matters leads to patient weight loss. To examine this issue, we analyzed physician weight loss advice and measured corresponding changes in patients' dietary intake, physical activity, and weight.

METHODS

Using audio-recorded primary care encounters between 40 physicians and 461 of their overweight or obese patients, we coded weight-related advice as nonspecific, specific nutritional, specific exercise, or specific weight. Physicians and patients were told the study was about preventive health, not weight. We used mixed models (SAS ProcMixed), controlled for physician clustering and baseline covariates, to assess changes in diet, exercise, and measured weight, both pre-encounter and 3 months post-encounter.

RESULTS

When discussing weight, physicians typically provided a combination of specific weight, nutrition, and physical activity advice to their patients (34%). Combined advice resulted in patients reducing their dietary fat intake (P=.02). However, when physicians provided physical activity advice only, patients were significantly (P=.02) more likely to gain weight (+1.41 kg) compared with those who received no advice.

CONCLUSION

When giving weight-related advice, most physicians provided a combination of lifestyle recommendations. Combining advice may help patients reduce their fat intake. Physical activity advice alone may not be particularly helpful.

Do the five A's work when physicians counsel about weight loss?

BACKGROUND AND OBJECTIVES

More than two thirds of Americans are overweight or obese. Physician counseling may help patients lose weight; however, physicians perceive these discussions as somewhat futile and time-consuming. An effective and efficient tool for smoking cessation is the Five A's (Ask, Advise, Assess, Assist, and Arrange). We studied the effectiveness of the Five A's in weight-loss counseling.

METHODS

We audiorecorded primary care encounters between 40 physicians and 461 of their overweight or obese patients. All were told the study was about preventive health, not weight specifically. Encounters were coded for physician use of the Five A's. Patients' motivation and confidence were assessed before and immediately after the encounter. Three months later, we assessed patient change in dietary fat intake, exercise, and weight.

RESULTS

Generalized linear models were fit adjusting for patient clustering within physician. Physicians used at least one of the Five A's often (83%). Physicians routinely Ask and Advise patients to lose weight; however, they rarely Assess, Assist, or Arrange. Assist and Arrange were related to diet improvement, whereas Advise was associated with increases in motivation and confidence to change dietary fat intake and confidence to lose weight.

CONCLUSIONS

Similar to smoking cessation counseling, physicians routinely Asked and Advised patients to lose weight; however, they rarely Assessed, Assisted, or Arranged. Given the potential impact of using all of these counseling tools on changing patient behavior, physicians should be encouraged to increase their use of the Five A's when counseling patients to lose weight.

Information giving and receiving in hematological malignancy consultations

PURPOSE

Little is known about communication with patients suffering from hematologic malignancies, many of whom are seen by subspecialists in consultation at tertiary-care centers. These subspecialized consultations might provide the best examples of optimal physician-patient communication behaviors, given that these consultations tend to be lengthy, to occur between individuals who have not met before and may have no intention of an ongoing relationship, and which have a goal of providing treatment recommendations. The aim of this paper is to describe and quantify the content of the subspecialty consultation in regards to exchanging information and identify patient and provider characteristics associated with discussion elements.

METHODS

Audio-recorded consultations between 236 patients and 40 hematologists were coded for recommended communication practices. Multilevel models for dichotomous outcomes were created to test associations between patient, physician and consultation characteristics and key discussion elements.

RESULTS

Discussions about the purpose of the visit and patient's knowledge about their disease were common. Other elements such as patient's preference for his/her role in decision-making, preferences for information, or understanding of presented information were less common. Treatment recommendations were provided in 97% of the consultations and unambiguous presentations of prognosis occurred in 81% of the consultations. Unambiguous presentations of prognosis were associated with non-White patient race, lower educational status, greater number of questions asked, and specific physician provider.

CONCLUSION

Although some communication behaviors occur in most consultations, others are much less common and could help tailor the amount and type of information discussed. Approximately half of the patients are told unambiguous prognostic estimates for mortality or cure.

Communication practices in physician decision-making for an unstable critically ill patient with end-stage cancer

BACKGROUND

Shared decision-making has become the standard of care for most medical treatments. However, little is known about physician communication practices in the decision making for unstable critically ill patients with known end-stage disease.

OBJECTIVE

To describe communication practices of physicians making treatment decisions for unstable critically ill patients with end-stage cancer, using the framework of shared decision-making.

DESIGN

Analysis of audiotaped encounters between physicians and a standardized patient, in a high-fidelity simulation scenario, to identify best practice communication behaviors. The simulation depicted a 78-year-old man with metastatic gastric cancer, life-threatening hypoxia, and stable preferences to avoid intensive care unit (ICU) admission and intubation. Blinded coders assessed the encounters for verbal communication behaviors associated with handling emotions and discussion of end-of-life goals. We calculated a score for skill at handling emotions (0-6) and at discussing end of life goals (0-16).

SUBJECTS

Twenty-seven hospital-based physicians.

RESULTS

Independent variables included physician demographics and communication behaviors. We used treatment decisions (ICU admission and initiation of palliation) as a proxy for accurate identification of patient preferences. Eight physicians admitted the patient to the ICU, and 16 initiated palliation. Physicians varied, but on average demonstrated low skill at handling emotions (mean, 0.7) and moderate skill at discussing end-of-life goals (mean, 7.4). We found that skill at discussing end-of-life goals was associated with initiation of palliation (p = 0.04).

CONCLUSIONS

It is possible to analyze the decision making of physicians managing unstable critically ill patients with end-stage cancer using the framework of shared decision-making.