The impact of expert- and peer feedback on communication skills of undergraduate dental students – a single-blinded,randomized, controlled clinical trial

ObjectiveTo evaluate the effect of peer- and expert feedback on communication skills of undergraduate dental students.MethodsAll students of the first clinical treatment course (n = 46) were randomly assigned into two groups. For three times a medical-dental interview/consultation of each student with a real patient was videotaped. After every consultation the videos were assessed either by a person experienced in communication (expert group) or by a fellow student (peer group), giving the students feedback regarding their chairside performed communication skills. Before and after the feedback-interventions all students conducted an interview with simulated patients, which was rated using a validated global rating and analyzed statistically.ResultsGlobal ratings mean scores after feedback-intervention were significantly improved (p < 0.05). Thereby, no significant differences in the overall assessment could be observed between expert and peer feedback (p > 0.05).ConclusionDuring this study students improved their communication skills in dentist-patient interactions. The communication experience of the feedback provider seems not to have any impact on the communication skills in undergraduate dental students.Practice implicationsThe clinical courses in dentistry offer the opportunity to implement peer-feedback interventions in real treatment situation as part of communication training to longitudinally improve communication skills.     

Forming connections in the homeopathic consultation

ObjectiveA previous study which explored homeopathic practitioners’ in depth understanding and experiences of homeopathic consultations identified “connecting” as a key component of the consultation. This paper reports on “connecting” and its role in the consultation.MethodUsing a qualitative grounded theory approach data was collected from homeopaths using in-depth interviews, observations of homeopathic consultations and solicited practitioner reflective diaries. Constant comparison assisted code, concept and category formation to form a model of the UK classical homeopathic consultation.Results“Connecting”, describes a complex notion of relationship in the homeopathic consultation consisting of four dimensions, and performs several roles within the consultation that enable practitioners to elicit symptoms, identify expectations, assist with prescribing, help patients engage with homeopathic principles and stimulate healing.ConclusionThis study shows the homeopath as an important component of the therapeutic context forming complex relationships and using communication that is skills based and inductively shaped to interpret and respond to each individual patient and their narrative in the consultation.Practice implicationsThis study could have implications for teachers, students and practitioners of homeopathy by influencing training needs, and could prove instructive for other clinicians as homeopaths’ communication style could be used to augment other consultations.     

Agency and the telephone: Patient contributions to the clinical and interactional agendas in telehealth consultations

ObjectivePatient-centredness is central to providing safe care and is achieved, in part, through involving patients in developing the agenda of the consultation. Medical consultations have changed significantly over the last two years as a result of COVID-19 and thus understanding how patients contribute to the clinical and interactional agendas within a telehealth consultation is important to supporting quality care.MethodsA collection (15) of consultations (in English) between specialists (3) and patients (14) were recorded in a metropolitan gastrointestinal clinic in Australia. These recordings were closely examined using conversation analysis, which focuses on the structural and sequential organisation of interaction.ResultsPatients used a variety of interactional approaches to contribute to the agenda throughout the consultations. This was achieved in collaboration with the doctors, whose responses generally allowed for these contributions. However, there were few doctor-driven, explicit opportunities provided to patients to contribute to the agenda.ConclusionMany patients and doctors are adept at managing the interactional challenges of telehealth consultations but there are clear opportunities to extend this advantage to those patients with less agency.Practice implicationsProviding an explicit space for patients to ask questions within the consultation would support those patients less inclined or able to assert themselves during a telehealth consultation.     

Qualitative analysis of cancer telephone consultations: Differences in the counseling needs of Japanese men and women

ObjectiveTo analyze large-scale data obtained from telephone cancer consultations and clarify sex differences in the information sought by callers to guide future cancer survivor support.MethodsWe qualitatively analyzed 10,534 cases of telephone consultations with cancer patients. The relationships between callers’ words and sex were visualized through a correspondence analysis, and the keywords extracted were visualized with a dependency relationship to the words “worry” and “anxiety,” which had a high prevalence in the text data.ResultsMost of the male callers sought consultation about stomach cancer (11.8%), the consultations were predominantly about “suspicion of having cancer” (25.2%), and males indicated that the goal was to gather accurate information. Female callers mostly sought consultation about breast cancer (18.4%) were mainly interested in learning about “treatment” (31.0%), and mostly used the keywords "worry" and "anxiety." The total number of callers without a definitive diagnosis accounted for 20% of all consultations.ConclusionsHealthcare providers need to understand unique sex-based coping styles and perform regular follow-ups. There is also a need for online platforms that provide information from the patient’s perspective.Practical implicationsProviding a cancer consultation support system and easy-to-understand medical information will improve communication between survivors, their families, and medical staff.     

Underpinning of the sharing knowledge about immunisation (SKAI) communication approach: A qualitative study using recorded observations

ObjectiveTo refine communication strategies to assist clinician conversations with vaccine hesitant and declining parents as part of the Sharing Knowledge About Immunisation (SKAI) package.MethodsWe recorded and analysed consultations held in two Specialist Immunisation Clinics in tertiary hospitals in Australia between consenting clinicians and parents. We undertook content analysis that was both iterative and informed by the Calgary Cambridge Model of health communication and motivational interviewing.ResultsWe found common strengths and opportunities in clinician's communication styles. Strengths included: rapport building; communicating care for both the parent and child; exhibiting depth of vaccination-specific communication skill and content knowledge. Opportunities for strengthening communication practices included: eliciting parents' concerns to saturation early in the consultation; structuring the consultation to prioritise and address parents' concerns; recognising and responding to parents' motivation to vaccinate; effectively closing consultations.ConclusionThis study has synthesised clinical communication strategies from expert vaccination communicators using well-established communication frameworks to advance a unique approach to the challenging task of addressing vaccine hesitancy and refusal.Practice implicationsThe clinic observations helped us to create a structured consultation guide that can enhance and provide greater structure to a clinician's existing communication skills.     

Using patient-generated health data in clinical practice: How timing influences its function in rheumatology outpatient consultations

ObjectiveUtilizing patient-generated health data (PGHD) in clinical consultations and informing clinical and shared decision-making processes has the potential to improve clinical practice but has proven challenging to implement. Looking at consultations between people with rheumatoid arthritis (RA) and rheumatologists, this study examines when and how daily PGHD was discussed in outpatient consultations.MethodsWe conducted a secondary qualitative analysis of 17 audio-recorded research outpatient consultations using thematic and interactional approaches.ResultsClinicians decided when to look at the PGHD and what symptoms to prioritise during the consultation. When PGHD was introduced early in consultations, it was usually used to invite patients to collaborate (elicit new information). When introduced later, PGHD was used to corroborate patient accounts and to convince the patient about proposed actions and treatments. Clinicians occasionally disregarded PGHD if it did not fit into their clinical assessment.ConclusionThe time that PGHD is introduced may influence how PGHD is used in consultations. Further research is needed to understand how best to empower patients to discuss PGHD.Practice implicationsEducating patients and clinicians about the importance of timing and strategies when using PGHD in consultations may help promote shared decision-making.     

Patients' reasons for not presenting emotional problems in general practice consultations.

BACKGROUND: Patients commonly do not mention emotional problems in consultations, and this is a factor in general practitioners' (GPs') difficulty in identifying psychological morbidity. AIM: To investigate patients' self-reported reasons for not disclosing psychological problems in consultations with GPs. METHOD: From nine general practices, a sample of patients with high General Health Questionnaire scores, who planned to present only somatic symptoms to the GP, were interviewed after their consultation with the GP. The interview covered their reasons for not mentioning emotional problems. A patient satisfaction questionnaire was administered. RESULTS: A total of 83 patients were interviewed. Sixty-four patients confirmed that they had not mentioned emotional problems in the consultation; 23 (36%) of these gave primarily realistic reasons for not presenting emotional problems (e.g. able to cope with distress), 29 (45%) gave reasons related to psychological embarrassment or hesitation to trouble the GP, and 12 (19%) were mainly deterred by the doctors' interview behaviours. The latter group had significantly lower satisfaction scores than patients in the other two groups. In addition, patients in all groups commonly reported perceptions of lack of time (48%) and that there is nothing doctors can do to help (39%) as barriers to mentioning emotional problems. CONCLUSION: An understanding of patients' reasons for not disclosing emotional problems can assist in identifying subgroups of patients with different management needs.     

Physicians’ views and experiences of discussing weight management within routine clinical consultations: A thematic synthesis

ObjectiveTo systematically search and synthesise qualitative studies of physicians’ views and experiences of discussing weight management within a routine consultation.MethodsA systematic search of four electronic databases identified 11,169 articles of which 16 studies met inclusion criteria. Quality was appraised using the Critical Appraisal Skills Programme tool and a thematic synthesis conducted of extracted data.ResultsFour analytical themes were found: (1) physicians’ pessimism about patients’ weight loss success (2) physicians’ feel hopeless and frustrated (3) the dual nature of the physician-patient relationship (4) who should take responsibility for weight management.ConclusionDespite clinical recommendations barriers remain during consultations between physicians and patients about weight management. Many of these barriers are potentially modifiable.Practice implicationsImproving training, providing clearer guidelines and placing a greater emphasis on collaboration within and between clinicians will help reduce barriers for both physicians and patients. In particular, there is an urgent need for more specialised training for physicians about weight management to promote knowledge and skills in behaviour change techniques and ways to broach sensitive topics without damaging patient relationships.     

Medical students’ communication skills in clinical education: Results from a cohort study

ObjectiveTo assess students’ communication skills during clinical medical education and at graduation.MethodsWe conducted an observational cohort study from 2007 to 2011 with 26 voluntary undergraduate medical students at Hamburg University based on video-taped consultations in year four and at graduation. 176 consultations were analyzed quantitatively with validated and non-validated context-independent communication observation instruments (interrater reliability ≥0.8). Based on observational protocols each consultation was also documented in free-text comments, salient topics were extracted afterwards.Results26 students, seven males, were enrolled in the survey. On average, graduates scored higher in differential-diagnostic questioning and time management but showed deficiencies in taking systematic and complete symptom-oriented histories, in communication techniques, in structuring consultations and in gathering the patients’ perspectives. Patient-centeredness and empathy were rather low at graduation. Individual deficiencies could barely be eliminated.ConclusionMedical students were able to enhance their clinical reasoning skills and their time management. Still, various communication deficiencies in final year students became evident regarding appropriate history taking, communication skills, empathy and patient-centeredness.Practice implicationsThe necessity of developing a longitudinal communication curriculum with enhanced communication trainings and assessments became evident. A curriculum should ensure that students’ communication competencies are firmly achieved at graduation.     

Medical students in general practice: how do patients feel?

BACKGROUND: The General Medical Council has recommended that medical students should gain more experience in general practice. AIM: The study set out to determine patients' reactions to the presence of medical students in general practice consultations. METHOD: Patients attending a random sample of general practice surgeries completed a questionnaire following consultation with and without a medical student present in six general practices in the Oxford area. RESULTS: The questionnaires were completed by 278 patients. Only eight (3%) of all respondents had negative responses to the presence of a medical student. Of those completing questionnaires following a teaching consultation, 107 (56%) felt positively about the presence of students, compared with 36 (41%) who had attended a nonteaching surgery. Only three patients (1%) felt the quality of the consultation to be impaired by the presence of a student, while 48 patients (17%) felt there to be some improvement. The majority felt that the sex of the student was unimportant, but significantly more female than male patients (17% versus 5%) felt that it made a difference. CONCLUSION: Only a small proportion of patients object to the presence of a medical student in general practice consultations. A significant minority said that the presence of a student improves the consultation.     

Quantifying implicit uncertainty in primary care consultations: A systematic comparison of communication about medically explained versus unexplained symptoms

ObjectiveGeneral practitioners (GPs) disclose more uncertainty (e.g. “I don’t know”) in consultations with patients presenting medically unexplained symptoms (MUS) versus medically explained symptoms (MES), which could negatively affect patient outcomes. This study assessed if this pattern also holds for more subtle, implicit uncertainty expressions (e.g. “maybe”, “might”) during different consultation phases, and assessed their relation to patient pre-post consultation anxiety.MethodsWe quantified implicit markers of uncertainty of 18 GPs in 82 consultations about MUS or MES during different consultation phases. Relative frequencies of implicit uncertainty per consultation were regressed on differences in momentary anxiety pre and post consultation.ResultsWe coded 2590 GP utterances. Uncertainty expressions were more frequent in MUS versus MES consultations (OR = 1.54, p = .004), especially during diagnosis and treatment recommendations compared to physical examinations (OR =0 .45, p = .001). Implicit uncertainty was not related to patients’ changes in anxiety (b = ?0.11, p = .817).ConclusionsGPs express more uncertainty during MUS (versus MES) consultations, especially during the diagnostic phase and treatment recommendations. This does not necessarily affect patient anxiety.Practice implicationsImplicit uncertainty expressions reflect the mere complexity of communicating a medically unexplained diagnosis, which does not affect patient anxiety.     

Development of a tool to support person-centred medicine-focused consultations with stroke survivors

Objective: To develop a tool to support medicine-focused person-centred consultations between community pharmacists and stroke survivors.Method: Semi-structured interviews with 15 stroke survivors and 16 community pharmacists were conducted. Thematic analysis of the data was performed and emerging themes examined to determine their relevance to the principles of delivering person-centred care. Findings were used to generate a framework from which a consultation tool was created. Face validity and the feasibility of using the tool in practice were explored with participating pharmacists.Results: Three major themes were identified; personal, process and environmental factors. A tool, in two parts, was developed, A ‘Getting to know me’ form which would help the pharmacist to appreciate the individual needs of the stroke survivor and a consultation guide to facilitate the consultation process. Pharmacists considered that both were useful and would support a person-centred medicine-focussed consultation.Conclusion: A consultation tool, reflecting the needs of stroke survivors, has been developed and is feasible for use within community pharmacy practice.Practice implications: Pharmacists must recognise the individual needs of stroke survivors to ensure that they provide consultations which are truly person-centred. The tool developed could support medicine-related consultations with patients with other long term conditions.     

The first steps towards professional distance: A sequential analysis of students’ interactions with patients expressing emotional issues in medical interviews

ObjectiveExplore sequential patterns in students’ interactions with patients expressing emotional concerns in a medical interview.MethodsConcepts and principles from conversation analysis (CA) were used to examine the turn-by-turn sequential organization of student actions in eleven video-taped medical interviews. We used results from an earlier coding with an interaction analysis system (VR-CoDES) in a previously published paper as a point of reference.ResultsBy using CA instead of VR-CoDES as our primary investigative method we observed that student turns previously coded as elicitations to simulated patients’ expressions of emotion were often preceded by subtle patient initiatives. Students encouraged further elaboration by displaying their understanding of the emotional issue as a story telling still in progress. Students’ expressions of understanding however, gave little room for further elaboration. Finally, students often addressed emotional issues as a medical issue and offered professional advice.ConclusionsStudents’ actions seemed specifically designed to display interest in the patients’ initiatives to talk about emotional experiences without departing from their initial interview task or violating norms for professional conduct.Practice implicationsEducators and practitioners should reconsider how the medical interview may shape expectations for professional conduct and can thereby unintentionally restrict students’ empathy development.     

How is complementary medicine discussed in oncology? Observing real-life communication between clinicians and patients with advanced cancer

ObjectiveThis study aims to examine the structure of communication about complementary medicine (CM) between patients with cancer and clinicians during oncology consultations.MethodsPreviously, consultations between 29 clinicians and 80 patients with advanced cancer were recorded in six hospitals in the Netherlands. The present study considers a secondary analysis. References to CM during the consultation were coded using a self-developed observational coding scheme.ResultsAt least one reference to CM was observed in 35 out of 80 consultations (44 %), with a total of 73 references. In most cases, CM was initially referred to by patients. Clinicians often did not elaborate on the subject of CM. Relevant aspects related to CM (e.g., safety, effectiveness) were infrequently discussed. Both patients and clinicians showed predominantly neutral to positive attitudes towards CM.ConclusionsThis study shows that patients are still the main initiators of discussions about CM and the topic is not consistently discussed in daily oncology practice.Practice implicationsIf exploration of patients’ interest in CM or its use became routine in oncology practice, it may relieve patients of the burden of introducing the topic, decrease potential risks of CM use and increase access to evidence-based CM for all patients with cancer.     

Anthroposophic medical therapy in chronic disease: a four-year prospective cohort study

Background  

The short consultation length in primary care is a source of concern, and the wish for more consultation time is a common reason for patients to seek complementary medicine. Physicians practicing anthroposophic medicine have prolonged consultations with their patients, taking an extended history, addressing constitutional, psychosocial, and biographic aspect of patients' illness, and selecting optimal therapy. In Germany, health benefit programs have included the reimbursement of this additional physician time. The purpose of this study was to describe clinical outcomes in patients with chronic diseases treated by anthroposophic physicians after an initial prolonged consultation.