Attributes of patient-physician interactions in a teaching hospital

The purposes of this qualitative study were to describe the attributes that characterize patient-physician communications, the effect of patient-physician interactions on patient satisfaction, and the correspondence between physicians' education and training and their interactions with patients. The authors used unobtrusive observations of patient-physician interactions, physician interviews, and patient interviews. The authors observed 7 physicians and interviewed 20 patients over a 6-month period. There was no agreement among the physicians about whether managed care influenced their ability to relate to patients. The majority of patients interviewed were satisfied with their interactions with their physician and hospital stay.     

Sexual minority status and long-term breast cancer survivorship

Sexual minority women, such as lesbians, bisexuals, and women who have a woman partner face unique challenges, such as deciding on disclosing their sexual minority status to health providers. The purpose of this qualitative study was to explore the perceptions of sexual minority women who were long-term breast cancer survivors. Twenty-two sexual minority women, diagnosed with non-metastatic breast cancer between 2000 and 2005, participated in semi-structured, open-ended interviews. Interviews were audio-recorded, transcribed, and analyzed to identify emergent themes to summarize sexual minority women's perceptions of breast cancer survivorship. Participants' perceptions about the impact of their sexual minority identity on breast cancer survivorship consisted of: (1) breast cancer is a women's issue, not a lesbian issue; (2) I can manage my identity in the context of breast cancer; and (3) I am better off than heterosexual women. The authors' findings suggest a possible disconnect between sexual minority women with breast cancer who de-emphasized the importance of sexual minority status and the research community that emphasizes the importance of this status. Prior to counting on sexual minority women's interest in studies, researchers may need to educate sexual minority women about the need of breast cancer studies.     

Sex and the 'recently single': perceptions of sexuality and HIV risk among mature women and primary care physicians

Primary care physicians may mistakenly conclude that sexual issues are unimportant to divorced or widowed mature women, based on age and gender biases. Although research suggests that many single mature women are sexually active, physicians are often reluctant to discuss sexual matters with them. Structured and open-ended interviews explored perceptions regarding mature women's sexuality and HIV-related risk for patient-physician communication among 44 'recently single' mature women aged 45-68 and 31 primary care physicians. Age and ethnic group comparisons with the mature women suggest that younger and African-American women reported higher HIV and STI risk perception than older and White women. Many mature women (64%) believed that they were at-risk for HIV and STIs, whereas physicians considered younger patients most at-risk and that risk declined with patients' advancing age and with female status. Mature women and physicians had different expectations regarding initiation of clinical sexual health discussions, with 44% of the mature women placing the onus of responsibility on the patient, whereas 74% of physicians believed it was the role of both doctors and patients to bring up these topics. The findings are instructive to primary care physicians and healthcare policy makers, indicating that sexual health issues are relevant to mature women's continued health and well-being.     

Patient–Provider Sexually Transmitted Infection Prevention Communication among Young Adult Sexual Minority Cisgender Women and Nonbinary Assigned Female at Birth Individuals

BackgroundHealth care providers are an important source of sexually transmitted infection (STI) prevention information for young adult sexual minority women (SMW). However, very few studies have described patient–provider STI communication in this understudied and underserved population. We explore sexual minority women's experiences communicating with health care providers about sexual health, with particular attention to STI prevention, to inform programs and practices that address their unique needs and concerns.MethodsWe conducted 29 in-depth interviews with sexual minority cisgender women and nonbinary assigned female at birth (AFAB) individuals aged 18–36 years. The sample included White (55%), Asian (31%), Black (17.2%), and Latina (3.4%) participants. We used thematic analysis with deductive and inductive coding to identify themes related to patient–provider STI prevention communication.ResultsHeteronormative health care provider assumptions inhibited participants' willingness to disclose their sexual orientation and discuss sexual health issues with providers. Most sexual health conversations focused on pregnancy and contraception, which many felt was irrelevant to them, and limited STI prevention recommendations to condom use. Participants reported that some providers lacked medical knowledge on AFAB-to-AFAB STI transmission and were not able to provide relevant STI prevention information. Providers' bias related to gender identity and race/ethnicity furthered some participants' mistrust generated from providers’ heteronormative assumptions.ConclusionsOur study describes several barriers that AFAB sexual minorities felt inhibited their patient–provider sexual health communication. Interventions are needed to improve patient–provider STI prevention conversations with AFAB sexual minorities so they can access the sexual health information they need to effectively protect themselves from STIs.     

Rural physicians' perspectives on cervical and breast cancer screening: a gender-based analysis

Several studies highlight the role of physicians in determining cervical and breast cancer screening rates, and some urban studies report higher screening rates by female physicians. Rural women in North America remain underscreened for breast and cervical cancers. This survey was conducted to determine if there were significant gender differences in practices and perceptions of barriers to breast and cervical cancer screening among rural family physicians in Ontario, Canada. One hundred ninety-one family physicians (response rate 53.1%) who practiced in rural areas, small towns, or small cities completed a mail questionnaire. The physicians' mean age was 44.4 years (SD 9.9), and mean number of years in practice was 16.6 years (SD 10.3). Over 90% of physicians reported that they were very likely to conduct a Pap test and clinical breast examination (CBE) during a periodic health examination, and they had high levels of confidence and comfort in performing these procedures. Male (68%) and female (32%) physicians were similar in their likelihood to conduct screening, levels of confidence and comfort, and knowledge of breast and cervical cancer screening guidelines. However, the self-reported screening rates for Pap tests and CBE performed during last year were higher for female than male physicians (p < 0.01). Male physicians reported they were asked more frequently by patients for a referral to another physician to perform Pap tests and CBE (p < 0.001). Also, male physicians perceived patients' embarrassment as a stronger barrier to performing Pap tests (p < 0.05) and CBE (p < 0.01) than female physicians. No gender differences were observed in screening rates or related barriers to mammography referrals. These findings suggest that physicians' gender plays a role in sex-sensitive examination, such as Pap tests and CBE. There is a need to facilitate physician-patient interactions for sex-sensitive cancer screening examinations by health education initiatives targeting male physicians and women themselves. The feasibility of providing sex-sensitive cancer screening examinations by a same-sex health provider should also be explored.     

Sexual Minority Women's Satisfaction with Health Care Providers and State-level Structural Support: Investigating the Impact of Lesbian,Gay, Bisexual,and Transgender Nondiscrimination Legislation

PurposeStructural discrimination is associated with negative health outcomes among sexual minority populations. Recent changes to state-level and national legislation provide both the opportunity and the need to further explore the impact of legislation on the health indicators of sexual minorities. Using an ecosocial theory lens, the present research addresses the relationship between structural support or discrimination and satisfaction with one's health care provider among sexual minority women.MethodsData were drawn from an online survey of sexual minority women's health care experiences. Using the Andersen Behavioral Model of Health Services Utilization to operationalize the variables in our model, we examined the relationship between state-level nondiscrimination legislation and satisfaction with provider—a widely used measure of health care quality—through regression analysis.FindingsParticipants in structurally supportive states (i.e., those with nondiscrimination legislation) were more likely to disclose their sexual identity to their providers and to report higher satisfaction with their providers. The absence of nondiscrimination legislation was associated negatively with satisfaction with providers.ConclusionsResults of our study show that the external environment in which sexual minority women seek health care, characterized by structural support or lack thereof, is related to perceived quality of health care.     

Provider Portrayals and Patient–Provider Communication in Drama and Reality Medical Entertainment Television Shows

Portrayals of physicians on medical dramas have been the subject of research attention. However, such research has not examined portrayals of interactions between physicians and patients, has not compared physician portrayals on medical dramas versus on medical reality programs, and has not fully examined portrayals of physicians who are members of minority groups or who received their education internationally. This study content-analyzes 101 episodes (85 hours) of such programs broadcast during the 2006–2007 viewing season. Findings indicate that women are underrepresented as physicians on reality shows, though they are no longer underrepresented as physicians on dramas. However, they are not as actively portrayed in patient-care interactions as are male physicians on medical dramas. Asians and international medical graduates are underrepresented relative to their proportion in the U.S. physician population, the latter by almost a factor of 5. Many (but certainly not all) aspects of patient-centered communication are modeled, more so on reality programs than on medical dramas. Differences in patient–provider communication portrayals by minority status and gender are reported. Implications for public perception of physicians and expectations regarding provider-patient interaction are discussed.     

Methodology for targeting physicians for interventions to improve breast cancer screening

INTRODUCTION: Uneven increases in mammography utilization rates call for methods to efficiently target educational interventions to women who do not regularly use mammography and physicians who do not adhere to national guidelines for breast cancer screening. This paper discusses a method for identifying physicians who are nonadherers to breast cancer screening guidelines or in need of continuing medical education (CME) in this area. METHODS: A 1995 community-based telephone survey of randomly selected women aged 50-80, residing in four Long Island, NY, townships was used to identify women who underuse mammography and their regular physicians. Community-based surveys of physicians permitted identification of nonadherent providers. Nonadherence to breast cancer screening recommendations was the primary criterion, but because of anticipated physician reluctance to self report nonadherence with screening guidelines, additional criteria were developed to identify physicians with educational needs relating to breast cancer screening. These criteria included lack of office reminder systems and knowledge relating to breast cancer screening, and lack of confidence in patient counseling and clinical breast examination skills. RESULTS: Overall response rates were 77% for women's survey, and 66% for the physician survey. 3427 women were classified as underusers (38.5%) and 87% of underusers provided the name and address of their regular physicians. By physician self report, 45% of physicians were classified as nonadherers and 42% were identified as having related educational needs. CONCLUSION: A feasible method for identifying physicians who are nonadherers to breast cancer screening recommendations or in need of CME about this is described, permitting efficient targeting of educational interventions to those with patients who underuse mammography. The method is not dependent on access to a specific provider or patient population.     

Physician–Patient Communication About Sexual Functioning in Patients with Multiple Sclerosis

Sexual dysfunction is quite common among individuals with multiple sclerosis (MS); however, severity of dysfunction alone does not account for the tremendous variation in sexual satisfaction across individuals living with MS. Individual characteristics, relationships with intimate partners, and environmental factors all likely contribute to the multidimensional experience of sexual satisfaction. Health care provider variables, including how one communicates with providers about sexual concerns, may also be influential. The purpose of this study was to examine factors that are associated with patients’ sex-related communications with their MS physicians and to overall patient sexual satisfaction. Individuals in an MS clinic (n = 73) completed a survey packet which included measures of physical and mental health, sexual dysfunction, sexual satisfaction, sex communication, health care provider relationships, and health care satisfaction. Findings suggest that while more than half of patients with MS reported experiencing sexual dysfunction, only a third of patients indicated addressing their sexual concerns with their physician during the past year. Interestingly, the frequency of communication about sexual concerns was associated with satisfaction with physician variables, whereas self-efficacy for these interactions was associated with emotional health variables. These results indicate that when considering interventions to increase confidence for communication and frequency of communication that differing factors may be taken into account.     

Sex and the ‘recently single’: perceptions of sexuality and HIV risk among mature women and primary care physicians

Primary care physicians may mistakenly conclude that sexual issues are unimportant to divorced or widowed mature women, based on age and gender biases. Although research suggests that many single mature women are sexually active, physicians are often reluctant to discuss sexual matters with them. Structured and open‐ended interviews explored perceptions regarding mature women's sexuality and HIV‐related risk for patient‐physician communication among 44 ‘recently single’ mature women aged 45–68 and 31 primary care physicians. Age and ethnic group comparisons with the mature women suggest that younger and African‐American women reported higher HIV and STI risk perception than older and White women. Many mature women (64%) believed that they were at‐risk for HIV and STIs, whereas physicians considered younger patients most at‐risk and that risk declined with patients' advancing age and with female status. Mature women and physicians had different expectations regarding initiation of clinical sexual health discussions, with 44% of the mature women placing the onus of responsibility on the patient, whereas 74% of physicians believed it was the role of both doctors and patients to bring up these topics. The findings are instructive to primary care physicians and healthcare policy makers, indicating that sexual health issues are relevant to mature women's continued health and well‐being.     

Effects of breast cancer risk counseling for sexual minority women

Sexual minority women (lesbian and bisexual) represent a vulnerable group regarding their breast health. The participants in this study were 150 women aged 18-74 recruited via public announcements in mainstream and sexual minority communities in the greater Seattle metropolitan area. Potential participants were recruited to participate in a randomized trial of a breast cancer risk counseling intervention for sexual minority women. The counseling intervention produced significant reductions in perceived risk of breast cancer, anxieties and fears about breast cancer at 6 and 24 months, and increases in breast screening rates at 24 months in the intervention arm, compared with the control arm participants. These data add to the growing body of knowledge on sexual minority women's health and point to areas of community action and future research.     

Primary Care Providers' Perspectives on Providing Care to Women Veterans with Histories of Sexual Trauma

BackgroundOne in four women Veterans who use the Veterans Health Administration (VA) screen positive for military sexual trauma and may need trauma-sensitive care and coordination. VA primary care providers (PCPs), women veterans' main source of care, need to be well-versed in trauma-sensitive approaches to care. Women veterans' numerical minority in the VA can make provider exposure to female patients inconsistent, which may impede PCP experience in providing appropriate care. To inform strategies for improving trauma-sensitive primary care, we sought to better understand PCPs’ current approaches to providing care to women veterans with sexual trauma histories.MethodsWe conducted semistructured telephone interviews with PCPs (n = 28) practicing in VA primary care clinics. Participants were asked about their experiences delivering trauma-sensitive care as well as best practices. Interviews were recorded, transcribed, and analyzed for major themes regarding barriers to and facilitators of trauma-sensitive care.ResultsParticipants expressed challenges delivering care to women with sexual trauma histories, including 1) insufficient time, 2) lack of perceived proficiency and/or personal comfort (with general physical examinations as well as gender-specific care such as Pap, breast, and pelvic examinations), and 3) difficulties with fostering positive patient–provider relationships. Access to mental health resources was noted as a key facilitator of providing trauma-sensitive care. Participants also shared existing (and potential) best practices and recommendations, such as paying special attention to patient behavioral cues related to comfort.ConclusionsPCPs delivering care to women in VA facilities may benefit from an increased awareness of best practices to facilitate the delivery of trauma-sensitive care.     

The role of physician gender in the evaluation of the National Centers of Excellence in Women's Health: test of an alternate hypothesis.

A 2002 evaluation of the National Centers of Excellence in Women's Health (CoE) provided evidence that women receive higher-quality primary health care, as indicated by receipt of recommended preventive care and patient satisfaction, when they receive their care in comprehensive women's health centers. A potential rival explanation for the CoE evaluation findings, however, is that the higher quality of care in the CoE may be attributable to a predominance of female physicians in CoE settings. More women who receive health care in a CoE have a female regular physician and female physicians may provide more preventive health services. Additionally, women may self-select into the CoE because of their preference for female providers. This paper presents results of an analysis examining the role of physician gender in the CoE evaluation. Women seen in three CoE clinics and women seen in other settings in the same communities who had a female physician are compared to assess the CoE effect while controlled for physician gender. The findings confirm a positive CoE effect for many of the quality of care indicators that were observed in the original evaluation. Women seen in CoEs are more likely to receive physical breast examinations and mammograms (ages > or =50). In addition, positive CoE findings for counseling on domestic violence, sexually transmitted diseases, family or relationship concerns, and sexual function or concerns were upheld. The CoE model of care delivers advantages to women that are not explained by the greater number of female physicians in these settings.     

Communicating breast cancer risk: patient perceptions of provider discussions

This study investigated the relationship between breast cancer risk communication delivered by providers and patient knowledge, perceptions, and screening practices. Telephone interviews were conducted with 141 African American (n = 71) and white (n = 70) first-degree relatives of breast cancer patients who received medical services at 2 university medical centers in North Carolina during 1994-95. Multiple items assessed subjects' reports of discussions with providers about family history and personal risk, knowledge of breast cancer risk factors, risk perceptions, breast cancer concerns, and screening practices. African American (AA) women were less likely than white women to report being informed of their increased personal risk of breast cancer because of family history. After controlling for education level, AA women aged > or = 50 years were less likely than white women to have ever had a mammogram. Both AA and white women who discussed family history and risk with their providers were significantly more likely to have had a mammogram within the past 2 years. Although these discussions seemed to increase participants' perceived risk of developing breast cancer, they did not promote knowledge of risk factors or increase levels of cancer concern. Study results indicate that provider discussions about family history and personal risk, accompanied by increases in risk perception, promote patient compliance with screening goals. Findings suggest that accurate knowledge about specific breast cancer risk factors may not be necessary to achieve screening compliance. However, additional studies are needed to investigate the relationship between knowledge of breast cancer risk factors and the adoption of behaviors associated with reducing breast cancer risk.     

Perceived health concerns among sexual minority women in Mumbai,India: an exploratory qualitative study

The experiences of sexual minority women (i.e., women who do not identify as ‘heterosexual’) in India have largely been absent in scientific literature. In partnership with India’s oldest and largest sexual and gender minority-advocacy organisation, the Humsafar Trust, our study used community-based participatory research principles to explore the lived experiences and health concerns of sexual minority women in Mumbai. Study methodologies included interviews with key informants, a focus group comprised of six women, and an additional 12 in-person interviews with sexual minority women to identify important physical, mental, social and other health priorities from these women’s perspectives. Thematic data are organised within the framework offered by the social ecological model, including individual, interpersonal, micro and macro levels. Findings from this study are important in providing the groundwork for future research and intervention involving sexual minority women in India, a dramatically underserved population.     

Cancer preventive screening behavior among elderly women

Screening procedures and recommendations for early detection of cervical and breast cancer are reviewed with special reference to suggested guidelines for screening among the elderly. Data on preventive practices related to cancer detection were obtained from 675 women in Maryland by telephone interviews. The elderly (65 years of age and older) reported fewer detection tests of any type; specifically, 23% report never having had a Pap test and an additional 28% have not had one within 5 years, compared with women under the age of 65, where 98% report having had a Pap test and 79% have had one within the past two years. Elderly women were also less likely than younger women to report receiving routine breast examinations by their physicians, to perform BSE, or to have been taught BSE by a health professional. Type of provider utilized, having a personal physician, and going to a gynecologist account for a significant proportion of the variance in screening practices.     

Determination of Changes in the Sexual Lives of Young Women Receiving Breast Cancer Treatment: A Qualitative Study

This qualitative study was performed to identify changes in the sexual lives of young women receiving breast cancer treatment. The study was conducted with eight exclusively self-defined heterosexual married women whose breast cancer treatments were ongoing in the ambulatory chemotherapy unit. The data were collected through semi-structured and in-depth individual interviews. All interviews were tape-recorded. The raw results were obtained by analyzing the content of the recorded data. In this study, the subject of the interviews was penile-vaginal intercourse, as the participants perceived sexuality as equivalent to penile-vaginal intercourse. The changes in the sexual lives of young women receiving breast cancer treatment were analyzed according to three themes as follows: (1) intermittent penile-vaginal intercourse, (2) sexual activity initiated by the male and (3) sexual dysfunction. This study assists health professionals in recognizing changes in young women’s sexual lives. Thus, healthcare professionals can provide couples with appropriate counseling to promote healthier sexuality and maintain a higher quality of life.     

Realizing the promise of breast cancer screening: clinical follow-up after abnormal screening among Black women

BACKGROUND: Delayed or incomplete follow-up after abnormal screening results may compromise the effectiveness of breast cancer screening programs, particularly in medically underserved and minority populations. This study examined the role of socioeconomic status, breast cancer risk factors, health care system barriers, and patient cognitive-attitudinal factors in the timing of diagnostic resolution after abnormal breast cancer screening exams among Black women receiving breast cancer screening at three New York city clinics. METHODS: We identified 184 Black women as having an abnormal mammogram or clinical breast exam requiring immediate follow-up and they were interviewed and their medical records examined. Bivariate and multivariate logistic regression analyses were used to assess the association between patient and health care system factors and diagnostic resolution within 3 months of the abnormal finding. RESULTS: Within 3 months, 39% of women were without diagnostic resolution and 28% within 6 months. Neither socioeconomic status nor system barriers were associated with timely diagnostic resolution. Timely resolution was associated with mammogram severity, patients asking questions (OR, 2.73; 95% CI, 1.25-5.96), or receiving next step information (OR, 2.6; 95% CI, 1.08-6.21) at the initial mammogram. Women with prior breast abnormalities were less likely to complete timely diagnostic resolution (OR, 0.42; 95% CI, 0.20-0.85), as were women with higher levels of cancer anxiety (OR, 0.50; 95% CI, 0.27-0.92). CONCLUSIONS: Interventions that address a woman's prior experience with abnormal findings and improve patient/provider communication may improve timely and appropriate follow-up.     

Physician‐related facilitators and barriers to patient involvement in treatment decision making in early stage breast cancer: perspectives of physicians and patients

Objective To identify patients’ and physicians’ perceptions of physician‐related verbal and nonverbal facilitators and barriers to patient involvement in treatment decision making (TDM) occurring during clinical encounters for women with early stage breast cancer (ESBC). Methods Eligible women were offered treatment options including surgery and adjuvant therapy. Eligible physicians provided care for women with ESBC in either a teaching hospital or an academic cancer centre. In Phase 1, women were interviewed 1–2 weeks after their initial consultation. In Phase 2, women and their physicians were interviewed separately while watching their own consultation on a digital video disk. All interviews were audiotaped, transcribed and analysed. Results Forty women with ESBC and six physicians participated. Patients and physicians identified thirteen categories of physician facilitators of women’s involvement. Of these, seven categories were frequently identified by women: conveyed a rationale for patient involvement in TDM; explained the risk of cancer recurrence; explained treatment options; enhanced patient understanding of information; gave time for TDM; offered a treatment recommendation; and made women feel comfortable. Physicians described similar information‐giving facilitators but less often mentioned other facilitators. Few physician barriers to women’s involvement in TDM were identified. Conclusions Women with ESBC and cancer physicians shared some views of how physicians involve patients in TDM, although there were important differences. Physicians may underestimate the importance that women’s place on understanding the rationale for their involvement in TDM and on feeling comfortable during the consultation.