Comparison of body perceptions between obese primary care patients and physicians: implications for practice

OBJECTIVE: To compare the body image and weight perceptions of primary care patients and their physicians as a first step toward identifying a potential tool to aid physician-patient communication. METHODS: Patients with a body mass index (BMI)>/=30 (n=456, 66% female) completed body image and weight status measures after office visits; physicians (n=29) rated the body figures and weight status of these same patients after office visits. RESULTS: Controlling for BMI, female patients and their physicians showed little or no difference in body figure selection or weight status classification, whereas male patients were significantly less likely than their physicians to self-identify with larger body figures (z=3.74, p<0.01) and to classify themselves as obese or very obese (z=4.83, p<0.0001). CONCLUSION: Findings reveal that physicians and female patients have generally concordant views of the patient's body size and weight status, whereas male patients perceive themselves to be smaller than do their physicians. The discrepancy between male patient and physician views is especially evident at increasingly larger body figure/weight status categories. PRACTICE IMPLICATIONS: When counseling male patients on weight loss, it could be helpful to assess body image and use this information to raise patient awareness of their size and to facilitate communication about weight.     

Understanding health care communication preferences of veteran primary care users

Objective

To assess veterans’ health communication preferences (in-person, telephone, or electronic) for primary care needs and the impact of computer use on preferences.

Methods

Structured patient interviews (n = 448). Bivariate analyses examined preferences for primary care by ‘infrequent’ vs. ‘regular’ computer users.

Results

Only 54% were regular computer users, nearly all of whom had ever used the internet. ‘Telephone’ was preferred for 6 of 10 reasons (general medical questions, medication questions and refills, preventive care reminders, scheduling, and test results); although telephone was preferred by markedly fewer regular computer users. ‘In-person’ was preferred for new/ongoing conditions/symptoms, treatment instructions, and next care steps; these preferences were unaffected by computer use frequency. Among regular computer users, 1/3 preferred ‘electronic’ for preventive reminders (37%), test results (34%), and refills (32%).

Conclusion

For most primary care needs, telephone communication was preferred, although by a greater proportion of infrequent vs. regular computer users. In-person communication was preferred for reasons that may require an exam or visual instructions. About 1/3 of regular computer users prefer electronic communication for routine needs, e.g., preventive reminders, test results, and refills.

Practice implications

These findings can be used to plan patient-centered care that is aligned with veterans’ preferred health communication methods.     

Verbal communication among Alzheimer's disease patients, their caregivers, and primary care physicians during primary care office visits

Objective

Primary care visits of patients with Alzheimer's disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual's verbal participation in these triadic interactions.

Methods

To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty-three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed.

Results

PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver's own verbal participation.

Conclusion

Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less.

Practice implications

Encouraging verbal participation by AD patients and their caregivers may increase the AD patient's active role and caregiver satisfaction with primary care visits.     

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.     

Challenges in delivering bad news in a multi-ethnic intensive care unit: An ethnographic study

ObjectiveDuring critical care, physicians are frequently confronted with bad-news communication because of patients’ frail conditions. Delivering bad news is not easy, certainly not when patients from ethnic minority groups are involved. In this study we investigate the delivery of bad news in a multi-ethnic critical care context.MethodsEthnographic fieldwork in one intensive care unit of a multi-ethnic urban hospital in Belgium. Data were collected through negotiated interactive observation, in-depth interviews and from reading patients’ medical records. Data were thematically analysed.ResultsBad-news communication was primarily dominated by physicians. Patients’ and relatives’ input and other professionals’ involvement in the communication was limited. Staff encountered ethno-cultural related difficulties, firstly, in choosing suitable conversation partner(s); secondly, in choosing the place of conversations and thirdly, in the information exchange. Staff usually tried to address these problems themselves on the spot in a quick, pragmatic way. Sometimes their approaches seemed to be more emotion-driven than well thought-out.ConclusionDelivering bad news in a multi-ethnic intensive care unit has a number of specific difficulties. These can have negative consequences for parties involved.Practice implicationsThe challenges of an adequate delivery of bad news need a team-approach and a well thought-out protocol.     

A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital

ObjectiveTransitions from hospital to home are high-risk episodes. Communication problems between patients/carers and their primary healthcare providers are a central part of the risk. This literature review aimed to identify any existing tools or information (including secondary care instruments) that would facilitate designing new communication instruments for primary care to manage and mitigate risk at discharge.MethodFive databases (Pubmed, Embase, Cinahl, Web of Science and Cochrane) were searched using a three stem approach (primary/transitional care, discharge period, communication). A dual reviewer system was used, following PRISMA guidelines.ResultsFrom 61 full text articles a total of ten tools were found, 25 articles contained other useful content, 19 further tools were found in grey literature. Most material originated from the USA and described hospital-based transitional care interventions.ConclusionNo ready-made patient/provider communication tool for the post-discharge period in primary care was found. Future communication tools should enhance education and engagement of patients so they feel able to initiate communication.Practice implicationsCollating post-discharge communication material is of importance to improving the safety of care transitions and will enable creation of new tools specifically designed for primary care. These tools will improve patient activation (‘the knowledge, skills and confidence a person has in managing their own health and care’) with the ultimate aim of reducing error and harm in primary care through improved communication of healthcare decisions.     

Attitudes toward integration of complementary and alternative medicine in primary care: perspectives of patients, physicians and complementary practitioners

OBJECTIVE: Our study explored the attitudes of patients toward complementary and alternative medicine (CAM) use, their family physicians' role regarding CAM, and models for CAM referral and treatment. We compared patients' perspectives regarding integration of CAM into primary care with attitudes of primary care physicians (PCPs) and CAM practitioners. METHODS: We conducted a comprehensive literature review and focus group discussions to develop a questionnaire, which we gave to three groups: a random sample of patients receiving care at an academic family medicine clinic and PCPs and CAM practitioners employed in the largest health maintenance organization in Israel. RESULTS: A total of 1150 patients, 333 PCPs, and 241 CAM practitioners responded to our questionnaire. Compared with PCPs, patients expected their family physician to refer them to CAM, to have updated knowledge about CAM, and to offer CAM treatment in the clinic based on appropriate training. When asked about CAM integration into medical care, more patients expected to receive CAM in a primary care setting compared to PCPs' expectations of prescribing CAM (62% vs. 30%; p=0.0001). Patients, CAM practitioners, and PCPs expected family practitioners to generate CAM referrals in an integrative primary care setting (85.6% vs. 82.4% vs. 62.6%; p<0.0001). Patients supported CAM practitioners providing CAM treatments in the primary care setting, regardless of whether the practitioner held a medical degree (MD). Also, more patients than PCPs or CAM practitioners expected their family physician to provide CAM (28.2% vs. 14.5% vs. 3.8%; p<0.0001). CONCLUSION: Patients, PCPs, and CAM practitioners suggested that family physicians play a central role in CAM referral and, to a lesser extent, that they actually provide CAM treatment themselves. PRACTICE IMPLICATIONS: PCPs need to be aware of their present and future role in informed referral to CAM and, to a lesser degree, in providing CAM in integrative primary care clinics. With the increasing use of CAM, patients may expect their family physician to be more knowledgeable, skillful, and have a balanced approach regarding CAM use. In addition, practitioners should learn how to communicate effectively and better collaborate with CAM practitioners to the benefit of their patients.     

An evidence base for patient-centered cancer care: A meta-analysis of studies of observed communication between cancer specialists and their patients

Objective

In the context of patients visiting cancer specialists, the objective is to test the association between both patient-centered communication (including Affective Behavior and Participation Behavior) and Instrumental Behavior and patients’ post-visit satisfaction with a variety of visit phenomena.

Methods

Meta-analysis of 25 articles representing 10 distinct data sets.

Results

Both patient-centered- and instrumental behavior are significantly, positively associated with satisfaction, with patient-centered communication having a relatively stronger association.

Conclusion

There is an evidence base for the efficacy of patient-centered care.

Practice implications

Cancer specialists need to train to improve their patient-centered communication.     

Verbal and non-verbal behavior of doctors and patients in primary care consultations - how this relates to patient enablement

Objective

To assess the relationship between observable patient and doctor verbal and non-verbal behaviors and the degree of enablement in consultations according to the Patient Enablement Instrument (PEI) (a patient-reported consultation outcome measure).

Methods

We analyzed 88 recorded routine primary care consultations. Verbal and non-verbal communications were analyzed using the Roter Interaction Analysis System (RIAS) and the Medical Interaction Process System, respectively. Consultations were categorized as patient- or doctor-centered and by whether the patient or doctor was verbally dominant using the RIAS categorizations.

Results

Consultations that were regarded as patient-centered or verbally dominated by the patient on RIAS coding were considered enabling. Socio-emotional interchange (agreements, approvals, laughter, legitimization) was associated with enablement. These features, together with task-related behavior explain up to 33% of the variance of enablement, leaving 67% unexplained. Thus, enablement appears to include aspects beyond those expressed as observable behavior.

Conclusion

For enablement consultations should be patient-centered and doctors should facilitate socio-emotional interchange. Observable behavior included in communication skills training probably contributes to only about a third of the factors that engender enablement in consultations.

Practice implications

To support patient enablement in consultations, clinicians should focus on agreements, approvals and legitimization whilst attending to patient agendas.     

Provider burnout and patient-provider communication in the context of hypertension care

ObjectiveBurnout is prevalent among healthcare providers and associated with poor patient-provider communication. Patient-provider communication is essential for effective care, particularly among patients with conditions such as hypertension. We examined the association between provider burnout and patient-provider communication in hypertension care.MethodsWe used cross-sectional data from 26 primary care providers and their 80 patients with hypertension. Patient-provider primary care visits were audiotaped and providers completed surveys. Patients were 65% Black/African American and 58% female. Providers were 54% white and 65% female. Patient-provider communication was coded using the Medical Interaction Process System (MIPS). We also assess provider-reported level of burnout and suboptimal patient care using validated surveys.ResultsOur findings show an inverse association between burnout and relationship building communication (e.g., displaying empathy) (b=-4.7 p < .05) and between relationship building communication and suboptimal patient care (b=-0.6 p < .05) in multivariate, adjusted models.ConclusionGiven the role of patient-provider communication, our work highlights provider burnout as a potentially significant hindrance to patient-provider relationship building in hypertension care.Practice implicationsFuture research should examine the factors that contribute to provider burnout in order to mitigate their negative effects on patient-provider communication and patient care.     

Delivery of telephone-based supportive care to people with cancer: An analysis of cancer helpline operator and cancer nurse communication

ObjectivesTelephone-based supportive care presents a potentially highly accessible means of addressing unmet supportive care needs for people with cancer. Identification of behaviours that facilitate communication is essential for development of training for telephone-based supportive care. The aim of this study was to describe communication behaviours within supportive care telephone calls in two contexts (1) a telephone outreach intervention and (2) cancer helpline calls, to identify potential areas for further training.Methods50 recorded calls were analysed using two standardised coding systems: the RIAS and Verona-CoDES-C.ResultsMean call length was 21 min (304 utterances) for nurse-outreach calls and 23 min (355 utterances) for helpline calls. Closed questioning, verbal attentiveness and giving information/counselling were the most common communication behaviours identified. Emotional cues were most commonly responded to through non-explicit back-channelling, exploration of content or provision of reassurance or advice.ConclusionsThis study confirmed the need to address the manner in which questions are framed to maximise patient disclosure. Responding to patent emotional cues was highlighted as an area for future training focus.Practice implicationsCommunication skills training that addresses each of these tasks is likely to improve the effectiveness of telephone-based delivery of supportive care.     

Delivery of telephone-based supportive care to people with cancer: An analysis of cancer helpline operator and cancer nurse communication

Objectives

Telephone-based supportive care presents a potentially highly accessible means of addressing unmet supportive care needs for people with cancer. Identification of behaviours that facilitate communication is essential for development of training for telephone-based supportive care. The aim of this study was to describe communication behaviours within supportive care telephone calls in two contexts (1) a telephone outreach intervention and (2) cancer helpline calls, to identify potential areas for further training.

Methods

50 recorded calls were analysed using two standardised coding systems: the RIAS and Verona-CoDES-C.

Results

Mean call length was 21 min (304 utterances) for nurse-outreach calls and 23 min (355 utterances) for helpline calls. Closed questioning, verbal attentiveness and giving information/counselling were the most common communication behaviours identified. Emotional cues were most commonly responded to through non-explicit back-channelling, exploration of content or provision of reassurance or advice.

Conclusions

This study confirmed the need to address the manner in which questions are framed to maximise patient disclosure. Responding to patent emotional cues was highlighted as an area for future training focus.

Practice implications

Communication skills training that addresses each of these tasks is likely to improve the effectiveness of telephone-based delivery of supportive care.     

Communicating acute coronary syndrome risk to women in primary care: A scoping review of the literature

ObjectivesDelay from symptom onset to hospital arrival drives poor outcomes in acute coronary syndrome (ACS), particularly for women. Primary care clinicians can discuss ACS with high-risk women, potentially reducing delay. We conducted a scoping review to assess what is known about ACS risk communication to women in primary care.MethodsWe used Arksey and O'Malley's framework. The PubMed, CINAHL, PsycINFO, and Embase databases were searched for relevant articles from inception through September, 2018. No restrictions on study methodology were applied. At least two reviewers assessed each article. Articles addressing risk communication, coronary heart disease, and ACS, related to primary care settings, and including women were retained.ResultsEleven articles met inclusion criteria. Cardiovascular disease (CVD) risk communication is common in primary care; however, ACS symptoms are rarely discussed. Structured risk calculators are used to frame discussions. Communication styles include patient-centered discussions, paternalistic orders, and “scare tactics;” no single style is more effective. Analysis of gender differences in risk communication is extremely limited.ConclusionThere is scant evidence that primary care clinicians communicate effectively about ACS risk, symptoms, and appropriate symptom response.Practice implicationsInterventions are needed to improve communication about ACS to at-risk women in the primary care setting.     

Patients' ratings of the in-hospital discharge briefing and post-discharge primary care follow-up: The association with 30-day readmissions

ObjectiveWe examined whether patients' ratings of their in-hospital discharge briefing and their post-discharge Primary Care Physicians' (PCP) review of the discharge summary are associated with 30-day readmissions.MethodsA prospective study of 594 internal-medicine patients at a tertiary medical-center in Israel. The in-hospital baseline questionnaire included sociodemographic characteristics, physical, mental, and functional health status. Patients were surveyed by phone about the discharge and post-discharge processes. Clinical data and health-service use was retrieved from a central data-warehouse. Multivariate regressions modeled the relationship between in-hospital baseline characteristics, discharge briefing, PCP visit indicator, the PCP discharge summary review, and 30-day readmissions.ResultsThe extent of the PCPs' review of the hospital discharge summary at the post-discharge visit was rated higher than the in-hospital discharge briefing (3.46 vs. 3.17, p = 0.001) and was associated with lower odds of readmission (OR=0.35, 95% CI 0.26–0.45). The model that included this assessment performed better than the in-hospital baseline, the in-hospital discharge-briefing, and the PCP visit models (C-statistic = 0.87, compared with: 0.70, 0.81, 0.81, respectively).ConclusionsProviding extensive post-discharge explanations by PCPs serves as a significant protective factor against readmissions.Practice implicationsPCPs should be encouraged to thoroughly review the discharge summary letter with the patient.     

Parent activation and pediatric primary care outcomes for vulnerable children: A mixed methods study

ObjectiveAmong children in low-income families 1) examine associations between parent activation and pediatric primary care outcomes and 2) explore parent perspectives on Parent-Patient Activation Measure (P-PAM) questions in relation to pediatric primary care experiences.MethodsWe examined associations between P-PAM score via Spanish- or English-language survey and healthcare outcomes abstracted from electronic medical records for parent/child dyads at an urban general pediatrics clinic. Parent perspectives were elicited via qualitative interviews with a subsample of parents who “thought aloud” during P-PAM completion.ResultsAmong 316 Spanish (68%) and English-language parent/child dyads, we found associations between parent activation and primary care outcomes only among Spanish-language dyads and only for weight and health status. Findings from 21 interviews provided possible explanations for quantitative findings including question limitations in assessing knowledge, skills, and confidence in pediatric primary care and P-PAM cultural and linguistic appropriateness for low-income Latino populations.ConclusionsPairing quantitative and qualitative methods provided insight on P-PAM measurement limitations and raised questions about its use in patient engagement interventions to reduce health disparities.Practice implicationsPractices serving vulnerable children and families should consider the limitations of the P-PAM for measuring parent healthcare engagement before utilizing the P-PAM in patient engagement interventions.     

Hospice nurse identification of comfortable and difficult discussion topics: Associations among self-perceived communication effectiveness,nursing stress,life events,and burnout

ObjectiveTo assess hospice nurses’ self-perceived communication effectiveness, identify comfortable and difficult discussion topics, and explore associations between self-perceived communication effectiveness, burnout, nursing stress, and life events.Methods181 nurses completed self-report measures, then listed comfortable and/or difficult patient and caregiver discussion topics.ResultsNurses were generally experienced (median 9 years, range <1–46 as a registered nurse; median 3 years, range <1–23 as a hospice nurse), reporting overall Effective/Very Effective communication skills (85.6%); 70% desired more communication training. As nursing stress increased perceived overall communication effectiveness decreased (r_s = ?0.198; p 0.012). As burnout increased overall effectiveness (r_s = ?0.233; p 0.002) and effectiveness with difficult topics (r_s = ?0.225; p 0.003) decreased. Content analysis revealed 9 categories considered both comfortable and difficult to discuss; contextual comments provided fuller explanation (e.g. providing general information on the Dying Process was comfortable, discussing Dying process during patient death was difficult). Seven additional categories (e.g. Denial) were deemed uniquely difficult.ConclusionHospice nurses perceive themselves as effective communicators, yet want additional training. Perceived communication effectiveness is associated with burnout and stress.Practice implicationsCommunication training that focuses on contextually grounded topics identified by participants may optimize communication between hospice nurses, patients and caregivers.     

Cultural competency and microaggressions in the provision of care to LGBT patients in rural and appalachian Tennessee

PurposeLack of provider training in lesbian, gay, bisexual, and transgender (LGBT) cultural competence may diminish healthcare access. Culturally competent providers may enact microaggressions when providing LGBT patient care, especially in sociopolitically conservative areas. Our study examined LGBT cultural competence and microaggressions among healthcare providers in rural Tennessee.MethodsProviders (n = 85) completed a self-report survey on LGBT cultural competence. Post-survey, we invited respondents to provide an interview to contextualize quantitative findings and identify barriers to LGBT patient care (n = 6).ResultsMost quantitative respondents disagreed that they preferred not to care for LGBT patients (85.9%) or that they would refuse care to LGBT patients (92.9%). Only half felt competent to provide LGBT patient care (54.1%). Fewer oncology than primary care providers felt competent treating LGBT patients, and more physicians than nurses reported their training did not adequately address LGBT issues. Qualitatively, interviewees reported serving patients “equally”, yet described discomfort with LGBT patients and LGBT microaggressions in clinical practice.Principal conclusionsWhile many providers felt competent to provide LGBT patient care, they described behaviors and attitudes that may contribute to LGBT healthcare inequities.Practice ImplicationsProvider training must address how microaggressions negatively influence patient-provider interactions and LGBT patient care.