What can people approaching death teach us about how to care?

Objective

This study sought to hear what patients approaching death had to say about doctor-patient interactions and care in order that doctors can learn how to demonstrate care more effectively so that each patient feels cared for as an individual.

Methods

In semi-structured interviews, 13 people dying of cancer shared their experiences and perspectives on care within the patient-doctor relationship.

Results

Participants’ recollections of experiences with doctors showed that genuine demonstration of care begins with doctors seeking common ground with the patient as a fellow human being and individual. The psychological and physical suffering that results from allowing stereotypical assumptions and behaviours to shape doctor-patient interaction was clear.

Conclusion

The consequences of allowing the stereotypes and power of the primary context in which patients and doctors interact challenge the process of building a caring doctor-patient relationship. Caring doctors overcame this by exploring and carefully attending to the individual characteristics and needs of patients as people first and foremost.

Practice implications

To demonstrate genuine care doctors must learn to recognise and question the social expectations and inherent assumptions of medical contexts and roles of patient and doctor and allow unique characteristics of patient and context to guide their interactions.     

The doctor and the patient--how is a clinical encounter perceived?

Objective

To examine the population distribution of different types of relationships between people with chronic conditions and their doctors that influence decisions being made from a shared-decision making perspective.

Methods

A survey questionnaire based on recurring themes about the doctor/patient relationship identified from qualitative in-depth interviews with people with chronic conditions and doctors was administered to a national population sample (n = 999) of people with chronic conditions.

Results

Three factors explained the doctor/patient relationship. Factor 1 identified a positive partnership characteristic of involvement and shared decision-making; Factor 2 doctor-controlled relationship; Factor 3 relationship with negative dimensions. Cluster analysis identified four population groups. Cluster 1 doctor is in control (9.7% of the population); Cluster 2 ambivalent (27.6%); Cluster 3 positive long-term relationship (58.6%); Cluster 4 unhappy relationship (4.4%). The proportion of 18-34 year olds is significantly higher than expected in Cluster 4. The proportion of 65+ year olds is significantly higher than expected in Cluster 1, and significantly lower than expected in Cluster 4.

Conclusion

This study adds to shared decision-making literature in that it shows in a representative sample of people with chronic illnesses how their perceptions of their experiences of the doctor-patient relationship are distributed across the population.

Practice implications

Consideration needs to be given as to whether it is better to help doctors to alter their styles of interactions to suit the preferences of different patients or if it is feasible to match patients with doctors by style of decision-making and patient preference.     

Kenyan patients’ attitudes regarding doctor ethnicity and doctor-patient ethnic discordance

Objective

This study explored Kenyan patients’ perspectives on the role of ethnicity in the doctor-patient relationship.

Methods

221 participants completed questionnaires on ethnicity in doctor-patient relationships; eight focus groups were held with low- and middle-income urban and rural women.

Results

About half of participants expressed no preference for doctor ethnicity. Participants rated demographic factors as less important than factors related to the doctor's qualifications, communication skills, and cost of service. Those who did indicate a preference were more likely to prefer Indian doctors for eye problems and Europeans for major surgery, cancer, and heart problems. With less severe medical issues participants were more likely to prefer a doctor who was ethnically concordant with them. Reasons for this centered around communication issues. In contrast, several focus group participants did not want to be treated by doctors from their own ethnic group because of concerns about confidentiality.

Conclusion

Additional research is needed on negative implications of patient-provider concordance.

Practice implications

Medical service providers must be aware of concerns about ethnic concordance. Alternatively medical centers that deal with sensitive medical information need to consider hiring staff who are not of the majority ethnic group in their region.     

Patients’ experiences with continuum of care across hospitals. A multilevel analysis of Consumer Quality Index Continuum of Care

Objective

Communication between professionals is essential because it contributes to an optimal continuum of care. Whether patients experience adequate continuum of care is uncertain. To address this, a questionnaire was developed to elucidate this care process from a patients’ perspective. In this study, the instrument's ability to measure differences in “Consumer Quality Index Continuum of Care” scores between hospitals was investigated.

Methods

The questionnaire was mailed to a random sample of 2159 patients and comprised of 22 items divided over four domains, GP approach, GP referral, specialist and collaboration. Multilevel analysis was conducted to identify case-mix and determine this questionnaire's ability to measure differences in domain scores between hospitals.

Results

Based on a 65% response rate, 1404 questionnaires were available for analysis. Case-mix of patient characteristics across hospitals could not be demonstrated. Some differences in scores between hospitals were observed. At most two in eight hospitals showed different domain scores.

Conclusion

The ability of this questionnaire to measure differences in continuum of care scores between hospitals is limited. The outcome of this survey suggests that hospitals provide a similar level of continuum of care from a patient's perspective.

Practical implications

This questionnaire is especially useful for measuring differences between patients.     

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

Objective

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

Methods

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

Results

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

Conclusion

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

Practice implications

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

Language barriers and the use of interpreters in the public health services. A questionnaire-based survey

Objective

This study aims to examine cross-cultural communication in health-care settings, which has implications for equal access to health services. We studied how often health-care workers experience a need for language assistance, what they do in such situations, what expectations they have of the interpreters and their evaluation of competency needs.

Methods

A quantitative cross-sectional design using a structured questionnaire was used. The participants were health-care providers in Oslo, and the survey was conducted 2004-2005.

Results

The response rate was 35.1%. The largest category of participants (51.1%) consisted of nurses, followed by the second largest category (26.6%) of 120 physicians. Our results suggested an underutilization of interpreter services in the public health-care system.

Conclusions

The use of interpreter services seems to be sporadic and dependent on the individual health-care practitioner's own initiative and knowledge. Many survey participants expressed dissatisfaction with both their own methods of working with interpreters and with the interpreter's qualifications.

Practice implications

A key area for further improvement is the process of raising awareness among health-care providers and institutions regarding the legal responsibility they have to ensure the sufficient level of communication with their patients/clients.     

Sharing vs. caring—The relative impact of sharing decisions versus managing emotions on patient outcomes

Objective

To assess the relative impact of cognitive and emotional aspects of shared decision making (SDM) on patient outcomes.

Methods

Cognitive and emotional aspects of SDM in consultations between 20 oncologists and 55 early breast cancer patients were coded using the Observing Patient Involvement (OPTION) scale and the Response to Emotional Cues and Concerns (RECC) coding system, plus blocking and facilitating behaviour scales. Patient outcomes including anxiety, decisional conflict, and satisfaction with: (i) the decision, (ii) the consultation, and (iii) doctor SDM skills, were assessed. Relationships between cognitive and emotional aspects of SDM, and patient outcomes were examined using hierarchical regression.

Results

The OPTION score predicted satisfaction with doctor SDM skills 2 weeks post-consultation (p = .010), and with the treatment decision 4 months post-consultation (p = .004). Emotional blocking predicted decisional conflict (p = .039), while the number of emotional cues emitted (p = .003), and the degree of empathy provided (p = .011), predicted post-consultation anxiety.

Conclusion

Cognitive and emotional aspects of SDM in oncology consultations have different effects on various patient outcomes.

Practice implications

It is important that doctors focus on both sharing decisions and managing emotions in consultations. Communication skills training addressing both these areas may be an effective way to improve diverse patient outcomes.     

Patient preference to use a questionnaire varies according to attributes

Objective

Health care professionals may assume questionnaires are burdensome to patients, and this limits their use in clinical settings and promotes simplification. However, patient adherence may improve by optimizing questionnaire attributes and contexts.

Methods

This cross-sectional survey used Contingent Valuation methods to directly elicit patient preference for conventional monitoring of symptoms, versus adding a tool to monitoring. Under explicit consideration was the 10-question Edmonton Symptom Assessment System (ESAS). In the questionnaire, attributes of ESAS were sequentially altered to try and force preference reversal. A separate group of participants completed both questionnaire and interviews to explore questionnaire reliability, and extend validity.

Results

Overall, 24 of 43 participants preferred using ESAS. Most important attributes to preference were frequency, specificity, and complexity. Where preference is initially against ESAS, it may reverse by simplifying the tool and its administrative processes. Interviews in 10 additional participants supported reproducibility and validity of the questionnaire method.

Conclusions

Preference for using tools increases when tools are made relevant and used more appropriately.

Practice implications

Questionnaires completed by patients as screening tools or aids to communication may be under-utilized. Optimization of ESAS and similar tools may be guided by empirical findings, including those obtained from Contingent Valuation methodologies.     

A randomized controlled trial of communication training with primary care providers to improve patient-centeredness and health risk communication

Objective

To determine the efficacy and effectiveness of training to improve primary care providers’ patient-centered communication skills and proficiency in discussing their patients’ health risks.

Methods

Twenty-eight primary care providers participated in a baseline simulated patient interaction and were subsequently randomized into intervention and control groups. Intervention providers participated in training focused on patient-centered communication about behavioral risk factors. Immediate efficacy of training was evaluated by comparing the two groups. Over the next 3 years, all providers participated in two more sets of interactions with patients. Longer term effectiveness was assessed using the interaction data collected at 6 and 18 months post-training.

Results

The intervention providers significantly improved in patient-centered communication and communication proficiencies immediately post-training and at both follow-up time points.

Conclusions

This study suggests that the brief training produced significant and large differences in the intervention group providers which persisted 2 years after the training.

Practice implications

The results of this study suggest that primary care providers can be trained to achieve and maintain gains in patient-centered communication, communication skills and discussion of adverse childhood events as root causes of chronic disease.     

The effect of numeracy on the comprehension of information about medicines in users of a patient information website

Objective

To investigate the relationship between numeracy and the accuracy of side effect risk estimation following the presentation of information about a medicine via the Cancer Research UK (CR-UK) patient information website.

Methods

591 website users were presented with information in different formats about the risks of side effects from taking tamoxifen. Participants estimated the risk of each side effect, provided other subjective ratings about the information and completed a numeracy task.

Results

Regardless of presentation format, numeracy was correlated with the accuracy of three side effect risk estimates. People with cancer and tamoxifen users showed stronger correlations for all side effect estimates. In addition, numeracy was positively related to the perceived influence of the information on the decision to take the medicine and was negatively related to ratings of satisfaction with the information.

Conclusion

People with a lower numeracy level make larger errors in interpreting medicines side effect risk information.

Practice implications

Pharmacists, other health professionals and patient information websites should ensure they provide clear explanations of risk, particularly to people with low numeracy, and assess their understanding of those explanations. Future research into risk communication should take account of numeracy level, to investigate the impact of different formats.     

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.     

Expectations and experiences of eHealth in primary care: A qualitative practice-based investigation

Objectives

(1) To assess expectations and experiences of a new eHealth service by patients and staff in three primary care settings; (2) to ascertain attitudes to a range of future, primary care-oriented eHealth services.

Design

Qualitative case study.

Setting

Three UK general practices introducing an eHealth service for booking patient appointments.

Participants

Ninety patients purposively selected from users and non-users of the new service and 28 staff (clinicians, management and administrative staff).

Results

Actual patient use of the service was lower than stated intention. Patients and staff felt that more active promotion of the service would have resulted in more use. Low usage did not result in a negative assessment of the service by most staff. Different patient groupings were identified with characteristics that may be used as predictors of eHealth service use and indicators of training needs. GPs and patients expressed opposing viewpoints on a range of future eHealth services.

Conclusions

Take-up of eHealth services may be lower than expected. To overcome patient barriers, factors that may narrow the intention-behaviour gap such as level of service promotion, GP endorsement, and usage by different patient groups, should be investigated. For clinician barriers, the eHealth evidence base needs strengthening, while for primary care practices, a learning process including staff training needs to be instituted. The differing views of patients and GPs about components of eHealth means that policymakers need to plan for a lengthy political process to obtain agreement on contentious issues if they are to achieve successful eHealth services.     

Dyadic OPTION: Measuring perceptions of shared decision-making in practice

Background

Current models of the medical consultation emphasize shared decision-making (SDM), whereby the expertise of both the doctor and the patient are recognised and seen to equally contribute to the consultation. The evidence regarding the desirability and effectiveness of the SDM approach is often conflicting. It is proposed that the conflicts are due to the nature of assessment, with current assessments from the perspective of an outside observer.

Aims

To empirically assess perceived involvement in the medical consultation using the dyadic OPTION instrument.

Method

36 simulated medical consultations were organised between general practitioners and standardized- patients, using the observer OPTION and the newly developed dyadic OPTION instruments.

Results

SDM behaviours observed in the consultations were seen to depend on both members of the doctor and patient dyad, rather than each in isolation. Thus a dyadic approach to measurement is supported.

Conclusions

This current study highlights the necessity for a dyadic approach to assessment and introduces a novel research instrument: the dyadic OPTION instrument.     

Doctors in a Southeast Asian country communicate sub-optimally regardless of patients' educational background

Objective

To explore the relationship between the style of doctor-patient communication and patients’ educational background in a Southeast Asian teaching hospital setting using the Roter Interaction Analysis System (RIAS).

Methods

We analyzed a total of 245 audio-taped consultations involving 30 internal medicine residents with 7-10 patients each in the internal medicine outpatient clinics. The patients were categorized into a group with a high and a group with a low educational level. We ranked the data into 41 RIAS utterances and RIAS-based composite categories in order of observed frequency during consultations.

Results

The residents invariantly used a paternalistic style irrespective of patients’ educational background. The RIAS utterances and the composite categories show no significant relationship between communication style and patients’ educational level.

Conclusion

Doctors in a Southeast Asian country use a paternalistic communication style during consultations, regardless of patients’ educational background.

Practice implication

To approach a more partnership doctor-patient communication, culture and clinical environment concern of Southeast Asian should be further investigated.     

Mixed methods evaluation: pharmacists' experiences and beliefs toward an interactive communication approach to patient interactions

Objective

To characterize pharmacists’ experience and explore their beliefs toward an interactive communication technique, the three prime questions (3PQs),where pharmacists ask about patients’ understanding of medication's purpose, directions, and monitoring.

Methods

Mixed method design. Pharmacists were briefly trained and then integrated the 3PQs into their practice for two weeks. Pharmacists recorded their perceptions of patient interactions, completed a survey addressing self-efficacy and role beliefs toward the 3PQs, and participated in a focus group.

Results

Eleven pharmacists participated and the 3PQs were used with 176 patients. Most interactions were under 5 min. Pharmacists reported that questions about directions and monitoring were most effective in gathering new information with refills whereas medication purpose question was preferred for new fills. The majority of pharmacists were certain they could use the 3PQs and agreed it was their role. Five themes arose from the qualitative analysis: established communication routines, enhanced patient-pharmacist relationships, good medication history, tailoring of the 3PQs, and impact of pharmacy organization.

Conclusion

The 3PQs enabled pharmacists to briefly assess patient medication experiences and tailor education while fostering patient-centered relationships in pharmacy practice.

Practice implications

While the 3PQs may enhance pharmacists’ patient assessment; integration may challenge pharmacists’ work routine.     

Parotitis associated with Crimean Congo hemorrhagic fever virus

Background

Crimean Congo Hemorrhagic Fever (CCHF) is a potentially fatal tick-borne viral disease, the course of which may accompanied by various clinical findings.

Objectives

We describe a picture of non-suppurative parotitis developing in association with CCHF virus.

Study design

A 48-year-old patient presenting to our hospital with lethargy, hemorrhage and pain and swelling below the left ear was diagnosed with CCHF through IgM antibody and polymerase chain reaction positivity in serum investigated for CCHF virus. A picture of non-suppurative parotitis developed on the 3rd day of admission.

Results

Other causes of parotitis were excluded with the help of serological tests, and the case was regarded as one of CCHF-associated parotitis. The patient was put on adjuvant therapy, an improvement in clinical findings was observed and he was discharged in a healthy condition on the 8th day.

Conclusions

Ours is the first case in the literature of parotitis seen during CCHF. CCHF should be considered in differential diagnosis in addition to other frequently encountered viral agents in patients from endemic regions presenting with a picture of non-suppurative parotitis.     

Teaching and evaluating breaking bad news: a pre-post evaluation study of a teaching intervention for medical students and a comparative analysis of different measurement instruments and raters

Objective

To investigate changes of different domains of breaking bad news (bbn) competences after a teaching module for medical students, and to collage the results generated by different approaches of evaluation.

Methods

Rating of medical student-SP interactions by means of a global rating scale and a detailed checklist used by SPs and independent raters.

Results

Students improved their breaking bad news competency. However, the changes vary between the different domains of bbn competency. In addition, results generated by different evaluation instruments differ.

Conclusion

This study serves as a stimulus for further research on the training of specific elements of bbn and different approaches of evaluating bbn competency.

Practice implications

In light of the different facets of bbn competency, it is important to set priorities regarding the teaching aims and to provide a consistent approach.     

“Ne diyor?” (What does she say?): Informal interpreting in general practice

Objective

The aim of this study was to offer a comparative analysis of informal interpreters during medical consultations with both good and poor mutual understanding between general practitioners (GPs) and patients.

Methods

Sixteen video-registered medical interviews of Turkish immigrant patients were analysed. Stretches of discourse of eight interviews with good mutual understanding between patient and doctor were compared to eight interviews with poor mutual understanding. The discourse analysis focused on: (1) miscommunication and its causes; (2) changes in the translation; (3) side-talk activities.

Results

In the cases of ‘poor mutual understanding’, the instances of miscommunication far exceeded those in the ‘good mutual understanding’ group. Style of self-presentation, content omissions and side-talk activities seemed to hinder good mutual understanding.

Conclusion

Alongside the evidence about problems with informal interpreting, sometimes the use of family interpreters can facilitate medical communication.

Practice implications

Recommendations are given in order to increase physicians’ awareness of the complex process of interpreting, as well as to empower informal interpreters and patients to effectively deal with this communicative triad.