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.     

Communication and education about triggers and environmental control strategies during pediatric asthma visits

Objective

To determine the extent to which providers, caregivers, and pediatric asthma patients discussed environmental trigger control during primary care visits, and any demographic characteristics associated with having these discussions.

Methods

Children ages 8-16 with persistent asthma and their caregivers were recruited at five pediatric practices in non-urban areas of North Carolina. All of the medical visits were audio-tape recorded. We administered questionnaires to the child's caregiver following the visit.

Results

Two hundred and ninety-six patients had useable audio-tape data. Providers typically discussed at least one type of asthma trigger during these visits (86% of visits). The most common discussions were about exercise (70%), the weather/season (42%), and allergies/pollen (35%). Environmental control strategies were discussed less frequently (27% of visits). Providers educated the patient and their caregiver about environmental control strategies during 14% of the visits.

Conclusion

Although providers frequently discuss some environmental triggers and provide education, there is room for more comprehensive discussions of these issues, which may contribute to decreased asthma exacerbations.

Practice implications

Providers, or alternatively, asthma health educators, should devote more time to discussing environmental asthma triggers and control strategies with pediatric asthma patients and their families, as they are important components of overall asthma control.     

The landscape of postgraduate education in palliative care for general practitioners: results of a nationwide survey in Flanders, Belgium

Objective

To describe the offer of continuing medical education (CME) in palliative care in Flanders, Belgium and to explore the way providers of CME address the preferences of general practitioners (GP's) towards CME.

Methods

Questionnaire-survey among official providers of formal CME.

Results

The response rate was 43%, equally distributed over all 5 provinces of Flanders. Data show large content gaps, an under usage of appropriate educational techniques and an absence of evaluation of the impact of CME on clinical practice. Providers of CME explain how they take the preferences of GP's concerning education in palliative care into account.

Conclusions

The present offer of CME is insufficient to educate GP's in palliative care. The absence of quality criteria and the lack of coordination between different providers results in an unattractive labyrinth of courses leaving GP's and their patients in the cold.

Practice implications

A comprehensive offer of CME sessions should be installed in a coordination between all providers. This could render the use of means (logistics and speakers) more efficient. Further research could look into other ways of acquiring palliative care competences such as evaluating the learning effect of GP's working together with specialized palliative home care teams.     

Structured contraceptive counseling—A randomized controlled trial

Objective

To evaluate the addition of structured contraceptive counseling to usual care on choice, initiation, and continuation of very effective contraception after uterine aspiration.

Methods

We conducted a RCT of a version of the WHO Decision-Making Tool for Family Planning Clients and Providers with women having a procedure for a spontaneous or induced abortion. Our intervention provided structured, standardized counseling. We randomized women to usual care or usual care with structured counseling. Our outcomes included choosing a very effective contraceptive method and 3 months continuation.

Results

Fifty-four percent of all participants chose a very effective method. Women in the intervention group were no more likely to choose a very effective method (OR 0.74, 95% CI 0.44, 1.26) or to initiate their method compared to the usual care group (OR 0.65, 95% CI 0.31, 1.34). In multivariate models, structured counseling was not associated with using a very effective method at 3 months (AOR 1.06, 95% CI 0.53, 2.14).

Conclusion

In this setting, structured counseling had little impact on contraceptive method choice, initiation, or continuation.

Practice implications

Adding structured counseling did not increase the proportion choosing or initiating very effective contraception in a practice setting where physicians already provide individualized counseling.     

Medical and psychology students' self-assessed communication skills: A pilot study

Objective

The purpose of this study was to describe how psychology and medical students assess their own competency and skills before and after training, in which role-play was used to teach interpersonal and communication skills.

Method

Interpersonal and communication skills were assessed with a semi-structured questionnaire before and after the training.

Results

The students of both medicine and psychology estimated their skill levels to be higher after the course. The psychology students estimated their skills for communication, motivating interviewing, empathy and reflection, and change orientation to be better at the end of the course. Medical students estimated their communication skills, motivating interviewing skills, and change orientation skills to be better at the end of the course.

Conclusion

Even a short period of training in interpersonal and communication skills can positively affect the self-assessed skills of the medical students.

Practice implications

In the future, it would be worthwhile to pay attention to reflective teaching practices in the training of both medical and psychology students. The cognitive and emotional components of these practices help students to develop their own communication skills.     

The role of cultural distance between patient and provider in explaining racial/ethnic disparities in HIV care

Objective

We sought to evaluate whether cultural distance between patients and providers was associated with quality of care for people living with HIV/AIDS, and whether cultural distance helped explain racial/ethnic disparities in HIV care.

Methods

We surveyed 437 patients and 45 providers at 4 HIV clinics in the U.S. We examined the association of patients’ perceived cultural distance from their providers with patient ratings of healthcare quality, trust in provider, receipt of antiretroviral therapy, medication adherence, and viral suppression. We also examined whether racial/ethnic disparities in these aspects of HIV care were mediated by cultural distance.

Results

Greater cultural distance was associated with lower patient ratings of healthcare quality and less trust in providers. Compared to white patients, nonwhites had significantly lower levels of trust, adherence, and viral suppression. Adjusting for patient-provider cultural distance did not significantly affect any of these disparities (p-values for mediation >.10).

Conclusion

Patient-provider cultural distance was negatively associated with perceived quality of care and trust but did not explain racial/ethnic disparities in HIV care.

Practice implications

Bridging cultural differences may improve patient-provider relationships but may have limited impact in reducing racial/ethnic disparities, unless coupled with efforts to address other sources of unequal care.     

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.     

Not all are desired: Providers’ views on interpreters’ emotional support for patients

Objective

This study examines (a) providers’ expectations and concerns for interpreters’ emotional support, and (b) the complexity and dilemma for interpreters to offer emotional support in health care settings.

Methods

We recruited 39 providers from 5 specialties to participate in in-depth interviews or focus groups. Grounded theory was used for data analysis to identify providers’ expectations and concerns for interpreters’ emotional support.

Results

From the providers’ perspective, interpreters’ emotional support: (a) is embodied through their physical presence, (b) is to be both a human being but also a professional, (c) represents the extension of the providers’ care, and (d) imposes potential risks to quality of care.

Conclusion

Emotional support in bilingual health care is accomplished through the alliance of providers and interpreters, complementing each other to support patients’ emotional needs.

Practice implication

Interpreters should be vigilant about how their emotional support may impact the provider-patient relationship and the providers’ therapeutic objectives. Interpreters should be aware that providers also rely on them to provide emotional support, which highlights the importance of giving medical talk and rapport-building talk equal attention in medical encounters.     

From patient to client

Objective

To gain insight in the knowledge, attitude and practices of users and providers of reproductive health services in rural areas of Kyrgyzstan and Tajikistan before and after interventions.

Methods

KAP (Knowledge, Attitude, Practices) studies under 500 respondents.

Results

Training that addressed the determinants of behavioural change contributed to the motivation under health care providers to improve performances. The simultaneously implemented education program for users of health services enhanced the preparedness for birth of pregnant women and their family members. Both interventions had positive effects on health outcomes.

Conclusions

Behavioural change, from hierarchic and directive into client-centred and supportive, can be realized in Central Asia by enhancing the decision-making capacities of providers. A client-centred attitude of health care providers is the key condition for sustainable improvement of service delivery. Improving client-provider communication is a cost-effective way to enhance the quality of care in low resource settings, such as in Central Asia.

Practice implications

The providers can be best trained in a practical setting, when trainees are enabled to practice with real patients, under guidance of a highly skilled professional. Psychological components such as addressing emotions and exploring the values and beliefs of providers should be incorporated in separate training modules.     

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.     

“I Wouldn’t Be this Firm if I Didn’t Care”: Preventive clinical counseling for reproductive health

Objective

This qualitative study of health care clinicians serving women at heightened risk of sexually transmitted infections and unintended pregnancy was undertaken to explore concepts underlying reproductive health counseling messages in clinical encounters.

Methods

In-depth interviews were conducted with 31 clinicians, including physicians and advanced practice nurses serving primarily low-income patients in high-risk communities throughout the U.S.

Results

Most of the clinicians describe their influence on patients and protective behaviors as derived from medical authority and the presentation of information. The use of a parental style of authority, particularly for young or vulnerable patients, and emotional appeals to evoke negative emotions, such as fear, were also used to motivate protective behaviors. Many clinicians highlighted the importance of empathy, and understanding the cultural and social context of health behaviors. A few clinicians described innovative efforts to empower women to protect themselves and exert more control in relationships.

Conclusion

Some of the reproductive health counseling approaches described by clinicians are not consistent with leading health behavior change theories or patient-centered counseling.

Practical implications

To improve counseling, these messages and concepts need to be evaluated for effectiveness, and possibly used to inform the development of novel theories for use in reproductive health counseling.     

Information needs of informal caregivers of older adults with chronic health conditions

Objective

To systematically examine current evidence pertaining to information needs of informal caregivers of older adults with chronic health conditions.

Methods

Structured search of MEDLINE, MEDLINE IN-PROCESS, CINAHL, and PsycINFO databases to identify studies of caregiver information needs, followed by data extraction and syntheses.

Results

The 62 articles that met the stated inclusion criteria highlighted extensive needs among informal caregivers for practical, accessible, timely information.

Conclusion

The identified information needs of informal caregivers can inform organizations and agencies that seek to provide disease and illness-related information.

Practice implications

Existing evidence supports the implementation of a health information delivery system designed to meet the needs of informal caregivers of older adults with chronic health conditions.     

Comparing clinician knowledge and online information regarding Alli (Orlistat)

Background

Many consumers join online communities focused on health. Online forums are a popular medium for the exchange of health information between consumers, so it is important to determine the accuracy and completeness of information posted to online forums.

Objective

We compared the accuracy and completeness of information regarding the FDA-approved over-the counter weight-loss drug Alli (Orlistat) from forums and from clinicians.

Methods

We identified Alli-related questions posted on online forums and then posed the questions to 11 primary care providers. We then compared the clinicians’ answers to the answers given on the forums. A panel of blinded experts evaluated the accuracy and completeness of the answers on a scale of 0-4. Another panel of blinded experts categorized questions as being best answered based on clinical experience versus review of the literature.

Results

The accuracy and completeness of clinician responses was slightly better than forum responses, but there was no significant difference (2.3 vs. 2.1, p = 0.5). Only one forum answer contained information that could potentially cause harm if the advice was followed.

Conclusions

Forum answers were comparable to clinicians’ answers with respect to accuracy and completeness, but answers from both sources were unsatisfactory.     

Web-enabled video-feedback: a method to reflect on the communication skills of experienced physicians

Objective

To describe our web-enabled video-feedback method designed to reflect on the communication skills of experienced physicians.

Methods

Participating physicians (n = 28) received a ‘personal web link’ to two of their video-recorded consultations. After watching the consultations physicians received feedback by telephone or in a face-to-face meeting, structured around an individualized feedback report. This report contained scores on the communication behavior of the physician in comparison with colleagues and their own communication behavior observed in a previous study, as well as patients’ opinions about their physician's communication behavior. The physicians were asked to reflect on their communication skills and to comment on the usefulness and efficiency of the feedback method.

Results

Almost all physicians were satisfied with the feedback method and in particular valued the web-enabled link to the video-recorded consultations and the structured written report. Feedback by telephone or face-to-face feedback was considered equally appropriate.

Conclusion

This web-enabled video-feedback method is a useful and structured design to reflect on the communication skills of physicians.

Practice implications

As part of continuing medical education, feedback on communication skills should become a recurrent activity for experienced physicians. This method can also be used to reflect on the communication skills of medical students.     

Who's in charge? The role of responsibility attribution in self-management among people with chronic illness

Objective

To explore how responsibility attribution influences self-management regimens among people with chronic illness.

Methods

This qualitative content analysis included 26 interviews with people living with chronic illness.

Results

The participants attributed responsibility to internal, external or a combination of these factors, meaning that they either assumed responsibility for self-management or considered other people or factors responsible. Internal responsibility was associated with a multifaceted self-management regimen, whereas external responsibility was related to “conventional” self-management such as taking medication, managing symptoms and lifestyle changes.

Conclusion

How responsibility is attributed is vital for the way in which individuals perform self-management. In this study, those who attributed responsibility to external factors mainly performed recommended behaviours to control their illness. In contrast, to take charge of their illness and be an active participant in the care, individuals must take responsibility for themselves, i.e. internal responsibility.

Practice implications

Health-care providers should acknowledge and support individuals’ wishes about various levels of responsibility as well as different kinds of patient-provider relationships.     

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.     

Systematic appraisal of dementia guidelines for the management of behavioural and psychological symptoms

Background

Within the treatment of dementia, management of behavioural and psychological symptoms (BPSD) is a complex component.

Purpose

We wanted to offer a pragmatic synthesis of existing specific practice recommendations for managing BPSD, based on agreement among systematically appraised dementia guidelines.

Data sources

We conducted a systematic search in MEDLINE and guideline organisation databases, supplemented by a hand search of web sites.

Study selection

Fifteen retrieved guidelines were eligible for quality appraisal by the Appraisal of Guidelines Research and Evaluation instrument (AGREE), performed by 2 independent reviewers.

Data extraction

From the 5 included guidelines, 18 specific practice recommendations for BPSD were extracted and compared for their level of evidence and strength.

Data synthesis

No agreement was found among dementia guidelines for the majority of specific practice recommendations with regard to non-pharmacological interventions, although these were recommended as first-line treatment. Pharmacological specific practice recommendations were proposed as second-line treatment, with agreement for the use of a selection of antipsychotics based on strong supporting evidence, but with guidance for timely discontinuation.

Limitations

The appraisal of the level of agreement between guidelines for each specific practice recommendation was complicated by variation in grading systems, and was performed with criteria developed a posteriori.

Conclusion

Despite the limited number of recommendations for which agreement was found, guidelines did agree on careful antipsychotic use for BPSD. Adverse events might outweigh the supporting evidence of efficacy, weakening the recommendation. More pivotal trials on the effectiveness of non-pharmacological interventions, as well as guidelines specifically focusing on BPSD, are needed.     

Averting adverse events in communication skills training: A case series

Objective

To document cases of adverse or near adverse events in communication skills training (CST) and to identify risk factors and strategies to reduce the likelihood of their occurrence.

Methods

Six physician CST cases meeting criteria for an adverse or near adverse collected from experienced facilitators are analyzed and discussed.

Results

Three types of adverse CST events are described: traumatic personal experiences or losses evoked by training; perception that feedback is not empathic; and where trainees are referred for remedial CST as a risk management strategy.

Conclusion

Early identification of risk factors and emotional cues of trainees is a key first step that facilitates implementation of remedial strategies to avert potential adverse events. Consideration of ways that physicians’ personal experiences impact communication and good feedback techniques are vital. The implications of physicians sent to CST for risk management purposes is a new scenario that deserves special consideration.

Practice implications

To make CST safer and to optimize learning, early recognition of potential adverse events is essential. Specific feedback techniques should be mastered by all CST facilitators.