Correcting corneal astigmatism by reinstating the correct neuromuscular message

The problem

The spasm of the oblique muscles contributes to astigmatism. The visual cortex interprets the tension of the oblique muscles as an eye that is in near focus mode. It overrides the information generated by depth perception to bring a distant image into focus.

Methodology

A plain contact lens “loosens” the oblique muscles by generating a “contact lens draw”. This triggers the visual cortex to reinstate the proper neuromotor message to stimulate the ciliary muscle to relax along certain meridians—which in turn “flattens” the crystalline lens along those meridians to bring a distant aberrant image into focus. The design of a special contact lens to treat simple myopic astigmatism is similar to the design of a contact lens to treat mild myopia as outlined in the paper Correcting Mild Myopia by Means of Orthoculogy.

Results

The treatment takes advantage of the ciliary muscle’s natural tendency to compensate for some of the distortion of the cornea prior to ortho C by stimulating the ciliary muscle to amplify the compensation. The correction only takes a few minutes because the ciliary muscle of an astigmatic eye was not compromised.

Conclusion

The correct neuromotor message immediately neutralizes the refractive error due to corneal astigmatism. It stimulates the ciliary muscle to offset the astigmatic cornea by modifying the crystalline lens.     

Developing communication skills in pharmacy: A systematic review of the use of simulated patient methods

Objective

To review the literature relating to the use of simulated patient methods to enhance communication skills of pharmacists.

Methodology

We searched Embase, Lilacs, Medline, Scielo, and Scopus databases between 1980 and 2008, using “communication skills”, “patient counseling” and “pharmacist” as keywords. This search was then further refined by using “simulated patients”, “pseudo-customer”, “standardized patients”, and “mystery shoppers” as additional keywords.

Results

The initial search identified 241 published studies. Once further refined, 15 studies met inclusion criteria.

Conclusion

The majority of studies had an assessment focus aimed at documenting counseling behavior of practicing pharmacists, rather than an educational focus aimed at equipping pharmacists with effective communication skills. In instances where simulated patient methods were used for educational purposes, little regard was given to the role of performance and corrective feedback in shaping communication behavior of pharmacists. The majority of studies failed to describe the competencies and skills being investigated in relation to communication in the practice of pharmacy.

Practice implications

Simulated patient methods provide pharmacy educators with a tool for implementing communication skills in the practice of pharmacy and will serve as a basis for implementing communication skills development programs at the College of Pharmacy of the Federal University of Sergipe in Brazil.     

Educating health consumers about cardio-metabolic health risk: What can we learn from lay mental models of risk?

Objective

To study lay conceptions of cardio-metabolic risk and compare them with those of experts, in order to formulate focal points for better educational risk information.

Methods

40 Dutch lay people were interviewed about the risks of developing cardio-metabolic diseases. Following a ‘mental models approach’, their conceptions were qualitatively analyzed and compared to an expert model.

Results

We identified four key themes representing lay conceptions: (1) “same factors, different value” (e.g. the dominance of certain factors, such as stress); (2) “superficiality and incoherence” (e.g. a focus on health and illness in general); (3) “misjudged elevated risk concept” (e.g. either being sick or not); and (4) “no concept of a link between cardio-metabolic diseases” (e.g. separate links between causes and diseases).

Conclusion

Potential mismatches between lay and expert conceptions do not seem to indicate a lack of basic knowledge among consumers, but rather that certain risk factors are not effectively translated into a coherent risk picture.

Practice implications

In improving educational materials, we could more explicitly take into account factors that lay people find important. Additionally, effort should be made to produce a more coherent risk understanding among consumers, for example through an alternative information structure.     

“Speaking-for” and “speaking-as”: Pseudo-surrogacy in physician–patient–companion medical encounters about advanced cancer

Objective

To examine using audio-recorded encounters the extent and process of companion participation when discussing treatment choices and prognosis in the context of a life-limiting cancer diagnosis.

Methods

Qualitative analysis of transcribed outpatient visits between 17 oncologists, 49 patients with advanced cancer, and 34 companions.

Results

46 qualifying companion statements were collected from a total of 28 conversations about treatment choices or prognosis. We identified a range of companion positions, from “pseudo-surrogacy” (companion speaking as if the patient were not able to speak for himself), “hearsay”, “conflation of thoughts”, “co-experiencing”, “observation as an outsider”, and “facilitation”. Statements made by companions were infrequently directly validated by the patient.

Conclusion

Companions often spoke on behalf of patients during discussions of prognosis and treatment choices, even when the patient was present and capable of speaking on his or her own behalf.

Practice implications

The conversational role of companions as well as whether the physician checks with the patient can determine whether a companion facilitates or inhibits patient autonomy and involvement. Physicians can reduce ambiguity and encourage patient participation by being aware of when and how companions may speak on behalf of patients and by corroborating the companion's statement with the patient.     

Information needs of post-menopausal women with hormone receptor positive early-stage breast cancer considering adjuvant endocrine therapy

Objective

To identify questions that post-menopausal women with receptor-positive early-stage breast cancer want answered before their adjuvant-endocrine-therapy decision is made.

Methods

We surveyed patients eligible for adjuvant-endocrine therapy in the previous 3–18 months. Participants rated the importance of getting each of 95 questions answered before the decision is made (options: essential/desired/not important or no opinion/avoid). For each question rated “essential”/“desired”, the participant also identified the purpose(s) for the answer: to help her understand, decide, plan, or other reason(s).

Results

The response rate was 55% (188/343). Participants rated a mean of 57 (range: 1–95) questions “essential”, 80 (range: 1–95) “essential” or “desired”, and 2 (range: 0–27) “avoid”. Every question was “essential” to ≥31% of participants, and “essential”/“desired” to ≥63%. All but eleven questions were rated as “avoid” by ≥1 participant. The most frequent purposes for “essential” questions were to: understand their situations (mean 45, range: 0–95), decide (mean 18, range: 0–94), and plan (mean 13, range: 0–95).

Conclusion

Many patients want a lot of information before this decision is made but there is wide variation within the group in both the number and in which questions they want answered.

Practice implications

Patient education in this setting needs to be tailored to the needs of the individual patient.     

Can physicians be replaced with gynecological teaching women to train medical students in their first pelvic examination? A pilot study from Northern Sweden

Objective

The main objective was to gain a deeper understanding of how medical students perceive and experience learning from gynecological teaching women (GTW) instead of physicians in their first pelvic examination. A second aim was to describe how the women experience their roles as GTW.

Methods

Data were collected from individual interviews with 24 medical students from a medical school in Sweden and with 5 GTW. Discourse analysis was performed to acquire a deeper understanding of the informants’ experiences and to understand social interactions.

Results

Five themes revealed in the medical students’ experiences: “Hoping that anxiety will be replaced with security,” “Meeting as equals creates a sense of calm,” “Succeeding creates a sense of security for the future,” “Wanting but not having the opportunity to learn more,” and “Feeling relieved and grateful.” One theme revealed in the GTW experiences: “Hoping to relate in a trustworthy way.”

Conclusion

To replace physicians with GTW may facilitate the learning process and may also help medical students improve their communicative skills. Using GTW will hopefully further improve students’ basic medical examination techniques and physician–patient relationships.

Practice implications

Since GTW seems to increase self-confidence and skills of medical students performing their first pelvic examination we recommend that the use of GTW is considered in the training of medical students.     

Patients’ and relatives’ complaints about encounters and communication in health care: Evidence for quality improvement

Objective

The aim of this study was to describe patients’ and relatives’ complaints to the local Patients’ Advisory Committee about their encounters and communication in health care.

Methods

Complaints (n = 105) regarding patients’ and relatives’ dissatisfaction with communication and encounters in health care, registered at a local Patients’ Advisory Committee between 2002 and 2004, were included. The texts were analysed using content analysis.

Results

Three categories were identified: “Not receiving information or being given the option to participate”, “Not being met in a professional manner” and “Not receiving nursing or practical support”. Insufficient information, insufficient respect and insufficient empathy were described as the most common reasons for a negative professional encounter.

Conclusion

Patients and relatives experienced unnecessary anxiety and reduced confidence in health care after negative professional encounters.

Practice implications

The complaints reported to the Patients’ Advisory Committee could be used more effectively in health care and be regarded as important evidence when working with quality improvement. To systematically use patient stories, such as those obtained in this report, as a reflective tool in education and supervision could be one way to improve communication and bring new understanding about the patient's perspective in health care.     

The menopause and oral health

Objectives

To review the literature about oral symptoms and signs at the menopause with an emphasis on hormone replacement therapy (HRT). To give practical guidelines for women and their physicians in menopause-related oral health problems.

Methods

The PubMed and Cochrane databases was searched until mid January 2009 with key words such as “menopause”, “menopausal complaints”, “postmenopausal complaints” and “oral diseases”, “oral discomfort”, “dental health”, “dental diseases”, “saliva”, “burning mouth syndrome”, “dry mouth”, “xerostomia”. Because of a scarcity of controlled studies no systematic review could be conducted.

Results

Oral discomfort is found in many menopausal women in addition to more general climacteric complaints. The principal peri- and postmenopausal symptoms are dry mouth and burning mouth (glossodynia) which, in turn, may increase the occurrence of oral mucosal and dental diseases, such as candidiasis. The mechanisms of hormone-related oral symptoms and signs are not known although oestrogen receptors, for example, have been detected in the oral mucosa and salivary glands. In principle, the histology of oral and vaginal mucosa is very similar and thus their symptoms might share a common cause. Yet, hormone replacement therapy use does not necessarily prevent or help women with oral symptoms.

Conclusion

Properly controlled long-term randomized studies are needed to assess the effect of HRT on oral discomfort. Future gene profiling could identify women who may or may not benefit from HRT with regard to oral symptoms.     

What are internal medicine residents missing? A communication needs assessment of outpatient clinical encounters

Objective

In order to guide curricular innovation, we looked at the feasibility and utility of performing a targeted needs assessment of the communication skills of PGY2 internal medicine (IM) residents in their continuity clinic, utilizing faculty direct observation with a validated instrument for communication skills evaluation.

Methods

A convenience sample of PGY2 residents in the Emory University School of Medicine IM Residency Program was invited to participate. Using the SEGUE Framework, a checklist of medical communication tasks, faculty assessed residents during a clinic encounter.

Results

Thirty out of 53 (57%) PGY2 residents were assessed. SEGUE results indicate residents were most likely to “maintain patient's privacy” (100%), “greet patient appropriately” (97%) and “check/clarify information” (100%). Residents were least likely to “acknowledge waiting time” (7%), “explore psychosocial/emotional factors” (27%) and “outline agenda for visit” (33%).

Conclusion

The SEGUE Framework is a feasible tool to evaluate the communication skills of IM residents in a clinic setting. Many PGY2 IM residents in a large, urban practice do not elicit important psychosocial information during outpatient clinic visits.

Practice implications

More observation and evaluation of residents’ communication skills are needed, with emphasis on building skills to “Understand the Patient's Perspective.”     

Five ways of being “theoretical”: Applications to provider–patient communication research

Objective

Analyzes the term “theoretical” as it applies to the area of provider–patient communication research, in order to understand better at a conceptual level what the term may mean for authors and critics.

Methods

Based on literature on provider–patient communication.

Results

Offers, and discusses, five definitions of the term “theoretical” as it applies to empirical research and its exposition: (1) grounding, (2) referencing, (3) design and analysis, (4) interpretation, and (5) impact. Each of these definitions embodies a different standard for evaluating the theoretical aspects of research.

Conclusion

Although it is often said that research on provider–patient communication is not “theoretical” enough, the term is ambiguous and often applied vaguely. A multidimensional analysis reveals that there are several distinct ways in which empirical research can be strong or weak theoretically.

Practice implications

Researchers, educators, editors, and reviewers could use the “Five Ways” framework to appraise the theory-relevant strengths and weaknesses of empirical research and its exposition.     

Doctor's attire influences perceived empathy in the patient–doctor relationship

Objective

This study investigated whether doctors’ attire influences the perception of empathy in the patient–doctor relationship during a therapeutic encounter.

Methods

A total number of 143 patients were divided into four groups when they were consulting a Traditional Korean Medicine doctor. Depending on the group, the same doctor was wearing four different attires – Casual, Suit, Traditional dress, White coat – when having a clinical consultation with the patients.

Results

The patients preferred white coat and traditional dress more than other attires, giving highest scores to white coat in competency, trustworthiness and preference of attire and to traditional dress in comfortableness and contentment with the consultation. The “Consultation and Relational Empathy (CARE)” score was significantly higher in the “White coat” and “Traditional” groups, compared to the “Casual” and “Suit” groups.

Conclusion

The strong association between the patients’ preference of doctors’ attire and the CARE score indicates that the doctor's attire plays not only an important role for establishing confidence and trustworthiness but also for the perception of empathy in the patient–doctor relationship.

Practice implications

The doctor's attire can function as an effective tool of non-verbal communication in order to signal confidence, trust and empathy and establish a good patient–doctor relationship.     

Do cancer-specific websites meet patient's information needs?

Objective

To evaluate commonly used cancer websites’ information provision, we developed and applied an Information Comprehensiveness Tool to breast and prostate cancer websites.

Methods

We first collated questions from a systematic literature review on patient information needs. We then classified the questions in terms of spectrum of care, theme, and nature of question. “Breast cancer” and “prostate cancer” were typed into Google, and websites listed on the first page of results were selected. Two researchers, blind to each others’ scores, assessed the same websites using the coding system. Each question was scored on a 3-point scale as not (0%), partially (50%) and fully (100%) answered by two researchers. Average scores were calculated across all questions. Inter-rater reliability was assessed.

Results

We identified 79 general, 5 breast, and 5 prostate cancer questions. Inter-rater reliability was good, with an intraclass coefficient of 0.756 (95% CIs 0.729–0.781). 17 questions were not answered thoroughly by any website. Questions about “future planning”, “monitoring”, and “decision-making” were discussed least. Biomedical questions scored highest.

Conclusions

More comprehensive information needs to be provided on breast and prostate cancer websites.

Practice implications

This ICT can improve cancer information online and enable patients to engage more actively regarding their information needs.     

SACA: Software Assisted Call Analysis – An interactive tool supporting content exploration,online guidance and quality improvement of counseling dialogues

Objective

Nearly 30,000 individual inquiries are answered annually by the telephone cancer information service (CIS, KID) of the German Cancer Research Center (DKFZ). The aim was to develop a tool for evaluating these calls, and to support the complete counseling process interactively.

Methods

A novel software tool is introduced, based on a structure similar to a music score. Treating the interaction as a “duet”, guided by the CIS counselor, the essential contents of the dialogue are extracted automatically. For this, “trained speech recognition” is applied to the (known) counselor's part, and “keyword spotting” is used on the (unknown) client's part to pick out specific items from the “word streams”. The outcomes fill an abstract score representing the dialogue.

Results

Pilot tests performed on a prototype of SACA (Software Assisted Call Analysis) resulted in a basic proof of concept: Demographic data as well as information regarding the situation of the caller could be identified.

Conclusion

The study encourages following up on the vision of an integrated SACA tool for supporting calls online and performing statistics on its knowledge database offline.

Practice implications

Further research perspectives are to check SACA's potential in comparison with established interaction analysis systems like RIAS.     

Teachable moments for health behavior change: A concept analysis

Objective

“Teachable moments” have been proposed as events or circumstances which can lead individuals to positive behavior change. However, the essential elements of teachable moments have not been elucidated. Therefore, we undertook a comprehensive review of the literature to uncover common definitions and key elements of this phenomenon.

Methods

Using databases spanning social science and medical disciplines, all records containing the search term “teachable moment^*” were collected. Identified literature was then systematically reviewed and patterns were derived.

Results

Across disciplines, ‘teachable moment’ has been poorly developed both conceptually and operationally. Usage of the term falls into three categories: (1) “teachable moment” is synonymous with “opportunity” (81%); (2) a context that leads to a higher than expected behavior change is retrospectively labeled a ‘teachable moment’ (17%); (3) a phenomenon that involves a cueing event that prompts specific cognitive and emotional responses (2%).

Conclusion

The findings suggest that the teachable moment is not necessarily unpredictable or simply a convergence of situational factors that prompt behavior change but suggest the possible creation of a teachable moment through clinician–patient interaction.

Practice implications

Clinician–patient interaction may be central to the creation of teachable moments for health behavior change.     

Whole mind and shared mind in clinical decision-making

Objective

To review the theory, research evidence and ethical implications regarding “whole mind” and “shared mind” in clinical practice in the context of chronic and serious illnesses.

Methods

Selective critical review of the intersection of classical and naturalistic decision-making theories, cognitive neuroscience, communication research and ethics as they apply to decision-making and autonomy.

Results

Decision-making involves analytic thinking as well as affect and intuition (“whole mind”) and sharing cognitive and affective schemas of two or more individuals (“shared mind”). Social relationships can help processing of complex information that otherwise would overwhelm individuals’ cognitive capacities.

Conclusions

Medical decision-making research, teaching and practice should consider both analytic and non-analytic cognitive processes. Further, research should consider that decisions emerge not only from the individual perspectives of patients, their families and clinicians, but also the perspectives that emerge from the interactions among them. Social interactions have the potential to enhance individual autonomy, as well as to promote relational autonomy based on shared frames of reference.

Practice implications

Shared mind has the potential to result in wiser decisions, greater autonomy and self-determination; yet, clinicians and patients should be vigilant for the potential of hierarchical relationships to foster coercion or silencing of the patient's voice.     

Mortality and profiles of community-dwelling fallers. Results from the EPIDOS cohort

Objectives

To assess long-term survival of community-dwelling elderly women after a fall according to various characteristics of whom four falling profiles.

Methods

The study included 329 women (mean age ± SD: 84 ± 3.5 years). Phone interviews were conducted every four months over four years to investigate the occurrence of falls and fill out a specific questionnaire. The vital status was checked up to 13 years after these four years. An accelerated failure-time model was used to estimate the effect of the falling profiles on women survival.

Results

During the four-year follow-up, 86 women (26%) belonged to the “outside falls” profile, 63 (19%) to “environmental falls”, 140 (43%) to “inside falls”, and 40 (12%) to “falls from height”. At 13 years, the survival probability was estimated at 20.8% [95% CI: 16.4–25.2%]. On average, women with “inside falls” had shorter survivals in comparison with each of the other falling profiles. Kaplan–Meier survival curves showed also shorter survivals of these women vs. all other women grouped together (HR = 1.33 [1.02–1.73], p = 0.03).

Conclusion

Elderly women with inside falls had shorter survivals than others. Indoor falls could be markers of an underlying frailty and should trigger adequate prevention and protection measures.     

Three types of ambiguity in coding empathic interactions in primary care visits: Implications for research and practice

Objective

To describe three methodological challenges experienced in studying patients’ expressions of emotion in a sample of periodic health exams, and the research and practice implications of these challenges.

Methods

Qualitative analysis of empathic cues in audio-taped and transcribed periodic health examinations of adult patients (n = 322) in an integrated delivery system. The empathic and potential empathic opportunities methodology was used.

Results

Identifying emotional cues that constitute “empathic opportunities” is a complex task. Three types of ambiguity made this task particularly challenging: 1) presentations of emotional cues can be “fuzzy” and varied; 2) expressions of illness can be emotionally laden in the absence of explicit “emotion words”; and 3) empathic opportunities vary in length and intensity.

Conclusion

Interactional ambiguities pose a challenge to researchers attempting to document emotional cues with a binary coding scheme that indicates only whether an empathic opportunity is present or absent. Additional efforts to refine the methodological approach for studying empathy in medical interactions are needed.

Practice implications

The challenges discussed likely represent the same types of situations physicians find themselves in when talking with patients. Highlighting these ambiguities may aid physicians in better recognizing and meeting the emotional needs of their patients.