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.     

The hospitalized psychiatric patient and the primary care physician

Patients admitted to a general hospital psychiatric service were divided into two groups depending on whether they had primary care physicians. Significant differences were found in age, sex, psychiatric diagnoses, and incidence of active medical problems. The primary care physicians said they were aware of these patients’ psychiatric problems and had treated them in their offices, but were reluctant to participate in medical care during psychiatric hospitalization. The reasons for this are dis cussed, and a model for collaborative treatment by primary care physicians and hospital-based psychiatrists is presented.     

Principles of effective communication with patients who have intellectual disability among primary care physicians

ObjectiveExamine physicians’ implementation of effective communication principles with patients with intellectual disabilities (ID) and its predictors.MethodsFocus groups helped construct a quantitative questionnaire. The questionnaire (completed by 440 physicians) examined utilization of effective communication principles, attitudes toward individuals with ID, subjective knowledge and number of patients with ID.ResultsSubjective knowledge of ID and more patients with ID increased utilization of effective communication principles. Provision of knowledge that allows patients to make their own medical decisions was predicted by more patients with ID, lower attitudes that treatment of this population group is not desirable, less negative affect and greater perception that treatment of this group is part of the physician's role. Effective preparation of patients with ID for treatment was predicted by higher perception of treatment of this group as part of the physician's role, lower perception of this field as undesirable and higher perception of these individuals as unable to make their own choice. Simplification of information was predicted by a greater perception of treatment of this group as part of the physician's role and more negative affect.ConclusionGreater familiarity may enhance care for these patients.Practice implicationsIncrease exposure to patients with ID within training.     

Second opinion behaviour among Japanese primary care patients.

BACKGROUND: Second opinion behaviour is often observed among Japanese primary care patients. These patients secretly visit university-affiliated hospitals without informing their doctors. Research to elucidate the psychosocial determinants of this behaviour in the Japanese primary care setting is needed. AIM: To describe the sociodemographic characteristics of second opinion patients (SOPs), and to determine the factors related to this behaviour. METHOD: Patients from the general medicine clinic answered our original questionnaire and a 30-item General Health Questionnaire (GHQ-30). A random sample of patients was questioned using the Diagnostic Interview Schedule. SOPs were defined as those patients who had visited another medical facility with the same complaint, and 'doctor-shopping' patients (DSPs) were defined as those patients who had visited two or more medical facilities with the same complaint. RESULTS: There were 420 SOPs among 1033 patients (41.0%). The multivariate analysis showed that residence and GHQ-30 were the significant differences between the SOPs and the first-visit patients (FVP) (P < 0.0005 for both factors). Also, the SOPs were anxious and sought advice from anybody, unlike the FVPs. Compared with the DSPs, they had a short duration of illness and they did not feel a worsening of their symptoms (P = 0.0001 for duration of illness; P = 0.006 for condition of illness). CONCLUSION: Our results showed that the SOPs who lived far from the medical school hospital felt anxiety and went to a university-affiliated hospital on the advice of anybody. Determining the reasons for this behaviour will require empirical studies regarding the nature of the patient's anxiety for illness.     

Race of physician and satisfaction with care among African-American patients

The purpose of this study is to examine predictors of physician-patient race concordance and the effect of race concordance on patients'' satisfaction with their primary physicians among African American patients. The specific research question is, do African American patients express greater satisfaction with their care when they have an African American physician? Using the Commonwealth Fund, Minority Health Survey, we conduct multivariate analysis of African American respondents who have a usual source of care (n = 745). More than 21% of African American patients reported having an African American physician. Patient income and having a choice in the selection of the physician were significant predictors of race concordance. And, patients who were race concordant reported higher levels of satisfaction with care compared with African American patients that were not race concordant.     

The role of the general physician in present-day medical care in Mexico

The issue of how medical specialization does not represent a novelty is discussed. The authors also approach the question of how the advantages and shortcomings of medical care provided by both general practitioners and medical specialists have been equally addressed previously by the ancient Greek classics as well as by outstanding Mexican specialists more than 50 years ago. A short review is made of the main current demographic, social, and health-related conditions of Mexico's society and of the public health system built up in the last 60 years. Some relevant data pertaining to the number of physicians and medical specialists and their distribution Mexico's 32 states are presented. The paper also includes a short argumentation of views on medical education in Mexico, and sets forth aproposal regarding the professional profile of the general practitioner and its role within Mexico's health system, as well as the need to enhance and reconsider the role played by general physicians. Authors conclude that within a comprehensive medical assistance model, both general practitioners and medical specialists are required.     

Community care of patients with schizophrenia: the role of the primary health care team.

Schizophrenia is a severe, chronic mental disorder that usually begins in early adulthood. Recurrent relapse leading to long-term psychological and social disability means that patients may require intensive community support. Despite a recent fall in the overall numbers of patients consulting their general practitioner with mental disorders, presentations by those suffering from severe mental disorders have risen. This review encompasses the role of general practitioner in the management of schizophrenia, considering in turn drug and psychological therapies, family interventions, innovations in care, the effects of community care developments, and the liasion between primary health care and mental health professionals. There is a need for further research in the area of family-practice-based interventions involving general practitioners and the practice team.     

The role of context in primary care

All doctor—patient interactions take place in a specific context—a particular physical, social or cultural setting. The important role of these contexts in doctor—patient communication, diagnosis and treatment is discussed, with reference to both hospital medicine and general practice.     

The role of coping in depression treatment utilization for VA primary care patients

Objective

To examine the impact of Veterans’ coping strategies on mental health treatment engagement following a positive screen for depression.

Methods

A mixed-methods observational study using a mailed survey and semi-structured interviews. Sample included 271 Veterans who screened positive for depression during a primary care visit at one of three VA medical centers and had not received a diagnosis of depression or prescribed antidepressants 12 months prior to screening. A subsample of 23 Veterans was interviewed.

Results

Logistic regression models showed that Veterans who reported more instrumental support and active coping were more likely to receive depression or other mental health treatment within three months of their positive depression screen. Those who reported emotional support or self-distraction as coping strategies were less likely to receive any treatment in the same time frame. Qualitative analyses revealed that how Veterans use these and other coping strategies can impact treatment engagement in a variety of ways.

Conclusions

The relationship between Veterans’ use of coping strategies and treatment engagement for depression may not be readily apparent without in-depth exploration.

Practice implications

In VA primary care clinics, nurse care managers and behavioral health providers should explore how Veterans’ methods of coping may impact treatment engagement.     

The role of screening for Helicobacter pylori in patients with duodenal ulceration in the primary health care setting.

BACKGROUND: It is known that at least 90% of duodenal ulcers are caused by infection with the bacterium Helicobacter pylori. Eradicating this organism usually results in complete resolution of the disease. Testing for H pylori was introduced relatively recently, and thus, many patients known to have uncomplicated peptic ulcer disease who continue to need long-term treatment with ulcer-healing drugs have never been tested for the infection or offered eradication therapy. In modern computerized practices, this subgroup of patients can readily be identified by reference to morbidity and repeat prescribing data. Eradication of H pylori infection in this group of patients has great potential benefit for the individuals concerned as well as cost-saving benefit for the National Health Service. AIM: The aim of this prospective study was to determine whether it is worthwhile screening for and treating H pylori infection in patients in a general practice population with previously diagnosed duodenal ulcer disease taking ulcer-healing drugs long term. METHOD: In 1994, in a practice of 7100 patients, morbidity and repeat prescribing data were used to identify 40 patients (0.6%) with proven duodenal ulcer disease taking ulcer-healing medication long term and with uncertain H pylori status. Twenty-nine of the 40 subjects agreed to undergo serology testing for H pylori antibodies. Of 20 (69%) who were positive, 18 (eight women, median age 63.8 years) were given eradication therapy. Seventeen patients received omeprazole 40 mg once daily and amoxycillin 500 mg three times daily for 14 days with metronidazole 400 mg three times daily for the first 7 days; for the remaining patient metronidazole was inadvertently omitted. [13C]Urea breath testing was carried out at the local hospital at least one month after therapy to determine whether eradication treatment had been successful. Subjects were also personally followed up by telephone after 1 and 4 months to assess the success of treatment subjectively. RESULTS: [13C]Urea breath testing showed that H pylori eradication was successful in all 17 patients (100%) who received the intended eradication regimen. Helicobacter pylori was not eradicated in the patient who received only omeprazole and amoxycillin. Four months after successful H pylori eradication, 13 of the 17 (76%) patients remained completely asymptomatic. Two of the four patients who had some recurrent dyspepsia had known gastro-oesophageal reflux and their ongoing symptoms after eradication therapy seemed, on close questioning, to be more attributable to this than to duodenal ulcer disease. CONCLUSION: Testing for and eradication of H pylori is worthwhile in general practice in those patients with previous proven duodenal ulceration who need long-term ulcer-healing medication. The high rate of eradication of H pylori achieved with the regimen used in this study compares very favourably with that of other treatment regimens. However, in patients with duodenal ulcers there may be coexisting pathology, and H pylori eradication does not necessarily result in complete disappearance of dyspeptic symptoms. Thus, when monitoring the outcome of treatment it is important to assess improvement of symptoms as well as objective evidence of eradication.     

Video analysis of communication in paediatric consultations in primary care.

BACKGROUND: There is a paucity of research evidence concerning communication in paediatric consultations between GPs, adults, and child patients. AIM: This study was carried out to identify features of the interaction between a doctor, a child patient aged 6-12 years, and their carer in the consultation associated with the child's participation. DESIGN OF STUDY: A qualitative analysis of video recordings of 31 primary care paediatric consultations was undertaken, using strategies from the methodology of conversation analysis. SETTING: Primary care, Suffolk, UK. METHOD: NHS GPs from three primary care trusts (PCTs), were invited to participate in this study. Sixteen volunteers from this sample took part. RESULTS: Analysis of the interaction in the consultations revealed that the children had little involvement. Children participated when invited to do so, and took more time than adults to answer a doctor's question. An adult carer was less likely to answer on behalf of a child, when they were in a position to see that the doctor's gaze was directed at the child, and the doctor addressed the child by name. Adult carers, who had not voiced their own concerns first, were seen to interrupt doctor-child talk. In consultations where the participants sat in a triangular arrangement, all parties being an equal distance apart, triadic talk was noted. CONCLUSION: Child involvement in the primary care consultation is associated with adult carers being able to voice their own concerns early in the consultation, and children being invited to speak with the appropriate recipient design.