Take the HEAT: A pilot study on improving communication with angry families

ObjectiveOur objective was to evaluate the utility of an educational program consisting of a workshop based on the Take the HEAT communication strategy, designed specifically for addressing patients who are angry, using a novel tool to evaluate residents’ skills in employing this method.Methods33 first-year pediatric and internal medicine-pediatrics residents participated in the study. The workshop presented the Take the HEAT (Hear, Empathize, Apologize, Take action) strategy of communication. Communication skills were assessed through standardized patient encounters at baseline and post-workshop. Encounters were scored using a novel assessment tool.ResultsAfter the workshop, residents’ Take the HEAT communication improved from baseline total average score 23.15 to total average score 25.36 (Z = −3.428, p < 0.001). At baseline, empathy skills were the lowest. Intraclass Correlation Coefficient demonstrated substantial agreement (0.60 and 0.61) among raters using the tool.ConclusionFirst-year pediatric trainees’ communication with angry families improved with education focused on the Take the HEAT strategy. Poor performance by residents in demonstrating empathy should be explored further.Practice implicationsThis study demonstrates the utility of a brief communications curriculum aimed at improving pediatric residents' ability to communicate with angry families.     

Racial and insurance status disparities in imaging modality among pediatric patients diagnosed with appendicitis

BackgroundStudies have assessed the type of diagnostic imaging used in the treatment of appendicitis in children. Few studies investigated racial/ethnic and insurance disparities in imaging modalities used in pediatric patients diagnosed with appendicitis. Our study seeks to determine whether race/ethnicity and insurance status are associated with imaging modality chosen for pediatric patients diagnosed with appendicitis in the emergency department.MethodsThis was a retrospective cohort study utilizing data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2010 to 2019. We included children <18 years old with a ICD-9-CM and ICD-10-CM diagnosis of appendicitis. Exposures were patient race/ethnicity and insurance status. Outcome of interest was imaging modality. We conducted adjusted survey logistic regression to evaluate the patient characteristics and receipt each of the imaging modalities among those with a diagnosis of appendicitis.ResultsOf 308,140,115 emergency department (ED) visits, 1,126,865 (0.37%) had a diagnosis of appendicitis. Overall, male patients were more likely to receive CAT scan in comparison to female children (OR=2.52, 95% CI= 1.16–5.49). Additionally, Hispanic children who had significantly greater odds of obtaining ultrasound (OR= 4.56, 95% CI=1.09–19.12). Hispanic children were also less likely to receive x-ray (OR= 0.31, 95% CI=0.11–0.89) or computed tomography (CT) scans (OR= 0.23, 95% CI=0.07–0.76). Children diagnosed with appendicitis who had insurance other than private, Medicare, Medicaid, or self-pay were significantly more likely to receive x-ray studies (OR=4.39, 95% CI= 1.23–15.69).Conclusions and global health implicationsThis study demonstrated the presence of racial/ethnic and insurance status disparities in the imaging modality chosen to assist in diagnosing appendicitis in pediatric patients.     

A Web-Based,Computer-Tailored Smoking Prevention Program to Prevent Children From Starting to Smoke After Transferring to Secondary School: Randomized Controlled Trial

BackgroundSmoking prevalence rates among Dutch children increase rapidly after they transit to secondary school, in particular among children with a low socioeconomic status (SES). Web-based, computer-tailored programs supplemented with prompt messages may be able to empower children to prevent them from starting to smoke when they transit to secondary school.ObjectiveThe main aim of this study is to evaluate whether computer-tailored feedback messages, with and without prompt messages, are effective in decreasing children’s smoking intentions and smoking behavior after 12 and 25 months of follow-up.MethodsData were gathered at baseline (T0), and after 12 months (T1) and 25 months (T2) of follow-up of a smoking prevention intervention program called Fun without Smokes. A total of 162 schools were randomly allocated to a no-intervention control group, an intervention prompt group, or an intervention no-prompt group. A total of 3213 children aged 10 to 12 years old participated in the study and completed a Web-based questionnaire assessing their smoking intention, smoking behavior, and sociocognitive factors, such as attitude, social influence, and self-efficacy, related to smoking. After completion, children in the intervention groups received computer-tailored feedback messages in their own email inbox and those messages could be accessed on the intervention website. Children in the prompt group received prompt messages, via email and short message service (SMS) text messaging, to stimulate them to reuse the intervention website with nonsmoking content. Multilevel logistic regression analyses were performed using multiple imputations to assess the program effects on smoking intention and smoking behavior at T1 and T2.ResultsA total of 3213 children participated in the Fun without Smokes study at T0. Between T0 and T1 a total of 1067 children out of the original 3213 (33.21%) dropped out of the study. Between T0 and T2 the number of children that did not participate in the final measurement was 1730 out of the original 3213 (53.84%). No significant program effects were observed for any of the intervention groups compared to the control group at T1 for the intention to engage in smoking—prompt, OR 0.67 (95% CI 0.30-1.50), no-prompt, OR 0.76 (95% CI 0.34-1.67)—or for smoking behavior—prompt, OR 1.13 (95% CI 0.13-9.98), no-prompt, OR 0.50 (95% CI 0.04-5.59). Similar nonsignificant program effects were found at T2 for the intention to start smoking—prompt, OR 0.78 (95% CI 0.26-2.32), no-prompt, OR 1.31 (95% CI 0.45-3.82)—and smoking behavior—prompt, OR 0.53 (95% CI 0.12-2.47), no-prompt, OR 1.01 (95% CI 0.24-4.21).ConclusionsThis study showed that the Web-based, computer-tailored feedback messages with and without prompt messages were not effective in modifying children’s smoking intentions and smoking behavior as compared to no information. Future smoking prevention interventions are recommended to start closer to the age of actual smoking uptake. Furthermore, future studies on Web-based, computer-tailored smoking prevention programs should focus on assessing and controlling exposure to the educational content and the response to the prompt messages.

Trial Registration

Netherlands Trial Register NTR3116; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3116 (Archived by WebCite at http://www.webcitation.org/6O0wQYuPI).     

There’s an app for that: Teaching residents to communicate diagnostic uncertainty through a mobile gaming application

BackgroundClear communication is integral to good clinical care; however, communication training is cost and time intensive. Mobile applications (apps) may provide a useful adjunct to traditional simulation skills training.ObjectiveTo evaluate (1) use of an app for teaching communication skills about diagnostic uncertainty, (2) feedback on app use, and (3) the association between use and skill mastery.Patient involvementThe app under study is designed to improve doctor-patient communication.MethodsThe study was a planned sub-analysis of a randomized controlled waitlist trial with emergency medicine resident physicians randomized to receive immediate or delayed access to an educational curriculum focused on diagnostic uncertainty. The curriculum included a web-based interactive module and the app. Metrics describing participants’ use of the app, feedback on use, and association of use and achieving mastery in communicating diagnostic uncertainty are reported. Differences between groups utilizing the app were analyzed using Chi-squared test; logistic regression assessed the association between app use and achieving mastery of the communication skill.ResultsAmong 109 participants completing the trial, only 34 (31.2%) used the app. Most participants engaged with the app on one occasion for a median of 50 min (IQR 31, 87). Senior residents were more likely to use the app than junior residents (41.3% vs 23.8%, p=0.05). Overall reviews were positive; 76% reported the app helped them learn. There was no significant association between app use and achieving mastery of the communication skill in the trial [OR 2.1, 95% CI (0.91–4.84)].DiscussionDespite positive reviews of app use, overall use was low and there was no association with achieving mastery.Practical valueOffering an app as an auxiliary training opportunity may be beneficial to some residents, but shouldn’t be planned for use as a primary didactic modality unless there is evidence for effectiveness and use is mandated.Availability of data and materialsThe datasets generated and/or analyzed during the current study are not publicly available since some data may be identifiable but are available from the corresponding author on reasonable request.     

“Conversational Advice”: A mixed-methods analysis of medical residents’ experiences co-managing primary care patients with behavioral health providers

Objective

When integrated behavioral health clinicians (IBHCs) and residents co-manage patients, residents may learn new approaches. We aimed to understand the effect of co-management on residents’ behavioral health (BH) management learning.

Using crowdsourced analog patients to provide feedback on physician communication skills

ObjectiveEffective physician-patient communication is important, but physicians who are seeking to improve have few opportunities for practice or receive actionable feedback. The Video-based Communication Assessment (VCA) provides both. Using the VCA, physicians respond to communication dilemmas depicted in brief video vignettes; crowdsourced analog patients rate responses and offer comments. We characterized analog patients’ comments and generated actionable recommendations for improving communication.MethodsPhysicians and residents completed the VCA; analog patients rated responses and answered:“What would you want the provider to say in this situation?” We used qualitative analysis to identify themes.ResultsForty-three participants completed the VCA; 556 analog patients provided 1035 comments. We identified overarching themes (e.g., caring, empathy, respect) and generated actionable recommendations, incorporating analog patient quotes.ConclusionWhile analog patients’ comments could be provided directly to users, conducting a thematic analysis and developing recommendations for physician-patient communication reduced the burden on users, and allowed for focused feedback. Research is needed into physicians’ reactions to the recommendations and the impact on communication.Practice implicationsPhysicians seeking to improve communication skills may benefit from practice and feedback. The VCA was designed to provide both, incorporating the patient voice on how best to communicate in clinical situations.     

Assessment of surgeon communication skills from the patient perspective: A national evaluation using the Communication Assessment Tool

ObjectiveThe Communication Assessment Tool (CAT) has previously been translated and adapted to the Italian context. This national study aimed to validate the CAT and evaluate communication skills of practicing surgeons from the patient perspective.MethodsCAT consists of 14 items associated with a 5-point scale (5 = excellent); results are reported as the percent of ‘‘excellent’’ scores. It was administered to 920 consenting outpatients aged 18–84 in 26 Italian surgical departments.ResultsThe largest age group was 45–64 (43.8%); 52.2% of the sample was male. Scores ranged from 44.6% to 66.6% excellent. The highest-scoring items were “Treated me with respect” (66.6%), “Gave me as much information as I wanted” (66.3%) and “Talked in terms I could understand” (66.0%); the lowest was “Encouraged me to ask questions” (44.6%). Significant differences were associated with age (18–24 year old patients exhibited the lowest scores) and geographical location (Northern Italy had the highest scores).ConclusionCAT is a valid tool for measuring communication in surgical settings.Practice ImplicationsResults suggest that expectations of young people for communication in surgical settings are not being met. While there is room to improve communication skills of surgeons across Italy, patients highlighted the greatest need in the Central and Southern regions.     

The lesson of Monsieur Nouma: effects of a culturally sensitive communication tool to improve health-seeking behavior in rural Cameroon

ObjectiveTo test the effect of patient counseling using educational tools, on rates of return for follow-up in newly diagnosed hypertensive and/or diabetic patients in a rural African context.MethodsFree screening for hypertension and elevated blood glucose was offered in primary health care centers in central Cameroon during 9 campaigns of 3 days each. Individuals with untreated hypertension and/or diabetes were divided into 2 groups: a control group receiving counseling according to routine procedures, and an intervention group receiving counseling with different educational tools to explain the diagnosis and its implications to the patient.ResultsPrevalence of hypertension and/or diabetes in the screened population was 41%. At 3 months from screening, rates of return visits were higher in the intervention group than in the control group: 55/169 (32%) vs. 15/92 (16%), OR 2.4; 95%CI 1.3–4.7; p < 0.001.ConclusionScreening may identify untreated individuals efficiently. Rates of return visits after screening, although low in both groups, could be doubled by a short communication intervention.Practice implicationsThis study suggests that modest communication interventions, e.g., the application of educational tools, may bring important benefits and increase the effectiveness of public health measures to combat chronic diseases in settings of limited resources.     

Lost in translation: Cultural divides in communication skills teaching identified in the ICCH 2016 student symposium

ObjectiveTo provide a platform for learners’ voices at an international conference on communication in healthcare.MethodsA group of medical students were invited to explore their experiences with communication skills learning at a symposium at the 2016 International Conference on Communication in Healthcare in Heidelberg, DE.ResultsStudents from the US, Denmark, Germany, and Russia discussed their experiences with communication skills curriculum at their institutions. We identified divides that have challenged our ability to develop and maintain strong communication skills: 1) valuation of communication skills vs. other topics, 2) curricular theory vs. practice, 3) evaluation vs. feedback, 4) preclinical vs. clinical learning, and 5) the medical student vs. practicing clinician role.ConclusionThe points of transition we identified on the road of communication skills teaching highlight opportunities to strengthen the educational experience for students. Without an effort to address these divides, however, our communication skills may be lost in translation.Practice implicationsStudents value communication skills teaching during their medical education and there are opportunities to translate this to countries that currently lack robust curricula and to the real-life post-graduate setting. Support is necessary from students, teachers, and administrators, and focus on translation of skills during role transitions is needed.     

Evaluating provider communication in pediatric chronic kidney disease care using a global coding system

ObjectiveAmong adolescents and young adults (AYAs) with chronic illness, effective provider communication is essential for patient-centered care during a sensitive developmental period. However, communication in chronic illness care for AYAs is not well studied. Our objectives were to describe the provider communication skills in pediatric chronic kidney disease (CKD) care visits; and determine if communication skills differ by AYA characteristics.MethodsWe adapted a global consultation rating system for pediatric subspecialty care using audiotaped clinic encounters of 18 pediatric nephrologists with 99 AYAs (age M(SD) = 14.9(2.6)) with CKD stages 1–5 and 96 caregivers. We hypothesized that provider communication skills would differ by AYA characteristics (age, gender, and race).ResultsThe strongest provider skills included initiating the session and developing rapport; lowest rated skills were asking patient’s perspective and checking understanding. Communication scores did not consistently differ by AYA age or race, but were rated higher with female AYAs in several domains (ps<0.05).ConclusionsPediatric providers generally had adequate or good communication scores with AYAs, but improvement in certain skills, particularly with male AYAs, may further support patient-centered care.Practice implicationsTo achieve consistent, patient-centered communication with AYAs, an observation-based global assessment may identify areas for provider improvement.     

A Web-Based Telehealth Training Platform Incorporating Automated Nonverbal Behavior Feedback for Teaching Communication Skills to Medical Students: A Randomized Crossover Study

BackgroundIn the interests of patient health outcomes, it is important for medical students to develop clinical communication skills. We previously proposed a telehealth communication skills training platform (EQClinic) with automated nonverbal behavior feedback for medical students, and it was able to improve medical students’ awareness of their nonverbal communication.ObjectiveThis study aimed to evaluate the effectiveness of EQClinic to improve clinical communication skills of medical students.MethodsWe conducted a 2-group randomized crossover trial between February and June 2016. Participants were second-year medical students enrolled in a clinical communication skills course at an Australian university. Students were randomly allocated to complete online EQClinic training during weeks 1–5 (group A) or to complete EQClinic training during weeks 8–11 (group B). EQClinic delivered an automated visual presentation of students’ nonverbal behavior coupled with human feedback from a standardized patient (SP). All students were offered two opportunities to complete face-to-face consultations with SPs. The two face-to-face consultations were conducted in weeks 6–7 and 12–13 for both groups, and were rated by tutors who were blinded to group allocation. Student-Patient Observed Communication Assessment (SOCA) was collected by blinded assessors (n=28) at 2 time points and also by an SP (n=83). Tutor-rated clinical communications skill in face-to-face consultations was the primary outcome and was assessed with the SOCA. We used t tests to examine the students’ performance during face-to-face consultations pre- and postexposure to EQClinic.ResultsWe randomly allocated 268 medical students to the 2 groups (group A: n=133; group B: n=135). SOCA communication skills measures (score range 4–16) from the first face-to-face consultation were significantly higher for students in group A who had completed EQClinic training and reviewed the nonverbal behavior feedback, compared with group B, who had completed only the course curriculum components (P=.04). Furthermore, at the second face-to-face assessment, the group that completed a teleconsultation between the two face-to-face consultations (group B) showed improved communication skills (P=.005), and the one that had teleconsultations before the first face-to-face consultation (group A) did not show improvement.ConclusionsThe EQClinic is a useful tool for medical students’ clinical communication skills training that can be applied to university settings to improve students clinical communication skills development.     

Validation of the ComCare index for rater-based assessment of medical communication and interpersonal skills

ObjectivesTo develop and validate a short instrument to assess undergraduate medical students’ communication and interpersonal skills in videographed history taking situations with simulated patients.MethodsSixty-seven undergraduate medical students participating in an assessment including videographed physician-patient encounters for history taking with five simulated patients were included in this study. The last video of each participant’s consultation hour was rated by two independent assessors with the eight-item ComCare index for assessment of communication and interpersonal skills newly designed for the external rater perspective (ComCareR). We compared the sum scores of the ComCareR with ratings of the same videos with the Kalamazoo Communication Skills Assessment Form from an observational perspective (KCSAFd-video) and the Global Rating scale (GR), which also measure communication and interpersonal skills.ResultsThe ComCareR showed an excellent interrater reliability (ICC = .85). We found a small but significant correlation with the KCSAFd-video Interpersonal Competence (ρ = .34, 95% CI [.10,.54]) and a high positive correlation with the GR (ρ = .59, 95% CI [.40,.73]).ConclusionsThe ComCareR is a valid and brief index for holistic assessment of communication and interpersonal skills in physician-patient encounters.Practice implicationsThe ComCareR can be used for quick rater-based assessment of physicians’ communication and interpersonal skills.     

Assessment of communication skills

ObjectiveThis paper addresses how communication skills can best be assessed. Since assessment and learning are strongly connected, the way communication skills are best learned is also described.ResultsCommunication skills are best learned in a longitudinal fashion with ample practice in an authentic setting. Confrontation of behavior initiates the learning process and should be supported by meaningful feedback through direct observation. When done appropriately a set of (learned) communication skills become integrated skilled communication, being versatilely used in purposeful goal-oriented clinical communication. The assessment of communication skills should follow a modern approach to assessment where the learning function of assessment is considered a priority. Individual assessments are feedback-oriented to promote further learning and development. The resulting rich information may be used to make progression decisions, usually in a group or committee decision.ConclusionThis modern programmatic approach to assessment fits the learning of skilled communication well.Practice implicationsImplementation of a programmatic assessment approach to communication will entail a major innovation to education.     

Communication skills preparedness for practice: Is there a key ingredient in undergraduate curricula design?

ObjectiveTo characterize medical interns’ experience regarding communication skills education and to explore potential associations with preparedness for practice.MethodsTwo hundred sixty-six medical interns answered an original questionnaire specifically developed to explore how well they feel their undergraduate training had prepared them in key aspects of medical communication. Instrument’s psychometric properties were tested. Medical schools’ curricula were considered and associations explored using non-parametric tests.ResultsThe questionnaire reliability was high, with Cronbach’s alphas ranging from 0.89 to 0.94 on all the factors. Core communication skills were highly rated. Perceived preparedness was lower in aspects concerning dealing with emotion, breaking bad news and communicating with speech impaired patients. Better preparedness was associated with a longitudinal integration of communication skills throughout the curriculum, simulation with standardized patients and real patient interviewing with feedback on communication skills.ConclusionsIntegrated programs, standing on a strong experimental component, particularly combining patient-simulation strategies with continuous supervision and learner centred feedback, were associated with higher preparedness. These results support the expansion of an educational model based on simulation strategies and structured longitudinally throughout the undergraduate medical curriculum.Practice implicationsThis study intends to inform educational background and to support further development of communication skills curricula.     

Mindfulness predicts student nurses’ communication self-efficacy: A cross-national comparative study

ObjectivesThe aim of this study was to compare student nurses’ communication self-efficacy, empathy, and mindfulness across two countries, and to analyse the relationship between these qualities.MethodsThe study had a cross-sectional design. Data was collected from final year student nurses in Norway and Sweden. Communication self-efficacy, empathy, and mindfulness were reported by questionnaires; Clear-cut communication with patients, Jefferson Scale of Empathy, and Langer 14 items mindfulness scale.ResultsThe study included 156 student nurses, 94 (60%) were Swedish. The mean communication self-efficacy score was 119 (95% CI 116–122), empathy score 115 (95% CI 113–117) and mindfulness score 79 (95% CI 78–81). A Mann-Whitney test showed that Swedish students scored significantly higher on communication self-efficacy, empathy, and mindfulness than Norwegian students did. When adjusted for age, gender, and country in a multiple linear regression, mindfulness was the only independent predictor of communication self-efficacy.ConclusionThe Swedish student nurses in this study scored higher on communication self-efficacy, empathy, and mindfulness than Norwegian students did. Student nurses scoring high on mindfulness rated their communication self-efficacy higher.Practice implicationsA mindful learning approach may improve communication self-efficacy and possibly the effect of communication skills training.     

The reliability of a modified Kalamazoo Consensus Statement Checklist for assessing the communication skills of multidisciplinary clinicians in the simulated environment

Objective

With increased recognition of the importance of sound communication skills and communication skills education, reliable assessment tools are essential. This study reports on the psychometric properties of an assessment tool based on the Kalamazoo Consensus Statement Essential Elements Communication Checklist.

Methods

The Gap-Kalamazoo Communication Skills Assessment Form (GKCSAF), a modified version of an existing communication skills assessment tool, the Kalamazoo Essential Elements Communication Checklist-Adapted, was used to assess learners in a multidisciplinary, simulation-based communication skills educational program using multiple raters. 118 simulated conversations were available for analysis. Internal consistency and inter-rater reliability were determined by calculating a Cronbach's alpha score and intra-class correlation coefficients (ICC), respectively.

Results

The GKCSAF demonstrated high internal consistency with a Cronbach's alpha score of 0.844 (faculty raters) and 0.880 (peer observer raters), and high inter-rater reliability with an ICC of 0.830 (faculty raters) and 0.89 (peer observer raters).

Conclusion

The Gap-Kalamazoo Communication Skills Assessment Form is a reliable method of assessing the communication skills of multidisciplinary learners using multi-rater methods within the learning environment.

Practice implications

The Gap-Kalamazoo Communication Skills Assessment Form can be used by educational programs that wish to implement a reliable assessment and feedback system for a variety of learners.     

Patient satisfaction in Kazakhstan: Looking through the prism of patient healthcare experience

ObjectivesThis study aimed to explore the relationship between patient satisfaction and patient experience after exposure to inpatient hospitalization.MethodsA cross-sectional self-completed survey at the bedside in the Inpatient departments of the University Medical Center hospitals (UMC) in Nur-Sultan city, Kazakhstan was submitted. A total of 153 patients completed the survey from September 2017 to June 2018. The survey used the Picker Patient Experience questionnaire validated in Russian and Kazakh languages.ResultsThe majority of patients were satisfied with their hospital stay (90.8 %). Only self-rated health status was associated with overall satisfaction (OR 1.922, 95 % CI 1.09−3.37). Patient experience assessment revealed an association of physical comfort and respect for patient preferences with overall satisfaction (OR 0.101, 95 % CI 0.01−0.91 and OR 0.317, 95 % CI 0.11−0.92).ConclusionsStudy findings support that patient satisfaction is an exaggerated image of healthcare performance. Groups with negative experience have shown lower overall satisfaction in the dimensions ‘physical comfort’ and ‘respect for patient preferences’.Practice implicationsImproving patient centered communication and pain control in clinical practice may lead to the improvement in patient satisfaction.     

Validación de la versión en español de un instrumento de evaluación de la comunicación centrada en el paciente en OSCE

ObjectiveThe aim of this study was to validate the Spanish version of the Communication Assessment Tool (CAT) to be used in an Objective Structured Clinical Evaluation (OSCE) to assess communication skills.MethodsData were collected from standardized patients evaluating 125 recent medical school graduates during a 12-station OSCE. A total of 1,500 completed CAT instruments were analyzed. Exploratory and confirmatory factorial analysis were performed and tested the internal consistency of the tool.ResultsWe found a single factor solution in the Spanish version of the instrument, similar to that described by the original author. Cronbach's alpha was high, ranging from 0.93 to 0.97. The overall mean percentage of ‘excellent’ ratings for the recent graduates was 38.07%.ConclusionsThe Spanish version of CAT is a feasible tool to be used in OSCE by standardized patients to assess communication skills in a standardized manner.     

Patient participation in the consultation process: a structured review of intervention strategies

OBJECTIVE: To describe the range and effectiveness of intervention strategies designed to enhance patient participation in the consultation process. METHODS: A systematic review of published literature (1976-2004) was undertaken. Controlled trials in English were included. Data regarding study design, intervention characteristics, patient populations and study results were extracted. RESULTS: One hundred and forty-six articles describing 137 trials were reviewed. A pragmatic categorisation of intervention strategies and study outcomes supported data synthesis. Patient-targeted coaching and educational materials, and provider-targeted communication skills training have a substantial impact on communication. Information feedback to providers from patient-reported outcome measures (PROMs) benefits provider diagnosis and management of patient conditions. Communication and provider diagnosis and management benefit most from the reviewed interventions. Although patient satisfaction and health status were two of the most frequently measured outcomes, overall, the interventions appeared to have less impact on patient self-efficacy, attitudes and behaviours, patient satisfaction, health status and resource use. CONCLUSION: Evidence is insufficient to strongly advocate one approach to enhancing patient participation in the consultation process. More rigorous research design with clearly specified intervention strategies and appropriately defined outcomes assessed over both the short and long term is required. PRACTICE IMPLICATIONS: Although limited and inconclusive, the most extensive and most encouraging evidence to enhance patient participation in the consultation process is available for three patient-targeted intervention strategies (coaching, educational materials and PROMs feedback to providers) and one provider-targeted intervention strategy (communication skills training).