A systematic review of surgeon–patient communication: Strengths and opportunities for improvement

Objective

Effective communication is critical to patient satisfaction, outcomes of care and malpractice prevention. Surgeons need particularly effective communication skills to discuss complicated procedures and help patients make informed choices. We conducted a systematic review of the literature on surgeon–patient communication.

Methods

Searches were conducted in MEDLINE, PsycINFO, and Sociological Abstract. Two reviewers screened citations and full-text articles. Quality was appraised using the Critical Appraisal Skills Program tool. Studies were categorized into content of communication, patient satisfaction, relationship of communication to malpractice, and duration of visits.

Results

2794 citations and 74 full-text articles, 21 studies and 13 companion reports were included. Surgeons spent the majority of their time educating patients and helping them to make choices. Surgeons were generally thorough in providing details about surgical conditions and treatments. Surgeons often did not explore the emotions or concerns of patients. Potential areas of improvement included discussing some elements of informed decision making, and expressing empathy.

Conclusion

Surgeons can enhance their communication skills, particularly in areas of relative deficiency. Studies in primary care demonstrate communication programs are effective in teaching these skills.

Practice implications

These can be adapted to surgical training and ultimately lead to improved outcomes and satisfaction with care.     

E-mail in patient–provider communication: A systematic review

Objective

To review systematically the role of e-mails in patient–provider communication in terms of e-mail content, and perspectives of providers and patients on e-mail communication in health care.

Methods

A systematic review of studies on e-mail communication between patients and health providers in regular health care published from 2000 to 2008.

Results

A total of 24 studies were included in the review. Among these studies, 21 studies examined e-mail communication between patients and providers, and three studies examined the e-mail communication between parents of patients in pediatric primary care and pediatricians. In the content analyses of e-mail messages, topics well represented were medical information exchange, medical condition or update, medication information, and subspecialty evaluation. A number of personal and institutional features were associated with the likelihood of e-mail use between patients and providers. While benefits of e-mails in enhancing communication were recognized by both patients and providers, concerns about confidentiality and security were also expressed.

Conclusion

The e-mail is transforming the relationship between patients and providers. The rigorous exploration of pros and cons of electronic interaction in health care settings will help make e-mail communication a more powerful, mutually beneficial health care provision tool.

Practice implications

It is important to develop an electronic communication system for the clinical practice that can address a range of concerns. More efforts need to be made to educate patients and providers to appropriately and effectively use e-mail for communication.     

Does patient coaching make a difference in patient-physician communication during specialist consultations? A systematic review

ObjectiveTo systematically review the literature on the effectiveness of a patient coach intervention on patient − physician communication in specialists consultations.MethodsPubMed, Cochrane, PsycInfo, Cinahl and Embase were searched until November 2015. Included were papers describing interventions directed at adult outpatients in secondary care with a variety of somatic diseases. Outcomes had to be measured in communication effectivity from a patient’s perspective.ResultsSeventeen publications met the inclusion criteria (involving 3787 patients), describing 13 unique interventions. Most interventions were single one-on-one sessions taking between 20 and 40 min before consultation. Research quality in ten studies was high. These studies showed significant improvement on immediate, intermediate and long term patient − physician communication.ConclusionWe found limited evidence suggesting an improvement of patient − physician communication by having multiple patient coaching encounters during which questions are prepared and rehearsed and consultations are evaluated and reflected upon, sometimes supported by audio recording the consultation.Practice implicationsThe results of this review contribute to the (re-)design of an effective model for patient coaching, a profile and training approach of patient coaches. Future research should aim at determining which patients will benefit most from coaching interventions.     

Physician–patient communication about dietary supplements

Objective

Describe the content and frequency of provider–patient dietary supplement discussions during primary care office visits.

Methods

Inductive content analysis of 1477 transcribed audio-recorded office visits to 102 primary care providers was combined with patient and provider surveys. Encounters were collected in Los Angeles, CA (2009–2010), geographically diverse practice settings across the United States (2004–2005), and Sacramento, CA (1998–1999).

Results

Providers discussed 738 dietary supplements during encounters with 357 patients (24.2% of all encounters in the data). They mentioned: (1) reason for taking the supplement for 46.5% of dietary supplements; (2) how to take the supplement for 28.2%; (3) potential risks for 17.3%; (4) supplement effectiveness for 16.7%; and (5) supplement cost or affordability for 4.2%. Of these five topics, a mean of 1.13 (SD = 1.2) topics were discussed for each supplement. More topics were reviewed for non-vitamin non-mineral supplements (mean 1.47 (SD = 1.2)) than for vitamin/mineral supplements (mean 0.99 (SD = 1.1); p < 0.001).

Conclusion

While discussions about supplements are occurring, it is clear that more discussion might be needed to inform patient decisions about supplement use.

Practice implications

Physicians could more frequently address topics that may influence patient dietary supplement use, such as the risks, effectiveness, and costs of supplements.     

Are you talking to me?! An exploration of the triadic physician–patient–companion communication within memory clinics encounters

Objective

To explore and gain further insight into the nature of the triadic interaction among patients, companions and physicians in first-time diagnostic disclosure encounters of Alzheimer's disease in memory-clinic visits.

Methods

Twenty-five real-time observations of actual triadic encounters by six different physicians were analyzed. The analysis was accomplished through an innovative combination of grounded theory text analysis and graphics to illustrate the communicational exchanges.

Results

The “triadic” communication was actually a series of alternating dyadic exchanges where the third person tries, with inconsistent degrees of success, to become actively involved. During the initial introduction (phase 1) and summation/disclosure (phase 3), the core dyad shifts from physician–patient to physician–companion.

Conclusion

The focus of communication shifts within these encounters: from talking with the patient to talking about him or ignoring him. These shifts may signify an emotionally loaded role transformation from companion to caregiver.

Practice implications

Effective and empathic management of a triadic communication that avoids unnecessary interruptions and frustrations requires specific communication skills (e.g., explaining the rules and order of the conversation). Professionals need to facilitate the emotionally difficult shift from companion to caregiver and the adjustment of companion and demented patient to this shift.     

Measuring patient empowerment – A systematic review

ObjectiveThe purpose of this systematic review was to identify generic instruments measuring patient empowerment and related concepts and analyse the main content and psychometric properties of these instruments.MethodsA systematic search was conducted using empowerment and related concepts (enablement, activation, engagement, perceived control) as search terms. The main content of the instruments was analysed by classifying the subscales and items of the elements of empowerment into patient’s capacities, patient’s knowledge, patient’s behaviour and support by others. Psychometric properties were analysed with the criteria of Terwee and colleagues (2007).ResultsThirteen instruments were identified; and out of them, five instruments covered all the four elements used to define of empowerment. Psychometric properties were variable; none of the instruments contained all the evaluated psychometric properties.ConclusionThere are generic instruments measuring empowerment and its related concepts. The instruments were heterogeneous in structure and psychometric properties. Empowerment is more wide-ranging and multidimensional than its related concepts.Practice ImplicationsThis review provides knowledge for healthcare professionals and researchers who want to support or evaluate patients’ empowerment. With a generic instrument, it is possible to obtain comparable information from diverse patient groups. Further testing of psychometric properties of each instrument is recommended.     

Physician–patient communication in single-bedded versus four-bedded hospital rooms

Objective

To examine whether physician–patient communication in multi-bedded rooms differs from communication in single rooms during ward rounds.

Methods

Ward rounds in single-bedded patient rooms and ward rounds in four-bedded rooms were audiotaped and analyzed with an adapted version of MIARS. The researcher completed an observational checklist of each encounter. We measured: the duration of speech time, the types of verbal and nonverbal communication, the extent to which patients and physicians raise intimate subjects.

Results

Encounters during ward rounds in single rooms significantly took up more time than encounters in four-bedded rooms. The patients asked more questions and made more remarks in single rooms compared to four-bedded rooms. Empathic reactions of the physician were scored significantly more often in single rooms than in four-bedded rooms. No differences were observed concerning the extent to which intimate subjects were brought up.

Conclusion

This study is the first that investigated this subject. Findings suggest that single rooms contribute positively to physician–patient communication.

Practice implications

The research findings indicate the relevance of taking account of the context in which physician–patient communication takes place.     

Does improving patient–practitioner communication improve clinical outcomes in patients with cardiovascular diseases? A systematic review of the evidence

Objective

To conduct a systematic literature review appraising the effects of interventions to improve patient–practitioner communication on cardiovascular-related clinical outcomes.

Methods

Databases were searched up to March 27, 2013 to identify eligible studies that included interventions to improve patient and/or practitioner communication skills and assessment of a cardiovascular-related clinical outcome in adults ≥18 years of age.

Results

Fifteen papers were reviewed: the primary focus in seven studies was the patient; seven included a practitioner-focused intervention and one targeted both. Two patient-focused and two practitioner-focused studies demonstrated a beneficial effect of the intervention compared to a control group. Patient-focused studies were designed to improve patients’ information-seeking and question-asking skills with their practitioner. Practitioner-focused studies were designed to either improve practitioner's general patient-centered communication or risk communication skills.

Conclusion

Few interventions targeting patient–practitioner communication have assessed the impact on cardiovascular-related clinical outcomes, limiting the ability to determine effectiveness. Additional rigorous research supported by theoretical frameworks and validated measurement is needed to understand the potential of patient–practitioner communication to improve cardiovascular-related clinical outcomes.

Practice implications

Investments in communication skills trainings in medical education and practice are needed in order to attain the full potential of patient-centered care on cardiovascular-related clinical outcomes.     

Influence of oxytocin on parenting behaviors and parent–child bonding: A systematic review

Oxytocin (OT) plays a pivotal role in early parent–child relationship formation and bonding that is critical for the social, cognitive, and emotional development of the child. Therefore, this systematic review aims to consolidate all available evidence regarding the associations of parental OT concentration levels with parenting behavior and bonding within the past 20 years. A systematic search was conducted in five databases from 2002 to May 2022, and 33 studies were finalized and included. Due to the heterogeneity of the data, findings were presented narratively based on the type of OT and parenting outcomes. Current evidence strongly suggests that parental OT levels are positively related to parental touch and parental gaze and affect synchrony and observer-coded parent–infant bonding. No gender difference in OT levels was observed between fathers and mothers, but OT strengthens affectionate parenting in mothers and stimulatory parenting in fathers. Child OT levels were also positively associated with parental OT levels. Family and healthcare providers could encourage more positive touch and interactive play between parent and child to strengthen parent–child relationships.     

Clinicians’ accounts of communication with patients in end-of-life care contexts: A systematic review

ObjectiveCommunication between patients and end-of-life care providers requires sensitivity given the context and complexity involved. This systematic review uses a narrative approach to synthesise clinicians’ understandings of communication in end-of-life care.MethodsA systematic, narrative synthesis approach was adopted given the heterogeneity across the 83 included studies. The review was registered prospectively on PROSPERO (ID: CRD42019125155). Medline was searched for all articles catalogued with the MeSH terms “palliative care,” “terminal care” or “end-of-life care,” and “communication”. Articles were assessed for quality using a modified JQI-QARI tool.ResultsThe findings highlight the centrality and complexity of communication in end-of-life care. The challenges identified by clinicians in relation to such communication include the development of skills necessary, complexity of interpersonal interactions, and ways in which organisational factors impact upon communication. Clinicians are also aware of the need to develop strategies for interdisciplinary teams to improve communication.ConclusionTraining needs for effective communication in end-of-life contexts are not currently being met.Practice ImplicationsClinicians need more training to address the lack of skills to overcome interactional difficulties. Attention is also needed to address issues in the organisational contexts in which such communication occurs.     

The professional interpreter’s effect on empathic communication in medical consultations: A qualitative analysis of interaction

ObjectiveTo investigate how empathic communication is expressed in interpreter-mediated consultations (IMCs) and the interpreter's effect on it.MethodsWe coded 20 authentic video-recorded IMCs by using the Empathic Communication Coding System (ECCS). We compared patient-initiated empathic opportunities (EOs) and doctors' responses as expressed by patients and doctors and as rendered by interpreters.ResultsWe identified 44 EOs. In 2 of the 44 EOs there was a close match in the way the EOs were expressed by the patient in the first place and in the way they were rendered by the interpreter. Twenty-four of the 44 EOs that were passed on by the interpreter to the doctor and presented the doctor with an opportunity to respond, came with a shift in meaning and/or intensity. Twenty of the 44 EOs were not passed on by the interpreter to the doctor.ConclusionIn IMCs, EOs are subject to the interpreter's renditions and the doctor's actions during interaction.Practice implicationsDoctors and interpreters require skills to detect patient cues, assess them correctly, render them completely and in an appropriate manner (interpreters) and display communicative behaviours that take into account the intricacies of interpreter-mediated clinical communication and facilitate each other’s communicative goals.     

Corridor consultations and the medical microbiological record: is patient safety at risk?

The performance procedures of the General Medical Council are aimed at identifying seriously deficient performance in a doctor. The performance procedures require the medical record to be of a standard that enables the next doctor seeing the patient to give adequate care based on the available information. Setting standards for microbiological record keeping has proved difficult. Over one fifth of practising medical microbiologists (including virologists) in the UK (139 of 676) responded to a survey undertaken by the working group developing the performance procedures for microbiology, to identify current practice and to develop recommendations for agreement within the profession about the standards of the microbiological record. The cumulative frequency for the surveyed recording methods used indicated that at various times 65% (90 of 139) of respondents used a daybook, 62% (86 of 139) used the back of the clinical request card, 57% (79 of 139) used a computer record, and 22% (30 of 139) used an index card system to record microbiological advice, suggesting wide variability in relation to how medical microbiologists maintain clinical records.     

Can public reporting impact patient outcomes and disparities? A systematic review

ObjectiveRecent US healthcare reforms aim to improve quality and access. We synthesized evidence assessing the impact that public reporting (PR), which will be extended to the outpatient setting, has on patient outcomes and disparities.MethodsA systematic review using PRISMA guidelines identified studies addressing the impact of PR on patient outcomes and disparities.ResultsOf the 1970 publications identified, 25 were relevant, spanning hospitals (16), nursing homes (5), emergency rooms (1), health plans (2), and home health agencies (1). Evidence of effect on patient outcomes was mixed, with 6 studies reporting a favorable effect, 9 a mixed effect, 9 a null effect, and 1 a negative effect. One study found a mixed effect of PR on disparities.ConclusionThe evidence of the impact of PR on patient outcomes is lacking, with limited evidence that PR has a favorable effect on outcomes in nursing homes. There is little evidence supporting claims that PR will have an impact on disparities or in the outpatient setting.Practice implicationsHealth systems should collect information on patient-relevant outcomes. The lack of evidence does not necessarily imply a lack of effect, and a research gap exists regarding patient-relevant outcomes and PR.     

Can public reporting impact patient outcomes and disparities? A systematic review

Objective

Recent US healthcare reforms aim to improve quality and access. We synthesized evidence assessing the impact that public reporting (PR), which will be extended to the outpatient setting, has on patient outcomes and disparities.

Methods

A systematic review using PRISMA guidelines identified studies addressing the impact of PR on patient outcomes and disparities.

Results

Of the 1970 publications identified, 25 were relevant, spanning hospitals (16), nursing homes (5), emergency rooms (1), health plans (2), and home health agencies (1). Evidence of effect on patient outcomes was mixed, with 6 studies reporting a favorable effect, 9 a mixed effect, 9 a null effect, and 1 a negative effect. One study found a mixed effect of PR on disparities.

Conclusion

The evidence of the impact of PR on patient outcomes is lacking, with limited evidence that PR has a favorable effect on outcomes in nursing homes. There is little evidence supporting claims that PR will have an impact on disparities or in the outpatient setting.

Practice implications

Health systems should collect information on patient-relevant outcomes. The lack of evidence does not necessarily imply a lack of effect, and a research gap exists regarding patient-relevant outcomes and PR.     

A video-based situational judgement test of medical students’ communication competence in patient encounters: Development and first evaluation

ObjectiveWe developed and evaluated the Video-Based Assessment of Medical Communication Competence (VA-MeCo), a construct-driven situational judgement test measuring medical students’ communication competence in patient encounters.MethodsIn the construction phase, we conducted two expert studies (n_panel1 = 6, n_panel2 = 13) to ensure curricular and content validity and sufficient expert agreement on the answer key. In the evaluation phase, we conducted a cognitive pre-test (n = 12) and a pilot study (n = 117) with medical students to evaluate test usability and acceptance, item statistics and test reliability depending on the applied scoring method (raw consensus vs. pairwise comparison scoring).ResultsThe results of the expert interviews indicated good curricular and content validity. Expert agreement on the answer key was high (ICCs> .86). The pilot study showed favourable usability and acceptance by students. Irrespective of the scoring method, reliability for the complete test (Cronbach’s α >.93) and its subscales (α >.83) was high.ConclusionThere is promising evidence that medical communication competence can be validly and reliably measured using a construct-driven and video-based situational judgement test.Practice ImplicationsVideo-based SJTs allow efficient online assessment of medical communication competence and are well accepted by students and educators.     

Depth of the patient–doctor relationship and content of general practice consultations: cross-sectional study

Background

Patient–doctor continuity is valued by both parties, yet the effect of the depth of the patient–doctor relationship on the content of consultations in general practice is unknown.

Aim

To assess whether differences in the depth of relationship between a patient and their GP affects the length of consultations, and the number and type of problems and issues raised during a consultation.

Design and setting

Cross-sectional study in 22 GP practices in the UK.

Method

GP consultations (n = 229) were videotaped and the number of problems and aspects of those problems and issues identified. Patients completed the Patient–Doctor Depth of Relationship (PDDR) and General Practice Assessment Questionnaire-communication (GPAQc) scales. Associations were explored using multivariable linear and logistic regression.

Results

Complete data were available on 190 participants consulting 30 GPs. In unadjusted analysis, patients with a deep relationship with their GP discussed more problems (mean 2.8) and issues (mean 4.7) compared with those with a moderate (2.4 problems; 4.0 issues) or shallow (2.3 problems; 3.8 issues) relationship. Patients with deep relationships had consultations that were on average 118 seconds (95% CI = 1 to 236) longer than those with shallow relationships. Adjustment for participant and GP factors attenuated these relationships, although the main trends persisted.

Conclusion

A greater number of problems and issues may be raised in a consultation when patients have a deeper relationship with their GP. Over several clinical encounters each year, this may be associated with significant benefits to patients and efficiencies in GP consultations and warrants further investigation.     

Quantifying positive communication: Doctor’s language and patient anxiety in primary care consultations

Objective

Positive communication is advocated for physicians during consultations with patients presenting medically unexplained symptoms (MUS), but studies generally focus on what is said rather than how it is said. This study quantified language use differences of general practitioners (GPs), and assessed their relation to patient anxiety.

Healthcare professionals’ behaviour regarding the implementation of shared decision-making in screening programmes: A systematic review

ObjectiveTo explore the barriers to and facilitators of healthcare professionals’ implementation of SDM regarding screening programmes.MethodA systematic review was conducted in PubMed, Cochrane Library, CINHAL, and PsyscInfo. The barriers and facilitators identified were classified into three factors based on their origin: patients, healthcare system performance, and healthcare professionals themselves.ResultsEight studies were selected: seven related to cancer screening. The most significant facilitators were literacy and interest in active participation, both of which have their origins in patients. The most significant barriers identified for the first time in a systematic review were legal conflict, lack of remuneration and lack of flexibility in clinical guidelines in screening programmes.ConclusionThe results of this study show that there are differences between barriers and facilitators for SDM when it is applied in the context of healthy people who perform preventive activities, particularly screening, in contrast to general medical consultation contexts.Practical implicationsThe authors suggest that to advance in the practice of SDM, we need to develop and disseminate training documents. Further, SDM should be incorporated into clinical guidelines. There should be more studies focusing on healthcare professionals’ behaviour within the context of the uncertainty of screening programmes.