Patterns in clinicians’ responses to patient emotion in cancer care

Objective

To investigate how patient, clinician and relationship characteristics may predict how oncologists and nurses respond to patients’ emotional expressions.

Methods

Observational study of audiotapes of 196 consultations in cancer care. The consultations were coded according to Verona Coding Definitions of Emotional Sequences (VR-CoDES). Associations were tested in multi-level analyzes.

Results

There were 471 cues and 109 concerns with a mean number of 3.0 (SD = 3.2) cues and concerns per consultation. Nurses in admittance interviews were five times more likely to provide space for further disclosure of cues and concerns (according to VR-CoDES definitions) than oncologists in out-patient follow-up consultations. Oncologists gave more room for disclosure to the first cue or concern in the consultation, to more explicit and doctor initiated cues/concerns and when the doctor and/or patient was female. Nurses gave room for further disclosure to explicit and nurse initiated cues/concerns, but the effects were smaller than for oncologists.

Conclusion

Responses of clinicians which provide room for further disclosure do not occur at random and are systematically dependent on the source, explicitness and timing of the cue or concern.

Practice implications

Knowledge on which factors influence responses to cues and concerns may be useful in communication skills training.     

Are GP patients’ needs being met? Unfulfilled information needs among native-Dutch and Turkish-Dutch patients

Objective

This study aims to assess unfulfilled information needs of native-Dutch and Turkish-Dutch general practitioner (GP) patients in the Netherlands. In addition, the relation between perceived and recorded information provision by GPs is studied.

Methods

Unfulfilled information needs of native-Dutch (N = 117) and Turkish-Dutch patients (N = 74) were assessed through pre- and post-consultation questionnaires. Audiotapes of GP consultations were made to code GPs’ information provision.

Results

Turkish-Dutch patients experience more unfulfilled information needs than native-Dutch patients, in particular those who identify equally with Dutch and Turkish culture. Overall, perceived information provision is hardly related to recorded information provision.

Conclusion

GPs insufficiently provide Turkish-Dutch patients and, to a lesser extent, native-Dutch patients as well, the information they need.

Practice implications

GPs should be trained in giving adequate, tailored information to patients with various ethnic and cultural backgrounds.     

Effects of an interactive tailored patient assessment tool on eliciting and responding to cancer patients' cues and concerns in clinical consultations with physicians and nurses

Objective

To test the effect of Choice, an interactive tailored patient assessment tool (ITPA), on cancer patients’ expressed cues and concerns (C&Cs), and clinicians’ responses to these C&Cs.

Methods

97 experimental group consultations, where patients used the Choice ITPA to report their symptoms and problems in preparation to their consultation, were compared to 99 control group consultations. All consultations were audio-taped and coded using the Verona Coding Definitions of Emotional Sequences (VR-CoDES).

Results

We identified 473 cues and 109 concerns with a mean number of 3.0 (SD = 3.2). The most frequent utterance was cue B (45.2%), indicating expression of uncertainty or hope. We found more C&Cs in consultations with the Choice ITPA compared to the control group (p < 0.01), and in consultations with nurses compared to physicians (p < 0.001). No differences in clinicians’ response types in the two groups were found. However, significant differences in response type between nurses and physicians were found.

Conclusion

The Choice ITPA was an effective tool to disclose cancer patients’ cues and concerns.

Practice implications

The Choice ITPA proved to be an effective intervention for cancer patients to express more C&Cs, but should be accompanied with communication skills training to potentially produce more patient-centered responses from the clinicians. (ClinicalTrials.gov number NCT00857103.)     

Patient-centered communication and prognosis discussions with cancer patients

Objective

To examine physician communication associated with prognosis discussion with cancer patients.

Methods

We conducted a study of physician–patient communication using trained actors. Thirty-nine physicians, including 19 oncologists and 20 family physicians participated in the study. Actors carried two hidden digital recorders to unannounced visits. We coded recordings for eliciting and validating patient concerns, attentive voice tone, and prognosis talk.

Results

Actor adherence to role averaged 92% and the suspected detection rate was 14%. In a multiple regression, eliciting and validating patient concerns (β = .40, C.I. = 0.11–0.68) attentiveness (β = .32, C.I. = 0.06–0.58) and being an oncologist vs. a family physician (β = .33, C.I. = 0.33–1.36) accounted for 46% of the variance in prognosis communication.

Conclusion

Eliciting and validating patient concerns and attentiveness voice tone is associated with increased discussion of cancer patient prognosis as is physician specialty.

Practice implications

Eliciting and validating patient concerns and attentive voice tone may be markers of physician willingness to discuss emotionally difficult topics. Educating physicians about mindful practice may increase their ability to collect important information and to attend to patient concerns.     

Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials

Objective

Motivational Interviewing (MI) is a method for encouraging people to make behavioral changes to improve health outcomes. We used systematic review and meta-analysis to investigate MI's efficacy in medical care settings.

Methods

Database searches located randomized clinical trials that compared MI to comparison conditions and isolated the unique effect of MI within medical care settings.

Results

Forty-eight studies (9618 participants) were included. The overall effect showed a statistically significant, modest advantage for MI: Odd ratio = 1.55 (CI: 1.40–1.71), z = 8.67, p < .001. MI showed particular promise in areas such as HIV viral load, dental outcomes, death rate, body weight, alcohol and tobacco use, sedentary behavior, self-monitoring, confidence in change, and approach to treatment. MI was not particularly effective with eating disorder or self-care behaviors or some medical outcomes such as heart rate.

Conclusion

MI was robust across moderators such as delivery location and patient characteristics, and appears efficacious when delivered in brief consultations.

Practice implications

The emerging evidence for MI in medical care settings suggests it provides a moderate advantage over comparison interventions and could be used for a wide range of behavioral issues in health care.     

Greater professional empathy leads to higher agreement about decisions made in the consultation

Objective

To examine the relationship between professional expression of empathy and agreement about decisions made in the consultation.

Methods

Consultations between 86 individuals with diabetes and four dieticians were audio-recorded. Immediately following consultations patients and dieticians independently reported decisions made in a booklet. Audio-recordings were coded directly for empathy using an amended version of the empathic communication coding system (ECCS).

Results

Empathy correlated significantly with patient and professional agreement about decisions made in the consultation (τ = .283, p = .0005). Multiple regression analysis indicates that for each dietician the greater the empathy the higher the level of agreement about decisions (p < .0005). Professional empathic response to patients statements of challenge was a significant factor in increasing agreement about decisions (p = .008).

Conclusion

Results support the hypothesis that greater professional empathy will result in greater agreement about decisions made in consultations.

Practice implications

Findings have implications for empathy training and provide guidance on the communication skills needed to support expression of empathy. Patient and professional agreement about decisions made provides a simple marker of effectiveness and highlights the importance of empathy as a seminal component of professional communication skills during a patient consultation.     

Sequence-analysis of video-recorded practitioner–patient communication about smoking in general practice: Do smokers express negative statements about quitting?

Objective

To examine the extent to which smokers express negative statements about quitting and the extent to which these statements influence general practitioners’ (GPs’) and practice nurses’ (PNs’) (dis)continuation of guideline-recommended smoking cessation care.

Methods

Fifty-two video-consultations were observed (GP-consultations: 2007–2008; PN-consultations: 2010–2011). Dialogues were transcribed verbatim and professionals’ and patients’ speech units were coded and analysed using sequential analyses (n = 1424 speech units).

Results

GPs focused on asking about smoking (GPs: 42.4% versus PNs: 26.2%, p = 0.011) and advising them to quit (GPs: 15.3% versus PNs: 3.5%, p < 0.001), whereas PNs focused on assisting them with quitting (GPs: 25.4% versus PNs: 55.2%, p < 0.001). Overall, patients expressed more negative statements about quitting than positive statements (negative: 25.3% versus positive: 11.9%, p < 0.001), especially when PNs assessed their willingness to quit (OR 3.61, 95% CI 1.44–9.01) or assisted them with quitting (OR 2.23, 95% CI 1.43–3.48).

Practice implications

An alternative approach to smoking cessation care is proposed in which GPs’ tasks are limited to asking, advising, and arranging follow-up. This approach seems the least likely to evoke negative statements of patients about quitting during dialogues with GPs and is compatible with the tasks and skills of PNs who could, subsequently, assist smokers with quitting.     

Shared decision-making in cardiology: Do patients want it and do doctors provide it?

Objective

Doctors should involve their patients in making decisions about their care. We studied patients with heart disease to assess if shared decision-making occurs and to study factors that predict patients’ choices or influence cardiologists’ behaviour.

Methods

85 patients attending for arteriography were assessed to elicit preferred involvement in decision-making, perception of involvement, and confidence in the decision.

Results

40% of patients wished to be involved in decisions. Preferences were unrelated to demographic factors. Cardiologists involved patients more in decisions concerning severe disease (p = 0.056). Involvement varied between cardiologists (p = 0.001). The mean duration of consultations was 5.5 min. Patients’ confidence in decisions correlated with duration (p = 0.001), explicit reference to a decision that needed to be made (p = 0.0026), and perceived, but not observed, involvement in decision-making (p = 0.05).

Conclusion

This study highlighted the complexity of doctor–patient communication. Irrespective of preferences for involvement, patients were more confident in decisions in which they perceived more involvement or which were the products of longer consultations.

Practice implications

Patients’ confidence in clinical decisions can be increased by increasing consultation length and increasing their perception of involvement. Patients perceive more involvement in decisions when doctors specifically identify the need for treatment decisions early in the consultation.     

Shared decision making coding systems: How do they compare in the oncology context?

Objective

The current study aimed to evaluate three coding systems which have been used to assess shared decision making in oncology consultations (OPTION, Decision Support Analysis Tool (DSAT) and Decision Analysis System for Oncology (DAS-O)): (i) comparing their ability to identify competencies of shared decision making, and (ii) determining their ability to predict patient outcomes in a single data set.

Method

Twenty oncologists from Australia and New Zealand participated in the IBCSG Trial 33-03. The consultations of 55 women with early stage breast cancer were audio-taped, transcribed and then coded using the OPTION, DAS-O and DSAT coding systems by three different raters. Women completed the questionnaires 2 weeks and 4 months after their consultation.

Results

DAS-O was strongly correlated with OPTION (r = 0.73). DSAT was moderately correlated with DAS-O and OPTION (r < 0.6). Decisional satisfaction and satisfaction with doctor SDM skills were significantly correlated with OPTION (r = 0.39 and 0.42 respectively) and the latter variable was correlated with DAS-O (r = 0.40). These relationships persisted in multiple linear regression analyses.

Conclusions

OPTION may be the most efficient and sensitive coding system for research purposes; however, DSAT appeared to document behaviours reducing decisional conflict and both DSAT and DAS-O offer more detailed feedback to doctors.

Practice implications

Optimal coding system will depend on research goals and training purposes.     

Existing instruments for assessing physician communication skills: Are they valid in a computerized setting?

Objectives

This study aims to highlight the differences in physicians’ scores on two communication assessment tools: the SEGUE and an EMR-specific communication skills checklist. The first tool ignores the presence of the EMR in the exam room and the second, though not formally validated, rather focuses on it.

Methods

We use the Wilcoxon Signed Ranks Test to compare physicians’ scores on each of the tools during 16 simulated medical encounters that were rated by two different raters.

Results

Results show a significant difference between physicians’ scores on each tool (z = −3.519, p < 0.05 for the first rater, and z = −3.521, p < 0.05 for the second rater), while scores on the EMR-specific communication skills checklist were significantly and consistently lower.

Conclusion

These results imply that current communication assessment tools that do not incorporate items that are relevant for communication tasks during EMR use may produce inaccurate results.

Practice implications

We therefore suggest that a new instrument, possibly an extension of existing ones, should be developed and empirically validated.     

Motivational cues as real-time feedback for changing daily activity behavior of patients with COPD

Objective

To investigate how COPD patients respond to motivational cues that aim to improve activity behavior and how these responses are related to cue- and context characteristics. In addition, to explore whether activity can be increased and better distributed over the day by providing such cues.

Methods

Fifteen COPD patients participated. Patients used an activity sensor with a smartphone for four weeks, at least four days/week. Patients received motivational cues every 2 h with advice on how to improve their activity, on top of real-time visual feedback. The response was calculated by the amount of activity 30 min before and after a cue.

Results

In total, 1488 cues were generated. The amount of activity significantly decreased in the 30 min after a discouraging cue (p < 0.001) and significantly increased (p < 0.05) in the 10 min after an encouraging cue. The activity level increased with 13% in the intervention period compared to corrected baseline (p = 0.008). The activity was not more balanced over the day.

Conclusions

COPD patients significantly change their activity level in response to motivational cues, based on continuous ambulatory assessment of activity levels.

Practice implications

Motivational cues could be a valuable component of telemedicine interventions that aim to improve activity behavior.     

Association between reported screening and counseling about energy drinks and energy drink intake among U.S. adolescents

Objective

Possible adverse health consequences of excessive energy drink (ED) consumption have led to recommendations by the American Academy of Pediatrics discouraging ED intake by youth. However, limited information on ED counseling by health care providers exists.

Methods

Data was obtained from the 2011 YouthStyles Survey administered to youth aged 12–17 (n = 815). The outcome variable was ED consumption (none vs. ≥1 time/week) and exposure variables were screening and counseling about ED (if doctor/nurse asked about ED consumption and if doctor/nurse recommended against ED consumption).

Results

Approximately 8.5% of youth consumed energy drinks weekly, 11.5% reported being asked by their doctor/nurse about frequency of ED consumption, and 11.1% were advised by their doctor/nurse against ED intake. Multivariable logistic regression analysis revealed that the odds for drinking ED ≥1 time/week was significantly higher in youth who were asked how often they drank ED by their doctor/nurse (odds ratio = 2.46) vs. those who were not asked.

Conclusion

About 1 in 9 youth reported receiving counseling discouraging ED consumption from their doctor/nurse, and a greater proportion of youth who were screened about ED also reported ED consumption.

Practice implications

Efforts by health care providers to educate youth about potential harms of consuming ED are needed.     

Should culture affect practice? A comparison of prognostic discussions in consultations with immigrant versus native-born cancer patients

Objective

Poor prognosis is difficult to impart, particularly across a cultural divide. This study compared prognostic communication with immigrants (with and without interpreters) versus native-born patients in audio-taped oncology consultations.

Methods

Ten oncologists, 78 patients (31 Australian-born, 47 immigrants) and 115 family members participated. The first two consultations after diagnosis of incurable disease were audiotaped, transcribed and coded. 142 consultations were included in the analysis.

Results

Fifty percent of doctor and 59% of patient prognostic speech units were not interpreted or interpreted non-equivalently when an interpreter was present. Immigrant status predicted few prognostic facts, and oncologist characteristics no prognostic facts, disclosed. Oncologists were significantly less likely to convey hope to immigrants (p = 0.0004), and more likely to use medical jargon (p = 0.009) than with Australian-born patients. Incurable disease status and a limited life span were commonly acknowledged, generally with no timeframe provided. Physical issues were discussed more commonly than emotional aspects.

Conclusions

While culture did not appear to influence doctor speech, interpreters filtered or blocked much prognostic communication.

Practice implications

Initiatives to empower all patients to attain needed information, optimise communication when an interpreter is present and train cancer health professionals in culturally appropriate care, are urgently required.     

Impact of two types of Internet-based information on medical students’ performance in an Objective Structured Clinical Exam (OSCE)

Objectives

Internet-based information has potential to impact physician–patient relationships. This study examined medical students’ interpretation and response to such information presented during an objective clinical examination.

Method

Ninety-three medical students who had received training for a patient centered response to inquiries about alternative treatments completed a comprehensive examination in their third year. In 1 of 12 objective structured clinical exams, a SP presented Internet-based information on l-theanine – an amino acid available as a supplement. In Condition A, materials were from commercial websites; in Condition B, materials were from the PubMed website.

Results

Analyses revealed no significant differences between Conditions in student performance or patient (SP) satisfaction. Students in Condition A rated the information less compelling than students in Condition B (z = −1.78, p = .037), and attributed less of the treatment's action to real vs. placebo effects (z = −1.61, p = .053).

Conclusions

Students trained in a patient centered response to inquiries about alternative treatment perceived the credibility of the two types of Internet-based information differently but were able to respond to the patient without jeopardizing patient satisfaction. Approach to information was superficial. Training in information evaluation may be warranted.     

Peer educator vs. respiratory therapist support: Which form of support better maintains health and functional outcomes following pulmonary rehabilitation?

Objective

This study examined if ongoing support delivered by telephone following pulmonary rehabilitation (PR) assisted chronic obstructive pulmonary disease (COPD) patients to maintain health outcomes.

Methods

Phase one (n = 79) compared post-rehabilitation telephone-based support delivered by peers compared to usual care (UC). The second phase (n = 168) compared post-rehabilitation support from peer educators, respiratory therapists (RT), or UC. Primary outcome variables were St. George's Respiratory Questionnaire (SGRQ) total score and the six minute walk test (6MWT). Measures were obtained at baseline, immediately following PR, and six-months post PR.

Results

Six-month follow-up data for phase one was collected for 66 COPD patients (n = 35 peer support, n = 31 UC) and 142 for phase two (n = 42 peer support, n = 52 RT support, n = 48 UC). Per-protocol and intention to treat (ITT) analysis in both phases found no significant group by time differences for SGRQ or 6MWT.

Conclusion

Providing peer or RT support via telephone following PR was not more effective than UC for maintaining health outcomes.

Practice implications

There are concerns with using peers to provide ongoing support to COPD patients. Additionally, COPD patients require a higher level of care than telephone support can provide.     

How emotions emerge and are dealt with in first diagnostic consultations in psychiatry

Objective

To illustrate how patients introduce cues and concerns during clinical consultations and how psychiatrists respond to them.

Method

Sixteen psychiatrists recorded 104 first diagnostic consultations, coded with the Verona Coding Definitions of Emotional Sequences (VR-CoDES). Cues, concerns and responses were analyzed in relation to patient gender and ICD-10 diagnosis, and psychiatrists’ age, gender, clinical experience and consultation process.

Results

Cues were more frequent among female patients and were equally distributed among diagnostic categories. Concerns were more frequent among patients with “Mood” or “Neurotic” disorders. Psychiatrists’ responses to cues tended to “provide space” without being explicit. Referral to the affective part was restricted to concerns which had been solicited by the psychiatrist. Empathic responses were infrequent. Cues and concerns received more attention by female psychiatrists.

Conclusion

The study confirms gender differences in expressing and dealing with emotions both by patients and psychiatrists. Females tend to give more space to this topic. Psychiatrists ‘responses differed according to cues, concerns, gender, diagnosis and to who prompted the cue/concern, showing a preference for topics introduced by themselves.

Practice implications

The VR-CoDES is a useful tool to define the strategies psychiatrists adopt when handling patients’ emotions in terms of cues and concern.