From support to boundary: A qualitative study of the border between self-care and professional care

Objective

While healthcare systems globally are promoting self-care, patients’ perceptions of the policy shift remain relatively unexplored. Our qualitative study explored how organisation of care shaped patients’ perceptions and experiences of self-care in dealing with their respiratory illnesses.

Methods

We recruited 31 people, representing a range of ages and respiratory conditions and generated data using illness diaries, telephone interviews and focus group discussions. Data were transcribed, analysed and triangulated using the framework approach.

Results

Patients were aware of the increasing focus on self-care, but felt that the term was incongruous as it described what they were already doing. While many respondents appreciated increased clinical responsibility some felt ‘abandoned’ by professionals. To be active partners in care, they needed flexible access to trusted healthcare professionals who respected patients’ knowledge about their condition and preferences for management.

Conclusion

The shift to self-care needs to be underpinned by a whole system change. Professionals need communication skills to engage with patients as partners in care, working within systems that offer flexible access to supportive care.

Practice implications

Systems of care for people with long-term conditions need to ensure flexible access between self-care and professional support. Simplification of systems, clear sign-posting and co-ordination of individual patient care by a key trusted professional are essential.     

Further validation of the Patient-Practitioner Orientation Scale (PPOS) from recorded visits for back pain

Objective

More patient-centered communication is associated with improved patient satisfaction and health status, fewer malpractice complaints, and increased adherence. In a study of medical encounters for acute low back pain (LBP), we conducted a secondary analysis to assess the validity of the Patient Practitioner Orientation Scale (PPOS), a measure of patient-centeredness.

Methods

Fourteen clinicians and 89 of their patients with acute LBP completed the PPOS and agreed to have verbal exchanges recorded and coded using the Roter Interaction Analysis System (RIAS). We examined correlations between the PPOS and counts of patient and provider utterances within 8 RIAS verbal exchange categories.

Results

Providers with a more patient-centered orientation asked fewer biomedical questions, posed more lifestyle questions, gave more lifestyle advice, and did more rapport-building. Their patients shared more lifestyle information and made more attempts at rapport building and provider engagement. In contrast, the patient-centered orientation of patients showed no effect on communication.

Conclusion

The PPOS scores of providers, but not patients, predicted significant and meaningful differences in the verbal exchanges of patients and providers.

Practice implications

The results support the validity of the PPOS measure and provide further evidence of the extent to which provider orientation influences patient communication and exchange.     

What do Nepalese medical students and doctors think about patient-centred communication?

Objective

To ascertain the attitudes of Nepalese medical students and doctors regarding aspects of doctor–patient communication.

Method

A cross-sectional survey, using the Patient–Practitioner Orientation Scale (PPOS), was undertaken with students and doctors in a teaching hospital in rural Nepal. Qualitative research was also done, using semi-structured interviews and focus groups, with a sample from the same population. The author's participant observations provided a third data source.

Results

Participants generally expressed ‘patient-centred’ attitudes, particularly in the following areas: power-sharing; the importance of social context; friendliness; providing adequate time and explanations. They thought that the hierarchical nature of society carried over into medical practice, particularly noting the exalted position of doctors and the importance of social and financial issues in patient outcomes. The participants thought that Nepalese doctors currently practice in a ‘doctor-centred’ manner but thought that this should change.

Conclusion

There was a marked contrast between the attitudes expressed by participants and the way that they see medicine is currently practiced. The results also showed an under-appreciation of Nepalese patients’ universal desire for being given good information.

Practice implications

This study underlines the need for an increased understanding of local preferences regarding medical communication styles. Methods of providing information to patients need to be strengthened in clinical practice.     

Determinants of patients’ attitudes toward patient-centered care: A cross-sectional study in Greece

Objective

The aim of this study was to investigate – for the first time in Greece – patients’ attitudes toward patient-centered care, by identifying the impact of socio-demographic factors, health condition, social support and religious beliefs.

Methods

454 Hospitalized patients were interviewed on the first day of their scheduled admission, answering demographic questions and the following questionnaires: Patient–Practitioner Orientation Scale (PPOS), Autonomy Preference Index (API), Short Form SF-12v2 Health Survey, God Locus of Health Control (GLHC) and Perceived Available Support (PAS).

Results

Mean PPOS and API scores were: PPOS Sharing 3.4 (sd = 0.69), Caring 3.99 (sd = 0.76), API Information-Seeking 88.32 (sd = 9.35) and Decision-Making 51.19 (sd = 9.27). Higher desire for information was associated with younger age, more years of education, weaker spiritual faith in healing and worse subjective health status. Higher expectations for caring physicians were correlated with older age, more years of education, higher perceived social support and weaker spiritual faith in healing.

Conclusion

Age, years of education, health status, social support and religious beliefs are determinants of patient-centered attitudes.

Practice implications

Patients expect to be informed, although they do not equally want to be involved in decision-making. Religious faith and perceived social support should be taken into consideration to further understand patients’ needs.     

How to define and measure concordance between patients’ preferences and medical treatments: A systematic review of approaches and recommendations for standardization

Objective

The purpose is to systematically review the methods used to calculate the association between patients’ preferences and treatment choices and to present a set of recommendations for definition and measurement of this concept.

Methods

A systematic review of the literature from 1967 to 2007 identified articles that reported a relationship between patients’ preferences and their treatment choices. Potential citations were identified from electronic databases, the Cochrane Collaborative review, and identified experts. Relevant articles were abstracted by two reviewers independently using standard forms.

Results

The search identified 3114 unique citations, the full text of 180 articles was examined, and 49 articles were included. These 49 studies used a variety of definitions of preferences and choices, and calculated concordance in different ways. Half of the studies tied their method to a theoretical framework. There were problems with many of the studies that limit the ability to generalize or make comparisons across studies.

Conclusion

There is no consistent method for defining or calculating the match between patients’ preferences and treatment choices. There is a need for more clarity in the definition and reporting of this type of concordance in measures of decision quality.

Practice Implications

The match between an informed patient's preferences and treatment choices is a key component of patient-centered care. Valid and reliable measures of the level of concordance are needed.     

A 3-stage model of patient-centered communication for addressing cancer patients’ emotional distress

Objective

To describe pathways through which clinicians can more effectively respond to patients’ emotions in ways that contribute to betterment of the patient's health and well-being.

Methods

A representative review of literature on managing emotions in clinical consultations was conducted.

Results

A three-stage, conceptual model for assisting clinicians to more effectively address the challenges of recognizing, exploring, and managing cancer patients’ emotional distress in the clinical encounter was developed. To enhance and enact recognition of patients’ emotions, clinicians can engage in mindfulness, self-situational awareness, active listening, and facilitative communication. To enact exploration, clinicians can acknowledge and validate emotions and provide empathy. Finally, clinicians can provide information empathetically, identify therapeutic resources, and give referrals and interventions as needed to help lessen patients’ emotional distress.

Conclusion

This model serves as a framework for future research examining pathways that link clinicians’ emotional cue recognition to patient-centered responses exploring a patient's emotional distress to therapeutic actions that contribute to improved psychological and emotional health.

Practical implications

Specific communicative and cognitive strategies are presented that can help clinicians better recognize a patient's emotional distress and respond in ways that have therapeutic value.     

What patients want

Objective

Although most health care professionals im- or explicitly will assume that they tend to use patient-centered communication strategies, there are reasons to believe that this might not always be a valid assumption. In everyday practice, professionals’ own value system is often the dominant steering guide. This Special Issue aims to bring together ongoing research and reflections about the quality of health care communication from the patients’ own perspective. In short: what do patients want?

Methods

This introduction presents a comprehensive overview of the papers in the special issue of Patient Education and Counseling within a framework that describes the collected papers according to the six functions of medical consultations, taking account of the studies’ applied methodologies: quantitative versus qualitative.

Results

Two functions of the medical consultation are strongly represented in the collected papers on the quality of communication from the patients’ perspective: ‘fostering the relationship’ and ‘information giving’. There is a remarkable difference between the qualiative and quantitative studies, showing that if patients are not limited to prestructured questionnaires but completely free to express themselves, they tend to focus on ‘fostering the relationship’ with an emphasis on personal attention, warmth and empathy.

Conclusions

Patients’ needs and preferences for personalized and humane medical care cannot be overestimated. For the rest, patient diversity is striking, showing the limited usefulness of general communication guidelines for the other five functions of the medical consultation. Researchers should be aware that patients’ views might be different dependent on the applied methodologies.     

Patients’ perspectives on psychiatric consultations in the Gender Identity Clinic: Implications for patient-centered communication

Objective

To explore transsexual patients’ perceptions of communication with psychiatrists in a Gender Identity Clinic and advance understanding of patient centered communication (PCC) in psychiatric, ‘gatekeeping’ settings.

Methods

21 qualitative interviews with a convenience sample of clinic patients. Interviews were coded at a semantic level and subject to an inductive thematic analysis.

Results

Patients’ perceptions clustered into three themes: (1) aspects of communication that patients described liking; (2) aspects of communication that patients described disliking; and (3) aspects of communication that patients deemed challenging but necessary or useful.

Conclusion

Patients described liking or disliking aspects of communication that reflect existing understandings of PCC. However, a striking feature of their accounts was how they were able to rationalize and reflect pragmatically on their negative communication experiences, welcoming doctors’ challenges as an opportunity to consider their life-changing decision to transition from their natal gender.

Practice implications

In certain clinical settings, current operationalizations of PCC may not apply. Patients’ perceptions of communication may be enhanced if an analysis of their experiences formed part of the professional training of doctors, who could be invited to consider the functional specificity of communication across settings and the consequences (both immediate and post hoc) of their communication practices.     

Physicians’ influence on veterans’ decision to use acupuncture

Objective

To compare patients’ acupuncture use with physician's attitudes toward and history of referral for acupuncture.

Methods

A questionnaire was administered to patients of the Atlanta Veterans Affairs Medical Center and the physicians whom they identified as most influencing their healthcare decisions. A total of 114 patients were matched with 33 physicians.

Results

Physicians’ history of referral was not significantly related to patients’ acupuncture use. Physicians’ belief that acupuncture would increase patient satisfaction, however, was associated with higher rates of patient acupuncture use (p = 0.01). Qualitative analysis of an open-ended question that probed further into physicians’ attitudes regarding acupuncture revealed three key themes: lack of knowledge about the treatment; misperceptions regarding availability of acupuncture at VA; and lack of VA providers to meet demand.

Conclusion

These results indicate that physicians’ referral patterns are not associated with patients’ acupuncture use. However, some evidence shows a link between patients’ acupuncture use and physicians’ beliefs that the treatment will increase patient satisfaction, showing that physician attitudes may have some influence on patients’ acupuncture use.

Practice implications

In order to cultivate shared-decision making between patients and their physicians it will be important to address gaps in provider knowledge about acupuncture and its availability.     

Physician's gender,communication style,patient preferences and patient satisfaction in gynecology and obstetrics: A systematic review

Objective

Review of studies published in the last 10 years about women seeking gynecological- or obstetrical care and physician's gender in relation to patient preferences, differences in communication style and patient satisfaction.

Methods

Studies were identified by searching the online databases PubMed, PsycINFO, Embase and the Cochrane Library. The search strategies ‘gender’; ‘obstetrics’ and ‘gynecology’ were combined with ‘communication’; ‘physician–patient relations’; ‘patient preference’ and ‘patient satisfaction’.

Results

After screening title and abstract, evaluating full text and quality assessment, 9 articles were included in this review. Most patients preferred a female rather than a male gynecologist–obstetrician. This was partly explained by a more patient-centered communication style used by female gynecologists–obstetricians. Also experience and clinical competence were important factors in choosing a gynecologist–obstetrician. It was not clear whether patient's age or ethnicity influenced patients gender preference. Patient satisfaction increased when gynecologists–obstetricians used a patient-centered communication style.

Conclusion

Preference for a female gynecologist–obstetrician might be explained by a more patient-centered communication style used by female gynecologists–obstetricians. Using a patient-centered communication style increases patient satisfaction.

Practice implications

To increase patient satisfaction, gynecologists–obstetricians should learn to integrate patient-centered communication style into the consultation.     

Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital

Objective

This study aimed to explore the relationships among physicians’ confidence in conducting medical interviews, their attitudes toward the patient–physician relationship, and undergraduate training in communication skills among resident physicians in Japan.

Methods

Participants were 63 first-year resident physicians at a university hospital in Tokyo. The Physician Confidence in the Medical Interview scale (PCMI) was constructed based on the framework of the Calgary–Cambridge Guide. Additionally, participants’ attitudes toward the patient–physician relationship (Patient–Practitioner Orientation Scale; PPOS), undergraduate experience of communication skills training, and demographic characteristics were assessed through a self-reported questionnaire.

Results

The internal consistency of the PCMI and PPOS scales were adequate. As expected from the undergraduate curriculum for medical interviews in Japan, residents had relatively higher confidence in their communication skills with respect to gathering information and building the relationship, whereas less confident about sharing information and planning treatment. The PCMI was associated with a more patient-centered attitude as measured by the PPOS.

Conclusion

These scales could be useful tools to measure physicians’ confidence and attitudes in communicating with patients and to explore their changes through medical education.

Practice implications

Residency programs should consider including systematic training and assessment in communication skills related to sharing information and planning treatment.     

Toward a greater understanding of breast cancer patients’ decisions to discuss cancer-related internet information with their doctors: An exploratory study

Objective

To investigate differences between breast cancer patients who do and do not discuss cancer-related internet information (CRII) with their doctors.

Methods

70 breast cancer patients completed questionnaires regarding internet use, discussions about CRII, and the doctor–patient relationship.

Results

No significant differences were noted across patient, disease, or visit characteristics, or physician reliance between those who intended to discuss CRII and those who did not. Patients who intended to discuss CRII rated significantly higher pre-consultation anxiety levels. No significant differences in satisfaction, anxiety reduction, or trust in physician were found between patients who had discussed and those who had not. Patients’ reasons for discussing or not discussing are detailed.

Conclusion

Factors influencing patients’ decisions to discuss CRII are complex and differ from those identified as leading patients to seek internet information. Future research about internet discussions should investigate the impact of patients’ preferred role in treatment, the doctor–patient relationship, anxiety level, attributes of CRII, and physician trust.

Practice implications

Understanding the characteristics of patients who do and do not discuss internet information is important given the impact internet information has on healthcare communication and the doctor–patient relationship, including the development of interventions aimed at improving such interactions.     

An evidence base for patient-centered cancer care: A meta-analysis of studies of observed communication between cancer specialists and their patients

Objective

In the context of patients visiting cancer specialists, the objective is to test the association between both patient-centered communication (including Affective Behavior and Participation Behavior) and Instrumental Behavior and patients’ post-visit satisfaction with a variety of visit phenomena.

Methods

Meta-analysis of 25 articles representing 10 distinct data sets.

Results

Both patient-centered- and instrumental behavior are significantly, positively associated with satisfaction, with patient-centered communication having a relatively stronger association.

Conclusion

There is an evidence base for the efficacy of patient-centered care.

Practice implications

Cancer specialists need to train to improve their patient-centered communication.     

A method to determine the impact of patient-centered care interventions in primary care

Objective

The implementation of patient-centered care (PCC) innovations continues to be poorly understood. We used the implementation effectiveness framework to pilot a method for measuring the impact of a PCC innovation in primary care practices.

Methods

We analyzed data from a prior study that assessed the implementation of an electronic geriatric quality-of-life (QOL) module in 3 primary care practices in central North Carolina in 2011–2012. Patients responded to the items and the subsequent patient–provider encounter was coded using the Roter Interaction Analysis System (RIAS) system. We developed an implementation effectiveness measure specific to the QOL module (i.e., frequency of usage during the encounter) using RIAS and then tested if there were differences with RIAS codes using analysis of variance.

Results

A total of 60 patient–provider encounters examined differences in the uptake of the QOL module (i.e., implementation-effectiveness measure) with the frequency of RIAS codes during the encounter (i.e., patient-centeredness measure). There was a significant association between the effectiveness measure and patient-centered RIAS codes.

Conclusion

The concept of implementation effectiveness provided a useful framework determine the impact of a PCC innovation.

Practice implications

A method that captures real-time interactions between patients and care staff over time can meaningfully evaluate PCC innovations.     

Developing a model of decision-making about complementary therapy use for patients with cancer: A qualitative study

Objective

To improve our understanding of patient participation in health care consultations and decision-making by exploring a consultation that lies at the interface between mainstream care and complementary therapies.

Methods

Thirty-four holistic consultations were observed at centres offering complementary therapies for cancer, followed by interviews with patients and focus groups with professionals.

Results

A model of decision-making about complementary therapy use emerged from the data: ‘Advice: Assessor led decision’, ‘Confirmation: Joint decision’, ‘Access: Patient-led decision’ and ‘Informed: Patient-led decision’. Decision-making style was contingent on identifiable communication strategies in the preceding information-sharing and discussion phases of the consultation.

Conclusion

This study confirms the importance of gauging patients’ preferences for level of participation in decision-making. Models of consultations are generally based on the assumption that a greater degree of patient participation is a good thing that access to information and decision-making power is sought by all patients. Data from this study suggest that, in this context at least, this is not necessarily the case. The study also stresses the dynamic nature of the consultation, in which roles are fluid rather than fixed.

Practice implications

Insight were gained into professionals’ communication strategies and patients’ role preferences in decision-making, which may be applicable more widely.     

Physician gender,physician patient-centered behavior,and patient satisfaction: A study in three practice settings within a hospital

Objective

To compare male and female physicians on patient-centeredness and patients’ satisfaction in three practice settings within a hospital; to test whether satisfaction is more strongly predicted by patient-centeredness in male than female physicians.

Methods

Encounters between physicians (N = 71) and patients (N = 497) in a hospital were videotaped and patients’ satisfaction was measured. Patient-centeredness was measured by trained coders.

Results

In the outpatient setting, female physicians were somewhat more patient-centered than male physicians; patient satisfaction did not differ. In the inpatient and emergency room settings, female physicians were notably more patient-centered than male physicians; satisfaction paralleled these differences. Nevertheless, there was some, though mixed, evidence that patient-centeredness predicted satisfaction more strongly in male than female physicians, suggesting that patients valued patient-centered behavior more in male than female physicians.

Conclusion

Even though satisfaction mirrored the different behavior styles of male and female physicians in the inpatient and emergency room settings, in all settings male physicians got somewhat more credit for being patient-centered than female physicians did.

Practice implications

If female physicians do not consistently receive credit for high patient-centeredness in the eyes of patients, this could lead female physicians to reduce their patient-centered behavior.     

Patient reported interpersonal processes of care and perceived social position: The Diabetes Study of Northern California (DISTANCE)

Objective

A patient's sense of his/her standing in the social hierarchy may impact interpersonal processes of care (IPC) within the patient–provider encounter. We investigated the association of perceived social position with patient-reported IPC.

Methods

We used survey data from the Diabetes Study of Northern California (DISTANCE), studying 11,105 insured patients with diabetes cared for in an integrated healthcare delivery system. Perceived social position was based on the MacArthur subjective social status ladder. Patient-reported IPC was based on a combined scale adapted from the Consumer Assessment of Health Plans Study provider communication subscale and the Trust in Physicians scale.

Results

Lower perceived social position was associated with poorer reported IPC (p < 0.001). The relationship remained statistically significant after controlling for age, sex, race/ethnicity, depressive symptoms, physical functioning, income and education.

Conclusion

Beyond objective measures of SES, patients’ sense of where they fall in the social hierarchy may represent a pathway between social position and patient satisfaction with the quality of patient–provider communication in chronic disease.

Practice implications

Interventions to address disparities in communication in primary care should incorporate notions of patients’ social position.     

Patients’ reflections on communication in the second-opinion hematology–oncology consultation

Objective

The nature of communication between patients and their second-opinion hematology consultants may be very different in these one-time consultations than for those that are within long-term relationships. This study explored patients’ perceptions of their second-opinion hematology–oncology consultation to investigate physician–patient communication in malignant disease at a critical juncture in cancer patients’ care and decision-making.

Methods

In-depth telephone interviews with a subset of 20 patients from a larger study, following their subspecialty hematology consultations.

Results

Most patients wanted to contribute to the consultation agenda, but were unable to do so. Patients sought expert and honest advice delivered with empathy, though most did not expect the consultant to directly address their emotions. They wanted the physician to apply his/her knowledge to the specifics of their individual cases, and were disappointed and distrustful when physicians cited only general prognostic statistics. In contrast, physicians’ consideration of the unique elements of patients’ cases, and demonstrations of empathy and respect made patients’ feel positively about the encounter, regardless of the prognosis.

Conclusions

Patients provided concrete recommendations for physician and patient behaviors to enhance the consultation.

Practice implications

Consideration of these recommendations may result in more effective communication and increased patient satisfaction with medical visits.     

Gender bias in patients’ perceptions of patient-centered behaviors

Objective

This research examines whether patient perceptions are equivalently associated with patient-centered behavior in male and female medical students, and tests the impact of a message emphasizing the importance of patient-centeredness on analogue patients’ perceptions of male and female medical students’ performance.

Methods

Sixty-one medical students interacting with standardized patients (SPs) were viewed by 384 analogue patients (APs). APs were randomly assigned to receive a message emphasizing the value of patient-centeredness or of technical competence, or a neutral message, and then evaluated the medical students’ competence in the interactions. Students’ patient-centeredness was measured using the Four Habits Coding Scheme and Roter Interaction Analysis System.

Results

APs in the neutral and technical competence conditions gave higher competence ratings to more patient-centered male students, but not to more patient-centered female students. However, APs who received the patient-centeredness message gave higher competence ratings to both male and female students who were higher in patient-centeredness.

Conclusion

Making it clear that patient-centeredness is a dimension of physician competence eliminated a gender bias in evaluating performance.

Practice implications

Because patient perceptions are often used in evaluations, gender biases must be understood and reduced so both male and female providers receive appropriate credit for their patient-centered behaviors.