Communication in the diagnostic mammography suite: implications for practice and training

RATIONALE AND OBJECTIVES: The diagnostic mammography suite is a microcosm of challenging physician-patient communication in radiology. Little has been written about communication practices in the diagnostic mammography suite, the effect of this communication on both physicians and patients, and implications for radiology training programs. We surveyed radiology residents and staff about communication training, practices, and experiences communicating directly with patients in the diagnostic mammography suite. MATERIALS AND METHODS: We asked the membership of the Association of Program Directors in Radiology to disseminate surveys to radiology residents and staff radiologists in their institutions. We analyzed response frequencies and correlations. RESULTS: We received responses from 142 residents and 120 staff radiologists. More than half of staff respondents spoke personally with every patient who had an abnormal diagnostic mammogram; 37% felt they had inadequate time to do so. Most residents and staff highly rated their own communication skills and confidence in ability to explain results and respond to patients' emotions, but experienced stress doing so. A majority of respondents reported no formal communication skills education after medical school. Twenty-nine percent of staff respondents regularly observed residents' communication with patients and 39% of residents reported receiving feedback about their communication. Residents' opportunities to observe staff communicate with a patient and to receive feedback on their own patient interactions were correlated with self-rated communication skill and confidence in ability to respond to patients' emotions (P < .05). CONCLUSIONS: Radiologists engage in challenging and stressful patient communication interactions. There is a paucity of educational curricula on interpersonal and communication skills in radiology. This has implications for both patient and physician satisfaction and patient outcomes.     

Patient education: using a radiology nurse

Employment of a radiology nurse in the patient education program of a 300-bed community hospital helps protect patients' rights and promotes efficient patient care. It has been shown to enhance efficient use of hospital services and to increase physician support, staff satisfaction, and patient satisfaction, while increasing community support for the hospitals.     

Development of prehospital medical classification criteria

INTRODUCTION: A trauma classification system (TCS) is widely used by many prehospital personnel to provide advanced activation of trauma teams. Specific criteria serve to notify specialty departments and enhance communication between prehospital and emergency department (ED) personnel. Because the TCS has worked so well, a medical classification criteria tool (MCCT) was developed to consistently notify EDs of medical patients' acuity, enhance communication, and provide a smooth transfer of care. METHOD: MCCT development included establishment of tool validity by experts; retrospective chart review to determine consistency and accuracy of classification; and a pilot test of the MCCT at three hospitals. After the pilot, satisfaction surveys were distributed to receiving hospitals to determine tool effectiveness, ease of use, and enhanced transition of care. RESULTS: Of the receiving staff surveyed, 97% found the tool easy to understand; 82% thought the MCCT enabled them to effectively prepare for patients; 62% perceived consistency in classification by the helicopter staff. The flight crew had a 100% positive response regarding ease of MCCT use; 36% noted a positive change in preparation for medical patients' transfer of care. CONCLUSION: The MCCT enhances communication and is useful in preparation and transition of patient care from prehospital to the hospital environment. Advanced notification of patient illness severity may enhance care and affect overall outcome.     

The quality of therapeutic alliance between patient and provider predicts general satisfaction

OBJECTIVES: Therapeutic alliance has been proposed as an ideal patient-provider relationship. The Kim Alliance Scale (KAS) measures the quality of therapeutic alliance, including patient empowerment. The objectives were to refine KAS and to measure the relationship between therapeutic alliance and patients' general satisfaction. METHODS: A total of 601 evaluable patients was recruited, 304 patients in exploratory series and 297 patients in validation series. Patients completed a demographics questionnaire, the KAS, and Patient Satisfaction with Health Care Provider Scale. RESULTS: Using the exploratory series, KAS was refined into a 16-item KAS-R consisting of collaboration, integration, empowerment, and communication subscales. Internal consistency reliability of KAS-R was 0.89. Hierarchical multiple regression analyses of the two series showed that KAS-R accounts for 35% to 36% of the variance in general satisfaction scores. CONCLUSIONS: Therapeutic alliance, as measured by KAS-R, predicted approximately one-third of patients' general satisfaction and empowerment was a significant predictor variable.     

Patient Information in Radiooncology

BACKGROUND: As a result of increased interest and public demand, providing patients with adequate information about radiooncology has become more and more difficult for the doctor. Insufficient patient information can not only cause anxiety for the patient, but can also lead to legal action against the physician. In order to gain a deeper insight into our clinical practice of providing patient information, we developed a special questionnaire. We describe our first experiences in using this questionnaire at our institute. PATIENTS AND METHODS: We examined the amount of information and level of satisfaction, as well as the agreement of assessment between patient and physician after the provision of standard patient information before and at the end of radiotherapy. 51 consecutive patients were interviewed with a newly designed questionnaire. The first questioning with 13 items was carried out before radiotherapy and the second with ten items was done at the end of treatment. Sum scores for information and satisfaction were defined and agreement was measured by the weighted kappa coefficient. RESULTS: Global level of information and satisfaction was good, and a significant increase in information level and a significant decline in satisfaction were seen between questionnaire 1 and 2. Agreement between patient and physician was fair, for example intent of treatment resulted in a kappa coefficient of 0.34, and poor for the doctor's role with a kappa coefficient of -0.002. Only 52% of the patients who received palliative radiotherapy rated correctly the non-curative intent of treatment, whereas 86% of the patients who received curative radiotherapy made a correct statement. Before radiotherapy, emotional state was often both negatively and positively assessed by the patients. CONCLUSION: Our short questionnaire is simple and easy to understand. It provides insights into patient information with respect to assessment of the information, satisfaction level, and agreement between doctor and patient. Therefore, it is suitable for use in the clinical routine. We found a high information and satisfaction score, but limited agreement between physician and patient. In the future, the questionnaire can be used as an aid to evaluate patient information in everyday practice and to train the communication skills of the physician. Further evaluation of the questionnaire is needed and, in particular, the aspect of patient information with palliative radiotherapy has to be improved.     

Physician's error: medical or legal concept?

This article deals with the common term of different physician's errors that often happen in daily practice of health care. Author begins with the term of medical malpractice, defined broadly as practice of unjustified acts or failures to act upon the part of a physician or other health care professionals, which results in harm to the patient. It is a common term that includes many types of medical errors, especially physician's errors. The author also discusses the concept of physician's error in particular, which is understood no more in traditional way only as classic error in acting something manually wrong without necessary skills (medical concept), but as an error which violates patient's basic rights and which has its final legal consequence (legal concept). In every case the essential element of liability is to establish this error as a breach of the physician's duty. The first point to note is that the standard of procedure and the standard of due care against which the physician will be judged is not going to be that of the ordinary reasonable man who enjoys no medical expertise. The court's decision should give finale answer and legal qualification in each concrete case. The author's conclusion is that higher protection of human rights in the area of health equaly demands broader concept of physician's error with the accent to its legal subject matter.     

Patient satisfaction during radiation therapy

Background

Assessing patient satisfaction might help to detect so far unknown patient needs and could contribute to quality assurance within the health care system. We evaluated patient satisfaction and its correlates in a consecutive sample of patients undergoing external beam radiation therapy.

Patients and methods

Patient satisfaction was evaluated within a prospective study with two validated instruments (FPZ, ZUF-8) during the first week of radiation therapy in two university-based radiation oncology departments.

Results

A total of 273?patients could be analyzed. Most patients were irradiated for breast or urogenital cancer. Overall patient satisfaction was high (94.9–98.8%). The most important items for patient satisfaction included the following: “skills of physicians” followed by “physician contact with patients,” “care,” and “information” (Tab. 2). Neither center nor disease entity correlated with global patient satisfaction. Of the patients, 46% reported that they would have preferred additional information prior to the onset of radiotherapy. Patients who sought additional information reported a lower global patient satisfaction (p?Tab. 6).

Conclusion

During the first week of radiation therapy, patients rate patient–physician interaction and communication on treatment and disease as important factors for their satisfaction. Supplying additional information to subsets of patients prior to starting radiotherapy might help to further improve satisfaction.     

A validated pediatric transport survey: how is your team performing?

INTRODUCTION: Understanding referring practitioners' satisfaction with pediatric transport services is useful for quality improvement. Formal survey methodology was applied to develop a pediatric transport satisfaction survey. SETTING: Large metropolitan area in the Southwestern United States. METHODS: A four-stage process was used to create a 20-item pediatric transport satisfaction survey. The final survey was analyzed for test-retest and internal consistency reliability, and surveys were mailed to a large practitioner base. RESULTS: The survey encompassed three domains: patient care, accessing the transport system, and communication. Test-retest and internal consistency reliability were good (final Cronbach alpha coefficient of 0.88.) Of the 229 providers responding, 69% were local (<60 miles), and 31% were served by our long distance transport team (>60 miles). Respondents reported that physicians selected the transport team in 82% of cases, whereas 9% reported that the charge nurse decided. Transport team selection was based on: (1) ease of initiation, (2) fastest arrival, (3) presence of a physician on the team, (4) stabilization time at the referring facility, and (5) team providing best follow-up. Satisfaction with our transport service was high, with a median survey score of 83 (interquartile [IQ] range, 74-92). Physicians and nurses reported equal satisfaction. CONCLUSION: Survey design methodology was successfully applied to assess satisfaction with pediatric transport. This transport survey offers a reliable measurement of providers' satisfaction with transport services.     

Chiropractic services in the Canadian Armed Forces: a pilot project

This article reports on satisfaction associated with the introduction of chiropractic services within a military hospital, through a Canadian Armed Forces Pilot Project. We distributed a 27-item survey that inquired about demographic information and satisfaction with chiropractic services to 102 military personnel presenting for on-site chiropractic services at the Archie McCallum Hospital in Halifax, Nova Scotia. We provided a second 3-item survey, designed to explore referral patterns and satisfaction with chiropractic services, to all referring military physicians. A multivariable linear regression model was constructed to explore which factors were associated with patients' satisfaction with chiropractic services. The response rate to the patient and physician satisfaction surveys was 67.6% (69 of 102) and 83.3% (10 of 12), respectively. Chronic low back pain accounted for most presentations to the hospital chiropractic clinic. The majority of military personnel (94.2%) and referring physicians (80.0%) expressed satisfaction with chiropractic services. Our adjusted analysis found that older age (beta = -0.37; 95% confidence interval = -0.73 to -0.02) and a presenting complaint of knee pain (beta = -15.56; 95% confidence interval = -29.61 to -1.51) was associated with decreased satisfaction with chiropractic care. Although our finding of high satisfaction with chiropractic services is encouraging, formal studies on functional outcomes and cost effectiveness of chiropractic care are required to better inform the role of chiropractic services in the Canadian Armed Forces.     

Primary care outcomes and provider practice styles

The purpose of this study was to evaluate change in patient outcomes as a function of practice styles of primary care providers. A prospective, repeated-measures, correlational design was used. Data were collected about (1) providers' self-ratings of practice styles, inclusive of practice model, confidence, autonomy, collaboration, information giving, and job satisfaction, and (2) primary care patients' self-ratings of health status, functional status, information seeking, and satisfaction. When severity and comorbidity were controlled, physicians, nurse practitioners, and physician assistants produced equivalent outcomes; neither practice style nor provider type resulted in differences in health outcomes of primary care patients. Practice style did affect patient satisfaction. Patients were least satisfied with providers who scored high on collaboration and most satisfied with providers who scored low on the practice model. Neither provider type nor interpersonal attributes had an effect on health outcomes; sicker patients got better and healthy patients stayed that way.     

Patient satisfaction in military medicine: model refinement and assessment of continuity of care effects

The Military Health System (MHS) identified patient-centered care and satisfied beneficiaries as main objectives in their 2006 Strategic Plan. The objective of this study was to expand upon the previous MHS model to determine predictors of patient satisfaction behaviors based upon associated attitudes and beliefs in addition to determining the predictive qualities presented by continuity of care. A sample of 90,318 patient responses from 2002 to 2004 was drawn from the Customer Satisfaction Survey database. Hierarchical multiple linear regression analyses were conducted to assess the uniquely predictive effects of the independent variables on the outcome variable. Results indicated the constructs from previous studies of satisfaction within the MHS using an attitude model were consistent when tested in a behavioral model. Hypothesis tests also indicated continuity of care demonstrated uniquely predictive qualities suggesting inclusion in the model. The final satisfaction with visit model yielded F(29, 90, 288) = 7062.37, p < 0.01 with R2 = 0.694.     

Nonclinical factors associated with primary care physicians’ ordering patterns of magnetic resonance imaging/computed tomography for headache

RATIONALE AND OBJECTIVES: The purpose of ordering an imaging test for headache, which is one of the most common reasons for patient consultation with a primary care physician (PCP), include medical indications as well as patient anxiety and medico-legal concerns. The impact of nonclinical factors on PCPs' ordering patterns of magnetic resonance imaging/computed tomography for patients presenting with a headache was examined. MATERIALS AND METHODS: A retrospective record review of all patients treated for headache as their primary complaint by a PCP from a multispecialty group practice associated with an 180,000-member Health Maintenance Organization during calendar year 2000 was examined. The practice included 18 clinics. Logistic regression was used to estimate the association between physician ordering patterns of imaging tests and patient, physician, and clinic setting characteristics. RESULTS: Of the total study subjects (n = 4,372), a magnetic resonance imaging/computed tomography imaging test was ordered for 5.3%. At their first encounter, patient's gender, site of care, and insurance status under the health care system's Health Maintenance Organization had statistically significant associations with the likelihood of imaging test orders. Female physicians were less likely to order an imaging test (OR = 0.65; 95% confidence interval, 0.39-1.08). For subsequent encounters, however, site of care was the only nonclinical factor that had a consistent association with the likelihood of having a magnetic resonance imaging/computed tomography ordered. CONCLUSION: These data show that a number of nonclinical factors may have been associated with having an imaging test ordered by a PCP when patients presented with a headache. These factors were more significant when the patient was being seen for the first time with this complaint.     

Patient satisfaction in military medicine: model refinement and assessment of Department of Defense effects

A sample of 154,893 patient responses from the Customer Satisfaction Survey database was drawn for 1999 to 2000. Average patient satisfaction levels consistently appeared to be high (between 6, very satisfied, and 7, completely satisfied, on the 7-point rating scale). Hierarchical regression results essentially replicated all three major constructs of an earlier theoretical attitude model. Refinements included adjustment and addition of categorical age and military beneficiary status for individual patient variables, addition of two beliefs about the care itself, substitution of waiting time variables, and addition of reason for visit situation variables. Hypothesis test results indicated that patient satisfaction constructs were homogeneous across the uniformed services for patients from all service branches, both enrolled and not enrolled within TRICARE regions, and among branch of service medical center, hospital, and clinic facilities. The final attitude model coefficient of multiple determinations obtained was R2 = 0.701 [F(25,154,867) = 14,539.33, p < 0.0001].     

介入病房医护成组责任制管理模式的探讨

目的:探讨医护成组责任制管理在介入专科病房中的应用效果。 方法:在介入专科病房实施医护成组责任制管理模式,采用自制的问卷调查表,对病人的满意度、护士的满意度和医生的满意度进行问卷调查,并采集护理服务质量相关数据,与实施医护成组责任制管理模式前的调查结果进行比较。 结果:实施医护成组责任制管理模式后,病人对医疗护理工作的满意度、医生对护理工作的满意度和护士对医生的满意度均明显提高,差异均有统计学意义(P<0.05);最满意医生护士的人次数、病人感谢信中点名表扬护士的人次数明显增多,差异均有统计学意义(P<0.05)。 结论:在介入专科病房实施医护成组责任制管理模式,能有效地加强医、护、患关系,达到"病人满意、医生满意、护士满意"的目标,让医护与病人及家属的关系更加和谐,具有十分重要的意义。     

Results of Postoperative 90Sr Radiotherapy of Keloids in View of Patients’ Subjective Assessment

BACKGROUND AND PURPOSE: As treatment of keloids is mainly a cosmetic indication, the authors investigated, beyond the recurrence rate, the patients' satisfaction with the result and its correlation with objective medical findings. PATIENTS AND METHODS: 83 keloids of 66 patients had been irradiated after excision by a uniform protocol with 4 x 5 Gy (strontium- 90 [(90)Sr] surface applicator). A questionnaire was developed and sent out in which, above all, the satisfaction with the therapeutic and cosmetic outcome was obtained. These results were correlated with objective parameters and medical findings which were ascertained during an extra follow-up examination. RESULTS: Among 18 of the 41 patients (44%), who had answered the questionnaire, 19 of the 53 keloids treated (36%) had relapsed. 61% of the patients were extremely or mainly satisfied with the therapeutic outcome, 51% extremely or mainly satisfied with the cosmetic outcome. The relief from former keloid-caused symptoms (therapeutic outcome: p = 0.0005; cosmetic outcome: p = 0.0011), the ear as keloid localization (p = 0.0008 and p = 0.0197), and male gender (therapeutic outcome: p = 0.0423) were significantly associated with higher satisfaction. The recurrence rate as well as the extent of radiation side effects had no significant influence on patients' assessment. CONCLUSION: Cosmetic aspects like the dermal side effects and the patients' satisfaction should be taken into account when evaluating the results of radiotherapy in keloids.     

Medical malpractice: managing the risk

STUDY OBJECTIVE: This is an attempt to present an analysis of the literature examining objective information concerning the likelihood of medicolegal errors as it applies to current medical practice. Hopefully this information will be synthesized to generate a cogent approach to manage risk in emergency medicine. METHODS: Articles were obtained by an English language search of MEDLINE from January 1976 to July 2003. This computerized search was supplemented with literature from the author's personal medicolegal collection of peer review articles. This information was presented in a qualitative fashion. RESULTS: There was a steady increase in both the incidence and the recovery amount of verdicts involving general malpractice litigation. There are clearly high-risk emergency medicine categories responsible for most malpractice events, involving such commonly encountered conditions such as chest pain, abdominal pain, pediatric fever, central nervous system (CNS) bleeding, and abdominal aortic aneurysm (AAA). Interestingly, there is a second peak of more minor emergencies, specifically wounds with neglected foreign bodies and missed fractures. Clearly, the largest dollar amount recovery still involves chest pain with subsequent missed transmural myocardial infarction (MI). Interestingly, there does not appear to be a strong correlation between adverse events, outcome and medicolegal risk. Likewise, there does not appear to be a strong correlation between socioeconomic status and a propensity to sue, but there were some defined links with physician profiles involving past malpractice history, as well as prior adverse relationships or communication skills to subsequent claims. Interestingly, a significant association appears to be advertising placed by local law offices seeking to provide services. Lastly in the emergency medical services (EMS) realm, the single strongest correlate to malpractice was the likelihood of an ambulance accident and not related to care delivered itself. CONCLUSION: The current emergency medicine medicolegal dilemmas are a complex interaction of both patient and physician factors specifically targeting several disease categories and damage claims. Awareness of these issues can help to minimize subsequent medicolegal risk and improve patient care.     

Patient satisfaction with the communication of mammographic results before and after the Mammography Quality Standards Reauthorization Act of 1998.

OBJECTIVE: The goal of this study was to evaluate the difference in patient satisfaction, timeliness of reporting, patient recollection of recommendations, and patient anxiety before and after passage of the Mammography Quality Standards Reauthorization Act of 1998, which requires written notification of all mammographic results. MATERIALS AND METHODS: We used a telephone survey with sampling that was stratified to reflect patients with normal and abnormal findings who had screening and diagnostic mammograms. Patients with visits before the mandate became effective (April 1999, n = 298) and after (January 2000, n = 316) were interviewed about the average time to receive results, satisfaction with communication about results, anxiety, and perceived follow-up recommendations. Multiple logistic regression was used to test the association of time period with patient dissatisfaction, controlling for age, anxiety level (considerable or extreme vs none or moderate), examination type (screening vs diagnostic), and examination result (normal vs abnormal findings). RESULTS: No significant difference was found between periods in anxiety about results or agreement with documented radiology recommendations, but we found a substantial increase in the number of screening patients who reported timely receipt of results. Significantly fewer patients were dissatisfied with mammographic results communication after the mandate (multivariable odds ratio = 0.46, p = 0.006). Screening examination patients and patients who reported considerable or extreme anxiety about test results were more likely to be dissatisfied in both periods. CONCLUSION: By standardizing results notification, the Mammography Quality Standards Reauthorization Act improved patient satisfaction and reporting timeliness among screening examination patients, but did little to improve anxiety or recollection of recommendations. Future quality improvement efforts should focus on improving patients' understanding of follow-up recommendations.     

Patients as partners in radiology education: an innovative approach to teaching and assessing patient-centered communication

RATIONALE AND OBJECTIVES: Effective communication is essential for high quality care, yet little is known about radiologists' communication with patients, what constitutes "best communication practices," and how best to teach and evaluate it. We piloted educational strategies and an assessment instrument to teach and evaluate radiologists' communication skills. We focused on communication in the diagnostic mammography suite, where patient-radiologist interactions are often intense and stressful. MATERIALS AND METHODS: We adapted existing instruments to create a Radiology Communication Skills Assessment Tool (RCSAT). We piloted an educational program that included patients as teachers and raters of interpersonal and communication skills, and implemented a radiology objective structured clinical examination (OSCE). We measured radiology residents' self-assessed skills, confidence and stress, as well as patient-rated communication skills using the RCSAT. RESULTS: Residents' baseline self-assessed communication skills regarding abnormal mammograms were fair, confidence in their communication was minimal, and they found this communication stressful. Overall baseline communication skills, rated by patient-teachers using the RCSAT, were 3.62 on a 5-point scale (1 = poor to 5 = excellent). Analysis of post-OSCE debriefing comments yielded nine themes regarding effective radiology communication, as well as residents' reflections on the communication challenges they experience. The themes were integrated into subsequent RCSAT revisions. Residents' reflections were used to inform teaching workshops. CONCLUSION: Educational curricula on communication about difficult information can be implemented in radiology training programs. Radiology residents' performance can be assessed using a communication skills assessment tool during standardized patient-teacher encounters. Further research is necessary in this important domain.     

Impact of Patient-Centered Care on the Patient Experience in Nuclear Medicine

ObjectiveTo quantify the impact of direct patient-physician interaction within a nuclear medicine pretherapy consultation clinic on the patient experience.MethodsPatients were asked to complete a survey before and after meeting with the nuclear medicine physician. During each visit, the physician provided disease-specific information, discussed the planned therapy, answered questions, and provided tip sheets and checklists to prepare the patient for therapy.ResultsThirty-eight patients were included in the analysis. Before consultation, 17 patients (44.7%) were “somewhat” or “extremely” familiar with the term “nuclear medicine doctor,” whereas after the consultation, 33 patients (86.8%) were “somewhat” or “extremely” familiar with the term “nuclear medicine doctor” (P < 0.001). Thirteen patients (37.1%) felt they had either no understanding or a vague understanding of the therapy and no understanding of the plan for follow-up before the consultation, whereas 2 patients (5.4%) chose this response after the consultation (P < 0.001). More patients responded that they felt “generally” or “perfectly calm” toward the therapy overall after their consultation: 26 patients (68.4%) before vs 34 patients (91.9%) after consultation (P < 0.001).DiscussionPatient- and family-centered care in radiology includes direct physician participation in care delivery. In this report, we evaluate and measure the impact of our nuclear medicine pretherapy consultation clinic on the patient experience. We demonstrate significant impact of direct patient-physician encounters on patient anxiety, patient knowledge of the role of the nuclear medicine physician, and overall patient understanding of their treatment plan.