Development and validation of the Medication-Related Consultation Framework (MRCF)

Objectives

To develop and test a framework for evaluating the consultation skills of practitioners undertaking medication-related consultations.

Methods

Key components of medication-related consultations were identified through a literature review and compiled to form an initial consultation skills framework. This was iteratively refined through consultation with experts (n = 21) to form the Medication-Related Consultation Framework (MRCF). Psychometric testing was undertaken by analyzing pharmacists’ (n = 10) assessment of fifteen pre-recorded simulated consultations.

Results

The MRCF consisted of 46 consultation behaviors, grouped into five sections. Performance was rated at individual behavior, framework section and global consultation levels. The MRCF discriminated between good, satisfactory and poor consultations at the global rating level (p < 0.01) with good test-retest reliability (rho = 0.59-0.95) and moderate inter-assessor reliability (Kendall's W = 0.67). There was also good internal consistency for the five sections (Cronbach's alphas = 0.58-0.97).

Conclusions

The MRCF demonstrated good psychometric properties at the global and section rating levels. Some inconsistencies in assessors’ ratings of individual consultation behaviors were indentified, which may represent a future training need.

Practice implications

The MRCF provides healthcare professionals with a patient-centered consultation structure, serving to identify medication-related needs and potentially support adherence. It also allows the quality of a practitioner's consultation to be evaluated.     

Physicians' responses to patients' expressions of negative emotions in hospital consultations: a video-based observational study

Objective

Patients express their negative emotions in medical consultations either implicitly as cue to an underlying unpleasant emotion or explicitly as a clear, unambiguous concern. The health provider's response to such cues and concerns is important for the outcome of consultations. Yet, physicians often neglect patient's negative emotions. Most studies of this subject are from primary health care. We aimed to describe how physicians in a hospital respond to negative emotions in an outpatient setting.

Methods

Ninety six consultations were videotaped in a general teaching hospital. The Verona Coding Definitions of Emotional Sequences was used to identify patients’ expression of negative emotions in terms of cue and concern and to code physicians’ subsequent responses. Cohen's kappa was used as interrater reliability measure. Acceptable kappa level was set to .60.

Results

We observed 163 expressions of negative emotions. In general, the physician responses to patients’ cues and concerns did not include follow up or exploration. Concerns more often than cues led to lack of emotional exploration.

Conclusions

When patients expressed negative emotions or cues to such, hospital physicians tended to move away from emotional communication, particularly if the emotion was expressed as an explicit concern.

Practice implications

Medical training should enable physicians’ to explore the patients’ emotions in situations where it will improve the medical treatment.     

How to make the medical consultation more successful from a patient's perspective? Tips for doctors and patients from lay people in the United Kingdom, Italy, Belgium and the Netherlands

Objective

The aim of this study is to generate empirically based ‘tips’ from lay people on how medical consultations could become more successful from a patient perspective.

Methods

258 Lay people in the United Kingdom, Italy, Belgium and the Netherlands, distributed over 32 focus groups, were invited to formulate ‘tips’ for doctors as well as patients after rating the quality of communication from videotaped consultations and discussing their arguments in focus groups.

Results

Tips were remarkably similar across the four countries. Most tips reflect the professional literature, such as the importance of nonverbal communication, personal attention and empathy, but also addressed issues as how to deal with new technologies and new accessibility arrangements (triage). The tips were targeted to the consultation itself, its preparation and the aftercare. Tips for doctors were mirrored in tips for patients.

Conclusion

Lay people seem to be competent in participating in quality-of-care debates. They are well aware of patients’ own responsibilities. Besides, they have clear opinions about novel technology and healthcare arrangements (triage).

Practice implications

Listening to patients, showing empathy and personal attention seem to have a universal value. Doctors should be trained to practice these behaviors, healthcare managers in involving patients in practice reorganisations.     

Emotional cues and concerns in hospital encounters with non-Western immigrants as compared with Norwegians: an exploratory study

Objective

To identify potential barriers in communication with non-Western immigrant patients by comparing the frequency and nature of emotional cues and concerns, as well as physician responses during consultations, between ethnically Norwegian patients and immigrant patients in a general hospital setting.

Methods

Consultations with 56 patients (30 non-Western immigrants and 26 ethnic Norwegians) were coded using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) and the Verona Codes for Provider Responses (Verona Codes-P).

Results

There were no significant differences in frequencies of cues and concerns between immigrant and Norwegian patients. However, the immigrant patients with high language proficiency expressed more concerns compared to immigrant patients with language problems and Norwegian patients. Moreover, more concerns were expressed during consultations with female physicians than with male physicians.

Conclusion

Expression of cues and concerns in immigrant patients is dependent on the patient's language proficiency and the physician's gender.

Practice implications

Providers should recognize that immigrant patients may have many emotional cues and concerns, but that language problems may represent a barrier for the expression of these concerns.     

Measuring the impact of nurse cue-response behaviour on cancer patients’ emotional cues

Objective

This study aimed to explore the impact of nurse responses to patients’ and family members’ emotional cues and concerns during the chemotherapy education consultation.

Methods

51 cancer patients and 13 nurses participated in this study. Nurse-delivered chemotherapy education sessions were audio-recorded, and patients completed the EORTC QLQ-C30 V3.0 questionnaire before the education. The audio records were transcribed and coded.

Results

Patients expressed their emotions more than family members, but patients’ cues decreased when family were present. Patients with lower emotional wellbeing (greater psychological distress) prior to the consultation did not express more cues/concerns. Nurses responded to patients’ and families’ cues equally in a cue-facilitative fashion. Facilitative responses were associated with decreased patients’ cues.

Conclusion

Family presence appears to hinder patients’ cues/concerns. Nurses’ PS responses were associated with less cues/concerns by patients.

Practice implication

The current study challenges the common assumption that a higher number of cues is indicative of effective consultation, and indicates the influence of family in patients’ cues/concerns.     

Impact of patient obesity on the patient-provider relationship

Objective

Health professionals’ weight bias may impair obese patients’ interactions with providers. However, few studies have examined how negative provider attitudes affect the patient-provider relationship for obese patients. We hypothesized that higher patient body mass index (BMI) would be negatively associated with patient-provider relationship quality.

Methods

We analyzed data from the 2007 Health Tracking Household Survey. BMI was the independent variable, and patient-perceived quality of the patient-provider relationship was the outcome. We performed log-binominal regression analyses accounting for complex survey design to examine the association of BMI with the patient-provider relationship.

Results

Of the 15,197 adult survey respondents, the 6427 who answered the quality of care questions were eligible for analysis. Overall, 29% had a normal range BMI, 34% were overweight, and 37% were obese. We found few differences in ratings of the patient-provider relationship for overweight and obese respondents when compared to respondents with a normal range BMI.

Conclusion

These unexpected findings may have occurred due to patients’ inability to perceive providers’ weight bias, measurement error in questionnaire items, or decreasing weight bias among health professionals.

Practice implications

Patient's positive perceptions of providers may indicate promise for health professionals acting as motivators of behavior change in obese patients.     

Doctors in a Southeast Asian country communicate sub-optimally regardless of patients' educational background

Objective

To explore the relationship between the style of doctor-patient communication and patients’ educational background in a Southeast Asian teaching hospital setting using the Roter Interaction Analysis System (RIAS).

Methods

We analyzed a total of 245 audio-taped consultations involving 30 internal medicine residents with 7-10 patients each in the internal medicine outpatient clinics. The patients were categorized into a group with a high and a group with a low educational level. We ranked the data into 41 RIAS utterances and RIAS-based composite categories in order of observed frequency during consultations.

Results

The residents invariantly used a paternalistic style irrespective of patients’ educational background. The RIAS utterances and the composite categories show no significant relationship between communication style and patients’ educational level.

Conclusion

Doctors in a Southeast Asian country use a paternalistic communication style during consultations, regardless of patients’ educational background.

Practice implication

To approach a more partnership doctor-patient communication, culture and clinical environment concern of Southeast Asian should be further investigated.     

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.)     

Not all are desired: Providers’ views on interpreters’ emotional support for patients

Objective

This study examines (a) providers’ expectations and concerns for interpreters’ emotional support, and (b) the complexity and dilemma for interpreters to offer emotional support in health care settings.

Methods

We recruited 39 providers from 5 specialties to participate in in-depth interviews or focus groups. Grounded theory was used for data analysis to identify providers’ expectations and concerns for interpreters’ emotional support.

Results

From the providers’ perspective, interpreters’ emotional support: (a) is embodied through their physical presence, (b) is to be both a human being but also a professional, (c) represents the extension of the providers’ care, and (d) imposes potential risks to quality of care.

Conclusion

Emotional support in bilingual health care is accomplished through the alliance of providers and interpreters, complementing each other to support patients’ emotional needs.

Practice implication

Interpreters should be vigilant about how their emotional support may impact the provider-patient relationship and the providers’ therapeutic objectives. Interpreters should be aware that providers also rely on them to provide emotional support, which highlights the importance of giving medical talk and rapport-building talk equal attention in medical encounters.     

The relationship of patient participation and diabetes outcomes for patients with high vs. low health literacy

Objective

To examine whether patient participation in medical consultations have differing effects on self-efficacy and diabetes control by the level of patient communicative health literacy (CHL).

Methods

Participants were 143 outpatients with type 2 diabetes at a university-affiliated hospital. Patient CHL was measured using a newly developed self-rated scale of health literacy. Patient perceived participation in medical consultations and self-efficacy of diabetes self-care were assessed using the self-reported questionnaire. Patient clinical characteristics were obtained from electronic medical records.

Results

Both patient CHL and perceived participation were related to greater self-efficacy and decreased HbA1c at the 3-month follow-up. Patient CHL had a moderating effect on the relationship between perceived participation and self-efficacy. Patients with lower CHL reported greater self-efficacy when they actively participated in patient-physician communication, whereas this relationship was less evident among patients with higher CHL.

Conclusions

The examination of patient CHL levels may provide a better understanding of the potential barriers to patients’ self-management of disease.

Practice implications

The benefit of active participation may be greater among patients with lower CHL who are likely to have greater difficulties in communicating with the physician, yet tend to rely on the physician as the sole source of health information.     

Development and validation of a patient measure of doctor-patient caring

Objective

Conceptualising the doctor-patient relationship as a ‘window mirror’ exposes care delivery from doctor to self, doctor to patient, patient to self, and patient to doctor. These directions have not been measured concurrently. We aimed to develop and validate a patient questionnaire informed by this model.

Methods

A modified-Delphi exercise was conducted to develop, and face and content validate, the questionnaire. Stage 2 surveyed 495 patients in general practice to assess the internal consistency and construct validity of the questionnaire.

Results

The questionnaire is face and content valid. Its internal reliability and construct validity appear good. Patients who care more about their doctor also care more about themselves. A patient or doctor who cares about the other person is associated with increased self-care by that person.

Conclusions

Further development and testing of the patient questionnaire is warranted to validate measurement of how patients perceive the caring they and their doctor give, and receive from, each other.

Practice implications

From the patient perspective the questionnaire may increase awareness of the importance of family doctors and patients caring about each other and themselves. It may inform and evaluate medical students, educational programmes and caring in doctor-patient relationships.     

Coding patient emotional cues and concerns in medical consultations: The Verona coding definitions of emotional sequences (VR-CoDES)

Objective

To present the Verona Coding Definitions of Emotional Sequences (VR-CoDES CC), a consensus based system for coding patient expressions of emotional distress in medical consultations, defined as Cues or Concerns.

Methods

The system was developed by an international group of communication researchers. First, consensus was reached in different steps. Second, a reliability study was conducted on 20 psychiatric consultations.

Results

A Cue is defined as a verbal or non-verbal hint which suggests an underlying unpleasant emotion that lacks clarity. A Concern is defined as a clear and unambiguous expression of an unpleasant current or recent emotion that is explicitly verbalized with or without a stated issue of importance. The conceptual framework sets precise criteria for cues and concerns and for whom (health provider or patient) elicits the cue/concern. Inter-rater reliability proved satisfactory (agreement 81.5%, Cohen's Kappa 0.70).

Conclusion

The VR-CoDES CC will facilitate comparative research on provider-patient communication sequences in which patients express emotional distress.

Practice implications

The VR-CoDES CC may be used to help clinicians in recognizing or facilitating cues and concerns, thereby improving the recognition of patients’ emotional distress, the therapeutic alliance and quality of care for these patients.     

Does questionnaire-based patient feedback reflect the important qualities of clinical consultations? Context, benefits and risks

Objective

To explore perceptions of clinical consultations and how they relate to questionnaire-based patient feedback.

Methods

Telephone interviews with 35 junior doctors and 40 general practice patients who had used the Doctors’ Interpersonal Skills Questionnaire (DISQ).

Results

Doctors and patients had similar views of ‘good consultations’ as relying on doctors’ listening and explaining skills. Preferences for a consultation style focused on an outcome or on the doctor-patient relationship may be independent of informational and/or affective consultation content. Respondents felt the important consultation elements were similar in different contexts, and so DISQ feedback would be useful in different settings. Benefits of feedback were identified in the form of patient empowerment and doctors’ learning. Risks were identified in the inappropriate use of feedback, both inadvertent and deliberate.

Conclusion

The style and content of consultations may be considered as separate dimensions, an approach that may help doctors adapt their communication appropriately to different consultations. Patient feedback focused on communication skills is appropriate, but there are potential risks.

Practice implications

Doctors should consider the transactional or relational preference of a patient in approaching a consultation. Patient feedback can deliver benefits to doctors and patients, but risks must be acknowledged and mitigated against.     

The physical examination in telecardiology and televascular consultations: A study using conversation analysis

Objective

This paper describes communication in the physical examination phases of telemedicine consultations.

Methods

Using the method of conversation analysis, we draw on 10 telemedicine consultations (five telecardiology and five televascular) between primary and tertiary care in the UK.

Results

Physical examination is absent in telecardiology consultations. In televascular consultations the professionals try to compensate for the lack of physical proximity by getting involved in a form of collaboration that constitutes a novel environment for all. Separated from the patient by physical space, the specialist orchestrates the positioning of the patient, the camera and the primary care nurse's activity via the use of a video-link.

Conclusion

Telemedicine offers primary care nurses a unique opportunity to engage in active collaboration with hospital specialists. The nurses’ examination skills are recruited because physical examination is conducted from distance and the specialist cannot touch the patient or see parts of the body with ease. We speculate that difficulties with the physical examination may have contributed to the relatively slow adoption of telemedicine.

Practice implications

The analysis reveals some new communication practices that participants in telemedicine are called to adopt. This can be used to inform training interventions that focus both on patient and professional.     

Lifestyle, health and the ethics of good living. Health behaviour counselling in general practice

Objective

To present theory that illustrates the relevance of ethics for lifestyle counselling in patient-centred general practice, and to illustrate the theory by a qualitative study exploring how doctors may obstruct or enhance the possibilities for ethical dialogue.

Methods

The theoretical part is based on theory of common morality and Habermas’ communication theory. The empirical study consists of 12 consultations concerning lifestyle changes, followed by interviews of doctors and patients. Analysis: Identification of two contrasting consultations holding much and little ethical dialogue, “translation” into speech acts, and interpretation of speech acts and interviews guided by theory.

Results

General advice obstructed possibilities for ethical clarification and patient-centredness. Ethical clarification was asked for, and was enhanced by the doctor using communication techniques such as interpretation, summarization, and exploration of the objective, subjective and social dimensions of the patients’ lifeworlds. However, to produce concrete good decisions an additional reflection over possibilities and obstacles in the patient's lifeworld is necessary.

Conclusion

Consultations concerning lifestyle changes hold opportunities for ethical clarification and reflection which may create decisions rooted in the patient's everyday life.

Practice implications

The study suggests that GPs should encourage active reflection and deliberation on values and norms in consultations concerning lifestyle changes.     

Web-enabled video-feedback: a method to reflect on the communication skills of experienced physicians

Objective

To describe our web-enabled video-feedback method designed to reflect on the communication skills of experienced physicians.

Methods

Participating physicians (n = 28) received a ‘personal web link’ to two of their video-recorded consultations. After watching the consultations physicians received feedback by telephone or in a face-to-face meeting, structured around an individualized feedback report. This report contained scores on the communication behavior of the physician in comparison with colleagues and their own communication behavior observed in a previous study, as well as patients’ opinions about their physician's communication behavior. The physicians were asked to reflect on their communication skills and to comment on the usefulness and efficiency of the feedback method.

Results

Almost all physicians were satisfied with the feedback method and in particular valued the web-enabled link to the video-recorded consultations and the structured written report. Feedback by telephone or face-to-face feedback was considered equally appropriate.

Conclusion

This web-enabled video-feedback method is a useful and structured design to reflect on the communication skills of physicians.

Practice implications

As part of continuing medical education, feedback on communication skills should become a recurrent activity for experienced physicians. This method can also be used to reflect on the communication skills of medical students.     

Patient validation of cues and concerns identified according to Verona coding definitions of emotional sequences (VR-CoDES): A video- and interview-based approach

Objective

A challenging but main task for clinicians is to identify patients’ concerns related to their medical conditions. The study aim was to validate a new coding scheme for identifying patients’ cues and concerns.

Methods

12 videotaped consultations between nurses and pain patients were coded according to the Verona Coding Scheme for Emotional Sequences (VR-CoDES). During a metainterview each patient watched his/her own video interview with the researcher to confirm or disconfirm the identified cues and concerns. A directive or an open format was applied. Quantitative and qualitative data analyses were performed.

Results

Patients’ confirmation in relation to the coding gave a sensitivity of 0.95 and specificity of 0.99 in the directive format and a sensitivity of 0.99 and specificity of 0.70 applying the open format. Through a qualitative analysis 83% of researcher-identified cues and concerns were validated. 17% were not confirmed or uncertain.

Conclusion

The VR-CoDES seems to capture what are experienced as real concerns to patients, and proves to be a coding scheme with a high degree of ecological validity.

Practice implications

The VR-CoDES provides a valid framework for detecting patients’ cues and concerns, and should be explored as a training tool to develop clinicians’ empathic accuracy.     

Are there interactional reasons why doctors may find it hard to tell patients that their physical symptoms may have emotional causes? A conversation analytic study in neurology outpatients

Objective

This qualitative study analyses patients’ conversational behaviours to explore whether there are interactional factors that could explain why doctors find clinical encounters in which the diagnosis of functional symptoms (physical symptoms with presumed emotional causes) is explained and psychological treatment offered particularly challenging.

Methods

Twenty out-patient consultations between neurologists and patients with functional symptoms were recorded and analysed using Conversation Analysis. Patients’ communication behaviour was characterised by pervasive interactional resistance. Instances of resistance were identified and counted.

Results

Interactional resistance was especially evident when the aetiology of symptoms and treatment recommendations were discussed. Resistance was expressed overtly (through disagreements, challenges, rejections) or more passively (through moves such as lack of engagement with the interaction, silences or the use of minimal responses).

Conclusion

This study provides objective evidence that doctors face interactional challenges when they try to explain that symptoms are medically unexplained and suggest psychological treatment.

Practice implications

Doctors may try to avoid provoking patients’ overt resistance because they perceive it as unpleasant. However, the display of overt resistance enables them to deal explicitly with the grounds on which patients reject their explanations and recommendations, and to address patients’ particular concerns.