Sharing vs. caring—The relative impact of sharing decisions versus managing emotions on patient outcomes

Objective

To assess the relative impact of cognitive and emotional aspects of shared decision making (SDM) on patient outcomes.

Methods

Cognitive and emotional aspects of SDM in consultations between 20 oncologists and 55 early breast cancer patients were coded using the Observing Patient Involvement (OPTION) scale and the Response to Emotional Cues and Concerns (RECC) coding system, plus blocking and facilitating behaviour scales. Patient outcomes including anxiety, decisional conflict, and satisfaction with: (i) the decision, (ii) the consultation, and (iii) doctor SDM skills, were assessed. Relationships between cognitive and emotional aspects of SDM, and patient outcomes were examined using hierarchical regression.

Results

The OPTION score predicted satisfaction with doctor SDM skills 2 weeks post-consultation (p = .010), and with the treatment decision 4 months post-consultation (p = .004). Emotional blocking predicted decisional conflict (p = .039), while the number of emotional cues emitted (p = .003), and the degree of empathy provided (p = .011), predicted post-consultation anxiety.

Conclusion

Cognitive and emotional aspects of SDM in oncology consultations have different effects on various patient outcomes.

Practice implications

It is important that doctors focus on both sharing decisions and managing emotions in consultations. Communication skills training addressing both these areas may be an effective way to improve diverse patient outcomes.     

Developing a dyadic OPTION scale to measure perceptions of shared decision making

Objective

Our aim was to develop a measurement which enables research into the interdependent nature of clinical encounters. The prime objective was to develop an instrument capable of assessing the extent to which patients have been involved in (shared) decision making from two viewpoints—that of the patient and the clinician.

Methods

To develop an initial ‘dyadic OPTION’ instrument, the twelve original third-person items were drafted in passive, first person plural forms. Using this version initially, three rounds of cognitive debriefing interviews were held. These were audio-recorded and analysed at the end of each round and the results used to revise the dyadic OPTION scale.

Results

It was possible to modify the observer OPTION instrument into an instrument for completion by both clinicians and patients after a dyadic interaction. Cognitive debriefing revealed five areas of interpretative difficulty. Each item of the observer OPTION scale underwent modification in order to develop a dyadic version of the scale.

Conclusions

The dyadic OPTION scale is acceptable and comprehensible by both clinicians and public respondents. Cognitive debriefing adapted and refined an existing scale and provided confidence that the core constructs of the scale (perceived involvement in decisions making) were understood.

Practice implications

Further validation of the dyadic OPTION scale is required prior to its use in research settings.     

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.     

Does the use of shared decision-making consultation behaviors increase treatment decision-making satisfaction among Chinese women facing decision for breast cancer surgery?

Objective

To assess the extent to which breast surgical consultations used shared decision making (SDM), identify factors associated with use of SDM, and assess if using SDM increases decision-making satisfaction.

Methods

Two hundred and eighty-three video-recorded diagnostic-treatment decision consultations between breast surgeons and women with breast cancer were assessed using the Decision Analysis System for Oncology (DAS-O) coding system designed for assessing SDM behaviors. Women completed a questionnaire at pre-consultation, one-week post-consultation and one-month post-surgery. Patient outcomes included decision conflict, patient satisfaction with medical consultation, and decision regret.

Results

Overall, the level of SDM behaviors was low. The extent of SDM behavior within consultation was related to greater consultation duration (p < 0.001), more than one treatment being offered (p < 0.001), and fewer questions raised by patients/companions (p < 0.05). While use of SDM consultation did not influence post-consultation decision conflict, it increased satisfaction with information given and explained, patients’ feelings of trust and confidence in their surgeons, and reduced post-surgical decision regret.

Conclusion

These breast surgical consultations mostly adopted informed treatment decision-making approaches. Using SDM improved patient consultation and decision satisfaction.

Practice implications

The study findings highlight a need to reinforce the importance of SDM in consultations among breast surgeons.     

Patients’ sense of relationship with breast cancer surgeons: The relative importance of surgeon and patient variability and the influence of patients’ attachment style

Objective

We examined to what extent variability in breast cancer patients’ sense of relationship with their surgeons was attributable to patient vs surgeon variation and we examined the role of one patient characteristic: attachment style.

Methods

Women (N = 133) due to undergo surgery for breast cancer with one of six surgeons self-rated their relationship with the surgeon, using the Working Alliance Inventory, and indicated their adult attachment style (secure vs insecure). Multilevel analysis of alliance scores quantified variance components at patient and surgeon levels and tested the relationship with attachment.

Results

Variability in alliance was overwhelmingly at the patient level. Alliance was greater in securely than non-securely attached patients, although this influence was small.

Conclusion

Variability in quality of clinical relationships after breast cancer diagnosis largely reflects variation between individual patients, not surgeons. Although patients’ attachment style is significant, its role is modest. More influential patient characteristics need to be identified.

Practice implications

Breast cancer patients report a strong relationship with their surgeons. Because differences between surgeons make only a small contribution to variability in relationship, it should be a priority to identify and address the characteristics or behaviours at the level of individual patients that are associated with poorer relationships.     

Shared decision making in medicine: The influence of situational treatment factors

Objective

Although shared decision making (SDM) has become increasingly important in bioethical discussions and clinical practice, it is not clear in which treatment situations SDM is suitable. We address this question by investigating social norms on the appropriateness of SDM in different situations.

Methods

We conducted qualitative expert interviews with patients, general practitioners, and health administration and research professionals.

Results

SDM was considered to be most important in severe illness and chronic condition. Furthermore, SDM was indicated to be required if there is more than one therapeutic option, especially if it is not clear which option is best. Interviewees classified end-of-life decisions and decisions about prevention as those that primarily should be made by informed patients. On the other hand a paternalistic decision was considered most appropriate in emergency situations and when the patient does not want to participate in decision making.

Conclusion

This study demonstrates that multiple situational factors and their interactions must be considered regarding the scope of SDM in medical consultation.

Practice implications

Research addressing this question will help physicians adjust their consultation style and allow implementations of SDM and decision aids to be tailored more appropriately to complex treatment situations.     

Quality of decision making is related to decision outcome for patients with cardiac arrhythmia

Objective

Clinical consultations with patients should be informed by the evidence-based and involve shared decision making (SDM). We aimed to determine the delivery of SDM by clinicians with patients referred for invasive treatment of cardiac electrical disease and to establish whether decisions made corresponded with patient and referring physician expectations.

Methods

Forty-nine outpatient consultations with two consultant cardiologists in one large tertiary centre were audio-recorded. Demographic data, diagnosis, reasons for referral and decision reached were compared directly with patient and referring physician expectations. The OPTION instrument was used to measure SDM. Patient expectations and satisfaction were elicited.

Results

Quality of SDM was good (mean OPTION score 49%) and there was broad patient satisfaction. While all patients were suitable for invasive treatment, and the majority (80%, n = 39) had been explicitly referred for it, only 59% (n = 29) opted to proceed. Consultation quality with respect to SDM was significantly greater for patients choosing a less invasive option.

Conclusion

These consultations often change expected management. Where decision making in the consultation is of higher quality, patients were more likely to change to a less invasive option.

Practice implications

Clinicians performing invasive cardiac treatment should be able to demonstrate high quality decision making.     

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.)     

Integrative qualitative communication analysis of consultation and patient and practitioner perspectives: towards a theory of authentic caring in clinical relationships

Objective

We developed a method whereby relationships can be studied simultaneously from the perspectives of each party and researchers’ observations of their dialogue. Then we used this method to study how to recognise authentic, caring clinical relationships.

Methods

Participants were 20 patients who had recently received surgery for breast cancer and nine surgeons with whom they had a post-operative consultation. We audiorecorded consultations, before interviewing patients and surgeons about their perceptions of the consultation and each other. Cross-case qualitative analyses (analysing consultations and surgeon and patient interviews, respectively) were supplemented by integrative, within-case analysis.

Results

Surgeons and patients described their relationship as personal and emotional, but emotional talk was absent from consultations. For patients and surgeons, their relationship depended, instead, on surgeons’ expertise and character.

Conclusion

Our integrative approach suggested that authentic caring in these relationships lay in practitioners’ conscientious execution of their role and, contrary to currently influential views, not in an explicit emotional engagement.

Practice implications

Relationships between patients and practitioners cannot be described adequately using analyses of interactions between them. Researchers will need to triangulate between these observations and the patient and practitioner perspectives in order to understand what makes for authentically caring relationships.     

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.     

The 8-hydroxydeoxyguanosine concentrations according to hormone therapy and S326C polymorphism of OGG1 gene in postmenopausal women

Background

The 8-hydroxydeoxyguanosine (8-OHdG) is widely used for determination of DNA damage since it is excised from oxidative damaged DNA with endonuclease repair enzymes coded by 8-oxoguanine DNA N-glycosylase gene (OGG1). The present study aimed at investigating whether hormone therapy (HT) may influence on the blood/urinary 8-OHdG levels and whether the level of 8-OHdG is different according to OGG1 S326C polymorphism in postmenopausal women receiving HT.

Methods

In 102 postmenopausal women receiving HT, the 8-OHdG levels were measured in the blood and urine using high performance liquid chromatography (HPLC) before HT and 3 months after HT. The genotyping of the S326C polymorphism of the OGG1 was performed by polymerase chain reaction (PCR) and restriction enzyme fragment length polymorphism (RFLP) analysis.

Results

After HT, mean blood 8-OHdG level significantly decreased compared to those before HT (P = 0.003), while urinary 8-OHdG level did not show any difference according to HT. Pre-HT level of 8-OHdG was not different according to OGG1 genotypes and similar finding was demonstrated in post-HT 8-OHdG concentration.

Conclusions

These findings imply that hormone therapy can reduce blood 8-OHdG concentration, one of the markers of oxidative damage. Further study is needed to confirm this association in larger population.     

Doctor, patient and computer--a framework for the new consultation

Purpose

The use of a computer during general/family practice consultations is on the rise across the world, yet little is known about the effect the use of a computer may have on the all important physician-patient relationship. This paper provides a framework for further analysis of computers influence on physician-patient interactions during general practice consultations.

Methods

This is an observational qualitative study informed by hermeneutics and the phenomenological tradition of Irving Goffman, based in Australian general practice. A single digital video recording of 141 patient encounters over 6 months was made and imported into a tagging software program to facilitate analysis. Through an iterative process several keys and behaviours were described for doctors, patients and the computers in the interaction.

Results

Physicians tended to fall into two categories; unipolar—those who tend to maintain the lower pole of their body facing the computer except were examination of the patient or some other action demands otherwise, and bipolar—those physicians who repeatedly alternate the orientation of their lower pole between the computer and the patient. Patients tended to demonstrate behaviours that focused on the physician to the exclusion of the computer (dyadic) and included the computer in the consultation (triadic). The computer was also seen to influence the physician-patient interaction passively or actively.

Conclusion

In describing and categorising the behaviours of the computer, in addition to the humans in the consultation, a framework is provided for further analytical work on the impact of computers in general practice.     

'Talking of Sex': developing and piloting a sexual health communication tool for use in primary care

Objective

To develop and pilot a communication aid aimed at increasing the frequency with which sexual health issues are raised proactively with young people in primary care.

Methods

Group interviews among primary health care professionals to guide development of the tool, simulated consultations to pre-test it, and a pilot study to assess effectiveness.

Results

We developed an electronic consultation aid: Talking of Sex and piloted it in eight general practices across the UK. 188 patients and 58 practitioners completed questionnaires pre-intervention, and 92 patients and 45 practitioners post-intervention. There was a modest increase in the proportion of consultations in which sexual health was raised, from 28.1% pre-intervention to 32.6% post-intervention. In consultations with nurses the rise was more marked. More patients reported discussing preventive practices such as condom use post-intervention. Patients unanimously welcomed the opportunity to discuss sexual health matters with their practitioner.

Conclusion

The tool has capacity to increase the frequency with which sexual health is raised in primary care, particularly by nurses, to influence the topics discussed, and to improve patient satisfaction.

Practice implications

The tool has potential in increasing the proportion of young people whose sexual health needs are addressed in general practice.     

Effects of rs6234/rs6235 and rs6232/rs6234/rs6235 PCSK1 single-nucleotide polymorphism clusters on proprotein convertase 1/3 biosynthesis and activity

Background

Proprotein convertase 1/3 (PC1/3) is one of the endoproteases initiating the proteolytic activation of prohormones and proneuropeptides in the secretory pathway. It is produced as a zymogen that is subsequently modified by activity-determining cleavages at the amino and the carboxyl termini. In human, it is encoded by the PCSK1 locus on chromosome 5. Spontaneous inactivating mutations in its gene have been linked to obesity. Minor alleles of the common non-synonymous single-nucleotide polymorphisms (SNPs) rs6232 (T > C, N221D), rs6234 (G > C, Q665E) and rs6235 (C > G, S690T) have been associated with increased risk of obesity. We have shown that the variations associated with these SNPs are linked on minor PCSK1 alleles.

Goal

In this study, we examined the impact of amino acid substitutions specified by the minor PCSK1 alleles on PC1/3 biosynthesis and prohormone processing activity in cultured cells.

Methods

The common and variant isoforms of PC1/3 were expressed in transfected rat pituitary GH4C1 cells with or without proopiomelanocortin (POMC) as a substrate. Secreted PC1/3- or POMC-related proteins and peptides were analyzed by immunoblotting and immunoprecipitation.

Results

When expressed in GH4C1 cells, the triple-variant PC1/3 underwent significantly more proteolytic processing at the amino and carboxyl termini than the common and double-variant isoforms. However, there was no detectable difference among these isoforms in their ability to process POMC in the transfected cells.

Conclusions

Since truncation of PC1/3 in its C-terminal region reportedly renders the enzyme unstable, we speculate that the accentuated processing of the triple variant in this region may, in vivo, create a subtle deficit of PC1/3 enzymatic activity in endocrine and neuroendocrine cells, causing impaired processing of prohormones and proneuropeptides to their bioactive forms.     

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.     

Impact of a brief intervention on patient communication and barriers to pain management: Results from a randomized controlled trial

Objective

This study examined the impact of a brief pain communication/education intervention on patient outcomes in breast cancer. We hypothesized that our intervention would improve patient communication and reduce misconceptions (“Barriers”) concerning pain management, and that patients with lower Barriers, or who perceived their physician as being more facilitative and receptive, would report better outcomes.

Methods

Female breast cancer patients with persistent pain (n = 89) were randomly assigned to either a 30-min in-person pain education/communication intervention or control condition and followed for 12 weeks.

Results

Intervention group patients reported a significant decrease in pain Barriers but not in other outcomes. Overall, patients with lower barrier scores reported less distress and better emotional well-being. Patients who scored higher in active communication (e.g., asking questions, giving information) reported fewer Barriers and better pain relief. Individuals who perceived their physicians as being more receptive reported better pain management while those who perceived their physicians as being both more receptive and facilitative were more satisfied with their health care.

Conclusion

A brief education/communication intervention reduced patients’ Barriers to pain management but did not impact other patient outcomes.

Practical Implications

Pain outcomes may be improved by addressing patients’ pain misconceptions and emphasizing a receptive and responsive communication style.     

Hospital consultants breaking bad news with simulated patients: an analysis of communication using the Roter Interaction Analysis System

Objective

To explore how experienced clinicians from wide ranging specialities deliver bad news, and to investigate the relationship between physician characteristics and patient centredness.

Methods

Consultations involving 46 hospital consultants from 22 different specialties were coded using the Roter Interaction Analysis System.

Results

Consultants mainly focussed upon providing biomedical information and did not discuss lifestyle and psychosocial issues frequently. Doctor gender, age, place of qualification, and speciality were not significantly related to patient centredness.

Conclusion

Hospital consultants from wide ranging specialities tend to adopt a disease-centred approach when delivering bad news. Consultant characteristics had little impact upon patient centredness. Further large-scale studies are needed to examine the effect of doctor characteristics on behaviour during breaking bad news consultations.

Practice implications

It is possible to observe breaking bad news encounters by video-recording interactions between clinicians and simulated patients. Future training programmes should focus on increasing patient-centred behaviours which include actively involving patients in the consultation, initiating psychosocial discussion, and providing patients with opportunities to ask questions.     

Three questions that patients can ask to improve the quality of information physicians give about treatment options: a cross-over trial

Objective

To test the effect of three questions (what are my options? what are the benefits and harms? and how likely are these?), on information provided by physicians about treatment options.

Methods

We used a cross-over trial using two unannounced standardized patients (SPs) simulating a presentation of mild-moderate depression. One SP was assigned the intervention role (asking the questions), the other the control role. An intervention and control SP visited each physician, order allocated randomly. The study was conducted in family practices in Sydney, Australia, during 2008-09. Data were obtained from consultation audio-recordings. Information about treatment options and patient involvement were analyzed using the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool and the OPTION tool.

Results

Thirty-six SP visits were completed (18 intervention, 18 control). Scores were higher in intervention consultations than controls: ACEPP scores 21.4 vs. 16.6, p < 0.001, difference 4.7 (95% CI 2.3-7.0) and OPTION scores 36 vs. 25, p = 0.001, difference 11.5 (95% CI 5.1-17.8), indicating greater information provision and behavior supporting patient involvement.

Conclusion

Asking these three questions improved information given by family physicians and increased physician facilitation of patient involvement. Practice implications. These questions can drive evidence-based practice, strengthen patient-physician communication, and improve safety and quality.