Perception of empathy in the therapeutic encounter: effects on the common cold

Objective

To evaluate the effects of patient-practitioner interaction on the severity and duration of the common cold.

Methods

We conducted a randomized controlled trial of 719 patients with new cold onset. Participants were randomized to three groups: no patient-practitioner interaction, “standard” interaction or an “enhanced” interaction. Cold severity was assessed twice daily. Patients randomized to practitioner visits used the Consultation and Relational Empathy (CARE) measure to rate clinician empathy. Interleukin-8 (IL-8) and neutrophil counts were obtained from nasal wash at baseline and 48 h later.

Results

Patients’ perceptions of the clinical encounter were associated with reduced cold severity and duration. Encounters rated perfect on the CARE score had reduced severity (perfect: 223, sub-perfect: 271, p = 0.04) and duration (perfect: 5.89 days, sub-perfect: 7.00 days, p = 0.003). CARE scores were also associated with a more significant change in IL-8 (perfect: mean IL-8 change 1586, sub-perfect: 72, p = 0.02) and neutrophil count (perfect: 49, sub-perfect: 12, p = 0.09).

Conclusions

When patients perceive clinicians as empathetic, rating them perfect on the CARE tool, the severity, duration and objective measures (IL-8 and neutrophils) of the common cold significantly change.

Practice implications

This study helps us to understand the importance of the perception of empathy in a therapeutic encounter.     

Chronic condition self-management: Expectations of responsibility

Objective

While self-management may be beneficial for many patients it assumes and encourages a particular conception of responsibility and self-management that may not fit with all patients’ experience of their chronic conditions and their management. It therefore warrants further examination.

Methods

We examine the concept of self-management and responsibility from a range of standpoints, focusing on the Australian context.

Results

Attempts to meet people's needs run the risk of imposing specific conceptions of how people should live their lives. While self-management appears to be consistent with placing patients’ needs, values and priorities at the heart of healthcare, ill-defined assumptions about responsibility may confound these goals.

Conclusions

Reflection on social determinants of health, the context in which patients seek self-management support from health services, and how their needs and preferences are listened to by health professionals, is critical for the collaborative self-management partnership between them to be effectively realized.

Practice implications

Providing services without reflecting on the meaning of self-management for the person with chronic conditions creates unintended assumptions about responsibility, engagement and care provision which may serve to alienate and further stigmatise some patients. Often, these are the very patients with complex needs who need such service support the most.     

Impact of patient level factors on the improvement of the ABCs of diabetes

Objective

To determine which patient factors contribute to improvements in the ABCs of diabetes following a multi-faceted diabetes care intervention.

Methods

A multi-level, cluster design, randomized controlled trial examined the effectiveness of a Chronic Care Model (CCM) intervention in an underserved community (n = 119).

Results

Improvements in glycemic control were experienced among older subjects (p = 0.02), those with higher scores on the WHO-10 Quality of Well-Being Subscale 1 (p = 0.05), and those in the CCM group (p = 0.04). Insulin use was associated with greater improvements in SBP and DBP. Those taking insulin (p = 0.07), and those more satisfied with their diabetes care and ready to make a behavior change (p = 0.08) experienced larger improvements in Non-HDLc. Medication treatment intensification (TI) did not significantly impact the ABCs.

Conclusion

Psychosocial and sociodemographic factors explained more of the variation in the ABCs than TI, and are important contributors to clinical improvement.

Practice Implications

Providers may be able to identify and intervene on patients who are at risk for developing diabetes complications and improve the consistency, quality, and effectiveness of patient care.     

Exploring the community pharmacist's role in palliative care: focusing on the person not just the prescription

Objective

Changes in health care provision have led to an emphasis on providing end of life care within the home. community pharmacists are well positioned to provide services to community-based palliative care patients and carers.

Methods

A multiple qualitative case study design was adopted. A total of 16 focus groups and 19 interviews with pharmacists, nurses, general practitioners and carers were undertaken across metropolitan and regional settings in Western Australia, New South Wales, Queensland and Victoria. Data were analysed thematically using a framework that allowed similarities and differences across stakeholder groups and locations to be examined and compared.

Results

Three main themes emerged: effective communication; challenges to effective communication; and: towards best practice, which comprised two themes: community pharmacists’ skills and community pharmacists’ needs.

Discussion

A key component of the provision of palliative care was having effective communication skills. Although community pharmacists saw an opportunity to provide interpersonal support, they suggested that they would need to develop more effective communication skills to fulfil this role.

Conclusion

There is clear need for continuing professional development in this area - particularly in communicating effectively and managing strong emotions.

Practice implications

Community pharmacists are willing to support palliative care patients and carers but need education, support and resources.     

The impact of financial incentives on physician empathy: A study from the perspective of patients with private and statutory health insurance

Objective

We hypothesized that patients’ ratings of physician empathy (PE) would be higher among those with private health insurance (PHI, referring to financial incentive) than among patients with statutory health insurance (SHI).

Methods

A postal survey was administered to 710 cancer patients. PE was assessed using the Consultation-and-Relational-Empathy measure. T-tests were conducted to analyse whether PHI and SHI-patients differ in their ratings of PE and variables relating to contact time with the physician. Structural-equation-modelling (SEM) verified mediating effects.

Results

PHI-patients rated physician empathy higher. SEM revealed that PHI-status has a strong significant effect on frequency of talking with the physician, which has a strong significant effect (1) on PE and (2) has a moderate effect on patients’ perception of medical staff stress, thereby also affecting patients’ ratings of PE.

Conclusions

Our findings suggest that PHI-status is one necessary precondition for physicians spending more time with the patient. Spending more time with the PHI-patient has two major effects: it results in a more positive perception of PE and positively impacts PHI-patients’ perception of medical staff stress, which in turn, again influences PE.

Practical implications

Health policy should discuss these findings in terms of equality in receiving high-quality care.     

Health literacy awareness training for healthcare workers: improving knowledge and intentions to use clear communication techniques

Objective

Health literacy is a growing concern as its relationship with health outcomes becomes clearer. Efforts to enhance awareness of patient health literacy in health professional education have focused on physicians, and the objective of this research was to provide an initial assessment of a training session designed for healthcare workers of all kinds.

Methods

Pre- and post-surveys were completed by 166 participants (N = 166) in training sessions designed to improve knowledge of health literacy and instruction in clear communication techniques. Participants provided baseline and post-training assessments of perceived knowledge of health literacy and use of strategies to improve communication with low health literate audiences.

Results

Participants, initially overestimating their own knowledge of health literacy, improved on outcome measures regarding perceived health literacy knowledge. Participants also indicated strong intentions to use clear communication techniques covered in the training.

Conclusion

Results suggest there is an opportunity and need to improve health literacy training for healthcare workers of all kinds. Widespread adoption of health literacy training programs would improve the delivery of healthcare to low health literate patients.

Practice implications

Participants initially overestimated their knowledge of health literacy, suggesting a need to improve initial training and continuing medical education regarding health literacy.     

Patients' perspectives on depression case management in general practice - a qualitative study

Objective

General practice-based case management is effective in improving symptoms, adherence, and the perceived process of care of patients living with major depression. The aim was to explore the patients’ perceptions of practice-based depression case management, their satisfaction with it and how living with depression contextualizes case management.

Methods

This qualitative study was nested in a large cluster-randomized controlled trial on the effectiveness of case management for patients living with major depression. Case management was provided over 12 months by practice-based health care assistants, who monitored symptoms. We undertook semi-structured interviews with 41 patients, then transcribed and analysed them using qualitative content analysis.

Results

Patients described depression as the unfortunate situation, where loneliness and lack of energy lead to being unable to actively seek help. Case management was appreciated because of regular, proactive contact and support by health care assistants. It was crucial to patients that they could trust the health care assistant. Some patients complained that case management was undertaken too mechanically and lacked empathy.

Conclusion

Patients living with depression may perceive practice-based case management as beneficial if carried out in a trustworthy and empathetic manner.

Practice implications

General practices should ensure that depression case management is patient-centered and non-mechanical.     

Development of an ICF-based patient education program

Objective

To describe the development of an ICF-based patient education program, to present the results of its pilot test and to present the adaptations and final version of the program.

Methods

The education program was developed in five steps: (1) definition of relevant areas of functioning, (2) development of strategies to enhance self-efficacy in these areas, (3) development of material and instructions, (4) definition of modules and setting and (5) performance of a pilot test targeting acceptability and feasibility of the program.

Results

Eleven stroke patients were enrolled in the pilot test. The intervention was well accepted on the part of participants. The developed patient education program is structured in three modules. Module 1 targets to increase patients’ understanding of their current level of functioning. Module 2 targets to identify concrete problems and corresponding solutions regarding limited areas. Module 3 is a refresher session.

Conclusion

Feasibility and acceptability of the intervention were verified and a final version of the patient education program was developed. The effectiveness of the program will be evaluated in a randomized controlled trial.

Practice implications

Due to the universality of the ICF and availability of ICF tools, it is possible to adapt the intervention to different chronic conditions.     

Can wireless text messaging improve adherence to preventive activities? Results of a randomised controlled trial

Objective

To determine the effectiveness of cell phone wireless text messaging for improving adherence to a healthy behaviour.

Design

A randomised, unblinded, controlled trial was conducted with 102 subjects, 18 years or older, each having a cell phone and willing to take 1 vitamin C pill per day for 1 month for preventive reasons. Intervention group participants received text messaging reminders and were asked to acknowledge receiving their messages after taking the vitamins, whereas control group subjects had no text messaging activity.

Measurements

Self-reported adherence and the number of participant text messages acknowledging vitamins taken.

Results

Both groups reported an increased adherence after the trial: by 246% for the intervention group and by 131% for the control group. There was a non-significant difference between the two groups at endpoint: an average difference of 0.8 between the number of pills missed in the last week of the trial (2.5 out of 7 in the intervention and 3.3 out of 7 in the control group) with a power of 0.54. The study revealed a significant correlation (coefficient = −0.352, sig. = 0.01) between the average number of text messaging acknowledgements sent by the intervention group participants and the number of pills they reported missed during the last week of the trial.

Conclusion

This was a small randomised controlled trial with inconclusive but encouraging results. It suggests a new approach in addressing insufficient adherence in outpatient conditions and shows that the use of information technology tools for compliance warrants further research.     

"User-testing" as a method for testing the fitness-for-purpose of written medicine information

Objective

Written medicine information is essential to support spoken information from pharmacists, but must be fit-for-purpose. This study applied “user testing” to the booklet supplied to UK patients taking anticoagulant medicines.

Methods

“User testing” uses mixed-methods, applied iteratively, to assess document performance - can people find and understand key points of information through a questionnaire and short semi-structured interview. The booklet was tested in 3 rounds of 10 people. After each round it was revised according to participants’ responses, and re-tested.

Results

The first round questionnaire identified problems with 6/18 information points (booklet purpose; other information; what affected daily doses; effect of ibuprofen; tablet colour; drinking alcohol); interviews raised further issues. The booklet was revised and, in the second testing round, one problem identified (changing doses of other medicines); the interviews raised fewer issues. After further re-wording and re-design, a third round showed all questions found and understood by at least 8/10 participants.

Conclusion

User testing assesses whether people can find and understand key information and can be applied using small numbers of participants. Application to medicine information can markedly improve performance.

Practice implications

Information producers should consider user testing to ensure documents are ‘fit for purpose’ in informing patients.     

“I Wouldn’t Be this Firm if I Didn’t Care”: Preventive clinical counseling for reproductive health

Objective

This qualitative study of health care clinicians serving women at heightened risk of sexually transmitted infections and unintended pregnancy was undertaken to explore concepts underlying reproductive health counseling messages in clinical encounters.

Methods

In-depth interviews were conducted with 31 clinicians, including physicians and advanced practice nurses serving primarily low-income patients in high-risk communities throughout the U.S.

Results

Most of the clinicians describe their influence on patients and protective behaviors as derived from medical authority and the presentation of information. The use of a parental style of authority, particularly for young or vulnerable patients, and emotional appeals to evoke negative emotions, such as fear, were also used to motivate protective behaviors. Many clinicians highlighted the importance of empathy, and understanding the cultural and social context of health behaviors. A few clinicians described innovative efforts to empower women to protect themselves and exert more control in relationships.

Conclusion

Some of the reproductive health counseling approaches described by clinicians are not consistent with leading health behavior change theories or patient-centered counseling.

Practical implications

To improve counseling, these messages and concepts need to be evaluated for effectiveness, and possibly used to inform the development of novel theories for use in reproductive health counseling.     

Coping with infertility online: An examination of self-help mechanisms in an online infertility support group

Objective

To examine communication within an online infertility support group.

Methods

A content analysis of 3500 messages posted to infertility bulletin boards.

Results

The most frequently used self-help mechanisms were support or empathy (45.5%) and sharing personal experiences (45.4%), followed by the provision of information and advice (15.9%), gratitude (12.5%), friendship (9.9%), chit-chat (9.4%), requests for information or advice (6.8%) and universality (4.8%), with negative statements (0.3%) and creative expressions (0.2%) being the least frequent categories.

Conclusion

These findings suggest that online support groups can provide a viable alternative source of support for couples dealing with infertility.

Practice implications

Health care professionals interested in developing online support interventions should look to tailor support resources to the specific needs of patients at different stages of the infertility journey.     

Otitis media and associations with overweight status in toddlers

Introduction

Otitis media (OM) is a significant disease that affects nearly all children early in life. Recently, childhood overweight has become an epidemic. Past research has demonstrated that a history of OM is related to food preferences and overweight through proposed physiological mechanisms. The purpose of this study was to explore the relationship between recurrent OM (ROM)/tympanostomy tube treatment and overweight status.

Methods

Data were analyzed from a prospective cohort of mothers and children recruited from 1991-1996 from a local health maintenance organization. ROM and tympanostomy tube status were obtained through a combination of physical exam and medical record abstraction. ROM and tympanostomy tube status were analyzed as categorical variables with weight-for-length (WFL) data from well child checks. Chi-square and logistic regression for univariate and multivariate analyses were performed.

Results

11.4% of children had a WFL measure at two years of age ≥ 95th percentile. Those children with a history of tympanostomy tube treatment had a significantly increased risk of having a WFL ≥ 95th percentile after controlling for birth weight, maternal prenatal smoking, maternal education, and family income (OR 3.32, 95% CI 1.43-7.72). The alternative hypothesis that children with larger WFL at two month of age would have a greater number of OM episodes by two years of age was not significant.

Conclusion

The findings of this study are consistent with the hypothesis and prior research that OM treated with tympanostomy tubes is associated with overweight status.     

Effective training strategies for teaching communication skills to physicians: An overview of systematic reviews

Objective

Physicians need good communication skills to communicate effectively with patients. The objective of this review was to identify effective training strategies for teaching communication skills to qualified physicians.

Methods

PubMED, PsycINFO, CINAHL, and COCHRANE were searched in October 2008 and in March 2009. Two authors independently selected relevant reviews and assessed their methodological quality with AMSTAR. Summary tables were constructed for data-synthesis, and results were linked to outcome measures. As a result, conclusions about the effectiveness of communication skills training strategies for physicians could be drawn.

Results

Twelve systematic reviews on communication skills training programmes for physicians were identified. Some focused on specific training strategies, whereas others emphasized a more general approach with mixed strategies. Training programmes were effective if they lasted for at least one day, were learner-centred, and focused on practising skills. The best training strategies within the programmes included role-play, feedback, and small group discussions.

Conclusion

Training programmes should include active, practice-oriented strategies. Oral presentations on communication skills, modelling, and written information should only be used as supportive strategies.

Practice implications

To be able to compare the effectiveness of training programmes more easily in the future, general agreement on outcome measures has to be established.     

Development and pilot testing of a culturally sensitive multimedia program to improve breast cancer screening in Latina women

Objective

Our study goal was to assess the effects of a brief patient video on breast cancer knowledge and attitudes among Latina women at a community health center.

Methods

We conducted pre- and post-testing of knowledge and attitudes in women aged 40 years or older with active screening referrals (n = 91). We compared pre- and post-test knowledge and attitudes overall and by baseline values.

Results

Mean knowledge increased from 5.8/10 to 6.9/10 (p < 0.05), with the greatest increases in those with low baseline knowledge (p < .001). There were no changes in mean attitudes, which were high at baseline (3.8/5); however, among the 16 women with negative/neutral attitudes, 50% developed positive attitudes after watching the video (p < 0.05). Baseline intention to complete screening was high at 98%.

Conclusion

Although the overall effects were modest, the greatest improvements were in those with low baseline knowledge scores and negative/neutral baseline attitudes. Future testing should examine the effects in a community-based sample.

Practice implications

A brief patient video has promise for influencing patient knowledge and perhaps attitudes while being amenable to integration into clinical flow.     

The efficacy of psychologically based interventions to improve anxiety, depression and quality of life in COPD: A systematic review and meta-analysis

Objective

To systematically evaluate the efficacy of psychologically based interventions for addressing psychological outcomes in patients with chronic obstructive pulmonary disease (COPD).

Methods

Electronic databases, key journals and reference lists of included studies were scrutinised for inclusion; in addition authors were contacted for potential unpublished research. Nine studies were identified for inclusion. Data was extracted by two reviewers independently using a standardised extraction sheet and a series of meta-analyses completed for measures of anxiety, depression and quality of life.

Results

Eight studies evaluated a cognitive behavioural- or psychotherapeutically based intervention and one study evaluated taped progressive muscle relaxation. The studies revealed some evidence for the interventions’ impact on anxiety, but, taken together interventions had limited effectiveness. The meta-analyses that were conducted revealed a small effect for anxiety only.

Conclusion

The results are discussed considering the limitations of the research and previous work in this area. A systematic evaluation of psychological interventions on psychological co-morbidity in patients with COPD is recommended.

Practice implications

There is some evidence that psychological interventions impact anxiety and this should be explored further and more interventions should target quality of life.     

Immune cell profile in invasive cholesteatomas: Preliminary findings

Background

Cholesteatoma consists of keratinizing squamous epithelium, granulation tissue and keratin plugs. The pathogenesis of cholesteatoma may be related to alterations in the stromal immune cell infiltrate.

Objective

To examine the immunophenotypic characteristics of the immune cell infiltrate in invasive cholesteatomas.

Materials and methods

This study included 12 patients with invasive cholesteatomas causing wide bone erosion of the mastoid, middle ear structures, and the bony plates of middle ear cleft. Diagnosis of invasiveness was based on the clinical, radiological and intraoperative findings. Canal wall-down surgical approach was done in all cases to control the disease process. We used the cholesteatomatous tissue specimens to perform immunohistochemical stains for B cells (CD20), T cells (CD3), histiocytes (CD68) and Langerhans' cells (CD1a). Mouse monoclonal antibodies and immunoperoxidase staining methods were used. The results of immunohistology were scored as mean values of positively stained immune cells. The data were compared with findings in 10 specimens of external ear skin (control group).

Results

Immunohistochemistry showed highly significant (p < 0.00) counts of immune cells in invasive cholesteatomas (CD3: 4.7 ± 0.4, CD68:4.6 ± 0.5, CD20: 0.8 ± 0.1 and CD1a: 0.8  ± 0.1) compared to those in external canal skin (control group: CD3:0.8 ± 0.3, CD68: 1.0 ± 0.4, CD20: 0.2 ± 0.1 and CD1a: 0.1 ± 0.1). In cholesteatomas, the predominant of CD3⁺ T lymphocytes and CD68⁺ cells (histiocytes). Rare CD20⁺ cells and CD1a⁺ cells (Langerhans' cells) were also observed.

Conclusions

This preliminary study describes the profile of the immune cell infiltrate in invasive cholesteatomas. The numeric dominance of CD3⁺ cells and CD68⁺ cells suggests that cell-mediated immunity has important role in the development of cholesteatoma and in its autodestructive properties. Further studies are recommended to categorize the T cell subsets in different stages of cholesteatomas.     

Using the Extended Health Belief Model to understand siblings’ perceptions of risk for hereditary hemochromatosis

Objective

This research focuses on individuals’ reactions to news that a sibling has been diagnosed with hereditary hemochromatosis (HH). We used the Extended Health Belief Model (EHBM) to frame our analysis of siblings’ perceptions of risk for HH and decision of whether to obtain diagnostic testing.

Method

60 patient and 25 sibling interviews were transcribed and thematically analyzed for the six components of the EHBM.

Results

Patient and sibling reports of siblings’ perceptions were categorized into the six components of the EHBM: susceptibility, severity, benefits, barriers, cue to action, and self-efficacy.

Conclusion

In the case of HH, siblings’ perceptions of HH are varied and include a range of motivators and barriers that may impact family-based detection. Family-based detection can often play an important part of effective public health strategies to address inherited risk of disease. Further research should examine the EHBM with other genetic conditions.

Practice implications

This analysis using the EHBM suggests areas of importance for message development for both medical personnel and HH patients to promote diagnostic testing of at-risk siblings.     

Effectiveness of small-group interactive education vs. lecture-based information-only programs on motivation to change and lifestyle behaviours. A prospective controlled trial of rehabilitation inpatients

Objective

Although patient education may promote motivation to change health behaviours, the most effective method has not yet been determined.

Methods

This prospective, controlled trial compared an interactive, patient-oriented group program with lectures providing only information. We evaluated motivational stages of change and self-reported behaviours in three domains (sports, diet, relaxation) at four times up to one year (60% complete data) among 753 German rehabilitation inpatients (mean age 50 years, 52% male) with orthopaedic (59%) or cardiologic disorders (10%) or diabetes mellitus (31%).

Results

We found improvements between baseline and follow up regarding each outcome (p < .001) in both groups. At the end of rehabilitation, participants of the interactive group, as compared to the lectures, showed more advanced motivation regarding diet (p < .10) and sports (p = .006). Interactive group patients reported healthier diets both after 3 months (p = 0.013) and 12 months (p = 0.047), more relaxation behaviours (p = .029) after 3 months and higher motivation for sports after 12 months (p = .08).

Conclusions

The superior effectiveness of the interactive group was only partly confirmed.

Practice implications

This short, 5-session interactive program may not be superior to lectures to induce major sustainable changes in motivation.     

Promoting decision aid use in primary care using a staff member for delivery

Objective

To determine the feasibility and effectiveness of in-clinic decision aid distribution using a care assistant.

Methods

We identified potentially eligible patients scheduled for upcoming appointments in our General Internal Medicine Clinic (n = 1229). Patients were deemed eligible for two decision aids: prostate cancer screening and/or weight loss surgery. Patients were approached to view the decision aid in-clinic. Our primary measures were the proportion of decision aids distributed to eligible patients, and the proportion of decision aids viewed.

Results

Among 913 patients who attended their scheduled appointments, 58% (n = 525) were approached and eligibility was assessed by the staff member. Among the 471 who remained eligible, 57% (n = 268) viewed at least a portion of the target decision aid. The mean viewing time for patients who watched less than the complete decision aid was 13 min.

Conclusions

In clinic viewing of decision aids may be a feasible and effective distribution method in primary care.

Practice implications

In clinic distribution requires an electronic health information system to identify potentially eligible patients, and a staff member dedicated to DA distribution. Brief decision aids (less than 10 min) are needed so patients can complete their use prior to the visit to facilitate patient-physician decision making.