The advantages and challenges of unannounced standardized patient methodology to assess healthcare communication

Objective

This paper provides an overview of the implementation of using unannounced standardized patients (USPs) to conduct health communication research in clinical settings.

Methods

Certain types of health communication situations are difficult to capture because of their rarity or unpredictable nature. In primary care the real reasons for a visit are frequently unknown until the consultation is well under way. Therefore, it is logistically difficult for communication studies to capture many real-time communications between patients and their physicians. Although the USP methodology is ideal for capturing these communication behaviors, challenges to using this method include developing collaborative relationships with clinical practices, logistical issues such as safeguarding the identity of the USP, training USPs and creating their identities, maintaining fidelity to the role, and analyzing the resultant data.

Results

This paper discusses the challenges and solutions to USP implementation. We provide an example of how to implement a USP study using an on-going study being conducted in primary care practices.

Conclusion

This paper explores the advantages and challenges as well as strategies to overcome obstacles to implementing a USP study.

Practice implications

Despite the challenges, USP methodology can contribute much to our understanding of health communication and practice.     

Survey of family physicians' perspectives on management of immigrant patients: attitudes, barriers, strategies, and training needs

Objective

Immigrants in Canada form a significant portion of the population and have unique and complex health needs. This study was undertaken to evaluate family physicians’ perspectives on the care of this population.

Methods

Questionnaires were distributed to family physicians in Montreal (n = 598). The main outcomes of interest were attitudes of family physicians to care of immigrants including barriers perceived, resources and strategies used to accommodate immigrant patients, as well as physicians’ training in immigrant care.

Results

Family physicians find communication difficulties to be the key barrier and would like to see the access to interpreters improved. Very few physicians make use of professional interpreters. Only a minority of physicians have received specific cross-cultural competence training but those who have seem to provide better quality of care.

Conclusions

Knowledge of physician perspectives is an essential element on which to base interventions to improve the quality of care to this population.

Practice implications

Physicians should be reminded of the importance of using professional interpretation services in multi-lingual encounters. Cross-cultural training should be further advanced in Canadian medical curricula.     

Context awareness in health care: a review

Background

Health care systems will integrate new computing paradigms in the coming years. Context-awareness computing is a research field which often refers to health care as an interesting and rich area of application.

Aim

Through a survey of the research literature, we intended to derive an objective view of the actual dynamism of context awareness in health care, and to identify strengths and weaknesses in this field.

Methods

After discussing definitions of context, we proposed a simple framework to analyse and characterize the use of context through three main axes. We then focused on context-awareness computing and reported on the main teams working in this area. We described some of the context-awareness projects in health care. A deeper analysis of the hospital-based projects demonstrated the gap between recommendations expressed for modelling context awareness and the actual use in a prototype. Finally, we identified pitfalls encountered in this area of research.

Results

A number of opportunities remain for this evolving field of research. We found relatively few groups with such a specific focus. As yet there is no consensus as to the most appropriate models or attributes to include in context awareness. We conclude that a greater understanding of which aspects of context are important in a health care setting is required; the inherent sociotechnical nature of context-aware applications in health care; and the need to draw on a number of disciplines to conduct this research.     

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.     

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.     

Perceived dominance in physicians: Are female physicians under scrutiny?

Objective

This research aims at identifying how specific physician verbal and nonverbal behaviors are related to perceived dominance of female and male physicians.

Method

Analogue patients (163 students) watched videotaped excerpts of eight physicians and indicated how dominant they perceived each physician to be.

Results

Female physicians who spoke more, talked more while doing something else, spoke with louder voices, modulated their voices more, were oriented more toward the patients, sat at a smaller interpersonal distance, were more expansive, and had a more open arm position were perceived as more dominant. These relations were significantly more pronounced in female than in male physicians. With respect to verbal behavior, not agreeing with the patient, structuring the discussion, setting the agenda, and asking questions were related to being perceived as significantly more dominant in female than in male physicians.

Conclusion

Patients interpret verbal and nonverbal female and male physicians’ cues differently. If a behavior contradicts gender stereotypes regarding women, this behavior is perceived as particularly dominant in female physicians.

Practice implications

To provide optimal care, physicians need to be aware of the expectations their patients harbor toward them—especially expected behavior related to the gender of the physician.     

Moving beyond the language barrier: The communication strategies used by international medical graduates in intercultural medical encounters

Objective

To understand the communication strategies international medical graduates use in medical interactions to overcome language and cultural barriers.

Methods

In-depth interviews were conducted with 12 international physicians completing their residency training in internal medicine in a large hospital in Midwestern Ohio. The interview explored (a) barriers participants encountered while communicating with their patients regarding language, affect, and culture, and (b) communication convergence strategies used to make the interaction meaningful.

Results

International physicians use multiple convergence strategies when interacting with their patients to account for the intercultural and intergroup differences, including repeating information, changing speaking styles, and using non-verbal communication.

Practice implications

Understanding barriers to communication faced by international physicians and recognizing accommodation strategies they employ in the interaction could help in training of future international doctors who come to the U.S. to practice medicine. Early intervention could reduce the time international physicians spend navigating through the system and trying to learn by experimenting with different strategies which will allow these physicians to devote more time to patient care. We recommend developing a training manual that is instructive of the socio-cultural practices of the region where international physician will start practicing medicine.     

Trust and distrust among Appalachian women regarding cervical cancer screening: a qualitative study

Objective

To explore Appalachian women's perceptions of trust and distrust of healthcare providers and the medical care system as they relate to views about cervical cancer and screening.

Methods

Thirty-six Ohio Appalachia female residents participated in community focus groups conducted by trained facilitators. Discussion topics included factors related to cervical cancer, and the issues of trust and distrust in medical care. The tape-recorded focus groups were transcribed and analyzed to identify salient themes.

Results

Five themes emerged related to trust in healthcare. Patient-centered communication and encouragement from a healthcare provider led women to trust their physicians and the medical care system. In contrast, lack of patient-centered communication by providers and perceptions of poor quality of care led to distrust. Physician gender concordance also contributed to trust as women reported trust of female physicians and distrust of male physicians; trust in male physicians was reported to be increased by the presence of a female nurse.

Conclusions

Important factors associated with trust and distrust of providers and the medical care system may impact health-seeking behaviors among underserved women.

Practice implications

Opportunities to improve patient-centered communication around the issues of prevention and cervical cancer screening (such as providing patient-focused information about access to appropriate screening tests) could be used to improve patient care and build patients’ trust.     

Employing immersive virtual environments for innovative experiments in health care communication

Objective

This report reviews the literature for studies that employ immersive virtual environment technology methods to conduct experimental studies in health care communication. Advantages and challenges of using these tools for research in this area are also discussed.

Methods

A literature search was conducted using the Scopus database. Results were hand searched to identify the body of studies, conducted since 1995, that are related to the report objective.

Results

The review identified four relevant studies that stem from two unique projects. One project focused on the impact of a clinician's characteristics and behavior on health care communication, the other focused on the characteristics of the patient. Both projects illustrate key methodological advantages conferred by immersive virtual environments, including, ability to maintain simultaneously high experimental control and realism, ability to manipulate variables in new ways, and unique behavioral measurement opportunities.

Conclusion

Though implementation challenges exist for immersive virtual environment-based research methods, given the technology's unique capabilities, benefits can outweigh the costs in many instances.

Practice implications

Immersive virtual environments may therefore prove an important addition to the array of tools available for advancing our understanding of communication in health care.     

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.     

Structured contraceptive counseling—A randomized controlled trial

Objective

To evaluate the addition of structured contraceptive counseling to usual care on choice, initiation, and continuation of very effective contraception after uterine aspiration.

Methods

We conducted a RCT of a version of the WHO Decision-Making Tool for Family Planning Clients and Providers with women having a procedure for a spontaneous or induced abortion. Our intervention provided structured, standardized counseling. We randomized women to usual care or usual care with structured counseling. Our outcomes included choosing a very effective contraceptive method and 3 months continuation.

Results

Fifty-four percent of all participants chose a very effective method. Women in the intervention group were no more likely to choose a very effective method (OR 0.74, 95% CI 0.44, 1.26) or to initiate their method compared to the usual care group (OR 0.65, 95% CI 0.31, 1.34). In multivariate models, structured counseling was not associated with using a very effective method at 3 months (AOR 1.06, 95% CI 0.53, 2.14).

Conclusion

In this setting, structured counseling had little impact on contraceptive method choice, initiation, or continuation.

Practice implications

Adding structured counseling did not increase the proportion choosing or initiating very effective contraception in a practice setting where physicians already provide individualized counseling.     

Patient-physician social concordance, medical visit communication and patients' perceptions of health care quality

Social characteristics (e.g. race, gender, age, education) are associated with health care disparities. We introduce social concordance, a composite measure of shared social characteristics between patients and physicians.

Objective

To determine whether social concordance predicts differences in medical visit communication and patients’ perceptions of care.

Methods

Regression analyses were used to determine the association of patient-provider social concordance with medical visit communication and patients’ perceptions of care using data from two observational studies involving 64 primary care physicians and 489 of their patients from the Baltimore, MD/Washington, DC/Northern Virginia area.

Results

Lower patient-physician social concordance was associated with less positive patient perceptions of care and lower positive patient affect. Patient-physician dyads with low vs. high social concordance reported lower ratings of global satisfaction with office visits (OR = 0.64 vs. OR = 1.37, p = 0.036) and were less likely to recommend their physician to a friend (OR = 0.61 vs. OR = 1.37, p = 0.035). A graded-response was observed for social concordance with patient positive affect and patient perceptions of care.

Conclusion

Patient-physician concordance across multiple social characteristics may have cumulative effects on patient-physician communication and perceptions of care.

Practice implications

Research should move beyond one-dimensional measures of patient-physician concordance to understand how multiple social characteristics influence health care quality.     

The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: The DISTANCE study

Objective

To assess the association of limited English proficiency (LEP) and physician language concordance with patient reports of clinical interactions.

Methods

Cross-sectional survey of 8638 Kaiser Permanente Northern California patients with diabetes. Patient responses were used to define English proficiency and physician language concordance. Quality of clinical interactions was based on 5 questions drawn from validated scales on communication, 2 on trust, and 3 on discrimination.

Results

Respondents included 8116 English-proficient and 522 LEP patients. Among LEP patients, 210 were language concordant and 153 were language discordant. In fully adjusted models, LEP patients were more likely than English-proficient patients to report suboptimal interactions on 3 out of 10 outcomes, including 1 communication and 2 discrimination items. In separate analyses, LEP-discordant patients were more likely than English-proficient patients to report suboptimal clinician-patient interactions on 7 out of 10 outcomes, including 2 communication, 2 trust, and 3 discrimination items. In contrast, LEP-concordant patients reported similar interactions to English-proficient patients.

Conclusions

Reports of suboptimal interactions among patients with LEP were more common among those with language-discordant physicians.

Practice implications

Expanding access to language concordant physicians may improve clinical interactions among patients with LEP. Quality and performance assessments should consider physician-patient language concordance.     

Towards client-centered counseling: development and testing of the WHO Decision-Making Tool

Objective

To describe development and testing of a counseling tool intended to inform family planning clients while helping the family planning provider facilitate the client's decision-making process; and to discuss challenges and requisites for shifting to shared decision-making from the extremes of decision-making dominated by the provider, on one hand, or unaided by the provider, on the other.

Development of the tool

The WHO Decision-Making Tool for Family Planning Clients and Providers is derived from evidence-based principles of client-centered care and counseling. This article discusses how these principles are manifested in the Tool and how the Tool aids both provider and client in improving counseling.

Methods

Development of the Tool involved formative workshops with providers in Indonesia, Mexico, South Africa and Trinidad and Tobago and observational evaluation research in Indonesia, Mexico, and Nicaragua. Analysis of videotaped counseling sessions quantitatively assessed client-provider communication and decision-making. Also, focus-group discussions, interviews, and a questionnaire collected qualitative data from providers and clients.

Results

In general, use of the Tool improved providers’ counseling performance: they engaged clients more and gave more and better tailored information. For clients, the Tool increased their communication and involvement. Both the Nicaraguan and Mexican studies found marked shifts toward the client in the locus of decision-making after introduction of the Tool.

Practice implications

Use of the tool improves the performance of both providers and clients in family planning counseling and decision-making. There are challenges, however, at the levels of both the provider and the organization in sustaining these changes and scaling up such initiatives in quality of 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.     

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.     

A randomized controlled trial of communication training with primary care providers to improve patient-centeredness and health risk communication

Objective

To determine the efficacy and effectiveness of training to improve primary care providers’ patient-centered communication skills and proficiency in discussing their patients’ health risks.

Methods

Twenty-eight primary care providers participated in a baseline simulated patient interaction and were subsequently randomized into intervention and control groups. Intervention providers participated in training focused on patient-centered communication about behavioral risk factors. Immediate efficacy of training was evaluated by comparing the two groups. Over the next 3 years, all providers participated in two more sets of interactions with patients. Longer term effectiveness was assessed using the interaction data collected at 6 and 18 months post-training.

Results

The intervention providers significantly improved in patient-centered communication and communication proficiencies immediately post-training and at both follow-up time points.

Conclusions

This study suggests that the brief training produced significant and large differences in the intervention group providers which persisted 2 years after the training.

Practice implications

The results of this study suggest that primary care providers can be trained to achieve and maintain gains in patient-centered communication, communication skills and discussion of adverse childhood events as root causes of chronic disease.     

From patient to client

Objective

To gain insight in the knowledge, attitude and practices of users and providers of reproductive health services in rural areas of Kyrgyzstan and Tajikistan before and after interventions.

Methods

KAP (Knowledge, Attitude, Practices) studies under 500 respondents.

Results

Training that addressed the determinants of behavioural change contributed to the motivation under health care providers to improve performances. The simultaneously implemented education program for users of health services enhanced the preparedness for birth of pregnant women and their family members. Both interventions had positive effects on health outcomes.

Conclusions

Behavioural change, from hierarchic and directive into client-centred and supportive, can be realized in Central Asia by enhancing the decision-making capacities of providers. A client-centred attitude of health care providers is the key condition for sustainable improvement of service delivery. Improving client-provider communication is a cost-effective way to enhance the quality of care in low resource settings, such as in Central Asia.

Practice implications

The providers can be best trained in a practical setting, when trainees are enabled to practice with real patients, under guidance of a highly skilled professional. Psychological components such as addressing emotions and exploring the values and beliefs of providers should be incorporated in separate training modules.