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.     

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.     

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.     

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.     

Attitudes of physical therapy students toward patient-centered care, before and after a course in psychosocial aspects of care

Objective

Patient-centered care is vital in developing the therapeutic relationship. Attitude may be an important measure of student potential for giving patient-centered care. The purpose of this study was to assess attitudes toward patient-centered care in doctor of physical therapy students before and after completion of a course that addresses communication skills and psychosocial aspects of care.

Methods

In 2009, forty-nine students in the Doctor of Physical Therapy educational program at Duke University took a required course which included recommended elements for teaching patient-centered care. Students completed the Patient-Practitioner Orientation Scale (PPOS) and the Tasks of Medicine Scale (TOMS) twice prior to the course and once at course completion. Demographic data were gathered and students responded to open-ended questions at final survey administration.

Results

There were statistically significant differences in student attitudes toward patient-centered care after the educational experience on the PPOS and the TOMS, which were supported by students’ written responses.

Conclusion

Changes in attitudes toward patient-centered care are possible with educational intervention.

Practice implications

The results of this study may help to inform educators of medical professionals about the education of practitioners to develop patient-centered attitudes.     

Patients' perception of communication with clinicians during screening and discussion of cancer supportive care needs

Objective

Effective communication between patients and clinicians is an essential aspect of supportive care for cancer patients, however many patients find this communication is inadequate. This study examined cancer patients’ perception of communication with their clinician during a supportive care screening and discussion process and the ways in which this process assisted communication.

Methods

One hundred and fifty-four patients undertaking treatment for cancer in chemotherapy, radiotherapy and surgical units in six hospitals in Australia participated in a formal supportive care screening, discussion and referral process and were interviewed about their experiences.

Results

The majority of patients interviewed felt that the process enhanced communication by encouraging them to reflect on their needs, assisting them to initiate a discussion with the clinician, validating their needs, encouraging them to seek help and support and focusing clinician attention on unmet needs.

Conclusion

Patients perceived the formal process of supportive care improved communication between themselves and their clinicians.

Practice implications

Undertaking a patient-centred process of supportive care can assist clinicians to meet the unmet needs of patients with cancer and can increase patient satisfaction.     

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.     

Using the word ‘cancer’ in communication about an abnormal Pap test: Finding common ground with patient-provider communication

Objective

To investigate provider and patient views about communication regarding cervical cancer screening follow-up.

Methods

Using qualitative analysis, we interviewed 20 providers and 10 patients from two urban clinics that serve low-income African American and Hispanic women. Semi-structured interviews and focus groups assessed familiarity with National Cancer Institute's Cancer Information Service (CIS) and reactions to a letter asking women with abnormal Pap test to telephone CIS. The letter suggested questions to ask prior to receiving follow-up.

Results

No patient or provider was familiar with CIS. Providers but not patients expressed discomfort with use of the word ‘cancer’ in the letter and in CIS's name. Providers feared that reference to cancer would provoke fatalism and impede timely follow-up, whereas patients felt information about cancer risk was needed to prompt timely follow-up. Information providers found necessary to convey in order to accurately explain abnormal Pap tests surpassed patients’ literacy levels.

Conclusion

Qualitative data suggest important gaps in perspective between providers and patients. There is a need to bridge the gap and overcome communication challenges to promote timely medical follow-up and have better health outcomes.

Practice implications

Implications and strategies for improving patient-provider education and communication about abnormal Pap test are discussed.     

Parotitis associated with Crimean Congo hemorrhagic fever virus

Background

Crimean Congo Hemorrhagic Fever (CCHF) is a potentially fatal tick-borne viral disease, the course of which may accompanied by various clinical findings.

Objectives

We describe a picture of non-suppurative parotitis developing in association with CCHF virus.

Study design

A 48-year-old patient presenting to our hospital with lethargy, hemorrhage and pain and swelling below the left ear was diagnosed with CCHF through IgM antibody and polymerase chain reaction positivity in serum investigated for CCHF virus. A picture of non-suppurative parotitis developed on the 3rd day of admission.

Results

Other causes of parotitis were excluded with the help of serological tests, and the case was regarded as one of CCHF-associated parotitis. The patient was put on adjuvant therapy, an improvement in clinical findings was observed and he was discharged in a healthy condition on the 8th day.

Conclusions

Ours is the first case in the literature of parotitis seen during CCHF. CCHF should be considered in differential diagnosis in addition to other frequently encountered viral agents in patients from endemic regions presenting with a picture of non-suppurative parotitis.     

Can private pharmacy providers offer comprehensive reproductive health services to users of emergency contraceptives? Evidence from Nairobi, Kenya

Objective

To evaluate the provision of reproductive health information and services to users of emergency contraceptives (ECs) by private pharmacists.

Methods

The study involved intervention (9) and control (8) pharmacies, with baseline and endline assessments of EC provision through the use of mystery clients. Intervention pharmacies received weekly updates on EC, fliers with three key messages on EC, and information, education, and communication materials. Logistic regression models are estimated to predict the provision of reproductive health services to EC clients.

Results

The differences between the control and intervention pharmacies with respect to the provision of additional information on EC and regular family planning services are in the expected direction but statistically insignificant. In contrast, the likelihood of providing information or referral for counseling or testing for sexually transmitted infections or HIV was lower in the intervention than in the control pharmacies but the difference was also not statistically significant.

Conclusion

Pharmacy providers in the country face institutional challenges in providing reproductive health services to EC clients.

Practice implications

The challenges could be addressed through pre-service training, targeted in-service training, sensitization of clients, and point-of-sale materials such as brochures, posters and package inserts.     

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.     

Cancer patients' satisfaction with doctors and preferences about death in a university hospital in Turkey

Objective

To determine the expectations and satisfaction levels of Turkish cancer patients regarding their doctors, their wishes about the place and process of dying and to elucidate factors affecting them.

Methods

For this cross-sectional study, a self-administered questionnaire was given to 150 cancer patients in 2009.

Results

Among respondents, 63% stated that they would like to know all the details about their disease and they generally preferred a sudden, painless death, without any intervention at the last moment, but in a hospital. Almost all wanted a religious ceremony after their death. The question with the highest reported level of satisfaction was whether patients had complete trust in their doctors, whereas the least satisfaction was reported for doctors’ explanations during visits. Gender, tumour type and level of education had statistically significant effects on patient satisfaction.

Conclusion

The majority of our cancer patients trusted doctors and wanted to learn more about the progress of their cancer, in contrast to the general tendency of their families to hide the diagnosis. The hospital is still the most preferred place for dying.

Practice implications

Alterations in communication may lead to disparities in patient outcomes; therefore, communication skill training should guide clinicians to recognise these tendencies.     

Communication with patients who are dispensed a first prescription of chronic medication in the community pharmacy

Objective

To analyze information and communication in the community pharmacy when patients collect a first dispensing for chronic medication.

Methods

In 3 pharmacies in the South-West of the Netherlands, counter-based communication with patients receiving a first dispensing for chronic medication was observed and audiotaped. Each contact was analyzed by two observers using an observation checklist. An 11-item questionnaire was given to the patients.

Results

72 Patients were included. Only pharmacy technicians provided information. Average contact lasted approximately 2 min. A computer checklist to support information giving was closely followed. Interactions were structured with introduction and closure. Mostly, information was given without exploring needs of the patient. Questioning showed open-ended questions (26%); check-questions and questions asking feedback (57%). A mean general score given was 5.8 (range 1-9). Of 46 responders who filled in a questionnaire, the majority felt that information was useful, clear and understandable.

Conclusion

Our results show a concise and efficient way of information giving, closely related to a computer checklist. Technicians dominate the interaction. They ask few questions. Patients are satisfied about provided information and the contact.

Practice implications

We suggest a more patient-centered way of communication to increase patients’ participation and to meet patients’ needs for information.     

Tele-health: lessons and strategies from specialists in poison information

Objective

The use of the telephone for providing healthcare is growing. The aim of this exploratory study was to describe tele-health lessons and strategies as discussed by specialists who provide information and recommendations on poison control hotlines.

Methods

Three focus groups of 25 participants who work as specialists in poison information in poison control centers were conducted. Group discussions were analyzed using qualitative content analysis.

Results

Themes that emerged from the data on strategies for telephone communication include: taking control of the call, developing a therapeutic relationship, tailoring communication to fit each caller, preventing information overload, confirming caller understanding, and hands-on training for the development of telephone communication skills.

Conclusion

Specialists in poison information identified challenges specific to communicating with patients over the telephone and reported several types of strategies they used to manage them.

Practice implications

Telephone communication training may be needed to assist health care providers in improving their communication skills.     

The value of training in communication skills for continuing medical education

Objective

Question arises as to what extent communication skills are considered in continuing medical education (CME).

Methods

Analysis for CME-courses in communication skills in the area of the Chamber of Physicians North Rhine (ÄkNo), Germany. Supply Arm(A): CME events (n = 19,320) certified in 2007 were evaluated. Demand Arm(B): course participation of 850 family physicians in the period 2002-2007 was analyzed (n = 37,724). Tests were calculated to the level 0.05 using Mann-Whitney U-test.

Results

(A) 388 (2.0%) events were concerned with the topic communications. 59.3% involved active cooperation of the participants. 0.5% events devoted more than 50% of their duration to the topic communication. Proportions in the subjects of internal medicine, general medicine and pediatrics amounted to 0.2%. (B) 803 (2.1%) events with a focus on communication were identified. Women took part in significantly more events than men (p < 0.002) and selected more interactive courses.

Conclusion

Content on communication training was small. Increasing experience does not automatically improve communication skills but an extent of deliberate praxis seems to be necessary and must be sought and developed.

Practice implications

Communication skills are still insufficiently provided in CME-courses and should be more directed to focus as treatment strategies and scientifically investigated for outcome improvements.     

Studying physician-patient communication in the acute care setting: The hospitalist rapport study

Objective

To assess the feasibility of studying physician-patient communication in the acute care setting.

Methods

We recruited hospitalist physicians and patients from two hospitals within a university system and audio-recorded their first encounter. Recruitment, data collection, and challenges encountered were tracked.

Results

Thirty-two physicians consented (rate 91%). Between August 2008 and March 2009, 441 patients were referred, 210 (48%) were screened, and 119 (66% of 179 eligible) consented. We audio-recorded encounters of 80 patients with 27 physicians. Physicians’ primary concern about participation was interference with their workflow. Addressing their concerns and building the protocol around their schedules facilitated participation. Challenges unique to the acute care setting were: (1) extremely limited time for patient identification, screening, and enrollment during which patients were ill and busy with clinical care activities and (2) little advance knowledge of when physician-patient encounters would occur. Employing a full-time study coordinator mitigated these challenges.

Conclusion

Physician concerns for participating in communication studies are similar in ambulatory and acute care settings. The acute care setting presents novel challenges for patient recruitment and data collection.

Practice implications

These methods should be used to study provider-patient communication in acute care settings. Future work should test strategies to increase patient enrollment.     

Identifying transparency in physician communication

Objective

To categorize physician communication demonstrating understanding of what patients want to know and skill in conveying that information. Physicians underestimate how much information patients want and patients rarely seek information during clinic visits. Transparent communication is advocated to facilitate patient understanding and support autonomy, informed decision-making and relationship development.

Methods

Analysis and coding of 263 audiotaped interactions between 33 primary care physicians and their patients in eight community-based, primary care clinics in Washington State, USA.

Results

Physicians proactively used five types of process transparency to preview speech and actions. Four types of content transparency were used to explicate diagnosis and treatment, demystify medical language and concepts, and interpret biomedical information. Physicians spent the greatest proportion of clinic time explicating medical content.

Conclusion

The primacy of information exchange over process-oriented, relational communication was demonstrated. Proactive transparency appears promising to increase understanding and collaboration.

Practice implications

In patient-centered care where collaboration is the ideal, transparency in its various forms is a critical ingredient. Without much communicative effort, physicians who proactively communicated that an examination was over, that they were leaving the exam room briefly so patients could dress provided information that appeared to address patient uncertainty and demonstrated empathy and respect.     

Information needs of informal caregivers of older adults with chronic health conditions

Objective

To systematically examine current evidence pertaining to information needs of informal caregivers of older adults with chronic health conditions.

Methods

Structured search of MEDLINE, MEDLINE IN-PROCESS, CINAHL, and PsycINFO databases to identify studies of caregiver information needs, followed by data extraction and syntheses.

Results

The 62 articles that met the stated inclusion criteria highlighted extensive needs among informal caregivers for practical, accessible, timely information.

Conclusion

The identified information needs of informal caregivers can inform organizations and agencies that seek to provide disease and illness-related information.

Practice implications

Existing evidence supports the implementation of a health information delivery system designed to meet the needs of informal caregivers of older adults with chronic health conditions.