Weight's up? Predictors of weight-related communication during primary care visits with overweight adolescents

Objective

Physicians’ use of Motivational Interviewing (MI) techniques when discussing weight with adolescent patients is unknown.

Methods

We coded audio-recorded encounters between 49 primary care physicians and 180 overweight adolescent patients. During weight discussions, we used the MITI 3.0 to assess: Empathy, MI Spirit, open-ended questions, reflections, MI consistent behaviors (e.g., praising) and MI inconsistent behaviors (e.g., confronting). We examined associations of patient and physician characteristics with (1) MI techniques, (2) time discussing weight, and (3) encounter time.

Results

Physicians used more MI consistent techniques with female patients (p = 0.06) and with heavier patients (p = 0.02). Physicians with prior MI training also used more MI consistent techniques (p = 0.04) and asked more open-ended questions (p = 0.05). Pediatricians had a higher MI Spirit score than family physicians (p = 0.03). Older patient age was associated with physicians spending less time discussing weight-related topics (p = 0.04) and higher BMI percentile was associated with physicians spending more time discussing weight-related topics (p = 0.01). Increased use of MI inconsistent techniques was associated with longer encounters (p = 0.02).

Conclusion

Physicians’ weight discussions vary based on adolescent and physician characteristics. Importantly, not using MI lengthened encounter time.

Practice implications

Physicians might consider using MI techniques more and attempt to use these equally with all adolescents.     

Implementation of Motivational Interviewing in a diabetes care management initiative in the Netherlands

Objective

Motivational Interviewing (MI) is a counseling approach to support behavioural change. The objective of the present study was to examine the uptake of MI in daily practice by health care professionals in a care management initiative for patients with diabetes in the region of Maastricht, the Netherlands.

Methods

MI was implemented by means of a training. Directly and six months after the training, the application of MI was measured objectively (MITI) and subjectively (questionnaire). In focus interviews, MI-trained professionals (n = 10) and MI untrained professionals (n = 10) were asked about facilitators and barriers for implementation. Additionally, data on patient characteristics (n = 141) were collected.

Results

Spirit of MI was present among professionals directly after the training and increased during follow-up. Mostly uncomplicated techniques were applied. Professionals stated the need for training and practice to be able to apply more complicated techniques.

Conclusion

The applicability of MI in daily practice was found feasible, with various degrees of uptake. Relevant conditions to further improve the implementation of MI in daily practice were identified.

Practice implications

In daily practice, a phased training in MI is recommended, with sufficient time and support by colleagues as essential conditions to profit most from the training sessions.     

Communicating consequences of risky behaviors: Life expectancy versus risk of disease

Objective

We investigate (1) whether presenting consequences of health-related behaviors in terms of life expectancy, rather than risk of disease, improves recall and (2) if yes, through which underlying mechanisms; (3) whether these effects hold for both low- and high-numeracy people and (4) in two countries with different cultural environments and medical systems.

Methods

Experiment within a computerized survey on probabilistic samples in the United States (n = 513) and Germany (n = 534).

Results

When consequences of health-related behaviors were presented in terms of changes in life expectancy, recall was better than when they were presented in terms of risks of a disease both after 10 min, Cohen's h = .51, F(1,543) = 34.12, p = .001, and after 3 weeks, h = .62, F(1,543) = 48.98, p = .001. This was so for participants of both high and low numeracy, and in both countries. The improved recall seems to be due to better imaginability of changes in life expectancy.

Conclusions

Consequences of health-related behaviors are easier to imagine and are recalled better when expressed as changes in life expectancy rather than as changes in risk of diseases.

Practice implications

When communicating with patients about medical risks, we recommend using concepts that they can readily relate to their own everyday experiences.     

Outcome of parent-physician communication skills training for pediatric residents

Objective

Communication skills represent an essential component of clinical competence. In the field of pediatrics, communication between physicians and patients’ parents is characterized by particular difficulties. To investigate the effects of a parent-physician communication skills training program on OSCE performance and self-efficacy in a group control design.

Methods

Parallel to their daily work in the outpatient department, intervention-group experienced clinicians in practice (n = 14) participated in a communication training with standardized parents. Control-group physicians (n = 14) did not receive any training beyond their daily work. Performance was assessed by independent video ratings of an OSCE. Both groups rated their self-efficacy prior to and following training.

Results

Regarding OSCE performance, the intervention group demonstrated superior skills in building relationships with parents (p < .024) and tended to perform better in exploring parents’ problems (p < .081). The communication training program led to significant improvement in self-efficacy with respect to the specific training objectives in the intervention group (p < .046).

Conclusion

Even in physicians with considerable experience, structured communication training with standardized parents leads to significant improvement in OSCE performance and self-efficacy.

Practise implications

Briefness and tight structure make the presented communication training program applicable even for experienced physicians in daily clinical practice.     

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.     

Computerized self-monitoring and technology-assisted feedback for weight loss with and without an enhanced behavioral component

Objective

The purpose of this study was to develop and evaluate a 12-week weight management intervention involving computerized self-monitoring and technology-assisted feedback with and without an enhanced behavioral component.

Methods

120 overweight (30.5 ± 2.6 kg/m²) adults (45.0 ± 10.3 years) were randomized to one of three groups: computerized self-monitoring with Basic feedback (n = 45), Enhanced behavioral feedback (n = 45), or wait-list control (n = 30). Intervention participants used a computer software program to record dietary and physical activity information. Weekly e-mail feedback was based on computer-generated reports, and participants attended monthly measurement visits.

Results

The Basic and Enhanced groups experienced significant weight reduction (−2.7 ± 3.3 kg and −2.5 ± 3.1 kg) in comparison to the Control group (0.3 ± 2.2; p < 0.05). Waist circumference and systolic blood pressure also decreased in intervention groups compared to Control (p < 0.01).

Conclusions

A program using computerized self-monitoring, technology-assisted feedback, and monthly measurement visits produced significant weight loss after 12 weeks. However, the addition of an enhanced behavioral component did not improve the effectiveness of the program.

Practice implications

This study suggests that healthcare professionals can effectively deliver a weight management intervention using technology-assisted strategies in a format that may complement and reduce face-to-face sessions.     

Factors associated with the accuracy of physicians' predictions of patient adherence

Objective

Physicians are inaccurate in predicting non-adherence in patients, a problem that interferes with physicians’: (1) appropriate prescribing decisions and (2) effective prevention/intervention of non-adherence. The purpose of the current study is to investigate potential reasons for the poor accuracy of physicians’ adherence-predictions and conditions under which their predictions may be more accurate.

Methods

After the medical encounter, predictions of patient-adherence and other ratings from primary-care physicians (n = 24) regarding patient-factors that may have influenced their predictions were collected. Patients (n = 288) rated their agreement regarding the prescribed treatment after the encounter and reported adherence 1 month later.

Results

Several factors were related to physicians’ adherence-predictions, including physicians’ perceptions of patient-agreement regarding treatment. However, some factors were not related to adherence and agreement-perceptions were inaccurate overall, potentially contributing to the poor accuracy of adherence-predictions. The degree to which physicians discussed treatment-specifics with the patient moderated agreement-perception accuracy but not adherence-prediction accuracy.

Conclusions

Training providers to discuss certain treatment-specifics with patients may improve their ability to perceive patient-agreement regarding treatment and may directly improve patient-adherence.

Practice implications

Discussing treatment-specifics with patients may directly improve adherence, but providers should not rely on these discussions to give them accurate estimates of the patients’ likely adherence.     

A course for nurses to handle difficult communication situations. A randomized controlled trial of impact on self-efficacy and performance

Objective

To evaluate the impact of a communication skills course for nurses on how to handle difficult communication situations in their daily work.

Methods

A 7-h course was developed using a construct of “Awareness, Feelings, Listen, Solve” (AFLS). A pedagogy of experiential, learner-centered learning was adopted. The course evaluation used a randomized controlled design with pre- and post-measures of self-efficacy and performance.

Results

Forty-one nurses volunteered and thirty-three nurses completed all assigned parts of the study. On self-assessment, there was significant improvement for self-efficacy (F = 24.43, p < 0.001), but not for emotional awareness. On performance, there was no significant improvement between intervention and control groups (F = 3.46, p = 0.073).

Conclusion

A short course for nurses on handling difficult communication situations achieved significant improvements in self-efficacy but not in performance.

Practice implications

Teaching communication skills in community-based settings is important for the safety and effectiveness of patient care. Sponsoring organizations should weigh trade-offs between feasibility and achievement of measurable improvements in performance. One possible approach is to focus on specific communication skills rather than a full suite of skills.     

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.     

The impact of patient-centered communication on patients' decision making and evaluations of physicians: a randomized study using video vignettes

Objective

To assess the impact of patient-centered communication (PCC) behaviors on patients’ evaluations of physicians and acceptance of clinical recommendations.

Methods

We randomized 248 patients to view video-recorded, standardized vignettes, depicting a cardiologist using a high vs. low degree of PCC while recommending bypass surgery to a patient with angina and 3-vessel coronary artery disease. We compared patients’ ratings of the physician and their decision making in response to the physician's recommendation, for high vs. low PCC vignettes.

Results

Patients viewing high PCC vignettes rated the video physician more favorably overall (3.01 vs. 2.12, p < 0.001) and as more competent (3.22 vs. 2.66, p < 0.001) and trustworthy (2.93 vs. 2.28, p < 0.001) than those viewing the low PCC version (0-4 range for all scales). Patients viewing the high PCC version more frequently said they would undergo bypass surgery (96% vs. 74%, p < 0.001) if they were the patient in the video.

Conclusion

Patients expressed greater confidence in physicians who used more PCC behaviors, and greater willingness to accept an evidence-based recommendation.

Practice implications

PCC may make physicians more effective in the delivery of evidence-based care.     

Assessment of a motivational interviewing curriculum for year 3 medical students using a standardized patient case

Objective

We sought to evaluate a year 3 motivational interviewing (MI) curriculum using a standardized patient case.

Methods

The 2-h small group MI curriculum included a didactic presentation followed by interactive role plays. During a clinical skills assessment at the end of year 3 the MI skills of 80 students who had participated in the curriculum were compared with those of 19 students who had not participated.

Results

The standardized patient reliably rated the students on their performance of 8 items. Students who had participated in the MI curriculum were significantly more proficient than nonparticipating students in the performance of 2 strategic MI skills, importance and confidence rulers (ps < .006). The groups did not differ in their use of patient-centered counseling skills or collaborative change planning commonly used in MI.

Conclusions

Third year medical students can learn to use MI skills that specifically aim to enhance patients’ motivations for change.

Practice implications

Medical schools should consider providing students with MI training and MI skill assessments using standardized patient cases to help students prepare to counsel patients for behavior change.     

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.     

Lingering questions and doubts: online information-seeking of support forum members following their medical visits

Objective

To examine the prevalence and predictors of patients’ post-appointment online health information-seeking and the reasons behind their information searches.

Methods

Survey of 274 Internet support community members who had been seen by a physician within 30 days. The questionnaire included measures of trust in the physician, health worries, changes in amount of worrying following the visit, online health information-seeking, and standard demographic and visit characteristics.

Results

A majority of respondents (68%) went online in search of information after their visits. In a logistic regression analysis, going online was associated with lower trust (P = .002), greater worrying (P = .049), and becoming more (P = .024) or less worried (P = .05) by the visit. Among those who went online, the most common reasons for doing so were sheer curiosity (71%) and disappointment with some aspect of the physician's behavior (32%).

Conclusion

Patients in this online forum routinely turned to the Internet after their medical visits, but were especially likely to do so when trust in the physician was low, anxieties were high, and the visit altered (for better or worse) their anxiety levels.

Practice Implications

Since many patients seek online information after their appointments, physicians should suggest credible websites suited to the circumstances of each patient.     

Preliminary evidence that acute long-chain omega-3 supplementation reduces cardiovascular reactivity to mental stress: a randomized and placebo controlled trial

Objective

Exaggerated cardiovascular reactivity predicts cardiovascular morbidity and mortality. Some evidence suggests that omega-3 fatty acids improve cardiovascular function. The objective of this study was to examine the influence of an acute low dose of long-chain omega-3 fatty acids on young, healthy individuals.

Methods

Participants (n = 34) were randomly assigned to either 21-days of omega-3 fatty acids (1.4 g EPA and DHA) or matched placebo. Cardiovascular measurements were obtained in the laboratory during baseline and during a standard mental arithmetic task, where participants were instructed to engage in serial subtractions by 17s from a four-digit number and cardiovascular reactivity to the task was calculated.

Results

Mean arterial pressure reactivity was significantly reduced by supplementation (F(1,32) = 5. 12, p = .03, η² = .144) but not by placebo.

Conclusion

Supplementation of omega-3 fatty acids may reduce cardiovascular reactivity to stress.     

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.     

Promoting advance care planning as health behavior change: development of scales to assess Decisional Balance, Medical and Religious Beliefs, and Processes of Change

Objective

To develop measures representing key constructs of the Transtheoretical Model (TTM) of behavior change as applied to advance care planning (ACP) and to examine whether associations between these measures replicate the relationships posited by the TTM.

Methods

Sequential scale development techniques were used to develop measures for Decisional Balance (Pros and Cons of behavior change), ACP Values/Beliefs (religious beliefs and medical misconceptions serving as barriers to participation), Processes of Change (behavioral and cognitive processes used to foster participation) based on responses of 304 persons age ≥ 65 years.

Results

Items for each scale/subscale demonstrated high factor loading (>.5) and good to excellent internal consistency (Cronbach α .76-.93). Results of MANOVA examining scores on the Pros, Cons, ACP Values/Beliefs, and POC subscales by stage of change for each of the six behaviors were significant, Wilks’ λ = .555-.809, η² = .068-.178, p ≤ .001 for all models.

Conclusion

Core constructs of the TTM as applied to ACP can be measured with high reliability and validity.

Practice implications

Cross-sectional relationships between these constructs and stage of behavior change support the use of TTM-tailored interventions to change perceptions of the Pros and Cons of participation in ACP and promote the use of certain Processes of Change in order to promote older persons’ engagement in ACP.     

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.     

The German version of the Four Habits Coding Scheme – Association between physicians’ communication and shared decision making skills in the medical encounter

Objective

To translate a measure of physicians’ communication skills, the Four Habits Coding Scheme (4HCS), into German, to examine its psychometric properties, and to analyze its association with the OPTION Scale, which assesses physicians’ shared decision making (SDM) behavior.

Methods

We performed a secondary data analysis of 67 audio-recorded medical consultations. Reliability, internal consistency, and factorial validity of the translated 4HCS were analyzed. The association with the OPTION Scale was examined using correlation and linear regression.

Results

Testing of reliability revealed intraclass correlation coefficients above .70. Results regarding internal consistency and factorial validity were inconclusive. The correlations between the OPTION score and the four dimensions of the 4HCS were .04 (p = .782), −.14 (p = .303), −.15 (p = .279) and .55 (p < .001), respectively. In multiple regression the four dimensions of the 4HCS explained substantial amount of variation in the OPTION scores (R² = .42, P < .001).

Conclusion

The measure showed good observer reliability, however further testing is necessary. Due to the strong interrelation of both measures, SDM should be seen in the context of broader communication skills.

Practice implications

The 4HCS can be used in research and medical education. Further studies are necessary that investigate SDM within the context of communication skills.     

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.