Specialties Differ in Which Aspects of Doctor Communication Predict Overall Physician Ratings

BACKGROUND

Effective doctor communication is critical to positive doctor–patient relationships and predicts better health outcomes. Doctor communication is the strongest predictor of patient ratings of doctors, but the most important aspects of communication may vary by specialty.

OBJECTIVE

To determine the importance of five aspects of doctor communication to overall physician ratings by specialty.

DESIGN

For each of 28 specialties, we calculated partial correlations of five communication items with a 0–10 overall physician rating, controlling for patient demographics.

PATIENTS

Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS®) 12-month Survey data collected 2005–2009 from 58,251 adults at a 534-physician medical group.

MAIN MEAsURES

CG-CAHPS includes a 0 (“Worst physician possible”) to 10 (“Best physician possible”) overall physician rating. Five doctor communication items assess how often the physician: explains things; listens carefully; gives easy-to-understand instructions; shows respect; and spends enough time.

KEY RESULTS

Physician showing respect was the most important aspect of communication for 23/28 specialties, with a mean partial correlation (0.27, ranging from 0.07 to 0.44 across specialties) that accounted for more than four times as much variance in the overall physician rating as any other communication item. Three of five communication items varied significantly across specialties in their associations with the overall rating (p?<?0.05).

CONCLUSIONS

All patients valued respectful treatment; the importance of other aspects of communication varied significantly by specialty. Quality improvement efforts by all specialties should emphasize physicians showing respect to patients, and each specialty should also target other aspects of communication that matter most to their patients. The results have implications for improving provider quality improvement and incentive programs and the reporting of CAHPS data to patients. Specialists make important contributions to coordinated patient care, and thus customized approaches to measurement, reporting, and quality improvement efforts are important.     

Identification of Limited English Proficient Patients in Clinical Care

Background

Standardized means to identify patients likely to benefit from language assistance are needed.

Objective

To evaluate the accuracy of the U.S. Census English proficiency question (Census-LEP) in predicting patients’ ability to communicate effectively in English.

Design

We investigated the sensitivity and specificity of the Census-LEP alone or in combination with a question on preferred language for medical care for predicting patient-reported ability to discuss symptoms and understand physician recommendations in English.

Participants

Three hundred and two patients > 18 who spoke Spanish and/or English recruited from a cardiology clinic and an inpatient general medical-surgical ward in 2004–2005.

Results

One hundred ninety-eight (66%) participants reported speaking English less than “very well” and 166 (55%) less than “well”; 157 (52%) preferred receiving their medical care in Spanish. Overall, 135 (45%) were able to discuss symptoms and 143 (48%) to understand physician recommendations in English. The Census-LEP with a high-threshold (less than “very well”) had the highest sensitivity for predicting effective communication (100% Discuss; 98.7% Understand), but the lowest specificity (72.6% Discuss; 67.1% Understand). The composite measure of Census-LEP and preferred language for medical care provided a significant increase in specificity (91.9% Discuss; 83.9% Understand), with only a marginal decrease in sensitivity (99.4% Discuss; 96.7% Understand).

Conclusions

Using the Census-LEP item with a high-threshold of less than “very well” as a screening question, followed by a language preference for medical care question, is recommended for inclusive and accurate identification of patients likely to benefit from language assistance. (246 words)     

Patient attitudes toward medical student participation in a general internal medicine clinic

OBJECTIVE: To study patient attitudes toward medical students in a faculty academic general internal medicine practice. DESIGN: Survey. SETTING: An academic general internal medicine ambulatory practice site at a university hospital. PATIENTS: Random selection of 199 patients attending the practice; 194 patients completed the survey. MAIN RESULTS: Approximately half (55.8%) of the patients had no preference regarding medical student participation, a third preferred to see the attending physician alone, and 10% preferred to see the student with the physician. Seventy-six percent were not reluctant to disclose “personal” information with the medical student, whereas 24% felt uncomfortable. Almost half (46.5%) of the patients enjoyed their encounters with medical students, 43% were neutral, and 10.3% disliked their encounters. Half of the patients desired some time aline with the attending physician. Thirty-seven percent of the patients reported that they had benefited from their interactions with the medical students. Patients who were men and older appeared to be more receptive of medical students. There was also a trend for patients who had had previous visits involving medical students to be more accepting of their participation. CONCLUSIONS: The majority of the patients in the study were receptive to medical student participation in this ambulatory setting. Patients should be adequately prepared for medical student involvement and each patient should have an opportunity to spend time alone with the attending physician. A sizable minority (a third) of patients do not desire medical student participation.     

Opinions of Students from a Brazilian Medical School Regarding Online Professionalism

INTRODUCTION

Unprofessional online behavior by medical students or physicians may damage individual careers, and the reputation of institutions and the medical profession. What is considered unprofessional online behavior, however, is not clearly defined and may vary in different cultures.

OBJECTIVES

To determine the frequency with which students from a Brazilian Medical School come across ten given examples of unprofessional online behavior by medical students or physicians, and gather the opinions of participants regarding the appropriateness of these behaviors.

METHODS

A cross-sectional survey of 350 students from the Medical School of Bahia, Brazil. Only those who had a profile in social media were included in the final analyses.

RESULTS

336/350 (96.0 %) medical students kept a profile in social media. Only 13.5 % reported having discussions about online professionalism during ethics classes. They reported witnessing the investigated examples of unprofessional online behavior with varying frequencies, ranging from 13.7 % for “violation of patient’s privacy” to 85.4 % for “photos depicting consumption of alcoholic beverages”. Most participants felt neutral about posting “pictures in bathing suits”, whereas the vast majority rated “violation of patient’s privacy” as totally inappropriate. When presented with a case vignette illustrating violation of patients’ privacy (publication of pictures of hospitalized children or neonates in social media), however, most participants felt neutral about it. Participants considered all investigated examples of unprofessional online behavior more inappropriate if carried out by doctors rather than by students.

CONCLUSIONS

Medical students are witnessing a high frequency of unprofessional online behavior by their peers and physicians. Most investigated behaviors were considered inappropriate, especially if carried out by physicians. Participants were not able to recognize the publication of pictures of hospitalized children or neonates in social media as cases of violation of patients’ privacy. Further studies are needed to determine if an academic curriculum that fosters online professionalism will change this scenario.     

Effect of the inpatient general medicine rotation on student pursuit of a generalist career

BACKGROUND: Entry into general internal medicine (GIM) has declined. The effect of the inpatient general medicine rotation on medical student career choices is uncertain. OBJECTIVE: To assess the effect of student satisfaction with the ipatient general medicine rotation on pursuit of a career in GIM. DESIGN: Multicenter cohort study. PARTICIPANTS: Third-year medical students between July 2001 and June 2003. MEASUREMENTS: End-of-internal medicine clerkship survey assessed satisfaction with the rotation using a 5-point Likert scale. Pursuit of a career in GIM defined as: (1) response of “Very Likely” or “Certain” to the question “How likely are you to pursue a career in GIM?”; and (2) entry into an internal medicine residency using institutional match data. RESULTS: Four hundred and two of 751 (54%) students responded. Of the student respondents, 307 (75%) matched in the 2 years following their rotations. Twenty-eight percent (87) of those that matched chose an internal medicine residency. Of these, 8% (25/307) were pursuing a career in GIM. Adjusting for site and preclerkship interest, overall satisfaction with the rotation predicted pursuit of a career in GIM (odds ratio [OR] 3.91, P < .001). Although satisfaction with individual items did not predict pursuit of a generalist career, factor analysis revealed 3 components of satisfaction (attending, resident, and teaching). Adjusting for preclerkship interest, 2 factors (attending and teaching) were associated with student pursuit of a career in GIM (P < .01). CONCLUSIONS: Increased satisfaction with the inpatient general medicine rotation promotes pursuit of a career in GIM.     

Directive Counsel and Morally Controversial Medical Decision-Making: Findings from Two National Surveys of Primary Care Physicians

BACKGROUND

Because of the potential to unduly influence patients’ decisions, some ethicists counsel physicians to be nondirective when negotiating morally controversial medical decisions.

OBJECTIVE

To determine whether primary care providers (PCPs) are less likely to endorse directive counsel for morally controversial medical decisions than for typical ones and to identify predictors of endorsing directive counsel in such situations.

DESIGN AND PARTICIPANTS

Surveys were mailed to two separate national samples of practicing primary care physicians. Survey 1 was conducted from 2009 to 2010 on 1,504 PCPs; Survey 2 was conducted from 2010 to 2011 on 1,058 PCPs.

MAIN MEASURES

Survey 1: After randomization, half of the PCPs were asked if physicians should encourage patients to make the decision that the physician believes is best (directive counsel) with respect to “typical” medical decisions and half were asked the same question with respect to “morally controversial” medical decisions. Survey 2: After reading a vignette in which a patient asked for palliative sedation to unconsciousness, PCPs were asked whether it would be appropriate for the patient’s physician to encourage the patient to make the decision the physician believes is best.

KEY RESULTS

Of 1,427 eligible physicians, 896 responded to Survey 1 (63 %). Physicians asked about morally controversial decisions were half as likely (35 % vs. 65 % for typical decisions, p?<?0.001) to endorse directive counsel. Of 986 eligible physicians, 600 responded to Survey 2 (61 %). Two in five physicians (41 %) endorsed directive counsel after reading a vignette describing a patient requesting palliative sedation to unconsciousness; these physicians tended to be male and more religious.

CONCLUSIONS

PCPs are less likely to endorse directive counsel when negotiating morally controversial medical decisions. Male physicians and those who are more religious are more likely to endorse directive counsel in these situations.     

Impact of Electronic Health Records on Malpractice Claims in a Sample of Physician Offices in Colorado: A Retrospective Cohort Study

BACKGROUND

Electronic health records (EHRs) might reduce medical liability claims and potentially justify premium credits from liability insurers, but the evidence is limited.

OBJECTIVES

To evaluate the association between EHR use and medical liability claims in a population of office-based physicians, including claims that could potentially be directly prevented by features available in EHRs (“EHR-sensitive” claims).

DESIGN

Retrospective cohort study of medical liability claims and analysis of claim abstracts.

PARTICIPANTS

The 26 % of Colorado office-based physicians insured through COPIC Insurance Company who responded to a survey on EHR use (894 respondents out of 3,502 invitees).

MAIN MEASURES

Claims incidence rate ratio (IRR); prevalence of “EHR-sensitive” claims.

KEY RESULTS

473 physicians (53 % of respondents) used an office-based EHR. After adjustment for sex, birth cohort, specialty, practice setting and use of an EHR in settings other than an office, IRR for all claims was not significantly different between EHR users and non-users (0.88, 95 % CI 0.52–1.46; p?=?0.61), or for users after EHR implementation as compared to before (0.73, 95 % CI 0.41–1.29; p?=?0.28). Of 1,569 claim abstracts reviewed, 3 % were judged “Plausibly EHR-sensitive,” 82 % “Unlikely EHR-sensitive,” and 15 % “Unable to determine.” EHR-sensitive claims occurred in six out of 633 non-users and two out of 251 EHR users. Incidence rate ratios were 0.01 for both groups.

CONCLUSIONS

Colorado physicians using office-based EHRs did not have significantly different rates of liability claims than non-EHR users; nor were rates different for EHR users before and after EHR implementation. The lack of significant effect may be due to a low prevalence of EHR-sensitive claims. Further research on EHR use and medical liability across a larger population of physicians is warranted.     

Using Patients Like My Patient for Clinical Decision Support: Institution-Specific Probability of Celiac Disease Diagnosis Using Simplified Near-Neighbor Classification

BACKGROUND

Interpretation of a diagnostic test result requires knowing what proportion of patients with a “similar” result has the condition in question. This information is often not readily available from the medical literature, or may be based on different clinical populations that make it nonapplicable. In certain settings, where correlated screening parameters and diagnostic data are available in electronic medical records, a representation of diagnostic test performance on “patients like my patient” can be obtained.

OBJECTIVE

We sought to integrate patient demographic and physician practice information using a simplified nearest neighbor algorithm. We used this method to illustrate the relationship between tTG IgA test result and duodenal biopsy for celiac disease in a local diagnostic context.

PARTICIPANTS

We used a data set of 1,461 paired tissue transglutaminase (tTG) IgA and definitive duodenal biopsy results from Intermountain Healthcare with data on patient age and ordering physician specialty. This was split into a discovery set of 1,000 and a validation set of 461 paired results.

MAIN MEASURES

Accuracy of the local discovery data set in predicting probability of positive duodenal biopsy and confidence intervals around predicted probability in the test data compared to probabilities of positive biopsy implied from published logistic regression and from published sensitivity and specificity studies.

KEY RESULTS

The near-neighbor method could estimate probability of clinical outcomes with predictive performance equivalent to other methods while adjusting probability estimates and confidence intervals to fit specific clinical situations.

CONCLUSIONS

Data from clinical encounters obtained from electronic medical records can yield prediction estimates that are tailored to the individual patient, local population, and healthcare delivery processes. Local analysis of diagnostic probability may be more clinically meaningful than probabilities inferred from published studies. This local utility may come at the expense of external validity and generalizability.     

Appraising the Practice of Etiquette-Based Medicine in the Inpatient Setting

BACKGROUND

The physician–patient relationship is at the heart of patient care. Dr. Michael Kahn proposed a checklist of six behaviors, defining “etiquette-based medicine”, as a strategy to start each encounter respectfully and improve patient–physician rapport.

OBJECTIVE

To assess performance of “etiquette-based medicine” in the inpatient setting.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional observational study using time-motion techniques between May and July, 2009. Eight hospitalists were randomly selected at each of three hospitals in the Greater Baltimore area. Each time the physician entered a patient’s room, a single observer recorded whether the “etiquette-based medicine” behaviors were performed: (1) knocking or asking to enter the patient’s room, (2) introducing oneself, (3) shaking the patient’s hand, (4) sitting down in the patient’s room, (5) explaining one’s role in the patient’s care, and (6) asking about the patient’s feelings regarding his or her hospitalization or illness.

MEASUREMENTS

The frequency with which physicians performed the six behaviors, predictors of behavior performance, and Press-Ganey performance scores. The etiquette-based medicine (EtBM) score was defined and calculated by dividing the number of observed behaviors by the number expected.

RESULTS

The 24 observed hospitalists collectively saw 226 unique patients. No individual behavior was performed with a majority of patients, and, with 30 % of the patients, none of the behaviors were performed. The average EtBM score for the physicians was 22.3 % (SD 10.9 %). Physicians who spent more time with patients were more likely to perform behaviors. Sitting down (p?=?0.026) and EtBM scores (p?=?0.019) were associated with physician-specific Press-Ganey ratings.

LIMITATIONS

Cross-sectional design does not allow for determination of causality.

CONCLUSIONS

“Etiquette-based medicine” was infrequently practiced by this sample of hospitalist physicians. Improving performance of etiquette-based medicine may improve patient satisfaction.     

Aufbau und Ergebnisse einer geriatrischen Medikamentendatenbank

Background

The aim of this project was to obtain information about drug therapy in geriatric units.

Patients and methods

Members of the geriatrics in Bavaria database (GiB-DAT) collected data on discharge medication and transferred them to the database. A total of 88,840 data sets of geriatric rehabilitation clinics and acute geriatric units were evaluated according to the anatomical therapeutic chemical (ATC) system.

Results

Patients (mean age: 81.1 years, female 67.7%) had an average of 10.4 diagnoses and took 8.0 drugs at discharge. A peak number of prescribed drugs was reached at the age of 60–70 years with a decrease in the following decades of life. Female patients received more drugs, significantly those in the decades from 71 to 80 and 81 to 90 years old. The bulk of the drugs were from the ATC groups “Cardiovascular system” (89.9%), “Nervous system” (82.3%) and “Alimentary tract and metabolism” (78%).     

Medical Students’ Attention to Multiple Risk Behaviors: A Standardized Patient Examination

BACKGROUND

Risk behaviors tend to cluster, particularly among smokers, with negative health effects. To optimize patients?? health and wellbeing, health care providers ideally would assess and intervene upon the multiple risks with which patients may present.

OBJECTIVE

This study examined medical students?? skills in assessing and treating multiple risk behaviors.

DESIGN

Using a randomized experimental design, medical students?? counseling interactions were evaluated with a standardized patient presenting with sexual health concerns and current tobacco use with varied problematic drinking status (alcohol-positive or alcohol-negative).

PARTICIPANTS

One hundred and fifty-six third-year medical students.

MAIN MEASURES

Student and standardized patient completed measures evaluated student knowledge, attitudes, and clinical performance.

KEY RESULTS

Overall, most students assessed tobacco use (85%); fewer assessed alcohol use (54%). Relative to the alcohol-negative case, students seeing the alcohol-positive case were less likely to assess sexually transmitted disease history (80% vs. 91%, p?=?0.042), or patients?? readiness to quit smoking (41% vs. 60%, p?=?0.025), and endorsed greater attitudinal barriers to tobacco treatment (p?=?0.030). Patient satisfaction was significantly lower for the alcohol-positive than the alcohol-negative case; clinical performance ratings moderated this relationship.

CONCLUSIONS

When presented with a case of multiple risks, medical students performed less effectively and received lower patient satisfaction ratings. Findings were moderated by students?? overall clinical performance. Paradigm shifts are needed in medical education that emphasize assessment of multiple risks, new models of conceptualizing behavior change as a generalized process, and treatment of the whole patient for optimizing health outcomes.     

Beobachtungen zur ?rztlichen übergabe auf der Intensivstation – ein Qualit?tsmanagementprojekt

Introduction

In medicine and especially in intensive care, errors lead to significant consequences especially due to the limited time and resources environment. The range of errors is wide, but a major portion is referred to “information loss” or “information degrading”. Therefore, we conducted a quality assurance audit to evaluate medical shift changes in the intensive care unit.

Methods

We analyzed the doctor’s shift change and sharing of information in a medical 12-bed ICU in a university hospital. The questionnaire was given to the physicians and a video documentation of the actual shift change was recorded. We compared the results of the audit before and after a switch from an 8-hour shift to a 12-hour shift a year later.

Results

A 60-minute shift change (for an average of 10 patients) was regarded sufficient. The sharing of information should be performed at the bed side or in front of the room/slot. Critical loss of information was not noted in this evaluation. Passing on social context information and the rationale for therapy changes were not regarded as important. We observed many disruptions during the shift change; combining the shift change with a regular ward round was not regarded useful.

Consequences

Shift changes in our institution are not conducted in a straightforward fashion. Loss of critical information was not observed. More detailed investigations to optimize medical shift changes are warranted.     

An assessment of the impact of type 2 diabetes on the quality of life based on age at diabetes diagnosis

Aims

This study aimed to determine whether Korean adults diagnosed with type 2 diabetes before the age of 40 have a different perception of the impact of diabetes on their quality of life (QoL) compared with that of patients diagnosed at an older age.

Methods

A total of 236 patients were investigated in this cross-sectional study. The patients were classified into two groups based on their age at diagnosis: early type 2 diabetes (age at diagnosis <40 years) and typical type 2 diabetes (age at diagnosis ≥40 years). The QoL was assessed using the latest version of the audit of diabetes-dependent quality of life (ADDQoL).

Results

The average weighted impact (AWI) of diabetes on QoL was significantly lower in adults with early type 2 diabetes than those diagnosed later. Patients with early type 2 diabetes reported a greater negative impact of diabetes on specific life domains “close personal relationship,” “sex life,” “self-confidence,” “motivation to achieve things,” “feelings about the future,” “freedom to eat,” and “freedom to drink” than patients with typical type 2 diabetes. In multivariate analysis adjusted for demographic and medical variables, a diagnosis of diabetes before the age of 40 was significantly associated with a lower ADDQoL AWI score [OR 3.60 (95 % CI: 1.12–11.55), P < 0.05].

Conclusions

Younger age at type 2 diabetes diagnosis is significantly associated with a poor diabetes-related QoL.     

The Impact of Health Literacy on Desire for Participation in Healthcare, Medical Visit Communication, and Patient Reported Outcomes among Patients with Hypertension

BACKGROUND

Low health literacy (HL) is associated with poor healthcare outcomes; mechanisms for these associations remain unclear.

OBJECTIVE

To elucidate how HL influences patients’ interest in participating in healthcare, medical visit communication, and patient reported visit outcomes.

DESIGN, SETTING, AND PATIENTS

Cross-sectional study of enrollment data from a randomized controlled trial of interventions to improve patient adherence to hypertension treatments. Participants were 41 primary care physicians and 275 of their patients. Prior to the enrollment visit, physicians received a minimal intervention or communication skills training and patients received a minimal intervention or a pre-visit coaching session. This resulted in four intervention groups (minimal patient/minimal physician; minimal patient/intensive physician; intensive patient/minimal physician; and intensive patient/intensive physician).

MEASUREMENTS

Rapid Estimate of Adult Literacy in Medicine; patients’ desire for involvement in decision making; communication behaviors; patient ratings of participatory decision making (PDM), trust, and satisfaction.

RESULTS

A lower percentage of patients with low versus adequate literacy had controlled blood pressure. Both groups were similarly interested in participating in medical decision making. Communication behaviors did not differ based on HL except for medical question asking by patients, which was lower among low literacy patients. This was particularly true in the intensive patient /intensive physician group (3.85 vs. 6.42 questions; p?=?0.002). Overall, ratings of care didn’t differ based on HL; however, in analyses stratified by intervention assignment, patients with low literacy in minimal physician intervention groups reported significantly lower PDM scores than adequate literacy patients.

CONCLUSIONS

Patients with low and adequate literacy were similarly interested in participating in medical decision making. However, low literacy patients were less likely to experience PDM in their visits. Low literacy patients in the intensive physician intervention groups asked fewer medical questions. Patients with low literacy may be less able to respond to physicians’ use of patient-centered communication approaches than adequate literacy patients.     

Priorities of elderly dizzy patients in general practice

Backgound

Dizziness as a geriatric syndrome needs to be assessed using a multi-dimensional, patient-centred approach in addition to a disease-orientated strategy. The aim of the study was to determine the priorities of elderly patients by a specific needs questionnaire, the“Dizziness Needs Assessment” (DiNA), and to evaluate its psychometric properties.

Methods

General practitioners (GPs) distributed questionnaires containing the DiNA as well as the Patients’ Intentions Questionnaire (PIQ) to patients aged at least 65 years and suffering from dizziness. Items of both questionnaires were analysed by frequencies, means and rank correlations. Factor structure was explored by principal component analysis.

Results

A total of n=123 patients (mean age 76 years, 73% women) had suffered from dizziness on average for more than 3 years (57% chronic, i.e. >6 months). Knowing the cause of the dizziness was rated as very important by patients, and about half of them wished that their doctor would make more effort to investigate this. Among other differences, chronically dizzy patients ranked the risk of falling significantly higher than those with acute dizziness. Factor analysis revealed four subscales: “handicap and mobility” showed a very good reliability of 0.77 (Cronbach’s α), indicating a “trait”, whereas the other subscales rather indicated “state” characteristics. Validation coefficients showed that PIQ assesses general patient needs compared to the more specific dizziness-related needs revealed by the DiNA.

Conclusion

The DiNA proved to be a valuable instrument to assess the specific priorities of elderly patients suffering from dizziness. Regarding the limited therapy options for dizziness in old age, a doctor-guided shift of patients’ attention from causes to symptom-related implications could be a promising approach.     

Brief Training of Student Clinicians in Shared Decision Making: A Single-Blind Randomized Controlled Trial

BACKGROUND

Shared decision making is a crucial component of evidence-based practice, but a lack of training in the “how to” of it is a major barrier to its uptake.

OBJECTIVE

To evaluate the effectiveness of a brief intervention for facilitating shared decision making skills in clinicians and student clinicians.

DESIGN

Multi-centre randomized controlled trial.

PARTICIPANTS

One hundred and seven medical students, physiotherapy or occupational therapy students undertaking a compulsory course in evidence-based practice as part of their undergraduate or postgraduate degree from two Australian universities.

INTERVENTION

The 1-h small-group intervention consisted of facilitated critique of five-step framework, strategies, and pre-recorded modelled role-play. Both groups were provided with a chapter about shared decision making skills.

MAIN MEASURES

The primary outcome was skills in shared decision making and communicating evidence [Observing Patient Involvement (OPTION) scale, items from the Assessing Communication about Evidence and Patient Preferences (ACEPP) Tool], rated by a blinded assessor from videorecorded role-plays. Secondary outcomes: confidence in these skills and attitudes towards patient-centred communication (Patient Practitioner Orientation Scale (PPOS)).

KEY RESULTS

Of participants, 95 % (102) completed the primary outcome measures. Two weeks post-intervention, intervention group participants scored significantly higher on the OPTION scale (adjusted group difference?=?18.9, 95 % CI 12.4 to 25.4), ACEPP items (difference?=?0.9, 95 % CI 0.5 to 1.3), confidence measure (difference?=?13.1, 95 % CI 8.5 to 17.7), and the PPOS sharing subscale (difference?=?0.2, 95 % CI 0.1 to 0.5). There was no significant difference for the PPOS caring subscale.

CONCLUSIONS

This brief intervention was effective in improving student clinicians’ ability, attitude towards, and confidence in shared decision making facilitation. Following further testing of the longer-term effects of this intervention, incorporation of this brief intervention into evidence-based practice courses and workshops should be considered, so that student clinicians graduate with these important skills, which are typically neglected in clinician training.     

Exploring Public Attitudes Towards Approaches to Discussing Costs in the Clinical Encounter

BACKGROUND

Patients’ willingness to discuss costs of treatment alternatives with their physicians is uncertain.

OBJECTIVE

To explore public attitudes toward doctor–patient discussions of insurer and out-of-pocket costs and to examine whether several possible communication strategies might enhance patient receptivity to discussing costs with their physicians.

DESIGN

Focus group discussions and pre-discussion and post-discussion questionnaires.

PARTICIPANTS

Two hundred and eleven insured individuals with mean age of 48 years, 51 % female, 34 % African American, 27 % Latino, and 50 % with incomes below 300 % of the federal poverty threshold, participated in 22 focus groups in Santa Monica, CA and in the Washington, DC metro area.

MAIN MEASUREMENTS

Attitudes toward discussing out-of-pocket and insurer costs with physicians, and towards physicians’ role in controlling costs; receptivity toward recommended communication strategies regarding costs.

KEY RESULTS

Participants expressed more willingness to talk to doctors about personal costs than insurer costs. Older participants and sicker participants were more willing to talk to the doctor about all costs than younger and healthier participants (OR?=?1.8, p?=?0.004; OR?=?1.6, p?=?0.027 respectively). Participants who face cost-related barriers to accessing health care were in greater agreement than others that doctors should play a role in reducing out-of-pocket costs (OR?=?2.4, p?=?0.011). Participants did not endorse recommended communication strategies for discussing costs in the clinical encounter. In contrast, participants stated that trust in one’s physician would enhance their willingness to discuss costs. Perceived impediments to discussing costs included rushed, impersonal visits, and clinicians who are insufficiently informed about costs.

CONCLUSIONS

This study suggests that trusting relationships may be more conducive than any particular discussion strategy to facilitating doctor–patient discussions of health care costs. Better public understanding of how medical decisions affect insurer costs and how such costs ultimately affect patients personally will be necessary if discussions about insurer costs are to occur in the clinical encounter.     

Changing Interactions Between Physician Trainees and the Pharmaceutical Industry: A National Survey

BACKGROUND

Increasingly, medical school policies limit pharmaceutical representatives’ access to students and gifts from drugmakers, but little is known about how these policies affect student attitudes toward industry.

OBJECTIVE

To assess interactions between trainees and the pharmaceutical industry, and to determine whether learning environment characteristics influence students’ practices and attitudes.

DESIGN, PARTICIPANTS

We conducted a cross-sectional survey with a nationally-representative sample of first- and fourth-year medical students and third-year residents, stratified by medical school, including ≥ 14 randomly selected trainees at each level per school.

MAIN MEASURES

We measured frequency of industry interactions and attitudes regarding how such interactions affect medical training and the profession. Chi-squared tests assessed bivariate linear trend, and hierarchical logistic regression models were fitted to assess associations between trainees’ attitudes and their schools’ National Institutes of Health (NIH) funding levels and American Medical Student Association (AMSA) PharmFree Scorecard grades reflecting industry-related conflict of interest policies.

KEY RESULTS

Among 1,610 student (49.3 % response rate) and 739 resident (43.1 %) respondents, industry-sponsored gifts were common, rising from 33.0 % (first-year students) to 56.8 % (fourth-year students) and 54 % (residents) (p?<?0.001). These gifts included meals outside the hospital (reported by 5 % first-year students, 13.4 % fourth-year students, 27.5 % residents (p?<?0.001)) and free drug samples (reported by 7.4 % first-year students, 14.1 % fourth-year students, 14.3 % residents (p?<?0.001)). The perception that industry interactions lead to bias was prevalent, but the belief that physicians receive valuable education through these interactions increased (64.1 % to 67.5 % to 79.8 %, p?<?0.001). Students in schools receiving more NIH funding reported industry gifts less often (OR?=?0.51, 95 % CI: 0.38–0.68, p?<?0.001), but the strength of institutional conflict of interest policies was not associated with this variable.

CONCLUSIONS

Despite recent policy changes, a substantial number of trainees continue to receive gifts from pharmaceutical representatives. We found no relation between these outcomes and a school’s policies concerning interactions with industry.