Patient–doctor interaction in rehabilitation: The relationship between perceived interaction quality and long-term treatment results

Objectives

A body of evidence suggests that good interaction is crucial for high-quality medical practice and has a considerable impact on treatment outcomes. Less is known about the role and significance of doctor–patient interaction in rehabilitation. The study aim was to capture perceived quality of doctor–patient interaction in rehabilitation by a rating instrument (P.A.INT-Questionnaire. P.A.INT is the abbreviation for Patient–Arzt-Interaktion (German)) and to examine the relationship between perceived quality of interaction and long-term treatment outcomes.

Methods

Referring to the approach of Bensing [Bensing JM. Doctor patient communication and the quality of care. Utrecht: NIVEL; 1990] we defined “quality of interaction” in terms of three dimensions: (1) affective behaviour, i.e. empathy, positive regard and coherence [Rogers CR. Die nicht direktive Beratung München: Kindler Studienausgabe [Counselling and psychotherapy, 1942]. Boston; 1972]; (2) instrumental behaviour: providing and collecting information, structuring and reinforcement; (3) participation and involvement of patients. Two parallel versions of the questionnaire were developed for patients and physicians. Seven rehabilitation clinics in north western Germany participated in the multi-centre study. Sixty-one doctors and their four hundred and seventy patients evaluated both their shared dialogues upon admission, discharge and ward round. Furthermore, patients rated their health status on admission (t0), discharge (t1) and six months after discharge (t2) with the IRES-3 (Indicators of Rehabilitation Status Questionnaire, Version 3).

Results

(1) Comparisons of patient and physician evaluations on admission revealed the following: affective quality of contact (empathy and coherence) was rated positively and without discrepancies by both patients and physicians. On the other hand, instrumental behaviour (information and structuring) was rated less positively by patients than by physicians. (2) Patients who rated the dialogue on admission more positively showed stronger treatment effects with respect to pain as well as to anxiety at discharge and six months after discharge. Analysis for single scales of the P.A.INT-Questionnaire revealed that this is due to affective and instrumental quality of the dialogues.

Conclusion

Our results suggest a correlation between perceived interaction quality, as defined by our questionnaire and treatment effects six months after discharge. Comparisons of patient and physician evaluations showed that physicians seem to be successful in building relationships on the affective level, but less successful on the instrumental level (i.e. information, structuring and reinforcement). They also perceive disturbances on the relational and organisational level more strongly than patients.

Practice implications

Our data underline the importance of interaction quality for the success of rehabilitation and thus the importance of specific skills such as providing and collecting information, recognizing patients’ concerns and goals as well as reinforcement of health related action. Regular training and supervision should be provided to support physicians and to enhance their competence in dealing with patients concerns.     

Initiation and Discontinuation of Hormone Therapy for Menopausal Symptoms: Results From a Community Sample

Factors related to initiation and discontinuation of hormonal therapy (HT) for treatment of menopausal symptoms were examined in a community sample of 533 peri/postmenopausal women aged 45–54 by telephone three times. Over 40 variables including: sociodemographic characteristics, clinical reasons to start HT use, HT contraindications, HT attitudes/knowledge, and health behaviors were examined in logistic regression models comparing women who discontinued HT to women who continued using HT over 9 months (discontinuers) and women who initiated HT versus women who never used HT over 9 months (initiators). Increased understanding of HT, confidence, mental health symptoms, perception that menopause is natural, and having gynecological surgery were related to decreased likelihood of HT discontinuation. Increased understanding about risks of HT, vasomotor symptoms, mood symptoms, and having gynecological surgery were related to increased likelihood of HT Initiation. These findings highlight the importance of physicians discussing HT with their patients, particularly because of recent clinical trial developments.     

Family attitudes in youth as a possible precursor of cancer among physicians: A search for explanatory mechanisms

A measure of youthful family attitudes, the Closeness to Parents Scale, has continued to be predictive of cancer among physicians in a prospective study of medical students. Nonetheless, questions have remained concerning the meaning and reliability of this measure and whether its predictive value is diminishing over time. Perhaps more important, it is necessary to ascertain whether the relationship is the result of some methodological artifact or whether it is mediated by an association with known risk factors, such as smoking, drinking, and radiation exposure. Each of these issues was examined in turn, using a variety of statistical techniques to refine the scale and to equate cancer and control groups with respect to risk factors as well as possible artifacts. In a group of 913 men, it was found that the scale is primarily a function of good father-son relationships and that its association with later cancer persists even after the influence of possible mediating and artifactual variables is statistically controlled. Several possible explanations for these findings are discussed.This work was supported by National Cancer Institute Grant 1 R18 CA24416-02, National Institute on Aging Grant 1 RO1 GM25822-01, and The Johns Hopkins University.     

Use of and reactions to a tailored CD-ROM designed to enhance oncologist–patient communication: The SCOPE trial intervention

Objective

Assess use of and reactions to an interactive, tailored CD-ROM to enhance oncologist–patient communication.

Methods

Participating oncologists (n = 48) agreed to have patient interactions audio recorded, be randomly assigned to receive/not receive a CD-ROM, have CD-ROM usage monitored (intervention group) and complete a follow-up survey.

Results

Twenty-one of 24 in the intervention group reported using the CD-ROM. Median usage minutes were 63.8. At follow-up, oncologists rated the CD-ROM from 1 (“none” or “not at all helpful”) to 5 (“a great deal” or “very helpful”). Mean responses were: 3.1 and 3.0 for 2 items assessing perceived impact on communications, 3.8–4.0 for 6 items assessing perceived helpfulness, 3.0 and 3.10 for 2 items assessing impact on affecting oncologists’ communication with patients and assistance with challenging conversations, respectively, and 3.6 for whether using the CD-ROM was worth their time. Self-report of how much oncologists had used the covered skills before and after intervention showed a perceived increase (2.8 before and 3.2 after).

Conclusions

Findings suggest the tailored interactive CD-ROM has promise for use and acceptance among oncologists.

Practice implications

If ultimately found effective in changing oncologist's communication with patients, the CD-ROM's widespread dissemination should be explored.     

Extravascular fibrinogen in the white matter of Alzheimer’s disease and normal aged brains: implications for fibrinogen as a biomarker for Alzheimer’s disease

The blood–brain barrier (BBB) regulates cerebrovascular permeability and leakage of blood‐derived fibrinogen. Dysfunction of the BBB has been associated with cerebral arteriolosclerosis small vessel disease (SVD) and white matter lesions (WML). Furthermore, BBB dysfunction is associated with the pathogenesis of Alzheimer’s disease (AD) with the presence of CSF plasma proteins suggested to be a potential biomarker of AD. We aimed to determine if extravascular fibrinogen in the white matter was associated with the development of AD hallmark pathologies, i.e., hyperphosphorylated tau (HPτ) and amyloid‐β (Aβ), as well as SVD, cerebral amyloid angiopathy (CAA) and measures of white matter damage. Using human post‐mortem brains, parietal tissue from 20 AD and 22 non‐demented controls was quantitatively assessed for HPτ, Aβ, white matter damage severity, axonal density, demyelination and the burden of extravascular fibrinogen in both WML and normal appearing white matter (NAWM). SVD severity was determined by calculating sclerotic indices. WML‐ and NAWM fibrinogen burden was not significantly different between AD and controls nor was it associated with the burden of HPτ or Aβ pathology, or any measures of white matter damage. Increasing severity of SVD was associated with and a predictor of both higher WML‐ and NAWM fibrinogen burden (all P < 0.05) in controls only. In cases with minimal SVD NAWM fibrinogen burden was significantly higher in the AD cases (P < 0.05). BBB dysfunction was present in both non‐demented and AD brains and was not associated with the burden of AD‐associated cortical pathologies. BBB dysfunction was strongly associated with SVD but only in the non‐demented controls. In cases with minimal SVD, BBB dysfunction was significantly worse in AD cases possibly indicating the influence of CAA. In conclusion, extravascular fibrinogen is not associated with AD hallmark pathologies but indicates SVD, suggesting that the presence of fibrinogen in the CSF is not a surrogate marker for AD pathology.     

Hypermobile Ehlers–Danlos syndrome: A review and a critical appraisal of published genetic research to date

The Ehlers–Danlos syndromes (EDS) are a collection of rare hereditary connective tissue disorders with heterogeneous phenotypes, usually diagnosed following clinical examination and confirmatory genetic testing. Diagnosis of the commonest subtype, hypermobile Ehlers–Danlos Syndrome (hEDS), relies solely on a clinical diagnosis since its molecular aetiology remains unknown. We performed an up-to-date literature search and selected 11 out of 304 publications according to a set of established criteria. Studies reporting variants affecting collagen proteins were found to be hindered by cohort misclassification and subsequent lack of reproducibility of these genetic findings. The role of the described variants affecting Tenascin-X and LZTS1 is yet to be demonstrated in the majority of hEDS cases, while the functional implication of associated signaling pathways and genes requires further elucidation. The available literature on the genetics of hEDS is scant, dispersed and conflicting due to out-dated nosology terminology. Recent literature has suggested the role of several promising candidate mechanisms which may be linked to the underlying molecular aetiology. Knowledge of the molecular genetic basis of hEDS is expected to increase in the near future through the mainstream use of high-throughput sequencing combined with the updated classification of EDS, and the upcoming Hypermobile Ehlers–Danlos Genetic Evaluation (HEDGE) study.     

Prevalence of shift work disorder among hospital personnel: A cross‐sectional study using objective working hour data

The prevalence of shift work disorder (SWD) has been studied using self‐reported data and the International Classification of Sleep Disorders, Second Edition (ICSD‐2) criteria. We examined the prevalence in relation to ICSD‐2 and ICSD‐3 criteria, work schedules and the number of non‐day shifts (work outside 06:00–18:00 hours) using objective working‐hours data. Secondly, we explored a minimum cut‐off for the occurrence of SWD symptoms. Hospital shift workers without (n = 1,813) and with night shifts (n = 2,917) and permanent night workers (n = 84) answered a survey (response rate 69%) on SWD and fatigue on days off. The prevalence of SWD was calculated for groups with ≥1, ≥3, ≥5 and ≥7 monthly non‐day shifts utilizing the working hours registry. ICSD‐3‐based SWD prevalence was 2.5%–3.7% (shift workers without nights), 2.6%–9.5% (shift workers with nights) and 6.0% (permanent night workers), depending on the cut‐off of non‐day shifts (≥7–1/month, respectively). The ICSD‐2‐based prevalence was higher: 7.1%–9.2%, 5.6%–33.5% and 16.7%, respectively. The prevalence was significantly higher among shift workers with than those without nights (p‐values <.001) when using the cut‐offs of ≥1–3 non‐day shifts. Shift workers with nights who had ≥3 days with ICSD‐3‐based SWD symptoms/month more commonly had fatigue on days off (49.3%) than those below the cut‐off (35.8%, p < .05). The ICSD‐3 criteria provided lower estimates for SWD prevalence than ISCD‐2 criteria, similarly to exclusion of employees with the fewest non‐day shifts. The results suggest that a plausible cut‐off for days with ICSD‐3‐based SWD symptoms is ≥3/month, resulting in 3%–6% prevalence of SWD.     

Significant Factors in The Development of Elective Mutism: A Single Case Study of a 5 Year‐Old Girl

A constellation of processes found to be characteristic in the aetiology of elective mutism is explored through clinical material from the psychotherapy of a 5 year‐old girl. The major factors significant in this process are excessive ties to the mother that hinder the child's social–emotional development; difficulties in discharging aggression in a situation when it is not possible to feel separate from mother; primitive ways of dealing with aggressive feelings based on phantasy and omnipotence; and – in my own experience – the symbolic equation of anus and mouth, at the developmental phase of mastery of both speech and sphincter control, as a cause of withholding words.     

Epidemiological and genetic analysis of a sustained community-wide outbreak of hepatitis A in the Republic of Korea, 2008: A hospital-based case–control study

BackgroundThe epidemiological shift of hepatitis A has contributed to a sustained community-wide outbreak in Korea during 2008.ObjectivesTo assess the risk factors associated with hepatitis A virus (HAV) propagation, and to analyze the circulating genotype in the sustained community-wide outbreak.Study designThe hospital-based case–control study was conducted in an 850-bed university hospital in Seoul from April to August, 2008. For molecular analysis of HAV isolates, a 488-bp gene fragment of the VP1 region was amplified and sequenced.ResultsIn the multivariated logistic regression model, the risk factors of HAV infection adjusted by age were contacts with hepatitis A case (OR 3.98, 95% CI: 1.36–11.66), residence with child aged ≤5 years (OR 3.43, 95% CI: 1.32–8.87), consuming uncooked lettuce (OR 3.98, 95% CI: 1.83–8.68) or carrot (OR 2.38, 95% CI: 2.38–5.09), drinking tap water (OR 3.68, 95% CI: 1.62–8.37) or portable spring water (OR 2.71, 95% CI: 1.11–6.62) supplied by water purifiers, and eating out (OR 3.87, 95% CI: 1.53–9.78). All isolates analyzed belonged to genotype IIIA. There were 42 nucleotide differences in the sequenced VP1 region among the isolates. Amino acid sequences were identical with each other.ConclusionsOur study suggests that sporadically contaminated food- or water-borne sources as well as person-to-person transmission might lead a sustained community-wide HAV outbreak and pre-existing dominant genotype IA might be replaced with genotype IIIA as a major epidemic strain in Korea. Our findings urge the health authority to make public guidelines for HAV vaccination and outbreak control.     

Dual colour fluorescence in situ hybridization to paraffin-embedded samples to deduce the presence of the der(X)t(X;18)(p11.2;q11.2) and involvement of either the SSX1 or SSX2 gene: a diagnostic and prognostic aid for synovial sarcoma

Identification of the t(X;18)(p11.2;q11.2) and the fusion gene products, SYT–SSX1 and SYT–SSX2, associated with a high proportion of synovial sarcomas, has been shown to be a useful diagnostic aid. This study demonstrates the application of dual colour fluorescence in situ hybridization to paraffin-embedded samples to deduce the presence of the derivative X chromosome and also the position of the breakpoint on chromosome X at either the SSX1 or the SSX2 gene. This used region specific markers from chromosomes X and 18 and an optimized protocol involving microwave exposure. Novel and rapid scoring criteria were validated which circumvented potential problems of nuclear truncation and defining cell boundaries. This involved blind analysis of two negative sarcoma samples and three synovial sarcomas in which corresponding frozen material had been previously shown to have the translocation involving different SSX genes. Six new cases diagnosed as synovial sarcoma were also analysed; two monophasic and two biphasic case were deduced to have a breakpoint in the SSX1 gene, one monophasic case an SSX2 breakpoint, and one case did not show rearrangement of the region. The ability to analyse formalin-fixed, paraffin-embedded samples in this way has practical implications for aiding the diagnosis of difficult cases, recently ascribed prognostic relevance, and allows further retrospective studies to be carried out. The methodology is also applicable to the identification of other tumour specific translocations in paraffin-embedded material. Copyright © 1999 John Wiley & Sons, Ltd.     

The role of feared possible selves in obsessive–compulsive and related disorders: A comparative analysis of a core cognitive self‐construct in clinical samples

Increasingly, cognitive‐behavioural models have been considering the role of beliefs about the self in the development and maintenance of obsessive–compulsive disorder (OCD), including sensitive domains of self‐concept and feared self‐perceptions. This has led to the development of the Fear of Self Questionnaire (FSQ; Aardema et al., 2013 ), which has shown strong internal consistency, divergent and convergent validity, and found to be a major predictor of unwanted thoughts and impulses (i.e., repugnant obsessions). The current study aimed to investigate fear of self‐perceptions using the FSQ in an OCD sample (n = 144) and related psychological disorders (eating disorders, n = 57; body dysmorphic disorder, n = 33) in comparison to a non‐clinical (n = 141) and clinical comparison group (anxiety/depressive disorders, n = 27). Following an exploratory factor analysis of the scale in the OCD sample, the results showed that participants with OCD in general did not score significantly higher on fear of self‐perceptions than did the clinical comparison participants. However, consistent with previous findings, fear of self was highly characteristic among OCD patients with unwanted repugnant thoughts and impulses. In addition, fear of self‐perceptions were significantly more elevated in those with eating or body dysmorphic disorders relative to the other non‐clinical and clinical groups. The construct of a “feared possible self” may be particularly relevant in disorders where negative self‐perception is a dominant theme, either involving concerns about one's inner self or concerns related to perceived bodily faults.