The impact of the hospital work environment on social support from physicians in breast cancer care

Objective

Research on determinants of a good patient–physician interaction mainly disregards systemic factors, such as the work environment in healthcare. This study aims to identify stressors and resources within the work environment of hospital physicians that enable or hinder the physicians’ provision of social support to patients.

Methods

Four data sources on 35 German breast cancer center hospitals were matched: structured hospital quality reports and surveys of 348 physicians, 108 persons in hospital leadership, and 1844 patients. Associations between hospital structures, physicians’ social resources as well as job demands and control and patients’ perceived support from physicians have been studied in multilevel models.

Results

Patients feel better supported by their physicians in hospitals with high social capital, a high percentage of permanently employed physicians, and less physically strained physicians.

Conclusion

The results highlight the importance of the work environment for a good patient–physician interaction. They can be used to develop interventions for redesigning the hospital work environment, which in turn may improve physician satisfaction, well-being, and performance and consequently the quality of care.

Practice implications

Health policy and hospital management could create conditions conducive to better patient–physician interaction by strengthening the social capital and by increasing job security for physicians.     

Does routine psychosocial screening improve referral to psychosocial care providers and patient–radiotherapist communication? A cluster randomized controlled trial

Objective

This study tests whether using a screening instrument improves referral to psychosocial care providers (e.g. psychologist) and facilitates patient–radiotherapist communication.

Methods

A cluster randomized controlled trial was used. Fourteen radiotherapists were randomly allocated to the experimental or control group and 568 of their patients received care in accordance with the group to which their radiotherapist was allocated. Patients in the experimental group were asked to complete a screening instrument before and at the end of the radiation treatment period. All patients were requested to complete questionnaires concerning patient–physician communication after the first consultation and concerning psychosocial care 3 and 12 months post-intervention.

Results

Patients who completed the screening instrument were referred to social workers at an earlier stage than patients who did not (P < 0.01). No effects were observed for numbers of referred patients, or for improved patient–radiotherapist communication.

Conclusions

Our results suggest that a simple screening procedure can be valuable for the timely treatment of psychosocial problems in patients. Future efforts should be directed at appropriate timing of screening and enhancing physicians’ awareness regarding the importance of identifying, discussing and treating psychosocial problems in cancer patients.

Practice implications

Psychosocial screening can be enhanced by effective radiotherapist–patient communication.     

Does improving patient–practitioner communication improve clinical outcomes in patients with cardiovascular diseases? A systematic review of the evidence

Objective

To conduct a systematic literature review appraising the effects of interventions to improve patient–practitioner communication on cardiovascular-related clinical outcomes.

Methods

Databases were searched up to March 27, 2013 to identify eligible studies that included interventions to improve patient and/or practitioner communication skills and assessment of a cardiovascular-related clinical outcome in adults ≥18 years of age.

Results

Fifteen papers were reviewed: the primary focus in seven studies was the patient; seven included a practitioner-focused intervention and one targeted both. Two patient-focused and two practitioner-focused studies demonstrated a beneficial effect of the intervention compared to a control group. Patient-focused studies were designed to improve patients’ information-seeking and question-asking skills with their practitioner. Practitioner-focused studies were designed to either improve practitioner's general patient-centered communication or risk communication skills.

Conclusion

Few interventions targeting patient–practitioner communication have assessed the impact on cardiovascular-related clinical outcomes, limiting the ability to determine effectiveness. Additional rigorous research supported by theoretical frameworks and validated measurement is needed to understand the potential of patient–practitioner communication to improve cardiovascular-related clinical outcomes.

Practice implications

Investments in communication skills trainings in medical education and practice are needed in order to attain the full potential of patient-centered care on cardiovascular-related clinical outcomes.     

A novel analytical strategy for patient–physician communication research: The one-with-many design

Objective

We aimed to demonstrate how a novel analytic strategy – the one-with-many (OWM) design – can provide unique information about patient–physician communication that cannot be obtained using traditional analytic strategies.

Methods

Using an OWM design we conducted a secondary analysis of behavioral (talk time) and self-reported (perceived teamness) data from a study of patient–physician communication, and examined variance decompositions of these variables.

Results

Talk time was largely relational, suggesting that there is no behavioral consistency on the part of physicians across patients or behavioral similarity among patients who see the same physician. In contrast, there was significant actor variance in perceived teamness, suggesting that some physicians consistently reported higher teamness with their patients than others. However, those physicians’ positive perceptions of the communication are not necessarily reciprocated by their patients.

Conclusions

OWM design provides researchers with the opportunity to take full advantage of rich non-independent data and explore interesting communication patterns (e.g., behavioral continuity, similarity, reciprocity unique to specific dyads) that have been omitted in prior literature.

Practical implications

OWM can be used to determine the relative differences in how patients and physicians influence communication patterns and identify which aspects of physician–patient communication are relational and which are not.     

Do breast cancer patients receive less support from physicians in German hospitals with high physician workload? A multilevel analysis

Objective

Little is known about how organizational factors influence the patient–physician interaction. This study investigates the relationship between physician workload in hospitals and breast cancer patients’ perceptions of the support provided by physicians.

Methods

Data from 1844 newly diagnosed breast cancer patients treated in 35 breast cancer center hospitals in the German state of North Rhine-Westphalia in 2010 were combined with data from 348 physicians from the same hospitals. Multilevel logistic regression models were calculated using 31 hospitals with complete patient and physician data. Patients’ perceptions of physician support were studied in relation to physician workload in hospitals.

Results

Breast cancer patients perceived themselves as receiving less support from physicians when treated in hospitals where physicians reported working more overtime hours and having less time for patient care.

Conclusion

This study provides preliminary evidence of the association between the hospital work environment and physicians’ ability to support patients. Future studies should investigate the extent to which physicians’ interaction performance can be modified through hospital-level interventions aimed at managing workload.

Practice implications

By approaching the problem of physician staffing in hospitals and investing in the hospitals’ working conditions, health policy and hospital management could create conditions conducive to better patient–physician interaction.     

What do Nepalese medical students and doctors think about patient-centred communication?

Objective

To ascertain the attitudes of Nepalese medical students and doctors regarding aspects of doctor–patient communication.

Method

A cross-sectional survey, using the Patient–Practitioner Orientation Scale (PPOS), was undertaken with students and doctors in a teaching hospital in rural Nepal. Qualitative research was also done, using semi-structured interviews and focus groups, with a sample from the same population. The author's participant observations provided a third data source.

Results

Participants generally expressed ‘patient-centred’ attitudes, particularly in the following areas: power-sharing; the importance of social context; friendliness; providing adequate time and explanations. They thought that the hierarchical nature of society carried over into medical practice, particularly noting the exalted position of doctors and the importance of social and financial issues in patient outcomes. The participants thought that Nepalese doctors currently practice in a ‘doctor-centred’ manner but thought that this should change.

Conclusion

There was a marked contrast between the attitudes expressed by participants and the way that they see medicine is currently practiced. The results also showed an under-appreciation of Nepalese patients’ universal desire for being given good information.

Practice implications

This study underlines the need for an increased understanding of local preferences regarding medical communication styles. Methods of providing information to patients need to be strengthened in clinical practice.     

Inconsistency of residents’ communication performance in challenging consultations

Objective

Communication performance inconsistency between consultations is usually regarded as a measurement error that jeopardizes the reliability of assessments. However, inconsistency is an important phenomenon, since it indicates that physicians’ communication may be below standard in some consultations.

Methods

Fifty residents performed two challenging consultations. Residents’ communication competency was assessed with the CELI instrument. Residents’ background in communication skills training (CST) was also established. We used multilevel analysis to explore communication performance inconsistency between the two consultations. We also established the relationships between inconsistency and average performance quality, the type of consultation, and CST background.

Results

Inconsistency accounted for 45.5% of variance in residents’ communication performance. Inconsistency was dependent on the type of consultation. The effect of CST background training on performance quality was case specific. Inconsistency and average performance quality were related for those consultation combinations dissimilar in goals, structure, and required skills. CST background had no effect on inconsistency.

Conclusion

Physician communication performance should be of high quality, but also consistent regardless of the type and complexity of the consultation.

Practice implications

In order to improve performance quality and reduce performance inconsistency, communication education should offer ample opportunities to practice a wide variety of challenging consultations.     

Doctor's attire influences perceived empathy in the patient–doctor relationship

Objective

This study investigated whether doctors’ attire influences the perception of empathy in the patient–doctor relationship during a therapeutic encounter.

Methods

A total number of 143 patients were divided into four groups when they were consulting a Traditional Korean Medicine doctor. Depending on the group, the same doctor was wearing four different attires – Casual, Suit, Traditional dress, White coat – when having a clinical consultation with the patients.

Results

The patients preferred white coat and traditional dress more than other attires, giving highest scores to white coat in competency, trustworthiness and preference of attire and to traditional dress in comfortableness and contentment with the consultation. The “Consultation and Relational Empathy (CARE)” score was significantly higher in the “White coat” and “Traditional” groups, compared to the “Casual” and “Suit” groups.

Conclusion

The strong association between the patients’ preference of doctors’ attire and the CARE score indicates that the doctor's attire plays not only an important role for establishing confidence and trustworthiness but also for the perception of empathy in the patient–doctor relationship.

Practice implications

The doctor's attire can function as an effective tool of non-verbal communication in order to signal confidence, trust and empathy and establish a good patient–doctor relationship.     

Determinants of patients’ attitudes toward patient-centered care: A cross-sectional study in Greece

Objective

The aim of this study was to investigate – for the first time in Greece – patients’ attitudes toward patient-centered care, by identifying the impact of socio-demographic factors, health condition, social support and religious beliefs.

Methods

454 Hospitalized patients were interviewed on the first day of their scheduled admission, answering demographic questions and the following questionnaires: Patient–Practitioner Orientation Scale (PPOS), Autonomy Preference Index (API), Short Form SF-12v2 Health Survey, God Locus of Health Control (GLHC) and Perceived Available Support (PAS).

Results

Mean PPOS and API scores were: PPOS Sharing 3.4 (sd = 0.69), Caring 3.99 (sd = 0.76), API Information-Seeking 88.32 (sd = 9.35) and Decision-Making 51.19 (sd = 9.27). Higher desire for information was associated with younger age, more years of education, weaker spiritual faith in healing and worse subjective health status. Higher expectations for caring physicians were correlated with older age, more years of education, higher perceived social support and weaker spiritual faith in healing.

Conclusion

Age, years of education, health status, social support and religious beliefs are determinants of patient-centered attitudes.

Practice implications

Patients expect to be informed, although they do not equally want to be involved in decision-making. Religious faith and perceived social support should be taken into consideration to further understand patients’ needs.     

Long-term effect of communication training on the relationship between physicians’ self-efficacy and performance

Objective

To examine the long term impact of a communication skills intervention on physicians’ communication self-efficacy and the relationship between reported self-efficacy and actual performance.

Methods

62 hospital physicians were exposed to a 20-h communication skills course according to the Four Habits patient-centered approach in a crossover randomized trial. Encounters with real patients before and after the intervention (mean 154 days) were videotaped, for evaluation of performance using the Four Habits Coding Scheme. Participants completed a questionnaire about communication skills self-efficacy before the course, immediately after the course, and at 3 years follow-up. Change in self-efficacy and the correlations between performance and self-efficacy at baseline and follow-up were assessed.

Results

Communication skills self-efficacy was not correlated to performance at baseline (r = −0.16; p = 0.22). The association changed significantly (p = 0.01) and was positive at follow-up (r = 0.336, p = 0.042). The self-efficacy increased significantly (effect size d = 0.27). High performance after the course and low self-efficacy before the course were associated with larger increase in communication skills self-efficacy.

Conclusion

A communication skills course led to improved communication skills self-efficacy more than 3 years later, and introduced a positive association between communication skills self-efficacy and performance not present at baseline.

Practice implications

Communication skills training enhances physicians’ insight in own performance.     

Existing instruments for assessing physician communication skills: Are they valid in a computerized setting?

Objectives

This study aims to highlight the differences in physicians’ scores on two communication assessment tools: the SEGUE and an EMR-specific communication skills checklist. The first tool ignores the presence of the EMR in the exam room and the second, though not formally validated, rather focuses on it.

Methods

We use the Wilcoxon Signed Ranks Test to compare physicians’ scores on each of the tools during 16 simulated medical encounters that were rated by two different raters.

Results

Results show a significant difference between physicians’ scores on each tool (z = −3.519, p < 0.05 for the first rater, and z = −3.521, p < 0.05 for the second rater), while scores on the EMR-specific communication skills checklist were significantly and consistently lower.

Conclusion

These results imply that current communication assessment tools that do not incorporate items that are relevant for communication tasks during EMR use may produce inaccurate results.

Practice implications

We therefore suggest that a new instrument, possibly an extension of existing ones, should be developed and empirically validated.     

Discrepancy between patients’ use of and health providers’ familiarity with CAM

Objective

To compare patients’ complementary and alternative medicine (CAM) use and physicians’ familiarity with certain CAM modalities in the same setting and to assess patient–provider dialogue about patients’ CAM use.

Methods

An observational survey study with convenience sampling at ambulatory family medicine clinics in two Texas cities. A total of 69 healthcare providers and 468 patients completed the surveys. Patients’ surveys assessed use of 27 CAM therapies, perception of CAM use and interaction with providers. Providers’ survey assessed perception and attitude toward CAM use.

Results

CAM modalities most used by the patients are not those modalities that providers best understood. Of the 330 patients (70%) who responded to the relevant questions about discussing CAM, 44.5% reported never having discussed CAM use with their providers. Binomial logistic regression revealed no link between age, gender or ethnicity for discussing CAM with providers. College-educated patients (adjust OR = 2.8, 95%CI = 1.3–6.0) and US citizens were both about three times more likely to discuss CAM than their counterparts.

Conclusion

Lack of knowledge and unfamiliarity with CAM modalities might prevent important patient–provider discussions.

Practice implications

Providers should use existing resources and encourage a bilateral dialogue that involves transferring of information and assisting patients in decisions making about CAM use and health care.     

The Group Objective Structured Clinical Experience: Building communication skills in the clinical reasoning context

Objective

Students are rarely taught communication skills in the context of clinical reasoning training. The purpose of this project was to combine the teaching of communication skills using SPs with clinical reasoning exercises in a Group Objective Structured Clinical Experience (GOSCE) to study feasibility of the approach, the effect on learners’ self-efficacy and attitude toward learning communication skills, and the effect of providing multiple sources of immediate, collaborative feedback.

Methods

GOSCE sessions were piloted in Pediatrics and Medicine clerkships with students assessing their own performance and receiving formative feedback on communication skills from peers, standardized patients (SPs), and faculty. The sessions were evaluated using a retrospective pre/post-training questionnaire rating changes in self-efficacy and attitudes, and the value of the feedback.

Results

Results indicate a positive impact on attitudes toward learning communication skills and self-efficacy regarding communication in the clinical setting. Also, learners considered feedback by peers, SPs, and faculty valuable in each GOSCE.

Conclusion

The GOSCE is an efficient and learner-centered method to attend to multiple goals of teaching communication skills, clinical reasoning, self-assessment, and giving feedback in a formative setting.

Practice implications

The GOSCE is a low-resource, feasible strategy for experiential learning in communication skills and clinical reasoning.     

The impact of residents’ training in Electronic Medical Record (EMR) use on their competence: Report of a pragmatic trial

Objectives

Even though Electronic Medical Records (EMRs) are increasingly used in healthcare organizations there is surprisingly little theoretical work or educational programs in this field. This study is aimed at comparing two training programs for doctor–patient–computer communication (DPCC).

Methods

36 Family Medicine Residents (FMRs) participated in this study. All FMRs went through twelve identical simulated encounters, six pre and six post training. The experiment group received simulation based training (SBT) while the control group received traditional lecture based training.

Results

Performance, attitude and sense of competence of all FMRs improved, but no difference was found between the experiment and control groups. FMRs from the experiment group evaluated the contribution of the training phase higher than control group, and showed higher satisfaction.

Conclusion

We assume that the mere exposure to simulation served as a learning experience and enabled deliberate practice that was more powerful than training. Because DPCC is a new field, all participants in such studies, including instructors and raters, should receive basic training of DPCC skills.

Practice implication

Simulation enhances DPCC skills. Future studies of this kind should control the exposure to simulation prior to the training phase. Training and assessment of clinical communication should include EMR related skills.     

Teaching patients how to talk with biomedical providers about their complementary and alternative medicine use

Objective

The goal was to examine the feasibility and impact of a face-to-face communication skills training intervention based on a current public health campaign to encourage patients to talk about complementary and alternative medicine (CAM) with their biomedical health providers.

Methods

Current CAM users were invited to complete a survey about current/past CAM use and communication with biomedical providers before beginning a communication skills training workshop. In the 6-month period following the training, participants were asked to record information on any CAM conversations with those providers.

Results

Of the 38 participants who received training, 32 finished the entire study. Over half of those participants reported discussing CAM in post-training visits with biomedical providers. Participants initiated the conversation in most cases, and were more likely to disclose CAM use than they were to ask questions about CAM. Participants who talked about CAM were significantly more likely to perceive CAM as relevant to their visit, compared with individuals who did not talk about CAM.

Conclusions

Participants positively evaluated this patient communication workshop. Consistent with previous research, most CAM conversations were patient-initiated.

Practice implications

These findings reinforce the importance of patient education interventions for improving patient–provider communication in general, and CAM communication specifically.     

Improving physician–patient communication about cancer pain with a tailored education-coaching intervention

Objective

This study examined the effect of a theoretically grounded, tailored education-coaching intervention to help patients more effectively discuss their pain-related questions, concerns, and preferences with physicians.

Methods

Grounded in social-cognitive and communication theory, a tailored education-coaching (TEC) intervention was developed to help patients learn pain management and communication skills. In a RCT, 148 cancer patients agreed to have their consultations audio-recorded and were assigned to the intervention or a control group. The recordings were used to code for patients’ questions, acts of assertiveness, and expressed concerns and to rate the quality of physicians’ communication.

Results

Patients in the TEC group discussed their pain concerns more than did patients in the control group. More active patients also had more baseline pain and interacted with physicians using participatory decision-making. Ratings of physicians’ information about pain were higher when patients talked more about their pain concerns.

Conclusions

The study demonstrates the efficacy of a theoretically grounded, coaching intervention to help cancer patients talk about pain control.

Practice implications

Coaching interventions can be effective resources for helping cancer patients communicate about their pain concerns if they are theoretically grounded, can be integrated within clinical routines, and lead to improve health outcomes.     

Communication skills in context: Trends and perspectives

Objective

Doctor–patient communication has been well researched. Less is known about the educational background of communication skills training. Do we aim for optimal performance of skills, or rather attempt to help students become skilled communicators?

Methods

An overview is given of the current view on optimal doctor–patient communication. Next we focus on recent literature on how people acquire skills. These two topics are integrated in the next chapter, in which we discuss the optimal training conditions.

Results

A longitudinal training design has more lasting results than incidental training. Assessment must be in line with the intended learning outcomes. For transfer, doctor–patient communication must be addressed in all stages of health professions training.

Conclusion

Elementary insights from medical education are far from realised in many medical schools. Doctor–patient communication would benefit strongly from more continuity in training and imbedding in the daily working contexts of doctors.

Practice implications

When an educational continuum is realised and attention for doctor–patient communication is embedded in the working context of doctors in training the benefits will be strong. Training is only a part of the solution. In view of the current dissatisfaction with doctor–patient communication a change in attitude of course directors is strongly called for.     

Discrepancies between adolescents’ attributed relevance and experiences regarding communication are associated with poorer client participation and learning processes in psychosocial care

Objective

To examine adolescents’ attributed relevance and experiences regarding communication, and whether discrepancies in these are associated with clients’ participation and learning processes in psychosocial care.

Methods

Adolescents receiving psychosocial care (n = 211) completed measures of communication in three domains: affective communication, information provision, and shared decision-making. Participation involved clients’ attendance and adherence (professional-reported). Learning processes involved clients’ improved understanding and improved confidence (client and professional-reported).

Results

Important but less often experienced affective communication was associated with low adherence (odds ratio, 95% confidence interval: 2.8, 1.1–6.8), less improvement in understanding (3.7, 1.5–9.0), and less improvement in confidence (4.5, 1.8–11.6). If information provision or shared decision-making was important but less often experienced, adolescents were more likely to demonstrate less improvement in understanding (3.1, 1.1–8.5; 4.2, 1.7–10.8). The combination “less important but experienced” only had an effect regarding affective communication; these adolescents were more likely to demonstrate less improvement in confidence (6.0, 2.3–15.4).

Conclusion

Discrepancies between attributed relevance and experiences frequently occur. These discrepancies negatively affect adolescents’ participation and their learning processes, although the pattern differs across communication domains.

Practice implications

Care professionals should pay considerable attention to their clients’ communication preferences and adapt their communication style when necessary.