Expert consensus on gender criteria for assessment in medical communication education

Objective

The aim of this study is to develop gender criteria that can be included in communication skills assessment in medical education.

Methods

A three-round Delphi study was conducted. The invited 59 participants were experts in the field of gender medicine education (n = 28) and doctor–patient communication (n = 31). Each Delphi round comprised a questionnaire, an analysis, and a feedback report. In the first round, gender experts explored gender themes in doctor–patient communication from which initial gender criteria were defined. The second and third rounds were used to validate the importance and feasibility of gender criteria. Consensus was defined as a 75% panel agreement and a mean of 4 or higher on a 5-point Likert scale.

Results

Four gender criteria achieved consensus after the third round. The importance of including the gender criteria in communication skills assessment was rated consistently higher than its feasibility. Gender criteria relating to the patients’ perspective, to gathering information and to gender and power were considered the most important.

Conclusion

Using a Delphi study, we have developed gender criteria for inclusion in communication skills assessment to promote good communication between doctors and patients.

Practice implications

Gender influences medical communication. Incorporating gender in communication skills assessment may be useful to improve the teaching and learning of communication skills.     

Peer-assessment of medical communication skills: The impact of students’ personality,academic and social reputation on behavioural assessment

Objective

Peer-assessment of communication skills may contribute to mastery of assessment criteria. When students develop the capacity to judge their peers’ performance, they might improve their capacity to examine their own clinical performance. In this study peer-assessment ratings are compared to teacher-assessment ratings. The aim of this paper is to explore the impact of personality and social reputation as source of bias in assessment of communication skills.

Methods

Second year students were trained and assessed history taking communication skills. Peers rated the students’ personality and academic and social reputation.

Results

Peer-assessment ratings were significantly correlated with teacher-ratings in a summative assessment of medical communication. Peers did not provide negative ratings on final scales but did provide negative ratings on subcategories. Peer- and teacher-assessments were both related to the students’ personality and academic reputation.

Conclusion

Peer-assessment cannot replace teacher-assessment if the assessment should result in high-stake decisions about students. Our data do not confirm the hypothesis that peers are overly biased by personality and reputation characteristics in peer-assessment of performance.

Practice implications

Early introduction of peer-assessment in medical education would facilitate early acceptance of this mode of evaluation and would promote early on the habit of critical evaluation of professional clinical performance and acceptance of being evaluated critically by peers.     

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.     

How doctors move from generic goals to specific communicative behavior in real practice consultations

Objective

To understand how recommendations for communication can be brought into alignment with clinical communication routines, we explored how doctors select communicative actions during consultations.

Methods

We conducted stimulated recall interviews with 15 GPs (general practitioners), asking them to comment on recordings of two consultations. The data analysis was based on the principles of grounded theory.

Results

A model describing how doctors select communicative actions during consultations was developed. This model illustrates how GPs constantly adapt their selection of communicative actions to their evaluation of the situation. These evaluations culminate in the selection of situation-specific goals. These multiple and often dynamic goals require constant revision and adaptation of communication strategies, leading to constant readjustments of the selection of communicative actions. When selecting consultation goals GPs weigh patients’ needs and preferences as well as the medical situation and its consequences.

Conclusions

GPs’ selection of communicative actions during consultations is situational and goal driven.

Practice implications

To help doctors develop communicative competence tailored to the specific situation of each consultation, holistic communication training courses, which pay attention to the selection of consultation goals and matching communication strategies besides training specific communication skills, seem preferable to current generic communication skills training.     

The impact of gender dyads on doctor–patient communication: A systematic review

Objective

Systematic review of evidence about the impact of gender dyads on clinician–patient communication.

Methods

Search of Medline, CINAHL and PsychINFO (1960–2007) and the British Library of grey literature, and hand searching of Patient Education and Counselling and Social Science and Medicine (2005–2007), returning 648 articles. Ten studies met all inclusion criteria.

Results

Gender dyads influenced the patient agendas elicited, talk content, communication style, non-verbal communication, the exhibition of power, and consultation length. Consultation length was studied and affected by gender dyads more frequently than any other phenomenon. Distinctive differences between the dyads were identified, largely as expected, but with some surprises. For example, female/female dyads were the most patient-centred, and had longer consultations containing the most talk. However they also contained the most bio-medical talk.

Conclusion

The evidence base is small, and a more rigorous approach to reporting quality indicators is needed. However, observed dyad differences may provide different opportunities for effective communication and clinical outcomes for patients. Further research with a primary focus on gender dyad effects is needed to test this.

Practice implications

Findings have implications for policy, healthcare organisations, and individual doctors alike, raising awareness about workforce issues and communication skills training needs in particular.     

Managing the delivery of bad news: an in-depth analysis of doctors' delivery style

Objective

The purpose of this study was to identify and describe the delivery styles doctors typically use when breaking bad news (BBN).

Methods

Thirty one doctors were recruited to participate in two standardised BBN consultations involving a sudden death. Delivery styles were determined using time to deliver the bad news as a standardised differentiation as well as qualitative analysis of interaction content and language style. Communication performance was also assessed.

Results

Analysis of BBN interactions revealed three typical delivery styles. A blunt style characterised by doctors delivering news within the first 30 s of the interaction; Forecasting, a staged delivery of the news within the first 2 min and a stalling approach, delaying news delivery for more than 2 min. This latter avoidant style relies on the news recipient reaching a conclusion about event outcome without the doctor explicitly conveying the news.

Conclusion

Three typical bad news delivery styles used by doctors when BBN were confirmed both semantically and operationally in the study. The relationship between delivery style and the overall quality of BBN interactions was also investigated.

Practice implications

This research provides a new template for approaching BBN training and provides evidence for a need for greater flexibility when communicating bad news.     

Complex health care decisions with older patients in general practice: Patient-centeredness and prioritization in consultations following a geriatric assessment

Objective

To examine to what extent general practitioners in consultations after a geriatric assessment set shared health priorities with older patients experiencing multimorbidity and to what extent this was facilitated through patient-centered behavior.

Methods

Observation of consultations embedded in a cluster randomized controlled trial,¹ in which 317 patients from 41 general practices received the STEP assessment followed by a care planning consultation with their GPs. GPs in the intervention group used a structured procedure for setting health (care) priorities in contrast to control GPs. A sample of 43 consultations (24 intervention; 19 control) were recorded, transcribed and analyzed with regard to priority setting and patient-centeredness.

Results

Patient-centeredness was only moderately apparent in consultations dealing with complex care plans for older patients with multimorbidity. The shared determination of health priorities seemed unusual for both doctors and patients and was rarely practiced, albeit more frequently in intervention consultations.

Conclusion

Setting health care priorities with patients experiencing multimorbidity is ethically desirable and medically appropriate. Yet a short structured guide for doctors cannot easily achieve this.

Practice implications

More research is needed in regard to handling complex health needs of older patients. It requires a professional approach and training in patient-centered holistic care planning.     

Interrater reliability for the Four Habits Coding Scheme as part of a randomized controlled trial

Objective

To describe the process for developing interrater reliability (IRR) for the Four Habits Coding Scheme (4HCS) for a heterogeneous material as part of a randomized controlled trial.

Methods

Videotapes from 497 hospital encounters involving 71 doctors from most clinical specialties were collected. Four experienced psychology students were trained as raters. We calculated Pearson's r and the intraclass correlation (ICC) on the total score across consecutive samples of twenty videos, and Pearson's r on single videos across items in the initial coding phase.

Results

After 18 h of training and one rating session, the total score Pearson's r and ICC exceeded .70 for all pairs of raters. Across items within single videos, the Pearson's r was never below 0.60 after the first 50 videos. At item and habit level Pearson's r remained unsatisfactory for some rater pairs mostly due to low variance on some items.

Conclusion

Based on the evaluation of the effect of communication skills training via a total score, IRR was satisfactory for the 4HCS as applied to heterogeneous material. However, good reliability at item level was difficult to achieve.

Practice implications

4HCS may be used as an outcome measure for clinical communication skills in randomized controlled trials.     

“They do what they think is the best for me.” Frail elderly patients’ preferences for participation in their care during hospitalization

Objective

To deepen the knowledge of frail elderly patients’ preferences for participation in medical decision making during hospitalization.

Methods

Qualitative study using content analysis of semi-structured interviews.

Results

Patient participation to frail elderly means information, not the wish to take part in decisions about their medical treatments. They view the hospital care system as an institution of power with which they cannot argue. Participation is complicated by barriers such as the numerous persons involved in their care who do not know them and their preferences, differing treatment strategies among doctors, fast patient turnover in hospitals, stressed personnel and linguistic problems due to doctors not always speaking the patient's own language.

Conclusion

The results of the study show that, to frail elderly patients, participation in medical decision making is primarily a question of good communication and information, not participation in decisions about medical treatments.

Practice implications

More time should be given to thorough information and as few people as possible should be involved in the care of frail elderly. Linguistic problems should be identified to make it possible to take the necessary precautions to prevent negative impact on patient participation.     

Revisiting patient communication training: An updated needs assessment and the AGENDA model

Objective

To assess physician needs for patient-centered communication training for medical consultations and to develop an updated patient training curriculum.

Methods

An online needs assessment was distributed through physician email listserves at the University of Florida College of Medicine. Frequency tabulation and content analyses were conducted to assess patient communication themes.

Results

Responses were received from 336 physicians. Physicians reported that patients are reluctant to ask questions when they do not understand information related to their medical condition, treatment plan, or medical advice. Furthermore, physicians reported that a lack of patient negotiation inhibits patient-centered communication and may negatively influence patient adherence and compliance. Based on these results the AGENDA model was created for patient training and consists of (1) agenda setting; (2) goals for health; (3) expressing concerns, questions, and negotiations; (4) navigating health literacy issues; (5) disclosing detailed information; and (6) active types of listening.

Conclusion

This study supports revisiting patient communication training and tailoring future training interventions to specific communities.

Practice implications

The AGENDA model can be used to train patients to enhance patient-centered communication with physicians. Additionally, patient communication training could help to address the barriers to care identified by the physicians in our study.     

Unraveling the relationship between literacy,language proficiency,and patient–physician communication

Objective

To examine whether the effect of health literacy (HL) on patient–physician communication varies with patient–physician language concordance and communication type.

Methods

771 outpatients rated three types of patient–physician communication: receptive communication (physician to patient); proactive communication (patient to physician); and interactive, bidirectional communication. We assessed HL and language categories including: English-speakers, Spanish-speakers with Spanish-speaking physicians (Spanish-concordant), and Spanish-speakers without Spanish-speaking physicians (Spanish-discordant).

Results

Overall, the mean age of participants was 56 years, 58% were women, 53% were English-speakers, 23% Spanish-concordant, 24% Spanish-discordant, and 51% had limited HL. Thirty percent reported poor receptive, 28% poor proactive, and 56% poor interactive communication. In multivariable analyses, limited HL was associated with poor receptive and proactive communication. Spanish-concordance and discordance was associated with poor interactive communication. In stratified analyses, among English-speakers, limited HL was associated with poor receptive and proactive, but not interactive communication. Among Spanish-concordant participants, limited HL was associated with poor proactive and interactive, but not receptive communication. Spanish-discordant participants reported the worst communication for all types, independent of HL.

Conclusion

Limited health literacy impedes patient–physician communication, but its effects vary with language concordance and communication type. For language discordant dyads, language barriers may supersede limited HL in impeding interactive communication.

Practice implications

Patient–physician communication interventions for diverse populations need to consider HL, language concordance, and communication type.     

Monitoring the implementation of Consultation Planning, Recording, and Summarizing in a breast care center

Objective

We implemented and monitored a clinical service, Consultation Planning, Recording and Summarizing (CPRS), in which trained facilitators elicit patient questions for doctors, and then audio-record, and summarize the doctor–patient consultations.

Methods

We trained 8 schedulers to offer CPRS to breast cancer patients making treatment decisions, and trained 14 premedical interns to provide the service. We surveyed a convenience sample of patients regarding their self-efficacy and decisional conflict. We solicited feedback from physicians, schedulers, and CPRS staff on our implementation of CPRS.

Results

278 patients used CPRS over the 22-month study period, an exploitation rate of 32% compared to our capacity. 37 patients responded to surveys, providing pilot data showing improvements in self-efficacy and decisional conflict. Physicians, schedulers, and premedical interns recommended changes in the program's locations; delivery; products; and screening, recruitment and scheduling processes.

Conclusion

Our monitoring of this implementation found elements of success while surfacing recommendations for improvement.

Practice implications

We made changes based on study findings. We moved Consultation Planning to conference rooms or telephone sessions; shortened the documents produced by CPRS staff; diverted slack resources to increase recruitment efforts; and obtained a waiver of consent in order to streamline and improve ongoing evaluation.     

Emotional communication in medical consultations with native and non-native patients applying two different methodological approaches

Objective

To explore the potential agreement between two different methods to investigate emotional communication of native and non-native patients in medical consultations.

Methods

The data consisted of 12 videotaped hospital consultations with six native and six non-native patients. The consultations were coded according to coding rules of the Verona Coding definitions of Emotional Sequences (VR-CoDES) and afterwards analyzed by discourse analysis (DA) by two co-workers who were blind to the results from VR-CoDES.

Results

The agreement between VR-CoDES and DA was high in consultations with many cues and concerns, both with native and non-native patients. In consultations with no (or one cue) according to VR-CoDES criteria the DA still indicated the presence of emotionally salient expressions and themes.

Conclusion

In some consultations cues to underlying emotions are communicated so vaguely or veiled by language barriers that standard VR-CoDES coding may miss subtle cues. Many of these sub-threshold cues could potentially be coded as cues according to VR-CoDES main coding categories, if criteria for coding vague or ambiguous cues had been better specified.

Practice implications

Combining different analytical frameworks on the same dataset provide us new insights on emotional communication.     

Patients’ perspectives on psychiatric consultations in the Gender Identity Clinic: Implications for patient-centered communication

Objective

To explore transsexual patients’ perceptions of communication with psychiatrists in a Gender Identity Clinic and advance understanding of patient centered communication (PCC) in psychiatric, ‘gatekeeping’ settings.

Methods

21 qualitative interviews with a convenience sample of clinic patients. Interviews were coded at a semantic level and subject to an inductive thematic analysis.

Results

Patients’ perceptions clustered into three themes: (1) aspects of communication that patients described liking; (2) aspects of communication that patients described disliking; and (3) aspects of communication that patients deemed challenging but necessary or useful.

Conclusion

Patients described liking or disliking aspects of communication that reflect existing understandings of PCC. However, a striking feature of their accounts was how they were able to rationalize and reflect pragmatically on their negative communication experiences, welcoming doctors’ challenges as an opportunity to consider their life-changing decision to transition from their natal gender.

Practice implications

In certain clinical settings, current operationalizations of PCC may not apply. Patients’ perceptions of communication may be enhanced if an analysis of their experiences formed part of the professional training of doctors, who could be invited to consider the functional specificity of communication across settings and the consequences (both immediate and post hoc) of their communication practices.     

Perceiving integration of a complementary medicine service within a general surgery department through documentation of consultations: A thematic analysis

Objective

This study aims to examine the meaning and practical implications of integration of a complementary medicine-based surgery service in a hospital setting (CISS – Complementary/Integrative Surgery Service) through analysis of consultation reports associated with this service.

Methods

Thematic analysis was used to evaluate CISS consultation reports in a hospital electronic consultant charting system during the first half year of the service's activity.

Results

304 consultation reports were analyzed. Nurses initiated significantly more consultations than physicians (55% vs 7%). Consultation requests were gradually more focused on specific symptoms, possibly manifesting a better understanding of the scope of complementary medicine in the surgery setting. CISS practitioners responded in more biomedical language over time, albeit offering a more holistic perspective regarding patients’ needs as well as clarifications regarding the nature of the treatment they provided.

Conclusions

Diverse communication patterns in consultations evolved over time representing dynamics in multiple levels of integration of the CISS.

Practice implications

Documented communication through consultations can provide a window to the process of integration of complementary medicine-based services in health systems.     

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.     

“I just answer ‘yes’ to everything they say”: Access to health care for deaf people in Worcester,South Africa and the politics of exclusion

Objective

To explore whether there are other factors besides communication difficulties that hamper access to health care services for deaf patients.

Methods

Qualitative methodology using semi-structured interviews with 16 deaf participants from the National Institute for the Deaf in Worcester and 3 Key informants from the Worcester area, South Africa.

Results

Communication difficulties were found to be a prominent barrier in accessing health care services. In addition to this interpersonal factors including lack of independent thought, overprotectedness, non-questioning attitude, and lack of familial communication interact with communication difficulties in a way that further hampers access to health care services.

Conclusion

These interpersonal factors play a unique role in how open and accepting health services feel to deaf patients.

Practice implications

Health care services need to take cognizance of the fact that providing sign language interpreters in the health care setting will not necessarily make access more equitable for deaf patients, as they have additional barriers besides communication to overcome before successfully accessing health care services.     

Consultation support for rural women with breast cancer: Results of a community-based participatory research study

Objective

This study asked: (1) What do rural women with breast cancer need to make the most out of their major medical appointments? and (2) What can the community resource centers do to best support those needs?

Methods

We interviewed 12 doctors, 12 breast cancer survivors and 10 community agency staff, including those who provide services to Latinos and Native Americans. Interviews generated success factors and barriers related to meeting patient information needs. Examples were categorized into themes.

Results

Success factors included making sure patients review high quality educational materials before the visit; and that someone is available to take notes. Doctors felt that a patient list of questions was productive, but some survivors felt doctors did not always respond productively to the list. Respondents did not mention audiorecording unless prompted. Most then endorsed it.

Conclusion

Educational materials, question lists, and note-takers can help rural women with breast cancer and their doctors achieve their goals during treatment discussions. Audiorecording may be an implicit but not explicit need.

Practice implications

Other cancer resource centers and support agencies should consider offering information, question-listing, and note-taking services. They should assess whether audiorecording is an implicit need in their settings.     

Patients’ evaluation of quality of care in general practice: What are the cultural and linguistic barriers?

Objective

Increased migration implies increased contacts for physicians with patients from diverse cultural backgrounds who have different expectations about healthcare. How satisfied are immigrant patients, and how do they perceive the quality of care? This study investigated which patient characteristics (such as cultural views and language proficiency) are related to patients’ satisfaction and perceived quality of care.

Methods

Patients (n = 663) from 38 general practices in Rotterdam (The Netherlands) were interviewed. General satisfaction with the general practitioner (GP) was measured by a report mark. Perceived quality of care was measured using the ‘Quote-mi’ scale (quality of care through the patient's eyes—for migrants), which contains an ethnic-specific subscale and a communication process subscale. Using multilevel regression techniques, the relation between patient characteristics (ethnicity, age, education, Dutch language proficiency, cultural views) and satisfaction and perceived quality of care was analysed.

Results

In general, patients seemed fairly satisfied. Non-Western patients perceived less quality of care and were less satisfied than Dutch-born patients. The older the patients and the more modern cultural views they had, the more satisfied they were about the GP in general, as well as about the communication process. However, non-Western patients holding more modern views were the most critical regarding the ethnic-specific quality items. The poorer patients’ Dutch language proficiency, the more negative they were about the communication process.

Conclusion

It is concluded that next to communication aspects, especially when the patient's proficiency in Dutch is poor, physician awareness about the patient's cultural views is very important during the consultation. This holds especially true when the immigrant patient seems to be more or less acculturated.

Practice implications

Medical students and physicians should be trained to become aware of the relevance of patients’ different cultural backgrounds. It is also recommended to offer facilities to bridge the language barrier, by making use of interpreters or cultural mediators.