Developing a model of decision-making about complementary therapy use for patients with cancer: A qualitative study

Objective

To improve our understanding of patient participation in health care consultations and decision-making by exploring a consultation that lies at the interface between mainstream care and complementary therapies.

Methods

Thirty-four holistic consultations were observed at centres offering complementary therapies for cancer, followed by interviews with patients and focus groups with professionals.

Results

A model of decision-making about complementary therapy use emerged from the data: ‘Advice: Assessor led decision’, ‘Confirmation: Joint decision’, ‘Access: Patient-led decision’ and ‘Informed: Patient-led decision’. Decision-making style was contingent on identifiable communication strategies in the preceding information-sharing and discussion phases of the consultation.

Conclusion

This study confirms the importance of gauging patients’ preferences for level of participation in decision-making. Models of consultations are generally based on the assumption that a greater degree of patient participation is a good thing that access to information and decision-making power is sought by all patients. Data from this study suggest that, in this context at least, this is not necessarily the case. The study also stresses the dynamic nature of the consultation, in which roles are fluid rather than fixed.

Practice implications

Insight were gained into professionals’ communication strategies and patients’ role preferences in decision-making, which may be applicable more widely.     

Talking about psychosocial problems: An observational study on changes in doctor–patient communication in general practice between 1977 and 2008

Objective

To examine whether GPs’ communication styles have changed since the introduction and implementation of clinical guidelines for psychosocial problems in Dutch general practice in the 1990s.

Methods

From a database of 5184 consultations videotaped between 1977 and 2008, 512 consultations assessed by GPs as ‘completely psychosocial’ were coded with RIAS (Roter Interaction Analysis System). The 121 consultations prior to and 391 consultations after implementation of guidelines were analyzed whether communication styles have changed over time.

Results

We found that GPs were more likely to consider consultations to be mainly (17%) or completely (12%) psychosocial after the implementation of guidelines. They gave more biomedical and psychosocial information and advice in the second period compared to the first period. We also found that empathy decreased over time (frequency of empathic statements by GPs changed from 2.9–3.2 to 1.4–1.6 between periods).

Conclusion

Communication in psychosocial consultations has changed; GPs have become more focused on task-oriented communication (asking questions, giving information and advice) and less on showing empathy.

Practice implications

GPs face the challenge of integrating an evidence-based approach of applying guidelines that promote active symptom exploration with understanding patients’ personal contexts and giving room to their emotions.     

What patients want

Objective

Although most health care professionals im- or explicitly will assume that they tend to use patient-centered communication strategies, there are reasons to believe that this might not always be a valid assumption. In everyday practice, professionals’ own value system is often the dominant steering guide. This Special Issue aims to bring together ongoing research and reflections about the quality of health care communication from the patients’ own perspective. In short: what do patients want?

Methods

This introduction presents a comprehensive overview of the papers in the special issue of Patient Education and Counseling within a framework that describes the collected papers according to the six functions of medical consultations, taking account of the studies’ applied methodologies: quantitative versus qualitative.

Results

Two functions of the medical consultation are strongly represented in the collected papers on the quality of communication from the patients’ perspective: ‘fostering the relationship’ and ‘information giving’. There is a remarkable difference between the qualiative and quantitative studies, showing that if patients are not limited to prestructured questionnaires but completely free to express themselves, they tend to focus on ‘fostering the relationship’ with an emphasis on personal attention, warmth and empathy.

Conclusions

Patients’ needs and preferences for personalized and humane medical care cannot be overestimated. For the rest, patient diversity is striking, showing the limited usefulness of general communication guidelines for the other five functions of the medical consultation. Researchers should be aware that patients’ views might be different dependent on the applied methodologies.     

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.     

Validity aspects of the patient feedback questionnaire on consultation skills (PFC), a promising learning instrument in medical education

Objective

A focus on the communicator competency is considered to be an important requirement to help physicians to acquire consultation skills. A feedback questionnaire, in which patients assess consultation skills might be a useful learning tool. An existing questionnaire on patient perception of patient-centeredness (PPPC) was adapted to cover the ‘communicator’ items in the competency profile. We assessed the face and content validity, the construct validity and the internal consistency of this new patient feedback on consultation skills (PFC) questionnaire.

Methods

We assessed the face validity of the PFC by interviewing patients and general practice trainees (GPTs) during the developmental process. The content validity was determined by experts (n = 10). First-year GPTs (23) collected 222 PFCs, from which the data were used to assess the construct validity (factor analysis), internal consistency, response rates and ceiling effects.

Results

The PFC adequately covers the corresponding ‘communicator’ competency (face and content validity). Factor analysis showed a one-dimensional construct. The internal consistency was high (Cronbach's alpha 0.89). For the single items, the response rate varied from 89.2% to 100%; the maximum score (ceiling effect) varied from 45.5% to 89.2%.

Conclusion

The PFC appears to be a valid, internally consistent instrument.

Practical implications

The PFC may be a valuable learning tool with which GPTs, other physicians and medical students can acquire feedback from patients regarding their consultation skills.     

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.     

Relatives’ perspectives on the quality of care in an Intensive Care Unit: The theoretical concept of a new tool

Objective

To examine the potential of a questionnaire (CQI ‘R-ICU’) to measure the quality of care from the perspective of relatives in the Intensive Care Unit (ICU).

Methods

A quantitative survey study has been undertaken to explore the psychometric properties of the instrument, which was sent to 282 relatives of ICU patients from the Erasmus MC, an academic hospital in Rotterdam, the Netherlands. Factor-analyses were performed to explore the underlying theoretical structure.

Results

Survey data from 211 relatives (response rate 78%) were used for the analysis. The overall reliability of the questionnaire was sufficiently high; two of the four underlying factors, namely ‘Communication’ and ‘Involvement’, were significant predictors. Two specific aspects of care that needed the most improvement were missing information about meals and offering an ICU diary. There is a significant difference in mean communication with nurses among the four wards in Erasmus MC.

Conclusions

The CQI ‘R-ICU’ seems to be a valid, reliable and usable instrument. The theoretical fundament appears to be related to communication.

Practice implications

The newly developed instrument can be used to provide feedback to health care professionals and policy makers in order to evaluate quality improvement projects with regard to relatives in the ICU.     

Physician's gender,communication style,patient preferences and patient satisfaction in gynecology and obstetrics: A systematic review

Objective

Review of studies published in the last 10 years about women seeking gynecological- or obstetrical care and physician's gender in relation to patient preferences, differences in communication style and patient satisfaction.

Methods

Studies were identified by searching the online databases PubMed, PsycINFO, Embase and the Cochrane Library. The search strategies ‘gender’; ‘obstetrics’ and ‘gynecology’ were combined with ‘communication’; ‘physician–patient relations’; ‘patient preference’ and ‘patient satisfaction’.

Results

After screening title and abstract, evaluating full text and quality assessment, 9 articles were included in this review. Most patients preferred a female rather than a male gynecologist–obstetrician. This was partly explained by a more patient-centered communication style used by female gynecologists–obstetricians. Also experience and clinical competence were important factors in choosing a gynecologist–obstetrician. It was not clear whether patient's age or ethnicity influenced patients gender preference. Patient satisfaction increased when gynecologists–obstetricians used a patient-centered communication style.

Conclusion

Preference for a female gynecologist–obstetrician might be explained by a more patient-centered communication style used by female gynecologists–obstetricians. Using a patient-centered communication style increases patient satisfaction.

Practice implications

To increase patient satisfaction, gynecologists–obstetricians should learn to integrate patient-centered communication style into the consultation.     

Older cancer patients’ information and communication needs: What they want is what they get?

Objective

To evaluate what information and communication aspects older cancer patients (≥65) consider important in preparing for chemotherapy treatment (CT), the extent to which this corresponds with what oncology nurses consider important, and the extent to which nurses attend to these aspects during real-life educational visits in oncology.

Methods

The QUOTE^chemo was used to have patients (n = 116) and nurses (n = 123) rate the importance of 66 aspects of patient education. Subsequently, the implementation of these 66 aspects during videotaped nursing visits (n = 155) with older cancer patients receiving CT for the first time was examined.

Results

Older cancer patients attached most importance to ‘treatment-related information’, ‘rehabilitation information’, ‘affective communication’ and discussing ‘realistic expectations’. Nurses placed great importance to almost all aspects except to discussing ‘realistic expectations’. Discrepancies were found between expressed importance and the actual performance during the videotaped consultations, particularly in discussing realistic expectations, coping information, interpersonal communication, and tailored communication.

Conclusion

Results pointed to aspects that need improvement to ensure high quality patient education tailored to the patients’ needs.

Practice implications

To make sure older cancer patients’ needs are met, more attention should be paid to the development of interventions supporting both needs assessment and fulfillment.     

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.     

Emotional and informational patient cues: The impact of nurses’ responses on recall

Objective

To investigate older cancer patients’ informational and emotional cues, how nurses respond to these cues and the effect of cues and responses on patients’ information recall.

Methods

105 cancer patients (aged ≥65 years) completed a recall questionnaire after an educational session preceding chemotherapy treatment. Recall was checked against the actual communication in videorecordings of the consultations. Patients’ emotional and informational cues and subsequent responses by the nurse were rated using an adaptation of the Medical Interview Aural Rating Scale (MIARS).

Results

Patients gave more informational than emotional cues. The most frequent response to emotional cues was distancing followed by acknowledgement. Nurses gave appropriate information in response to the majority of informational cues. Patients’ expression of emotional or informational cues did not influence recall; neither did nurses’ responses to informational cues. Responses to emotional cues did affect recall. The more nurses responded by giving ‘minimal’ encouragements (e.g. ‘Hmmm’), the more patients recalled, while distancing responses (e.g. switching focus) were associated with lower recall scores.

Conclusion

Responding to patients’ emotions is likely to impact information recall.

Practice implications

These results highlight the importance of addressing patients’ expressions of emotions in the context of patient education, as it enhances information recall.     

What to listen for in the consultation. Breast cancer patients’ own focus on talking about acceptance-based psychological coping predicts decreased psychological distress and depression

Objective

To analyze whether qualitative themes in breast cancer patients’ self-presentations predicted symptoms of psychological distress and depression in order to improve the consultation process.

Methods

Ninety-seven breast cancer patients gave unstructured, 10-min self-presentations at their first consultation in a clinical registered trial (CRT identifier: NCT00990977). Self-presentations were categorized thematically and the most prevalent themes investigated as predictors for scores on the symptom check-list 90-revised (SCL-90-R) and the center for epidemiological studies depression scale (CES-D).

Results

Among the qualitative themes, only the percentage of words spent on talking about ‘Acceptance-based psychological coping’ was related to symptoms. In regression models controlling for age, education and time since diagnosis, a stronger focus on acceptance-based coping predicted less psychological distress and depression, respectively. A cross-validation including only the first few minutes of speech per patient confirmed these results and supported their practical utility in health consultations.

Conclusion

Patients’ focus on acceptance-based coping significantly predicted decreased psychological distress and depression, respectively. No other qualitative themes predicted symptoms. Doctor–patient studies may benefit from combined qualitative–quantitative methods.

Practice implications

While quantitative symptom assessment is important for a consultation, health care providers may improve their understanding of patients by attending to patients’ presentations of acceptance-based psychological coping.     

General practitioners’ and psychiatrists’ responses to emotional disclosures in patients with depression

Objective

To investigate general practitioners’ (GPs’) and psychiatrists’ responses to emotional disclosures in consultations with patients with depression.

Methods

Thirteen patient consultations with GPs and 17 with psychiatrists were video-recorded and then analyzed using conversation analysis (CA).

Results

Psychiatrists responded to patients’ emotional disclosures by attempting to clarify symptoms, by rational argumentation, or by offering an interpretation of the emotions from their own perspectives. GPs responded by claiming to understand the emotions or by formulating the patients’ statements, but without further exploring the emotions.

Conclusion

GPs displayed a greater engagement with patients’ emotions than psychiatrists. Their approach could be described as empathic, corresponding to a mentalizing stance. The different approaches taken by psychiatrists could represent conceptual differences and might affect fruitful interdisciplinary work. Psychiatric nurses’ responses to patients’ emotions must also be studied to complete our knowledge from psychiatry.

Practice implications

Experiences from training in mentalization could be used to develop physicians’ empathic or mentalizing approach. As most patients with depression are treated in primary care, developing GPs’ mentalizing capacity instead of offering didactic training could have a substantial effect in the population.     

Development of a behaviour change communication tool for medical students: The ‘Tent Pegs’ booklet

Objective

To describe the development and validation of a behaviour change communication tool for medical students.

Methods

Behaviour change techniques (BCTs) were identified within the literature and used to inform a communication tool to support medical students in discussing health-related behaviour change with patients. BCTs were organized into an accessible format for medical students (the ‘Tent Pegs’ booklet) and validated using discriminant content validity methods with 11 expert judges.

Results

One-sample t-tests showed that judges reliably mapped BCTs onto six of the seven Tent Pegs domains (confidence rating means ranged from 4.0 to 5.1 out of 10, all p ≤ 0.002). Only BCTs within the ‘empowering people to change’ domain were not significantly different from the value zero (mean confidence rating = 1.2, p > 0.05); these BCTs were most frequently allocated to the ‘addressing thoughts and emotions’ domain instead.

Conclusion

BCTs within the Tent Pegs booklet are reliably allocated to corresponding behaviour change domains with the exception of those within the ‘empowering people to change’ domain.

Practice implications

The existing evidence-base on BCTs can be used to directly inform development of a communication tool to support medical students facilitate health behaviour change with patients.     

Patients’ reflections on communication in the second-opinion hematology–oncology consultation

Objective

The nature of communication between patients and their second-opinion hematology consultants may be very different in these one-time consultations than for those that are within long-term relationships. This study explored patients’ perceptions of their second-opinion hematology–oncology consultation to investigate physician–patient communication in malignant disease at a critical juncture in cancer patients’ care and decision-making.

Methods

In-depth telephone interviews with a subset of 20 patients from a larger study, following their subspecialty hematology consultations.

Results

Most patients wanted to contribute to the consultation agenda, but were unable to do so. Patients sought expert and honest advice delivered with empathy, though most did not expect the consultant to directly address their emotions. They wanted the physician to apply his/her knowledge to the specifics of their individual cases, and were disappointed and distrustful when physicians cited only general prognostic statistics. In contrast, physicians’ consideration of the unique elements of patients’ cases, and demonstrations of empathy and respect made patients’ feel positively about the encounter, regardless of the prognosis.

Conclusions

Patients provided concrete recommendations for physician and patient behaviors to enhance the consultation.

Practice implications

Consideration of these recommendations may result in more effective communication and increased patient satisfaction with medical visits.     

Advanced cancer patients’ and caregivers’ use of a Question Prompt List

Objective

The objective of this study was to provide insight into how advanced cancer patients and their caregivers use a Question Prompt List (QPL) during a consultation and for preparation for future consultations.

Methods

Audiotaped consultations and follow-up phone calls of 28 advanced cancer patients were coded and content analyzed. Questions asked and concerns expressed in consultations were coded for initiator, content, inclusion in the QPL and exact wording. Patients’ reported and future use of the QPL were coded from the phone calls.

Results

The majority of patients reported that they used the QPL. Questions asked by patients and caregivers predominately coincided with questions from the prognosis section of the QPL. Questions were rarely asked literally from the QPL, instead questions were tailored to patients’ own circumstances.

Conclusion

QPLs are useful to stimulate discussion on prognosis among advanced cancer patients and caregivers. Patients tailored questions from the QPL to their own circumstances which may suggest high involvement and engagement. The development of more specific tailored communication interventions for advanced cancer patients is warranted.

Practice implications

Implementation of QPLs in the advanced cancer setting may be beneficial for patients, caregivers and healthcare providers to facilitate discussion of topics such as prognosis.     

The effects of self-assessment and supervisor feedback on residents’ patient-education competency using videoed outpatient consultations

Objectives

To determine the effects of residents’ communication self-assessment and supervisor feedback on residents’ communication-competency awareness, on their patient-education competency, and on their patients’ opinion.

Methods

The program consisted of the implementation of a communication self-assessment and feedback process using videoed outpatient consultations (video-CAF). Residents wrote down communication learning objectives during the instruction and after each video-CAF session. Residents’ patient-education competency was assessed by trained raters, using the CELI instrument. Participating patients completed a questionnaire about the contact with their physician.

Results

Forty-four residents and 21 supervisors participated in 87 video-CAF sessions. After their first video-CAF session, residents wrote down more learning objectives addressing their control and rapport skills and their listening skills. Video-CAF participation improved residents’ patient-education competency, but only in their control and rapport skills. Video-CAF participation had no effect on patients’ opinion.

Conclusions

Video-CAF appears to be a feasible procedure and might be effective in improving residents’ patient-education competency in clinical practice.

Practice implications

Video-CAF could fill the existing deficiency of communication training in residency programs.