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.     

Physician empathy and subjective evaluation of medical treatment outcome in trauma surgery patients

Objective

To analyze whether patients’ perception of their medical treatment outcome is higher among patients who experienced a higher empathy by trauma surgeons during their stay in hospital.

Methods

127 patients were surveyed six weeks after discharge from the trauma surgical general ward. Subjective evaluation of medical treatment outcome was measured with the corresponding scale from the Cologne Patient Questionnaire. Clinical empathy was assessed by using the CARE measure. The influence of physician empathy and control variables on a dichotomized index of subjective evaluation of medical treatment outcome was identified with a logistic regression.

Results

120 patients were included in the logistic regression analysis. Compared to patients with physician empathy ratings of less than 30 points, patients with ratings of 41 points or higher have a 20-fold higher probability to be in the group with a better medical treatment outcome on the CPQ-scale (α-level < .001, R² 46.9).

Conclusion

Findings emphasize the importance of a well-functioning relationship between physician and patient even in a surgical setting where the focus is mostly on the bare medical treatment.

Practice implications

Communication trainings i.e. in surgical education can be an effective way to improve the ability to show empathy with patients’ concerns.     

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.     

Psychosocial predictors of attitudes toward physician empathy in clinical encounters among 4732 1st year medical students: A report from the CHANGES study

Objective

Medical school curricula intended to promote empathy varies widely. Even the most effective curricula leave a significant group of students untouched. Pre-existing student factors influence their response to learning experiences. We examined the individual predictors of first semester medical students’ attitudes toward the value of physician empathy in clinical encounters.

Methods

First year students (n = 4732) attending a stratified random sample of 49 US medical schools completed an online questionnaire that included measures of dispositional characteristics, attitudes and beliefs, self-concept and well-being.

Results

Discomfort with uncertainty, close-mindedness, dispositional empathy, elitism, medical authoritarianism, egalitarianism, self-concept and well-being all independently predicted first year medical students’ attitudes toward the benefit of physician empathy in clinical encounters.

Conclusion

Students vary on their attitude toward the value of physician empathy when they start medical school. The individual factors that predict their attitudes toward empathy may also influence their response to curricula promoting empathic care.

Practice implications

Curricula in medical school promoting empathic care may be more universally effective if students’ preexisting attitudes are taken into account. Messages about the importance of physician empathy may need to be framed in ways that are consistent with the beliefs and prior world-views of medical students.     

Physicians’ influence on veterans’ decision to use acupuncture

Objective

To compare patients’ acupuncture use with physician's attitudes toward and history of referral for acupuncture.

Methods

A questionnaire was administered to patients of the Atlanta Veterans Affairs Medical Center and the physicians whom they identified as most influencing their healthcare decisions. A total of 114 patients were matched with 33 physicians.

Results

Physicians’ history of referral was not significantly related to patients’ acupuncture use. Physicians’ belief that acupuncture would increase patient satisfaction, however, was associated with higher rates of patient acupuncture use (p = 0.01). Qualitative analysis of an open-ended question that probed further into physicians’ attitudes regarding acupuncture revealed three key themes: lack of knowledge about the treatment; misperceptions regarding availability of acupuncture at VA; and lack of VA providers to meet demand.

Conclusion

These results indicate that physicians’ referral patterns are not associated with patients’ acupuncture use. However, some evidence shows a link between patients’ acupuncture use and physicians’ beliefs that the treatment will increase patient satisfaction, showing that physician attitudes may have some influence on patients’ acupuncture use.

Practice implications

In order to cultivate shared-decision making between patients and their physicians it will be important to address gaps in provider knowledge about acupuncture and its availability.     

Negative emotions in cancer care: Do oncologists’ responses depend on severity and type of emotion?

Objective

To examine how type and severity of patients’ negative emotions influence oncologists’ responses and subsequent conversations.

Methods

We analyzed 264 audio-recorded conversations between advanced cancer patients and their oncologists. Conversations were coded for patients’ expressions of negative emotion, which were categorized by type of emotion and severity. Oncologists’ responses were coded as using either empathic language or blocking and distancing approaches.

Results

Patients presented fear more often than anger or sadness; severity of disclosures was most often moderate. Oncologists responded to 35% of these negative emotional disclosures with empathic language. They were most empathic when patients presented intense emotions. Responding empathically to patients’ emotional disclosures lengthened discussions by an average of only 21 s.

Conclusion

Greater response rates to severe emotions suggest oncologists may recognize negative emotions better when patients express them more intensely. Oncologists were least responsive to patient fear and responded with greatest empathy to sadness.

Practice implications

Oncologists may benefit from additional training to recognize negative emotions, even when displayed without intensity. Teaching cancer patients to better articulate their emotional concerns may also enhance patient–oncologist communication.     

What parents want from emails with their pediatrician: Implications for teaching communication skills

Objective

Physician–patient email communication is increasing but trainees receive no education on this communication medium. Research eliciting patient preferences about email communication could inform training. Investigators elicited parents’ perspectives on physician–parent email communication and compared parent and faculty assessments of medical students’ emails.

Methods

This mixed methods study explored physician–parent email communication in 5 parent focus groups using qualitative analyses to identify themes. Differences between faculty and parent assessment scores for students’ email responses were calculated using univariate general linear modeling.

Results

Themes that emerged were: (1) Building the Relationship, (2) Clarity of Communication and (3) Expectations. Parents criticized student's statements as condescending. The sum of assessment scores by parents and faculty were moderately correlated (r(44) = .407, P < .01), but parents gave students lower scores on “acknowledges validity/expresses empathy” (P = .01) and higher scores on “provides next steps” (P < .01) and “identifies issues” (P < .01).

Conclusion

Parents place value on students’ abilities to communicate clearly and convey respect and empathy in email. Parent and faculty perspectives on email communication are similar but not the same.

Practice implications

Differences between parental and faculty assessments of medical students’ emails supports the need for the involvement of patients and families in email communication curriculum development.     

Patient-centered interviewing and student performance in a comprehensive clinical skills examination: Is there an association?

Objective

Communication skills, including patient-centered interviewing (PCI), have become a major priority for educational and licensing organizations in the United States. While patient-centered interviewing is associated with positive patient outcomes and improved diagnostic accuracy, it is unknown if an association exists between patient-centered interviewing and student performance in high-stakes clinical skills assessment (CSA) examinations. The purpose of this study was to determine if generic communication skills and patient-centered interviewing skills were associated with students’ overall student performance on a multi-station clinical skills assessment (CSA) examination.

Methods

This was a cross-sectional study to assess student performance with standardized patients (SPs). We conducted a retrospective review of 30 videotaped SP encounters of Third year medical students (class of 2006) at the University of Kansas School of Medicine. We measured correlations between observed PCI scores, overall CSA scores and CSA interpersonal and communication (ICS) skills scores of student–SP encounters.

Results

PCI scores, as measured with the Four Habits Coding Scheme, a measurement tool of patient-centered communication, were not correlated with either overall CSA scores or ICS scores. Students’ PCI scores were lower than the ICS scores (57% vs. 85% of correct items). The students performed poorly (30% mean score of correct items) in eliciting patient perspectives, compared to three other domains (Invest in the beginning, Demonstrate empathy, and Invest in end) of patient-centered interviewing.

Conclusions

Our study failed to demonstrate any association between student performance and patient-centered interviewing skills (PCI) in the setting of a comprehensive in-house CSA examination. Third-year medical students in our study did not practice some elements of patient-centered interviewing.

Practice implications

Given the increasing importance of patient-centered communication, the high-stakes in-house clinical skills examinations may consider assessing patient-centered interviewing using a more comprehensive and valid checklist.     

Exploring patient-centeredness: The relationship between self-reported empathy and patient-centered communication in medical trainees

Objective

To explore the relationships between self-reported Empathy and the patient-centered communication patterns of physician trainees.

Gender bias in patients’ perceptions of patient-centered behaviors

Objective

This research examines whether patient perceptions are equivalently associated with patient-centered behavior in male and female medical students, and tests the impact of a message emphasizing the importance of patient-centeredness on analogue patients’ perceptions of male and female medical students’ performance.

Methods

Sixty-one medical students interacting with standardized patients (SPs) were viewed by 384 analogue patients (APs). APs were randomly assigned to receive a message emphasizing the value of patient-centeredness or of technical competence, or a neutral message, and then evaluated the medical students’ competence in the interactions. Students’ patient-centeredness was measured using the Four Habits Coding Scheme and Roter Interaction Analysis System.

Results

APs in the neutral and technical competence conditions gave higher competence ratings to more patient-centered male students, but not to more patient-centered female students. However, APs who received the patient-centeredness message gave higher competence ratings to both male and female students who were higher in patient-centeredness.

Conclusion

Making it clear that patient-centeredness is a dimension of physician competence eliminated a gender bias in evaluating performance.

Practice implications

Because patient perceptions are often used in evaluations, gender biases must be understood and reduced so both male and female providers receive appropriate credit for their patient-centered behaviors.     

Does being informed and feeling informed affect patients’ trust in their radiation oncologist?

Objective

We investigated whether the content of information provided by radiation oncologists and their information giving performance increase patients’ trust in them.

Methods

Questionnaires were used to assess radiotherapy patients (n = 111) characteristics before their first consultation, perception of information giving after the first consultation and trust before the follow-up consultation. Videotaped consultations were scored for the content of the information provided and information giving performance.

Results

Patients mean trust score was 4.5 (sd = 0.77). The more anxious patients were, the less they tended to fully trust their radiation oncologist (p = 0.03). Patients’ age, gender, educational attainment and anxious disposition together explained 7%; radiation oncologists’ information giving (content and performance) explained 3%, and patients’ perception of radiation oncologists’ information-giving explained an additional 4% of the variance in trust scores.

Conclusion

It can be questioned whether trust is a sensitive patient reported outcome of quality of communication in highly vulnerable patients.

Practice implications

It is important to note that trust may not be a good patient reported outcome of quality of care. Concerning radiation oncologists’ information giving performance, our data suggest that they can particularly improve their assessments of patients’ understanding.     

Residents’ perceived barriers to communication skills learning: Comparing two medical working contexts in postgraduate training

Objective

Contextual factors are known to influence the acquisition and application of communication skills in clinical settings. Little is known about residents’ perceptions of these factors. This article aims to explore residents’ perceptions of contextual factors affecting the acquisition and application of communication skills in the medical workplace.

Method

We conducted an exploratory study comprising seven focus groups with residents in two different specialities: general practice (n = 23) and surgery (n = 18).

Results

Residents perceive the use of summative assessment checklists that reduce communication skills to behavioural components as impeding the learning of their communication skills. Residents perceive encouragement to deliberately practise in an environment in which the value of communication skills is recognised and support is institutionalised with appropriate feedback from role models as the most important enhancing factors in communication skills learning.

Conclusion

To gradually realise a clinical working environment in which the above results are incorporated, we propose to use transformative learning theory to guide further studies.

Practical implications

Provided it is used continuously, an approach that combines self-directed learning with observation and discussion of resident-patient consultations seems an effective method for transformative learning of communication skills.     

Medical interpreters as tools: Dangers and challenges in the utilitarian approach to interpreters’ roles and functions

Objective

This study explores the tensions, challenges, and dangers when a utilitarian view of interpreter is constructed, imposed, and/or reinforced in health care settings.

Methods

We conducted in-depth interviews and focus groups with 26 medical interpreters from 17 different languages and cultures and 39 providers of five specialties. Grounded theory was used for data analysis.

Results

The utilitarian view to interpreters’ roles and functions influences providers in the following areas: (a) hierarchical structure and unidirectional communication, (b) the interpreter seen as information gatekeeper, (c) the interpreter seen as provider proxy, and (d) interpreter's emotional support perceived as tools.

Conclusion

When interpreters are viewed as passive instruments, a utilitarian approach may compromise the quality of care by silencing patients’ and interpreters’ voice, objectifying interpreters’ emotional work, and exploiting patients’ needs.

Practice implications

Providers need to recognize that a utilitarian approach to the interpreter's role and functions may create interpersonal and ethical dilemmas that compromise the quality of care. By viewing interpreters as smart technology (rather than passive instruments), both providers and interpreters can learn from and co-evolve with each other, allowing them to maintain control over their expertise and to work as collaborators in providing quality care.     

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.     

The relationship between nurses’ religiosity and willingness to let patients control the conversation about end-of-life care

Objective

The study attempts to examine the relationship between nurses’ religious beliefs and how nurses communicate with patients.

Method

An online census survey was administered to graduate students in the School of Nursing at a Midwestern university. The survey was designed to measure: relational control, as measured by the subscales of dominance and task orientation in Burgoon and Hale's scale of relational communication; clinician empathy, as measured by the Jefferson scale of clinician empathy; and intrinsic and extrinsic religiosity, whether religious views are held for deep personal reasons or social reasons, as measured by the Maltby and Lewis scale. Data were analyzed using multiple regressions and one-way ANOVAs.

Results

Intrinsic religiosity and empathy were both associated with the willingness to relinquish relational control in certain, specific contexts, such as end-of-life care.

Conclusion

Nurses who scored higher on a scale of intrinsic religious beliefs were more willing to let patients take control of conversations about end-of-life care.

Practice implications

A nurse's religious beliefs can enhance the clinical experience without the nurse trying to impose his or her beliefs on the patient, as the nurse works to make sure the patient's religious beliefs are upheld.     

I will always be with you: Traditional and complementary therapists’ perspectives on patient–therapist–doctor communication regarding treatment of Arab patients with cancer in Israel

Objective

In 2008, an Integrative Oncology Program was implemented at the Clalit Oncology Service in Haifa, Israel, to promote patients’ well-being during chemotherapy and advanced stages of disease. We hypothesized that studying the perceptions of Arab complementary and alternative medicine (CAM) therapists would facilitate development of a cross-culturally integrative oncology approach.

Methods

Semi-structured interviews were held with 27 Arab therapists who use medicinal herbs, the Quran and various CAM modalities, with the aim of characterizing their treatment practices and learning about their perspectives regarding conventional cancer care.

Results

Thematic analysis revealed that therapists act as go-betweens, mediating between patients and conventional physicians. Therapists translate diagnoses into Arabic and elucidate key concepts. They tend to perceive their role as gatekeepers accompanying patients through the conventional health system, referring them for further examinations, and providing CAM-based supportive care consultation.

Conclusions

CAM therapists have an essential role in supportive care of Arab patients with cancer. Triangular patient–therapist–oncologist communication may have an impact on patients’ experience and treatment quality.

Practice implications

Recognition of CAM therapists as mediators between patients’ health beliefs and conventional perceptions of care may improve doctor–patient dialogue and facilitate supportive care provision in a cross-cultural context.     

Patients’ and relatives’ complaints about encounters and communication in health care: Evidence for quality improvement

Objective

The aim of this study was to describe patients’ and relatives’ complaints to the local Patients’ Advisory Committee about their encounters and communication in health care.

Methods

Complaints (n = 105) regarding patients’ and relatives’ dissatisfaction with communication and encounters in health care, registered at a local Patients’ Advisory Committee between 2002 and 2004, were included. The texts were analysed using content analysis.

Results

Three categories were identified: “Not receiving information or being given the option to participate”, “Not being met in a professional manner” and “Not receiving nursing or practical support”. Insufficient information, insufficient respect and insufficient empathy were described as the most common reasons for a negative professional encounter.

Conclusion

Patients and relatives experienced unnecessary anxiety and reduced confidence in health care after negative professional encounters.

Practice implications

The complaints reported to the Patients’ Advisory Committee could be used more effectively in health care and be regarded as important evidence when working with quality improvement. To systematically use patient stories, such as those obtained in this report, as a reflective tool in education and supervision could be one way to improve communication and bring new understanding about the patient's perspective in health care.     

Turkish migrant GP patients’ expression of emotional cues and concerns in encounters with and without informal interpreters

Objective

The aim of this study was to compare patients’ expressions of emotional cues and concerns, and GPs’ responses during consultations with and without informal interpreters. Furthermore, informal interpreters’ expression of emotional cues and concerns and their responses were examined too.

Methods

Twenty-two audiotaped medical encounters with Turkish migrant patients, eleven with and eleven without an informal interpreter, were coded using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) and the Verona Codes for Provider Responses (VR-CoDES-P).

Results

In encounters with informal interpreters, patients expressed less emotional concerns than in encounters without informal interpreters. Only half of all patients’ cues is being translated by the informal interpreter to the GP. Furthermore, 20% of all cues in encounters with informal interpreters is being expressed by the interpreter, independent of patients’ expression of emotions.

Conclusion

The presence of an informal interpreter decreases the amount of patients’ expression of emotional concerns and cues. Furthermore, a substantial amount of cues is being expressed by the informal interpreter, corroborating the often-made observation that they are active participants in triadic medical encounters.

Practice implications

GPs should be trained in communication strategies that enable elicitation of migrant patients’ emotions, in particular in encounters with informal interpreters.     

Health literacy: Use of the Four Habits Model to improve student pharmacists’ communication

Objective

To assess whether student pharmacists’ communication skills improved using the Four Habits Model (FHM) at the St. Louis College of Pharmacy.

Methods

During the Fall of 2009 and 2010, student pharmacists in the third professional year learned and practiced the FHM. They were given feedback by faculty on three of the four Habits, used the FHM for self and peer assessment, and were formally evaluated on all four Habits during a standardized patient encounter.

Results

Student pharmacist performance significantly improved from baseline during both Fall 2009 and Fall 2010 in the majority of the Habits assessed.

Conclusion

Use of the FHM in pharmacy education can improve a student pharmacists’ ability to display the four Habits of communicating and developing relationships with patients. Tailoring of the FHM to pharmacy encounters will further enhance the utility of this communication framework.

Practice implications

Use of the FHM enhances the measurement and assessment of the relational aspects of student pharmacist–patient communication skills. Consistent use of the FHM over time is likely necessary to fully develop and retain communication skills. The overall goal is to improve patient's health literacy and appropriate medication use by improving communication and the pharmacist–patient relationship.     

Patient understanding of medical jargon: A survey study of U.S. medical students

Objective

With increasing exposure, medical students may forget that technical jargon is unfamiliar to laypeople. To investigate this possibility, authors assessed student perceptions of patient understanding across different years in medical school.

Methods

533 students at 4 U.S. medical schools rated the proportion of patients likely to understand each of twenty-one different jargon terms. Students were either in the first month of their first year, the middle of their first year, or the middle of their fourth year of medical school.

Results

Fourth-year students were slightly more pessimistic about patients’ understanding compared to new first-year students (mean percent understanding of 55.1% vs. 58.6%, p = 0.004). Students both over- and under-estimated patient understanding of specific words compared to published estimates. In a multivariate model, other factors did not explain these differences.

Conclusion

Students do not generally presume that patients understand medical jargon. In many cases they actually underestimate patients’ understanding, and these estimates may become more pessimistic longitudinally. Jargon use in communication with patients does not appear to stem from unrealistic presumptions about patients’ understanding or from desensitization to jargon during medical school.

Practice implications

Training about patient knowledge of medical jargon may be a useful addition to communication skills curricula.