Cancer screening adherence: Does physician–patient communication matter?

Objective

The objective of this study was to examine the separate contributions of patients and physicians to their communication regarding cancer screening.

Methods

Research design and subjects: The authors conducted a cross-sectional analysis of survey data collected from 63 community-based primary care physicians and 904 of their female patients in Los Angeles.

Results

Patients who perceived their physicians to be enthusiastic (at any level) in their discussions of mammography or fecal occult blood tests (FOBT) were significantly more likely to report a recent test than patients who reported no discussions.

Conclusion

Physician discussions of cancer screening are important and effective even when, as in the case of mammography, screening rates are already high, or, as in the case of FOBT, rates have tended to remain low. The value of communication about screening should be taught and promoted to primary care physicians who serve as gatekeepers to screening.

Practice implications

Those who train physicians in communication skills should take into account our finding that the communication style of physicians (e.g., enthusiasm for screening) was the only patient or physician variable that both influenced screening adherence and that could be taught.     

Education in patient–physician communication: How to improve effectiveness?

Objective

Despite educational efforts expertise in communication as required by the CanMEDS competency framework is not achieved by medical students and residents. Several factors complicate the learning of professional communication.

Methods

We adapted the reflective–impulsive model of social behaviour to explain the complexities of learning professional communication behaviour. We formulated recommendations for the learning objectives and teaching methods of communication education. Our recommendations are based on the reflective–impulsive model and on the model of deliberate practice which complements the reflective–impulsive model. Our recommendations are substantiated by those we found in the literature.

Results

The reflective–impulsive model explains why the results of communication education fall below expectations and how expertise in communication can be attained by deliberate practice. The model of deliberate practice specifies learning conditions which are insufficiently fulfilled in current communication programmes.

Conclusion

The implementation of our recommendations would require a great deal of effort. Therefore we doubt whether expertise in professional communication can be fully attained during medical training.

Practice implications

We propose that the CanMEDS communication competencies not be regarded as endpoints in medical education but as guidelines to improve communication competency through deliberate practice throughout a professional career.     

E-mail in patient–provider communication: A systematic review

Objective

To review systematically the role of e-mails in patient–provider communication in terms of e-mail content, and perspectives of providers and patients on e-mail communication in health care.

Methods

A systematic review of studies on e-mail communication between patients and health providers in regular health care published from 2000 to 2008.

Results

A total of 24 studies were included in the review. Among these studies, 21 studies examined e-mail communication between patients and providers, and three studies examined the e-mail communication between parents of patients in pediatric primary care and pediatricians. In the content analyses of e-mail messages, topics well represented were medical information exchange, medical condition or update, medication information, and subspecialty evaluation. A number of personal and institutional features were associated with the likelihood of e-mail use between patients and providers. While benefits of e-mails in enhancing communication were recognized by both patients and providers, concerns about confidentiality and security were also expressed.

Conclusion

The e-mail is transforming the relationship between patients and providers. The rigorous exploration of pros and cons of electronic interaction in health care settings will help make e-mail communication a more powerful, mutually beneficial health care provision tool.

Practice implications

It is important to develop an electronic communication system for the clinical practice that can address a range of concerns. More efforts need to be made to educate patients and providers to appropriately and effectively use e-mail for communication.     

A systematic review of surgeon–patient communication: Strengths and opportunities for improvement

Objective

Effective communication is critical to patient satisfaction, outcomes of care and malpractice prevention. Surgeons need particularly effective communication skills to discuss complicated procedures and help patients make informed choices. We conducted a systematic review of the literature on surgeon–patient communication.

Methods

Searches were conducted in MEDLINE, PsycINFO, and Sociological Abstract. Two reviewers screened citations and full-text articles. Quality was appraised using the Critical Appraisal Skills Program tool. Studies were categorized into content of communication, patient satisfaction, relationship of communication to malpractice, and duration of visits.

Results

2794 citations and 74 full-text articles, 21 studies and 13 companion reports were included. Surgeons spent the majority of their time educating patients and helping them to make choices. Surgeons were generally thorough in providing details about surgical conditions and treatments. Surgeons often did not explore the emotions or concerns of patients. Potential areas of improvement included discussing some elements of informed decision making, and expressing empathy.

Conclusion

Surgeons can enhance their communication skills, particularly in areas of relative deficiency. Studies in primary care demonstrate communication programs are effective in teaching these skills.

Practice implications

These can be adapted to surgical training and ultimately lead to improved outcomes and satisfaction with care.     

Does physician–patient communication that aims at empowering patients improve clinical outcome?: A case study

OBJECTIVE: A case study at the department for heart surgery of an Austrian University Hospital in 2001, examined the outcome of improved communication aimed at empowering patients to be more effective co-producers of recuperation after surgery. METHODS: Evaluated were the effects of a training program for developing communication skills of health professionals (physicians, physiotherapists, and nurses) along with a reorganization of patient information schemes. The clinical outcomes after four types of surgery (bypass, stent, artificial valve insertion and combination of these) were observed in 100 patients without (control group) and 99 with the intervention administered (intervention group). Two objective and two subjective health outcome parameters were selected for analysis: care level adjusted length of stay in hospital, frequency of post-surgery complications, subjective health, subjective satisfaction with care received. Self-administered breathing exercises were measured as an intermediary outcome parameter. RESULTS: In the intervention group length of hospital stay was shorter (by 1 day), incidence of post-surgery tachyarrhythmia was reduced (by 15%), transfer to less intensive care levels was faster and patient ratings for communicative quality of care by doctors and nurses were improved. CONCLUSION: Professional communication aimed at empowering patients to act as co producers can indeed have an effect on clinical outcome. PRACTICE IMPLICATIONS: Staff training and reorganization of communication schemes can be an effective intervention in hospital care.     

The challenge of talking about sex: The importance of patient–physician interaction

Sexuality is a complex phenomenon, with physical, psychological, and social components. In evaluating and counselling the patient with sexual problems, it is important for the physician to communicate effectively and to be open to the patient's own experience of sexuality. This paper provides an overview of important issues related to evaluation of these patients and presents a stepwise approach to the clinical evaluation suitable to the limited time frame of a medical consultation.     

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.     

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.     

Rational versus unreasonable persuasion in doctor–patient communication: A normative account

Objective

Persuasion plays a critical role in doctor–patient communication. The relevant literature tends to equate persuasion to manipulation as a suboptimal form of interaction. The objective of this paper is to distinguish among different types of persuasion processes and to highlight when their use can be beneficial or risky from the perspective of the patient's autonomy.

Methods

This paper presents a conceptual analysis of persuasion based on the analytical and normative frameworks of argumentation theory.

Results

Persuasion is a generic term that refers to at least four main forms of persuasion: rational persuasion, unintentional unreasonable persuasion, intentional (without deception) unreasonable persuasion and intentional (with deception) unreasonable persuasion (i.e., manipulation).

Conclusion

Rational persuasion can be a process of value for the medical encounter. The other forms of persuasion can negatively impact patients’ decision making. They are suboptimal for different reasons that are partly due to the quality of communication, and partly due to ethics of the medical conduct.

Practice implications

This paper offers a basis for developing training opportunities that foster deeper understanding of different forms and uses of persuasion. Also, it can inspire the development of educational material for patients targeted to the enhancement of their critical health literacy.     

Five ways of being “theoretical”: Applications to provider–patient communication research

Objective

Analyzes the term “theoretical” as it applies to the area of provider–patient communication research, in order to understand better at a conceptual level what the term may mean for authors and critics.

Methods

Based on literature on provider–patient communication.

Results

Offers, and discusses, five definitions of the term “theoretical” as it applies to empirical research and its exposition: (1) grounding, (2) referencing, (3) design and analysis, (4) interpretation, and (5) impact. Each of these definitions embodies a different standard for evaluating the theoretical aspects of research.

Conclusion

Although it is often said that research on provider–patient communication is not “theoretical” enough, the term is ambiguous and often applied vaguely. A multidimensional analysis reveals that there are several distinct ways in which empirical research can be strong or weak theoretically.

Practice implications

Researchers, educators, editors, and reviewers could use the “Five Ways” framework to appraise the theory-relevant strengths and weaknesses of empirical research and its exposition.     

Physician–patient–companion communication and decision-making: A systematic review of triadic medical consultations

Objective

To systematically review quantitative and qualitative studies exploring physician–adult patient–adult companion (triadic) communication and/or decision-making within all medical encounters.

Methods

Studies were identified via database searches and reference lists. One author assessed eligibility of studies, verified by two co-authors. Data were extracted by one author and cross-checked for accuracy. Two authors assessed the quality of included articles using standardized criteria.

Results

Of the 8409 titles identified, 52 studies were included. Summary statements and tables were developed for each of five identified themes. Results indicated companions regularly attended consultations, were frequently perceived as helpful, and assumed a variety of roles. However, their involvement often raised challenges. Patients with increased need were more often accompanied. Some companion behaviours were felt to be more helpful (e.g. informational support) and less helpful (e.g. dominating/demanding behaviours), and preferences for involvement varied widely.

Conclusion

Triadic communication in medical encounters can be helpful but challenging. Based on analysis of included studies, preliminary strategies for health professionals are proposed.

Practice implications

Preliminary strategies for health professionals include (i) encourage/involve companions, (ii) highlight helpful companion behaviours, (iii) clarify and agree upon role preferences of patient/companions. Future studies should develop and evaluate specific strategies for optimizing triadic consultations.     

Physician–patient communication about dietary supplements

Objective

Describe the content and frequency of provider–patient dietary supplement discussions during primary care office visits.

Methods

Inductive content analysis of 1477 transcribed audio-recorded office visits to 102 primary care providers was combined with patient and provider surveys. Encounters were collected in Los Angeles, CA (2009–2010), geographically diverse practice settings across the United States (2004–2005), and Sacramento, CA (1998–1999).

Results

Providers discussed 738 dietary supplements during encounters with 357 patients (24.2% of all encounters in the data). They mentioned: (1) reason for taking the supplement for 46.5% of dietary supplements; (2) how to take the supplement for 28.2%; (3) potential risks for 17.3%; (4) supplement effectiveness for 16.7%; and (5) supplement cost or affordability for 4.2%. Of these five topics, a mean of 1.13 (SD = 1.2) topics were discussed for each supplement. More topics were reviewed for non-vitamin non-mineral supplements (mean 1.47 (SD = 1.2)) than for vitamin/mineral supplements (mean 0.99 (SD = 1.1); p < 0.001).

Conclusion

While discussions about supplements are occurring, it is clear that more discussion might be needed to inform patient decisions about supplement use.

Practice implications

Physicians could more frequently address topics that may influence patient dietary supplement use, such as the risks, effectiveness, and costs of supplements.     

A novel treatment strategy for type 2 diabetes: Targeting glucose variability and β-cell failure

Blood glucose control has been a main focus for the treatment of type 2 diabetes. However, poor control and side-effect still are urgent problems to be solved. According to common blood glucose variability and its extremely deleterious diabetic-related complications in clinical practice, it should be considered as a potential key target. And β-cell failure has been approved that it can be reversible for early type 2 diabetes, which suggests another promising target. In this hypothesis, we propose a novel treatment strategy against on the two targets. An intelligent double-target drug delivery system is presented and characterized by dual-responsive functional gates for glucose sensitivity used controlled-release hypoglycemic agents and a sustained-release osmotic pump loaded drugs to repair impaired β-cell into the repository, respectively. The proposition may provide a new early therapeutic strategy for type 2 diabetes in order to better hold blood glucose homeostasis.     

Are you talking to me?! An exploration of the triadic physician–patient–companion communication within memory clinics encounters

Objective

To explore and gain further insight into the nature of the triadic interaction among patients, companions and physicians in first-time diagnostic disclosure encounters of Alzheimer's disease in memory-clinic visits.

Methods

Twenty-five real-time observations of actual triadic encounters by six different physicians were analyzed. The analysis was accomplished through an innovative combination of grounded theory text analysis and graphics to illustrate the communicational exchanges.

Results

The “triadic” communication was actually a series of alternating dyadic exchanges where the third person tries, with inconsistent degrees of success, to become actively involved. During the initial introduction (phase 1) and summation/disclosure (phase 3), the core dyad shifts from physician–patient to physician–companion.

Conclusion

The focus of communication shifts within these encounters: from talking with the patient to talking about him or ignoring him. These shifts may signify an emotionally loaded role transformation from companion to caregiver.

Practice implications

Effective and empathic management of a triadic communication that avoids unnecessary interruptions and frustrations requires specific communication skills (e.g., explaining the rules and order of the conversation). Professionals need to facilitate the emotionally difficult shift from companion to caregiver and the adjustment of companion and demented patient to this shift.     

Counseling overweight in primary care: An analysis of patient–physician encounters

Objective

The aim of this study was to assess general practitioners’ (GPs’) and patients’ practices and attitudes regarding overweight encountered during preventive counseling talks.

Methods

Twelve GPs audiotaped their preventive counseling talks with overweight patients, including the assessment of individual risk profiles and further medical recommendations. Fifty-two dialogues were transcribed and submitted to qualitative content analysis.

Results

Dietary advice and increased physical activity are mostly discussed during talks. Recommendations appear to be more individual if patients are given the chance to reflect on causes of their overweight during counseling talks.

Conclusions

A dialogue approach affects the strength and quality of weight loss counseling in primary care. However, physicians and overweight patients rarely agreed on weight loss goals during the physician–patient talks.

Practical implications

Patient centeredness, particularly the integration of patients’ perceptions towards weight management, might be an important step towards improving weight counseling in primary care.     

Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor–patient communication and attention

ObjectiveThe aim of this study was to examine eye gaze patterns between patients and physicians while electronic health records were used to support patient care.BackgroundEye gaze provides an indication of physician attention to patient, patient/physician interaction, and physician behaviors such as searching for information and documenting information.MethodsA field study was conducted where 100 patient visits were observed and video recorded in a primary care clinic. Videos were then coded for gaze behaviors where patients’ and physicians’ gaze at each other and artifacts such as electronic health records were coded using a pre-established objective coding scheme. Gaze data were then analyzed using lag sequential methods.ResultsResults showed that there are several eye gaze patterns significantly dependent to each other. All doctor-initiated gaze patterns were followed by patient gaze patterns. Some patient-initiated gaze patterns were also followed by doctor gaze patterns significantly unlike the findings in previous studies. Health information technology appears to contribute to some of the new significant patterns that have emerged. Differences were also found in gaze patterns related to technology that differ from patterns identified in studies with paper charts. Several sequences related to patient–doctor–technology were also significant. Electronic health records affect the patient–physician eye contact dynamic differently than paper charts.ConclusionThis study identified several patterns of patient–physician interaction with electronic health record systems. Consistent with previous studies, physician initiated gaze is an important driver of the interactions between patient and physician and patient and technology.