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.     

Validation of the Norwegian version of MAPPIN’SDM,an observation-based instrument to measure shared decision-making in clinical encounters

ObjectiveTo validate the Norwegian version of MAPPIN’SDM observer scales with regard to reliability, accuracy and the extent to which the scales include the essentials of the shared decision-making concept.MethodsThree MAPPIN’SDM scales, focusing on the skills of doctor, patient and dyad, were applied to audiovisual records of 35 decision sequences. Inter-rater reliabilities were determined based on kappa coefficients. Sensitivities and specificities were calculated with regard to an expert reference standard. Convergent validities were calculated with the OPTION₅ scale. MAPPIN’SDM was qualitatively compared to OPTION5 using Makoul & Clayman’s Integrative Model structure.ResultsInter-rater reliabilities were high on average over 11 items in each of three observer scales (MAPPIN_doctor = 0.77, MAPPINpatient = 0.82, MAPPIN_dyad = 0.77). Patient involvement was detected accurately (MAPPIN_dyad: mean sensitivity/specificity 93/91%). Comparison with OPTION₅ showed weak to moderate correlation (Spearman’s ρ/p-value: MAPPIN_doctor: = 0.44/0.009, MAPPIN_patient: 0.38/0.024, MAPPIN_dyad 0.40/0.016) and little content overlap.ConclusionMAPPIN’SDM_norge is capable of assessing SDM highly reliably and accurately. Divergence from OPTION₅ reflects explicit disagreement regarding the concept’s assumptions.Practice implicationsMAPPIN’SDM_norge is ready for use in Norway. In-depth debate on the SDM concept’s essentials is urgently needed.     

Assessment of medical students’ shared decision-making skills in simulated physician-patient encounters

ObjectiveTo compare shared decision-making skills of medical students who voluntarily translate medical documents into plain language with students who do not participate in this voluntary task.Methods29 medical students who voluntarily translated medical documents for patients into plain language on the online-platform https://washabich.de (WHI group) and 29 medical students who did not (non-WHI group) participated in a simulated virtual consultation hour. Via skype, participants communicated with six simulated patients. All conversations were transcribed and a blinded rater assessed them with the OPTION scale for shared decision-making.ResultsThe WHI group received significantly (p < .001) higher total scores for shared decision-making with the OPTION scale than the non-WHI group. The greatest differences in scores were found for the items “The clinician checks that the patient has understood the information.” (WHI: 2.98 ± 0.77 vs. non-WHI: 2.61 ± 0.89, p < .001) and “The clinician offers the patient explicit opportunities to ask questions during the decision-making process.” (WHI: 2.83 ± 1.00 vs. non-WHI: 2.40 ± 1.07, p < .001).ConclusionWritten translation of medical documents is associated with significantly better OPTION scores for shared decision-making in simulated physician-patient encounters.Practice ImplicationsTo use written medial translation exercises in general to improve medical students’ shared decision-making skills.     

The study protocol of: ‘Initiating end of life care in stroke: clinical decision-making around prognosis’

Background

The initiation of end of life care in an acute stroke context should be focused on those patients and families with greatest need. This requires clinicians to synthesise information on prognosis, patterns (trajectories) of dying and patient and family preferences. Within acute stroke, prognostic models are available to identify risks of dying, but variability in dying trajectories makes it difficult for clinicians to know when to commence palliative interventions. This study aims to investigate clinicians’ use of different types of evidence in decisions to initiate end of life care within trajectories typical of the acute stroke population.

Methods/design

This two-phase, mixed methods study comprises investigation of dying trajectories in acute stroke (Phase 1), and the use of clinical scenarios to investigate clinical decision-making in the initiation of palliative care (Phase 2). It will be conducted in four acute stroke services in North Wales and North West England. Patient and public involvement is integral to this research, with service users involved at each stage.

Discussion

This study will be the first to examine whether patterns of dying reported in other diagnostic groups are transferable to acute stroke care. The strengths and limitations of the study will be considered. This research will produce comprehensive understanding of the nature of clinical decision-making around end of life care in an acute stroke context, which in turn will inform the development of interventions to further build staff knowledge, skills and confidence in this challenging aspect of acute stroke care.

     

Shared decision-making in the context of menopausal health: Where do we stand?

Most health decisions occur in contexts of scientific uncertainty, the “grey zone” of decision-making and many decisions faced by menopausal women are no exception. These contexts are characterized either by scientific evidence that points to a balance between harms and benefits within or between options, or by the absence or insufficiency of scientific evidence: both situations give rise to degrees of uncertainty. Moreover, probabilities of risks and benefits in a population cannot be directly attributed at the individual level, and so uncertainty inevitably exists when considering individual decisions. Consequently, both clinicians and menopausal women need help in resolving uncertainty when facing clinical decisions. In other words, we argue that the ideal model for making decisions in the context of scientific uncertainty is the sharing of decisions between a clinician and a patient, a process known as shared decision-making (SDM). The objectives of this paper are to: (1) review the theoretical basis underlying effective interventions for SDM to occur in the context of menopausal health; (2) present the evidence regarding existing decision support interventions for menopausal women; and (3) identify implications for clinicians, health professional educators and researchers.     

Shared decision-making – transferring research into practice: The Analytic Hierarchy Process (AHP)

ObjectiveTo illustrate how the Analytic Hierarchy Process (AHP) can be used to promote shared decision-making and enhance clinician–patient communication.MethodsTutorial review.ResultsThe AHP promotes shared decision-making by creating a framework that is used to define the decision, summarize the information available, prioritize information needs, elicit preferences and values, and foster meaningful communication among decision stakeholders.ConclusionsThe AHP and related multi-criteria methods have the potential for improving the quality of clinical decisions and overcoming current barriers to implementing shared decision-making in busy clinical settings. Further research is needed to determine the best way to implement these tools and to determine their effectiveness.Practice implicationsMany clinical decisions involve preference-based trade-offs between competing risks and benefits. The AHP is a well-developed method that provides a practical approach for improving patient–provider communication, clinical decision-making, and the quality of patient care in these situations.     

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.     

Time use in clinical encounters: are African-American patients treated differently?

Racial disparities in the process and outcome of health care may be partially explained by differences in time use during outpatient visits by African-American and white patients. This study was undertaken to determine whether physicians use their time in clinical encounters with African-American patients differently than with white patients. This study was a multimethod, cross-sectional study conducted between October 1994 and August 1995 in 84 family practices in northeast Ohio. Participants were 4,352 white and African-American outpatients visiting 138 physicians. Time use during the patient visit was measured by the Davis Observation Code, which categorizes every 20-second interval into 20 different behavioral categories. Among 3,743 white and 509 African-American patients, after adjustment for potential confounders, visits by African-American patients were slightly longer than visits with white patients (10.7 vs. 10.1 minutes, p = 0.027). After further adjustment for multiple comparisons, physicians spent a lower proportion of time intervals with African-American patients as compared to white patients planning treatment (29.0% vs. 32.1%, p < 0.001), providing health education (16.4% vs. 19.7%, p < 0.001), chatting (5.2% vs. 7.6%, p < 0.001), assessing patients' health knowledge (0.8% vs. 1.2%, p < 0.001), and answering questions (5.8% vs. 6.9%, p = 0.002). Physicians spent relatively more time intervals with African-American patients discussing what is to be accomplished (9.3% vs. 7.6%, p < 0.001) and providing substance use assessment and advice (0.8% vs. 0.4%, p = 0.001). In conclusion, physicians spend time differently with African-American as compared with white patients. These differences may represent appropriate tailoring of services to meet unique needs, but could also represent racial bias.     

Shared decision-making in older patients with colorectal or pancreatic cancer: Determinants of patients’ and observers’ perceptions

Objective

To identify determinants of older patients’ perceptions of involvement in decision-making on colorectal (CRC) or pancreatic cancer (PC) treatment, and to compare these with determinants of observers' perceptions.

Shared decision-making in cardiology: Do patients want it and do doctors provide it?

Objective

Doctors should involve their patients in making decisions about their care. We studied patients with heart disease to assess if shared decision-making occurs and to study factors that predict patients’ choices or influence cardiologists’ behaviour.

Methods

85 patients attending for arteriography were assessed to elicit preferred involvement in decision-making, perception of involvement, and confidence in the decision.

Results

40% of patients wished to be involved in decisions. Preferences were unrelated to demographic factors. Cardiologists involved patients more in decisions concerning severe disease (p = 0.056). Involvement varied between cardiologists (p = 0.001). The mean duration of consultations was 5.5 min. Patients’ confidence in decisions correlated with duration (p = 0.001), explicit reference to a decision that needed to be made (p = 0.0026), and perceived, but not observed, involvement in decision-making (p = 0.05).

Conclusion

This study highlighted the complexity of doctor–patient communication. Irrespective of preferences for involvement, patients were more confident in decisions in which they perceived more involvement or which were the products of longer consultations.

Practice implications

Patients’ confidence in clinical decisions can be increased by increasing consultation length and increasing their perception of involvement. Patients perceive more involvement in decisions when doctors specifically identify the need for treatment decisions early in the consultation.     

European standard clinical practice – Key issues for the medical care of individuals with familial leukemia

Although hematologic malignancies (HM) are no longer considered exclusively sporadic, additional awareness of familial cases has yet to be created. Individuals carrying a (likely) pathogenic germline variant (e.g., in ETV6, GATA2, SAMD9, SAMD9L, or RUNX1) are at an increased risk for developing HM. Given the clinical and psychological impact associated with the diagnosis of a genetic predisposition to HM, it is of utmost importance to provide high-quality, standardized patient care. To address these issues and harmonize care across Europe, the Familial Leukemia Subnetwork within the ERN PaedCan has been assigned to draft an European Standard Clinical Practice (ESCP) document reflecting current best practices for pediatric patients and (healthy) relatives with (suspected) familial leukemia. The group was supported by members of the German network for rare diseases MyPred, of the Host Genome Working Group of SIOPE, and of the COST action LEGEND. The ESCP on familial leukemia is proposed by an interdisciplinary team of experts including hematologists, oncologists, and human geneticists. It is intended to provide general recommendations in areas where disease-specific recommendations do not yet exist. Here, we describe key issues for the medical care of familial leukemia that shall pave the way for a future consensus guideline: (i) identification of individuals with or suggestive of familial leukemia, (ii) genetic analysis and variant interpretation, (iii) genetic counseling and patient education, and (iv) surveillance and (psychological) support. To address the question on how to proceed with individuals suggestive of or at risk of familial leukemia, we developed an algorithm covering four different, partially linked clinical scenarios, and additionally a decision tree to guide clinicians in their considerations regarding familial leukemia in minors with HM. Our recommendations cover, not only patients but also relatives that both should have access to adequate medical care. We illustrate the importance of natural history studies and the need for respective registries for future evidence-based recommendations that shall be updated as new evidence-based standards are established.     

Rational decision-making about treatment and care in dementia: A contradiction in terms?

Objective

To gain caregivers’ insights into the decision-making process in dementia patients with regard to treatment and care.

Methods

Four focus group interviews (n = 29).

Results

The decision-making process consists of three elementary components: (1) identifying an individual's needs; (2) exploring options; and (3) making a choice. The most important phase is the exploration phase as it is crucial for the acceptance of the disease. Furthermore, the decision is experienced more as an emotional choice than a rational one. It is influenced by personal preferences whereas practical aspects do not seem to play a substantial role.

Conclusion

Several aspects make decision-making in dementia different from decision-making in the context of other chronic diseases: (1) the difficulty accepting dementia; (2) the progressive nature of dementia; (3) patient's reliance on surrogate decision-making; and (4) strong emotions. Due to these aspects, the decision-making process is very time-consuming, especially the crucial exploration phase.

Practice implications

A more active role is required of both the caregiver and the health care professional especially in the exploration phase, enabling easier acceptance and adjustment to the disease. Acceptance is an important condition for reducing anxiety and resistance to care that may offer significant benefits in the future.     

Microcomputers in clinical psychology – a personal view

The applications of microcomputers in clinical psychology are discussed. The author illustrates the paper with examples drawn from his own experience and suggests some ways in which microcomputers might be of value to doctors in other areas of medicine.