Measuring patient-centered communication in Patient–Physician consultations: Theoretical and practical issues

Elements of effective communication--rediscoveries from homeopathy

OBJECTIVE

Patients are increasingly attracted to homeopathy despite the unproven effectiveness of homeopathic remedies. Clinical benefit of homeopathy may be due to communication. This review aims to identify and assess effective communication patterns in homeopathy.

METHODS

Narrative review and synthesis of published communication patterns, patient narratives and the author's professional experience as a homeopathic practitioner.

RESULTS

In the biomedical model, where the focus is on disease, communication is physician-centered with early redirection of patients' concerns, and associated with reduced compliance, increasing risk of malpractice claims and low professional fulfillment. The biopsychosocial and the developing integrative medicine models are based on biomedicine but aim to include the whole person. Patient-centeredness is a behavior that elicits, respects and incorporates patients' wishes, allows active patient participation and is related to improved outcomes. The homeopathic model is based on holism and comprehension of the totality of the patient and uses patient-centered communication with a high degree of physician co-operation, empathy, hopefulness, enablement and narrative competence, all of which can improve outcomes.

CONCLUSION

Both biopsychosocial and homeopathic models rely on patient-centered communication. Regardless of conceptual differences, they overlap in their common respect for the totality and individuality of the patient. The study of the homeopathic model shows that respect for the whole person is a basic requirement to entrench patient-centeredness more firmly in medicine.

PRACTICE IMPLICATIONS

Medical education should include values such as individual coping strategies, the benefits of a sound and healthy life-style and the necessity of hope and enablement. Health care should be redesigned to honor physicians who practice these values.

The impact of patients' participation on physicians' patient-centered communication

OBJECTIVE

The goal of this study is to add to a small, but growing body of research exploring how patients' communication style affects physicians' communication. In particular, we examine how patients' active participation (e.g., asking questions, providing information) affects physicians' use of patient-centered communication.

METHODS

The same 25 physicians were observed interacting with high and low participation patients. High participation was defined as the frequency of information seeking/verifying, information provision, assertive utterances, and expressing concerns. On average, physicians interviewed 2.56 high participation patients and 3.44 low participation patients. Transcripts of the interviews were coded for physicians' patient-centered communication. High and low patient participation interviews were then compared using nested ANOVAs.

RESULTS

When interacting with high participation patients, physicians engaged in significantly more patient-centered communication overall than when interacting with low participation patients. Analyses on separate components of patient-centeredness indicated that physicians engaged in significantly more exploring of patients' disease and illness, but did not engage in significantly more understanding of the whole person or finding of common ground.

CONCLUSION

Patients who actively participate in medical interviews influence physicians to adopt a more patient-centered style of communication.

Internet information and medical consultations: experiences from patients' and physicians' perspectives

OBJECTIVE

Many patients use the Internet to obtain health-related information. It is assumed that health-related Internet information (HRII) will change the consultation practice of physicians. This article explores the strategies, benefits and difficulties from the patients' and physicians' perspective.

METHODS

Semi-structured interviews were conducted independently with 32 patients and 20 physicians. Data collection, processing and analysis followed the core principles of Grounded Theory.

RESULTS

Patients experienced difficulties in the interpretation of the personal relevance and the meaning of HRII. Therefore they relied on their physicians' interpretation and contextualisation of this information. Discussing patients' concerns and answering patients' questions were important elements of successful consultations with Internet-informed patients to achieve clarity, orientation and certainty. Discussing HRII with patients was appreciated by most of the physicians but misleading interpretations by patients and contrary views compared to physicians caused conflicts during consultations.

CONCLUSION

HRII is a valuable source of knowledge for an increasing number of patients. Patients use the consultation to increase their understanding of health and illness. Determinants such as a patient-centred consultation and timely resources are decisive for a successful, empowering consultation with Internet-informed patients.

PRACTICAL IMPLICATIONS

If HRII is routinely integrated in the anamnestic interview as a new source of knowledge, the Internet can be used as a link between physicians' expertise and patient knowledge. The critical appraisal of HRII during the consultation is becoming a new field of work for physicians.

[Evaluation of the patient centered clinical relationship: analysis of psychometric properties using the CICAA scale]

OBJECTIVE

To analyse the psychometric properties by a scale for evaluating patient centered clinical communication.

DESIGN

Validation and observational study of a measurement tool.

SETTING

Health centres and hospital outpatient clinics.

PARTICIPANTS

Three researchers independently evaluated video recorded interviews of different sub-samples: health professionals (family medicine medical residents, family doctors, specialist care physicians, and primary care nurses), actual patients who consulted for chronic or acute health problems, and standardised patients.

PRIMARY MEASUREMENTS

Dimensionality (exploratory factor analysis), internal consistency (alpha de Cronbach), intra- and inter-observer agreement (Kappa index, intraclass correlation coefficient [ICC], generalisability), sensitivity to change (Student t test) and convergent validity with the GATHA questionnaire (Pearson correlation coefficient).

RESULTS

Six factors have been identified that explain 66.0% of the variance. The overall internal consistency of the test was alpha=0.94. The overall intra-observer agreement, measured with the ICC, varied between 0.94 and 0.97, whilst the inter-observer was between 0.82-0.90. The number of completed questionnaires required for the evaluator to obtain adequate reproducibility (generalisability) varied between 6 and 12. Statistical significance was not obtained when testing the sensitivity to change. The CICAA scale and the GATHA questionnaire had a correlation of 0.67.

CONCLUSIONS

The CICAA scale is a generic patient centered clinical communication evaluation tool that may be used in different clinical contexts and situations, since it has shown to be reliable, valid and efficient.

Patient-centered communication in primary care: physician and patient gender and gender concordance

BACKGROUND

Physicians' use of patient-centered communication (PCC) affects important outcomes of care. Although there is evidence that both patient and physician gender affect the process of care, there is limited information about their impact on PCC. Our objective was to investigate the influence of patient and physician gender, as well as gender concordance between patient and physician, on the patient centeredness of primary care visits.

METHODS

Participating primary care physicians (100 family physicians and internists) with clinical practices in the Rochester, New York area, had two unannounced covertly audiorecorded standardized patients' visits. Encounters were analyzed using the Measure of Patient-Centered Communication (MPCC), which measures three aspects of physician communication: Component 1 (Exploring both the disease and illness experience), Component 2 (Understanding the whole person), and Component 3 (Finding common ground).

RESULTS

Compared with male patients, females had interactions characterized by greater PCC (total and Component 2 scores). Whereas female physicians exhibited higher Component 1 scores, male physicians had higher Component 2 scores, and gender-concordant visits also exhibited higher Component 2 scores. However, there were no significant differences in total MPCC scores for encounters of female vs. male physicians or for gender-concordant compared with discordant patient-physician dyads.

CONCLUSIONS

These findings add further evidence that patient gender can affect the interactions between physicians and patients. More research is needed to understand why male patients are less likely to have medical encounters in which their physicians employ a patient-centered practice style.

The impact of electronic medical records on patient-doctor communication during consultation: a narrative literature review

RATIONALE, AIMS AND OBJECTIVE

The effect of Electronic Medical Record (EMR) use on Patient-Doctor Communication (PDC) has rarely been studied. As data accumulate, the purpose of this article is to review the literature on EMR effect on PDC, to identify recurring themes and to offer preliminary guidelines and future directions for medical education and research.

METHOD

A database search was conducted and 14 articles that met inclusion criteria (published in the past 10 years, empirical investigations, direct assessment of the EMR impact on patient-doctor communication) were selected for review. A qualitative, grounded theory-like approach was employed to analyse the data.

RESULTS

EMR use often has a positive impact on information exchange, but exerts a negative influence on patient centredness. Some physician characteristics such as their computer skills and behavioural style assist in overcoming this negative influence.

CONCLUSION

The use of EMR exerts both positive and negative impacts on physician-patient relationships. The negative impacts can be overcome by some simple means as well as better designs of EMR systems and medical education interventions. Physicians' everyday practices of integrating EMR use into the clinical encounter as well as better design of EMR systems and EMR and communication training may facilitate PDC in computerized settings.

What do Nepalese medical students and doctors think about patient-centred communication?

OBJECTIVE

To ascertain the attitudes of Nepalese medical students and doctors regarding aspects of doctor-patient communication.

METHOD

A cross-sectional survey, using the Patient-Practitioner Orientation Scale (PPOS), was undertaken with students and doctors in a teaching hospital in rural Nepal. Qualitative research was also done, using semi-structured interviews and focus groups, with a sample from the same population. The author's participant observations provided a third data source.

RESULTS

Participants generally expressed 'patient-centred' attitudes, particularly in the following areas: power-sharing; the importance of social context; friendliness; providing adequate time and explanations. They thought that the hierarchical nature of society carried over into medical practice, particularly noting the exalted position of doctors and the importance of social and financial issues in patient outcomes. The participants thought that Nepalese doctors currently practice in a 'doctor-centred' manner but thought that this should change.

CONCLUSION

There was a marked contrast between the attitudes expressed by participants and the way that they see medicine is currently practiced. The results also showed an under-appreciation of Nepalese patients' universal desire for being given good information.

PRACTICE IMPLICATIONS

This study underlines the need for an increased understanding of local preferences regarding medical communication styles. Methods of providing information to patients need to be strengthened in clinical practice.

The potential of complementary and alternative medicine in promoting well-being and critical health literacy: a prospective, observational study of shiatsu

Background

The potential contribution of complementary and alternative medicine (CAM) modalities to promote and support critical health literacy has not received substantial attention within either the health promotion or the CAM literature. This paper explores the potential of one CAM modality, shiatsu, in promoting well-being and critical health literacy.

Methods

Data are drawn from a longitudinal, 6 months observational, pragmatic study of the effects and experience of shiatsu within three European countries (Austria, Spain and the UK). Client postal questionnaires included: advice received, changes made 6 months later, clients 'hopes' from having shiatsu and features of the client-practitioner relationship.

Result

At baseline, three-quarters of clients (n = 633) received advice, on exercise, diet, posture, points to work on at home or other ways of self-care. At 6 months follow-up, about four-fifths reported making changes to their lifestyle 'as a result of having shiatsu treatment', including taking more rest and relaxation or exercise, changing their diet, reducing time at work and other changes such as increased body/mind awareness and levels of confidence and resolve. Building on the findings, an explanatory model of possible ways that a CAM therapy could contribute to health promotion is presented to guide future research, both within and beyond CAM.

Conclusion

Supporting individuals to take control of their self-care requires advice-giving within a supportive treatment context and practitioner relationship, with clients who are open to change and committed to maintaining their health. CAM modalities may have an important role to play in this endeavour.

The Experience of Discrimination and Black-White Health Disparities in Medical Care

The current study of Black patients focuses on how discrimination contributes to racial disparities in health. The authors used a longitudinal methodology to study how perceived past discrimination affects reactions to medical interactions and adherence to physician recommendations. In addition, they explored whether these reactions and/or adherence mediate the relationship between discrimination and patients' health. The participants in this study were 156 Black patients of low socioeconomic status at a primary care clinic. Patients completed questionnaires on their current health, past adherence, and perceived past discrimination. Then, they saw a physician and rated their reactions to the visit. Four and 16 weeks later they reported on their adherence to physician recommendations and overall health. Perceived discrimination was significantly and negatively associated with patient health, reactions to the physician, and adherence. Path analyses indicated that adherence mediated the relationship between discrimination and patient health, but patient reactions to the interaction did not.

Patient-centered care and adherence: definitions and applications to improve outcomes

PURPOSE

The implementation of patient-centered care (PCC) has been hampered by the lack of a clear definition and method of measurement. The purpose of this review is to identify the fundamental characteristics of PCC to clarify its definition, propose a method for measurement of PCC, and recommend effective PCC practices.

DATA SOURCES

Review of literature related to PCC, adherence and communication from Cinahl, PubMed Academic Search Premier, and Cochrane Library databases.

CONCLUSIONS

Research has shown that patient-centered interactions promote adherence and lead to improved health outcomes. The fundamental characteristics of PCC were identified as (a) patient involvement in care and (b) the individualization of patient care. The use of a numeric rating scale to measure the presence of these characteristics allows quantification from the patient perspective. Effective PCC practices were related to communication, shared decision making, and patient education.

IMPLICATIONS FOR PRACTICE

PCC is a measure of the quality of health care. Understanding the characteristics of PCC facilitates its implementation and measurement. Promoting PCC activities will improve adherence and encourage patient responsibility for health status.

'They don't ask me so I don't tell them': patient-clinician communication about traditional, complementary, and alternative medicine

PURPOSE

Although high rates of traditional medicine and complementary and alternative medicine (TM/CAM) use have been well documented, there has been less attention to the factors influencing communication between patients and their primary care clinicians about TM/CAM. Such communication can be important in anticipating possible drug-herb interactions and in assuring agreement about therapeutic plans.

METHODS

We used sequential, multistage, qualitative methods, including focus groups, in-depth interviews, and a video vignette, to explore communication about TM/CAM between patients and their primary care clinicians. The study was conducted in RIOS Net (Research Involved in Outpatient Settings Network), a Southwestern US practice-based research network, situated largely in Hispanic and American Indian communities where TM/CAM is an important part of self-care.

RESULTS

One hundred fourteen patients, 41 clinic staff members, and 19 primary care clinicians in 8 clinic sites participated. The degree and nature of TM/ CAM communication is based on certain conditions in the clinical encounter. We categorized these findings into 3 themes: acceptance/nonjudgment, initiation of communication, and safety/efficacy. Perceived clinician receptivity to and initiation of discussion about TM/CAM strongly influenced patients' decisions to communicate; perceived clinician expertise in TM/CAM was less important. Clinicians' comfort with patients' self-care approaches and their level of concern about lack of scientific evidence of effectiveness and safety of TM/CAM influenced their communication about TM/CAM with patients.

CONCLUSIONS

Specific communication barriers limit patient-clinician communication about TM/CAM. Clinicians who wish to communicate more effectively with their patients about these topics and better integrate the types of care their patients use can change the communication dynamic with simple strategies designed to overcome these barriers.

Older people's experiences of patient-centered treatment for chronic pain: a qualitative study

INTRODUCTION

Older adults with chronic pain who seek treatment often are in a health care environment that emphasizes patient-directed care, a change from the patriarchal model of care to which many older adults are accustomed.

OBJECTIVE

To explore the experiences of older adults seeking treatment for chronic pain, with respect to patient-directed care and the patient-provider relationship.

DESIGN

In-depth interviews with 15 Caucasian older adults with chronic pain who had been evaluated at a university-based pain clinic. All interviews were audiotaped and the transcripts were analyzed using a grounded theory based approach.

RESULTS

Older adults with chronic pain vary in their willingness to be involved in their treatment decisions. Many frequently participate in decisions about their pain treatment by asking for or refusing specific treatments, demanding quality care, or operating outside of the patient-provider relationship to manage pain on their own. However, others prefer to let their provider make the decisions. In either case, having a mutually respectful patient-provider relationship is important to this population. Specifically, participants described the importance of "being heard" and "being understood" by providers.

CONCLUSIONS

As some providers switch from a patriarchal model of care toward a model of care that emphasizes patient activation and patient-centeredness, the development and cultivation of valued patient-provider relationships may change. While it is important to encourage patient involvement in treatment decisions, high-quality, patient-centered care for older adults with chronic pain should include efforts to strengthen the patient-provider relationship by attending to differences in patients' willingness to engage in patient-directed care and emphasizing shared decision-making.

The role of the clinician in cancer clinical communication

Clinician communication is critical to positive outcomes for patients and families in most health contexts. Researchers have investigated areas such as defining and teaching effective communication and identifying specific outcomes that can be improved through more effective communication. In the area of cancer care, advances in detection and treatment require that clinicians develop new skills to adapt to the evolving needs of patients, families, and other members of the health care team. Some areas that require the attention of researchers are defining, assessing, and teaching effective communication in the context of the specific desires and preferences of individual patients and special populations; and meeting the needs of patients across the cancer continuum from screening, diagnosis, treatment to palliative care and survivorship. This report highlights three areas of research in cancer clinician communication including key areas of current and emerging research and theories and approaches for future research.

Reproductive health service preferences and perceptions of quality among low-income women: racial, ethnic and language group differences

CONTEXT

Eliminating racial and ethnic disparities in health care is an important national priority. Despite substantial research documenting such disparities, this topic has received limited attention in the reproductive health field.

METHODS

Logistic regression was used to test for group differences in three service delivery preferences and five service quality perceptions among a nationally representative sample of 1,741 low-income black, Latina and white women aged 18-34; the data were collected in 1995 and represent the most recent data available for looking at these issues.

RESULTS

English-speaking Latinas and Spanish-speaking Latinas were more likely than whites to prefer a female clinician at their visits (odds ratios, 1.8 and 3.6, respectively) and to highly value clinician continuity (1.7 and 2.2). English-speaking Latinas and blacks were more likely than whites to prefer receiving reproductive health care at a site delivering general health care (1.5 and 1.6). Both groups of Latinas were less likely than whites to give the facility environment or the patient-centeredness at their most recent reproductive health visit the highest rating (0.3-0.5). Blacks were more likely than whites to report ever having been pressured by a clinician to use contraceptives (2.3).

CONCLUSIONS

Efforts to reduce racial, ethnic and language group differences in clients' perceptions of reproductive health service quality should focus on improving client-clinician communication, the service environment and contraceptive counseling. Future research should continue to assess group differences and try to determine their underlying causes.

Types of centredness in health care: themes and concepts

BACKGROUND

For a variety of sociological reasons, different types of centredness have become important in health and social care. In trying to characterize one type of centredness, we were led to consider, at a conceptual level, the importance of the notion of centredness in general and the reasons for there being different types of centeredness.

METHOD

We searched the literature for papers on client-, family-, patient-, person- and relationship- centred care. We identified reviews or papers that defined or discussed the notions at a conceptual level. The reviews and papers were analyzed as text transcripts.

RESULTS

We identified 10 themes that were common to all the types of centredness. At a conceptual level we could not identify thematic differences between the types of centredness. These findings were subjected to a philosophical critique using ideas derived from Wittgenstein.

CONCLUSION

Different types of centredness are required in different contexts. The differences are justified by their practical utility. The unifying themes of centredness, however, reflect a movement in favour of increasing the social, psychological, cultural and ethical sensitivity of our human encounters.

Critical elements of culturally competent communication in the medical encounter: a review and model

Increasing the cultural competence of physicians is one means of responding to demographic changes in the USA, as well as reducing health disparities. However, in spite of the development and implementation of cultural competence training programs, little is known about the ways cultural competence manifests itself in medical encounters. This paper will present a model of culturally competent communication that offers a framework of studying cultural competence 'in action.' First, we describe four critical elements of culturally competent communication in the medical encounter--communication repertoire, situational awareness, adaptability, and knowledge about core cultural issues. We present a model of culturally competent physician communication that integrates existing frameworks for cultural competence in patient care with models of effective patient-centered communication. The culturally competent communication model includes five communication skills that are depicted as elements of a set in which acquisition of more skills corresponds to increasing complexity and culturally competent communication. The culturally competent communication model utilizes each of the four critical elements to fully develop each skill and apply increasingly sophisticated, contextually appropriate communication behaviors to engage with culturally different patients in complex interactions. It is designed to foster maximum physician sensitivity to cultural variation in patients as the foundation of physician-communication competence in interacting with patients.

Everyday use of patient-centred, motivational techniques in routine consultations between doctors and patients with diabetes

OBJECTIVE

Facilitating lifestyle change and improved self-management are important aspects of diabetes treatment. Previous research shows motivational, patient-centred approaches are more effective at this than traditional, didactic approaches. This study explores the degree to which doctors with no previous training in motivational techniques employ these methods to affect behaviour change in routine consultations.

METHODS

A cross-sectional design was employed. Forty-four routine consultations with nine physicians were tape-recorded, of which nineteen focussed on behaviour change; patient questionnaires assessed patient demographics, intention to self-manage and satisfaction with consultation. Physician behaviour was coded for use of motivational, behaviour change techniques, patient-centeredness and other verbal communication variables; patient communication was also assessed.

RESULTS

Lifestyle issues were raised in 43% of consultations but few motivational strategies were employed; 10% of physicians' communication was patient-centred. An association was found between physicians' use of patient-centred strategies and patients expressing views (r = .44, p < .05). Higher patient satisfaction with the consultation was related to physician partnership-building (r = .37, p < or = .05) and patients asking questions (r = -.31, p < or = .05). Familiarity between doctor and patient was associated with more physician recommendations and directives (r = .35, p < or = .05) and information giving (r= .30, p < or = .05), and more assertive responses by the patient (r = .31, p < or = .05).

CONCLUSION

Effective communication strategies related to behaviour change were not used routinely in diabetes consultations in the clinic studied. More patient-centred approaches were associated with higher indicators of patient satisfaction.

PRACTICE IMPLICATIONS

Physicians require training and support in employing behaviour change techniques if these are to be integrated into routine care.

Physician personality characteristics and inquiry about mood symptoms in primary care

BACKGROUND

Depression treatment is often initially sought from primary care physicians.

OBJECTIVE

To explore the influence of physician personality on depression assessments.

DESIGN

Secondary analysis of data collected in a randomized controlled trial.

SETTING

Offices of primary care physicians in Rochester, NY.

PARTICIPANTS

Forty-six physicians; six female actors.

INTERVENTION

Eighty-six unannounced standardized patient (SPs) visits; physicians saw one SP with major depression and one with adjustment disorder.

MEASUREMENTS

SPs listened to audiotapes and completed a form on doctoring behaviors and symptom inquiry immediately following the visit. For the assessment of diagnostic documentation, SPs' medical records were reviewed. Physician personality was assessed via items from the NEO-PI-R.

RESULTS

Physicians who are more dutiful and more vulnerable were more likely to document a diagnosis of depression; those who are more dutiful also asked fewer questions concerning mood symptoms.

LIMITATION

Roles portrayed by the SPs may not reflect the experience of a typical primary care patient. Most of the PCPs were white men. The sample of PCPs was limited to a single geographic location. Effect sizes were modest.

CONCLUSIONS

The clinical, educational, and translational, implications of research showing that physician personality traits could affect practice behaviors warrant consideration. Current models of treatment for depression in primary care could be engineered to accommodate the variability in physician personality. Given that there is no single "correct" way to ask about mood disorders or suicide, clinicians are encouraged to adopt an approach that fits their personal style and preferences.

Veterans' decision-making preferences and perceived involvement in care for chronic heart failure

BACKGROUND

Patients with heart failure require a great deal of information about their disease, but it is also important to know about their preferences for involvement in medical decision making and about factors that may influence their preferences so that patients' needs, values, and preferences can be met by clinicians.

OBJECTIVES

We assessed patients' preferred role and perceived level of involvement in medical decision making and tested the effects of patients' age and role preference on perceived involvement in medical decision making.

METHODS

We conducted a telephone survey of 90 adults being treated for heart failure by a Veterans Affairs primary care provider or cardiologist. Patients' preferred role in treatment decisions was assessed using the Control Preferences Scale. Perceptions about their involvement in decision making during the most recent clinic visit was measured using a subscale of the Perceived Involvement in Care Scale. Descriptive, correlational, and generalized linear regression analyses were conducted.

RESULTS

Most patients were elderly (mean = 70.1 years), male (94.4%), and white (85.6%), and had New York Heart Association class II disease (55.6%). Forty-three patients (47.8%) preferred a passive role in decision making, 19 patients (21.1%) preferred an active role, and 28 patients (31.1%) preferred a collaborative role. Most patients believed that their decision-making involvement was relatively passive, as indicated by a mean score of .96 (range, 0-4) on the Perceived Involvement in Care Scale decision-making subscale. Older age was associated with passive role preference (r = .263; P < .05) and less perceived involvement in decision making (r = -.279; P < .01). In addition, less perceived involvement in decision making during the last clinic visit was associated with a preference for a more passive decision-making role (r = rho.355; P < .01). Generalized linear regression analysis indicated that when patients' perceived decision-making involvement was regressed on age and patients' role preferences, age was no longer significantly associated with involvement (beta = -.196; P = .061), but that control preferences continued to exhibit an independent effect on perceived involvement in medical decision making (beta = -.341; P = .003).

CONCLUSION

The results suggest that the preferences of patients with heart failure for a more passive role in decision making may be a stronger independent predictor of patients' perceived involvement in decision making than patients' age.

The patient, the doctor and the emergency department: a cross-sectional study of patient-centredness in 1990 and 2005

OBJECTIVE

To compare and contrast the duration and content of physician-patient interaction for patients presenting to an emergency department with problems of low acuity in 1990 and 2005 treated by different grades of physician.

METHODS

Observational study with data collection in May-July 1990 and May-July 2005. Patients identified at nurse triage as presenting with 'primary care' problems were allocated by time of arrival to senior house officers (1990, n=7; 2005, n=10), specialist registrars/staff grades (1990, n=4; 2005, n=7) or sessionally employed general practitioners (1990, n=8; 2005, n=12) randomly rostered to work in a consulting room that had a wall-mounted video camera. A stratified sample of 430 video-taped consultations (180 (42%) from 1990 and 250 (58%) from 2005) was analysed using the Roter Interaction Analysis System. Main outcome measures -- length of consultation; numbers of utterances of physician and patient talk related to building a relationship, data gathering, activating/partnering (i.e. actively encouraging the patient's involvement in decision-making), and patient education/counselling.

RESULTS

On average consultation length was 251s (95% CI for difference: 185-316) longer in 2005 than in 1990. The difference was especially marked for senior house officers (mean duration 385s in 1990 and 778s in 2005; 95% CI of difference: 286-518). All groups of physician showed increased communication related to activating and partnering and building a therapeutic relationship with the patient. While senior house officers demonstrated a greatly increased focus on data gathering, only general practitioners substantially increased the amount of talk centred on patient education and counselling; compared to senior house officers, the odds ratio for the number of such utterances included in consultations was 2.8 (95% CI: 1.4, 5.3).

CONCLUSION

Although patient-centredness together with consultation length increased for all three physician groups over the duration of this study, senior house officers and specialist registrars/staff grades continued to place less emphasis on advice-giving and counselling than did general practitioners. The extent to which these observed changes in practice were determined by policy, management and training initiatives, and their impact on patient outcome, needs further study.

PRACTICE IMPLICATIONS

Video-recording consultations is feasible in an acute hospital setting, and could be used to support training and workforce development. General practitioners can make a distinctive contribution to the workforce of emergency departments. Their consulting style differs from that of hospital physicians and may benefit patient care through a greater focus on patient education and counselling.

Physician-patient and pharmacist-patient communication: geriatrics' perceptions and opinions

OBJECTIVE

Earlier research examined the perceptions of the pharmacist-patient relationship quality using data from a systematic random sample of non-institutionalized elderly in the United States. The purposes of this study were to determine: (1) how the findings of this study, conducted in a culturally diverse urban area in Queens, New York, compare with the earlier study; (2) how community-dwelling elderly patients in a metropolitan area perceive their relationship with the pharmacist compared to the physician; and (3) the extent to which their perceived relationship quality predicts medication-related knowledge, medication-related outcomes, and self-efficacy for medication management.

METHODS

One hundred and twenty-one elderly individuals aged 65 and over who took at least one prescription medication, selected from three senior centers, participated in the study. Of the total responses, 102 were useable.

RESULTS

Our sample demonstrated significantly lower levels of perceived quality of relationship with their pharmacist compared to earlier research. In contrast, the participants in this study perceived a better quality of relationship with their physicians than pharmacists. Further, the quality of relationship with physician predicted medication-related knowledge, medication-related outcome expectations, and self-efficacy for medication management.

CONCLUSION

The findings of this study suggest that pharmacists still have a way to go to fully meet patients' healthcare needs, particularly in culturally diverse urban settings.

PRACTICE IMPLICATIONS

Further research is needed to examine ways to improve pharmacist-patient interactions and, therefore, patients' perceptions of pharmacists.

Understanding concordance in patient-physician relationships: personal and ethnic dimensions of shared identity

PURPOSE

Although concordance by race and sex in physician-patient relationships has been associated with patient ratings of better care, mechanisms through which concordance leads to better outcomes remains unknown. This investigation examined (1) whether patients' perceptions of similarity to their physicians predicted their ratings of quality of care and (2) whether perceived similarity was influenced by racial and sexual concordance and the physician's communication.

METHODS

The research design was a cross-sectional study with 214 patients and 29 primary care physicians from 10 private and public outpatient clinics. Measures included postvisit patient ratings of similarity to the physician; satisfaction, trust, and intent to adhere; and audiotape analysis of patient involvement and physicians' patient-centered communication.

RESULTS

Factor analysis revealed 2 dimensions of similarity, personal (in beliefs, values) and ethnic (in race, community). Black and white patients in racially concordant interactions reported more personal and ethnic similarity (mean score, 87.6 and 78.8, respectively, on a 100-point scale) to their physicians than did minority patients (mean score, 81.4 and 41.2, respectively) and white patients (mean score, 84.4 and 41.9, respectively) in racially discordant encounters. In multivariable models, perceived personal similarity was predicted by the patient's age, education, and physicians' patient-centered communication, but not by racial or sexual concordance. Perceived personal similarity and physicians' patient-centered communication predicted patients' trust, satisfaction, and intent to adhere.

CONCLUSIONS

The physician-patient relationship is strengthened when patients see themselves as similar to their physicians in personal beliefs, values, and communication. Perceived personal similarity is associated with higher ratings of trust, satisfaction, and intention to adhere. Race concordance is the primary predictor of perceived ethnic similarity, but several factors affect perceived personal similarity, including physicians' use of patient-centered communication.

Exploration of communicative patterns of consultations in palliative cancer care

Building on the research conducted on institutional communication, and the analysis of actual communication taking place in clinical settings, this study describes and highlights features of palliative care consultations and focuses on the distribution of discursive space (i.e., share of words, lengths of turns), occurring topics and conversational frames. Six consultations between physicians, patients and significant others were videotaped and all participants took part in audio-taped interviews. The recordings were transcribed and analysed in regard to expectations of, the discursive space of, and topics addressed in the consultations. The distribution of the discursive space was unequal; the physicians had the greatest share of words and length of turns in all six consultations, and they mostly initiated discussion of medical issues connected to examinations and treatment, while only patients initiated the topic of the patient's future. During the consultations, institutional framing tended to dominate over client framing. There was found to be room for further study of the structure and content of palliative care consultations with emphasis on how the voice of the patient can manifest itself within the framework of the medical agenda of the consultation and its significance for palliative cancer team work.

Self-monitoring in clinical practice: a challenge for medical educators

Recent literature has described how the capacity for concurrent self-assessment-ongoing moment-to-moment self-monitoring-is an important component of the professional competence of physicians. Self-monitoring refers to the ability to notice our own actions, curiosity to examine the effects of those actions, and willingness to use those observations to improve behavior and thinking in the future. Self-monitoring allows for the early recognition of cognitive biases, technical errors, and emotional reactions and may facilitate self-correction and development of therapeutic relationships. Cognitive neuroscience has begun to explore the brain functions associated with self-monitoring, and the structural and functional changes that occur during mental training to improve attentiveness, curiosity, and presence. This training involves cultivating habits of mind such as experiencing information as novel, thinking of "facts" as conditional, seeing situations from multiple perspectives, suspending categorization and judgment, and engaging in self-questioning. The resulting awareness is referred to as mindfulness and the associated moment-to-moment self-monitoring as mindful practice-in contrast to being on "automatic pilot" or "mindless" in one's behavior. This article is a preliminary exploration into the intersection of educational assessment, cognitive neuroscience, and mindful practice, with the hope of promoting ways of improving clinicians' capacity to self-monitor during clinical practice, and, by extension, improve the quality of care that they deliver.

Measuring shared decision making in the consultation: a comparison of the OPTION and Informed Decision Making instruments

OBJECTIVE

To investigate the applied and conceptual relationship between two measures of shared decision making using the OPTION instrument developed in Wales and the Informed Decision Making instrument developed in Seattle, USA using audio-taped consultation data from a UK general practice population.

METHODS

Twelve general practitioners were recruited from 6 general practices in the southwest of England. One hundred twenty-three GP-patient consultations were audio-recorded. Audiotapes were sent off to, and rated by, respective experts in the use of the OPTION and the Informed Decision Making instruments.

RESULTS

Compared to earlier work using the Informed Decision Making tool, consultations in this sample were shorter, had fewer decisions and tended to have a greater number of elements present. Similar to previous research using the OPTION, values using the OPTION instrument were low with two items, giving the patient opportunities to ask questions and checking patient understanding, exhibiting the most variability. Using a 'key' decision in each consultation as the basis for comparison, the Informed Decision Making score was not related to the overall OPTION score (Spearman's rho=0.14, p=0.13). Both instruments also predicted different 'best' and 'worst' doctors. Using a Bland-Altman plot for assessing agreement, the mean difference between the two measures was 1.11 (CI 0.66-1.56) and the limits of agreement were -3.94 to 6.16. There were several elements between the two instruments that appeared conceptually similar and correlations for these were generally higher. These were: discussing alternatives or options (Spearman's rho=0.35, p=0.0001), discussion of the patient's role in decision making (Spearman's rho=0.23, p=0.012), discussion of the pros/cons of the alternatives (Spearman's rho=0.20, p=0.024) and assessment of the patient's understanding (Spearman's rho=0.19, p=0.03).

CONCLUSION

Measures of shared decision making are helpful in identifying those shared decision making skills which may be problematic or difficult to integrate into practice and provide a tool by which the development of skills can be assessed over time. Research may implicitly place undue value on those aspects of shared decision making which are most easily measured.

PRACTICE IMPLICATIONS

Shared decision making tools are a useful way of capturing the presence or absence of specific shared decision making skills and changes in skills acquisition over time. However there may be limits in the extent to which the concept of shared decision making can be measured and that more easily measured skills will be emphasised to the detriment of other important shared decision making skills.

What does patient-centred communication mean in Nepal?

OBJECTIVES

To ascertain the expectations of Nepalese patients regarding aspects of doctor-patient communication and to review a model of patient-centred care for its appropriateness to Nepalese medical communication training.

METHODS

A cross-sectional survey, using an adapted version of the Patient-Practitioner Orientation Scale (PPOS), was undertaken with a random sample of patients attending a general outpatients department in rural Nepal. An alternative survey instrument, derived from the PPOS, was also used.

RESULTS

The following issues were most important to patients: being treated in a friendly and respectful manner; being fully informed, and being given adequate consultation time. Patients were happy for the doctor to be in charge and did not want to seek information outside the doctor's advice. They expressed a strong preference for receiving advice about preventative care. Patient responses were significantly more 'doctor-centred' than those found in comparable studies in the USA.

DISCUSSION

Patients expressed strong preferences for some aspects of patient-centred communication (PCC), but were not very concerned with sharing power and control. Models of PCC in Nepal require modification to reflect these local preferences. The importance of good communication techniques requires emphasis in clinical training and practice. Methods of disseminating information need to be enhanced in this low-literacy setting.

[Therapeutic education in asthma management]

All guidelines, protocols and recommendations underline the importance of therapeutic education as a key element in asthma management and control. Considerable evidence supports the efficacy and effectiveness of this measure. Health personnel, as well as patients and their parents, can and should be educated with two main objectives: to achieve the best possible quality of life and to allow self control of the disease. These goals can be attained through an educational process that should be individually tailored, continuous, progressive, dynamic, and sequential. The process poses more than a few difficulties involving patients, health professionals, and the health systems. Knowledge of the various psychological factors that can be present in asthmatic patients, as well as the factors related to the highly prevalent phenomenon of non-adherence, is essential. Awareness of the factors influencing physician-patient-family communication is also highly important to achieve the objectives set in therapeutic education. The educational process helps knowledge and abilities to be acquired and allows attitudes and beliefs to be modified. Patients and caregivers should be provided with an individual written action plan based on symptoms and/or forced expiratory volume in 1 second. Periodic follow-up visits are also required.

"Could this be something serious?" Reassurance, uncertainty, and empathy in response to patients' expressions of worry

BACKGROUND

Previous work suggests that exploration and validation of patients' concerns is associated with greater patient trust, lower health care costs, improved counseling, and more guideline-concordant care.

OBJECTIVE

To describe physicians' responses to patients' worries, how their responses varied according to clinical context (straightforward versus medically unexplained symptoms [MUS]) and associations between their responses and patients' ratings of interpersonal aspects of care.

DESIGN

Multimethod study. For each physician, we surveyed 50 current patients and covertly audiorecorded 2 unannounced standardized patient (SP) visits. SPs expressed worry about "something serious" in 2 scenarios: straightforward gastroesophageal reflux or poorly characterized chest pain with MUS.

PARTICIPANTS

One hundred primary care physicians and 4,746 patients.

MEASUREMENTS

Patient surveys measuring interpersonal aspects of care (trust, physician knowledge of the patient, satisfaction, and patient activation). Qualitative coding of 189 transcripts followed by descriptive, multivariate, and lag-sequential analyses.

RESULTS

Physicians offered a mean of 3.1 responses to each of 613 SP prompts. Biomedical inquiry and explanations, action, nonspecific acknowledgment, and reassurance were common, whereas empathy, expressions of uncertainty, and exploration of psychosocial factors and emotions were uncommon. Empathy expressed during SP visits was associated with higher patient ratings of interpersonal aspects of care. After adjusting for demographics and comorbidities, the association was only statistically significant for the MUS role. Empathy was most likely to occur if expressed at the beginning of the conversational sequence.

CONCLUSIONS

Empathy is associated with higher patient ratings of interpersonal care, especially when expressed in situations involving ambiguity. Empathy should be expressed early after patient expressions of worry.

Sequence analysis in multilevel models. A study on different sources of patient cues in medical consultations

The aims of the study were to explore the importance of macro (patient, physician, consultation) and micro (doctor-patient speech sequences) variables in promoting patient cues (unsolicited new information or expressions of feelings), and to describe the methodological implications related to the study of speech sequences. Patient characteristics, a consultation index of partnership and doctor-patient speech sequences were recorded for 246 primary care consultations in six primary care surgeries in Verona, Italy. Homogeneity and stationarity conditions of speech sequences allowed the creation of a hierarchy of multilevel logit models including micro and macro level variables, with the presence/absence of cues as the dependent variable. We found that emotional distress of the patient increased cues and that cues appeared among other patient expressions and were preceded by physicians' facilitations and handling of emotion. Partnership, in terms of open-ended inquiry, active listening skills and handling of emotion by the physician and active participation by the patient throughout the consultation, reduced cue frequency.

Parent-provider communication and parental satisfaction with care of children with psychosocial problems

OBJECTIVE

The objective of the present paper was to determine the association between parent-provider communication and parent ratings of satisfaction and quality of care for a group of parents of children identified with a psychosocial problem.

METHODS

A sample of 804 parents of children with psychosocial concerns enrolled in the Child Behavior Study (CBS) was used for the present analyses. As part of the CBS, parents of children with psychosocial problems answered questions that assessed parent-provider communication and parent ratings of satisfaction and quality of care.

RESULTS

Overall, parents reported good communication with their child's provider. Eighty-two percent of parents were very satisfied with the care received and 68% reported a very high quality of care. Parent-provider communication (e.g., collaboration and mutual understanding) was strongly related to parental reports of both satisfaction and quality of care.

CONCLUSIONS

Parent-provider communication is an important correlate of parental report of satisfaction and quality of care. Involvement of parents in the treatment planning process was particularly important in determining satisfaction and quality ratings within this sample.

PRACTICE IMPLICATIONS

When working with families with identified psychosocial concerns, the use of collaboration and an empathic style by providers may enhance the quality of care parents report receiving from their primary care clinicians.

Doctors' responses to patients with medically unexplained symptoms who seek emotional support: criticism or confrontation?

OBJECTIVE

Consultations about medically unexplained symptoms (MUSs) can resemble contests over the legitimacy of patients' demands. To understand doctors' motivations for speech appearing to be critical of patients with MUSs, we tested predictions that its frequency would be related to patients' demands for emotional support and doctors' patient-centered attitudes as well as adult attachment style.

METHODS

Twenty-four general practitioners identified 249 consecutive patients presenting with MUSs and indicated their own patient-centered attitudes as well as adult attachment style (positive models of self and others). Before consultation, patients self-reported their desire for emotional support. Consultations were audio recorded and coded utterance by utterance. The number of utterances coded as criticism was the response variable in the multilevel regression analyses.

RESULTS

Frequency of criticism was positively related to patients' demands for emotional support, to doctors' belief in sharing responsibility with patients and to doctors' positive model of themselves. It was inversely associated with doctors' belief that patients' feelings were legitimate business for consultation and was unrelated to their model of others.

CONCLUSIONS

From the perspective of doctors, speech that appears to be critical probably reflects therapeutic intent and might therefore be better described as "confrontation." Understanding doctors' motivations for what they say to patients with MUSs will allow for more effective interventions to improve the quality of consultations.

Human papillomavirus vaccination programmes

Need to have a broader perspective than simply increasing uptake of the vaccine

Promoting lifestyle self-awareness among the medical team by the use of an integrated teaching approach: a primary care experience

OBJECTIVES

Healthy lifestyle is recommended in clinical guidelines for the prevention and treatment of chronic diseases such as cardiovascular disease and diabetes. Research previously identified a gap between lifestyle recommendations and their implementation in clinical practice. In this paper, we describe a pilot educational program aimed to promote providers' awareness of their own lifestyles, and to explore whether increased personal awareness enhances providers' willingness to engage in lifestyle-change discussion with patients.

METHODS

Two primary-care urban clinics in Northern Israel participated in the program, which consisted of a series of six biweekly educational sessions, each lasting 2-4 hours. Each session included both knowledge-based and experiential learning based on complementary medicine modalities. Surveys at the end of the program and a year later provided the program evaluation.

RESULTS

Thirty-five personnel participated in the program. Thirteen (13) of the 20 participants (65%) reported an attitude change regarding eating habits after the program. At 1-year follow up, 24 of the 27 respondents (89%) stated that they were more aware of their eating habits and of their physical activity compared with precourse status. Twenty-three (23) of 27 respondents (85%) stated that after the program they were better prepared to initiate a conversation with their patients about lifestyle change.

CONCLUSIONS

An integrated educational approach based on knowledge-based and complementary and alternative medicine experiential modalities, aimed to facilitate self-awareness, may enhance learners' attitude change. The findings demonstrate readiness of learners to reexamine their lifestyles. Increased self-awareness helped participants to make a positive attitude change regarding eating habits and physical activity and was associated with participants' increased engagement in lifestyle-change discussions with patients. The teaching approach had longstanding effect, noted in the one-year follow-up.

Views on sick-listing practice among Swedish General Practitioners--a phenomenographic study

BACKGROUND

The number of people on sick-leave started to increase in Sweden and several other European countries towards the end of the 20th century. Physicians play an important role in the sickness insurance system by acting as gate-keepers. Our aim was to explore how General Practitioners (GPs) view their sick-listing commission and sick-listing practice.

METHODS

Semi-structured interviews with 19 GPs in 17 Primary Health Care settings in four mid-Sweden counties. Interview transcripts were analysed with phenomenographic approach aiming to uncover the variation in existing views regarding the respondents' sick-listing commission and practice.

RESULTS

We found large qualitative differences in the GPs' views on sick-listing. The sick-listing commission was experienced to come either from society or from patients, with no responsibility for societal interests, or as an integration of these two views. All the GPs were aware of a possible conflict between the interests of society and patients. While some expressed feelings of strong conflict, others seemed to have solved the conflict, at least partly, between these two loyalties. Some GPs experienced carrying the full responsibility to decide whether a patient would get monetary sick-leave benefits or not and they were not comfortable with this situation. Views on the physician's and the patient's responsibility in sick-listing and rehabilitation varied from a passive to an empowering role of the physician. GPs expressing a combination of less inclusive views of the different aspects of sick-listing experienced strong conflict and appeared to feel distressed in their sick-listing role. Some GPs described how they had changed from less to more inclusive views.

CONCLUSION

The clearer understanding of the different views on sick-listing generated in this study can be used in educational efforts to improve physicians' sick-listing practices, benefiting GPs' work situation as well as their patients' well-being. The GP's role as a gatekeeper in the social security system needs further exploration. Our findings could be used to develop a questionnaire to measure the distribution of different views in a wider population of GPs.

Patient Education About Treatment in Cancer Care

An increasing number of older people are treated for cancer. Several factors, such as comorbidity and sensory deficits, occur more frequently in older patients than in younger patients. In addition, their life circumstances, values, and preferences may differ. These factors ask for tailored nurse-older patient communication. This article reviews recent literature on the specific needs of older patients with cancer in the treatment phase of the disease. No studies addressed treatment-related needs of older patients specifically. Seventeen studies controlled for age showed that many older patients want as much information on disease and treatment as possible, but they are less interested in details than younger patients. Furthermore, older patients reported less need for information on sexual consequences and psychosocial support. The results remain difficult to interpret because of variation in study designs and questionnaires. Moreover, none of the studies controlled for age-related variables. Studies that illuminate the unique needs of older patients with cancer in the treatment phase of the disease are strikingly limited given the demographics of cancer in our society. Research is needed that explicitly investigates these needs and the influence of age-related changes in cognitive, physical, and psychosocial functioning.

Medical specialists' patient-centered communication and patient-reported outcomes

BACKGROUND

Physicians' patient-centered communication in the medical consultation is generally expected to improve patient outcomes. However, empirical evidence is contradictory so far, and most studies were done in primary care.

OBJECTIVE

We sought to determine the association of specialists' patient-centered communication with patient satisfaction, adherence, and health status.

METHODS

Residents and specialists in internal medicine (n = 30) and their patients (n = 323) completed a questionnaire before a (videotaped) follow-up encounter. Patients' satisfaction was assessed immediately after the consultation and their self-reported treatment adherence, symptoms, and distress 2 weeks later. Specialists' patient-centered communication was assessed by coding behaviors that facilitate or rather inhibit patients to express their perspective. Patient participation was assessed by determining their relative contribution to the conversation and their active participation behavior. Outcomes were assessed using standard questionnaires. Analyses accounted for relevant patient, visit and physician characteristics.

RESULTS AND CONCLUSIONS

Medical specialists' facilitating behavior was associated with greater satisfaction in patients who were less confident in communicating with their doctor. Patient-centered communication was not associated with patients' health status or adherence in general, but facilitating behavior was positively related to the adherence of patients with a foreign primary language. In general, patients appeared to be more satisfied after an encounter with a more-facilitating and a less-inhibiting physician, but these associations diminished when controlling for background characteristics. We conclude that the absence of strong associations between patient-centered communication and patient-reported outcomes may be explained by medical specialists being responsive to patients' characteristics.

Caring for Somali women: implications for clinician-patient communication

OBJECTIVE

We sought to identify characteristics associated with favorable treatment in receipt of preventive healthcare services, from the perspective of resettled African refugee women.

METHODS

Individual, in-depth interviews with 34 Somali women in Rochester, NY, USA. Questions explored positive and negative experiences with primary health care services, beliefs about respectful versus disrespectful treatment, experiences of racism, prejudice or bias, and ideas about removing access barriers and improving health care services. Analysis was guided by grounded theory.

RESULTS

Qualities associated with a favorable healthcare experience included effective verbal and nonverbal communication, feeling valued and understood, availability of female interpreters and clinicians and sensitivity to privacy for gynecologic concerns. Participants stated that adequate transportation, access to healthcare services and investment in community-based programs to improve health literacy about women's preventive health services were prerequisite to any respectful health care system.

CONCLUSION

Effective communication, access to healthcare services with female interpreters and clinicians, and community programs to promote health literacy are themes associated with respectful and effective healthcare experiences among Somali women.

PRACTICE IMPLICATIONS

Adequate interpreter services are essential. Patient-provider gender concordance is important to many Somali women, especially for gynecological concerns.

Impact of asthma education received from health care providers on parental illness representation in childhood asthma

The burden of asthma has increased dramatically despite increased understanding of asthma and new medication regimens. Data reported here are part of a larger study investigating factors that influence parental asthma illness representation and the impact of this representation on treatment outcomes, including the parent/health care provider relationship. We investigated the influence of asthma related education provided by health care providers on these outcomes. After interviewing 228 parents of children with asthma, we found that asthma education received from the child's health care providers positively influenced parental belief systems, especially attitudes towards anti-inflammatory medications and facts about asthma. Parents who reported receiving more education also reported stronger partnerships with their child's health care provider.

The effect of professional skills training on patient-centredness and confidence in communicating with patients

OBJECTIVES

The effect of introducing professional skills training on students' patient-centred attitudes and perceptions of ability to communicate was examined. The professional skills training included weekly training in communication skills, ethics and law, and clinical skills.

METHODS

Consecutive cohorts of medical students receiving a traditional pre-clinical curriculum (n = 199) and a new curriculum including professional skills training (n = 255) were compared. Students completed the Doctor-Patient Scale to assess patient-centred attitudes and an 11-item scale to assess confidence in their ability to communicate with patients. Students completed the measures at the start of Year 1 and the end of Year 2.

RESULTS

Students receiving the professional skills training showed increased confidence in communicating with patients and increases in 2 dimensions of patient-centredness ('holistic care' and 'patient decision making'). Students receiving the traditional curriculum showed increased nervousness in talking to patients. Gender and ethnic differences were found in patient-centredness and confidence in communicating, which were maintained over time.

CONCLUSIONS

The introduction of professional skills training was successful in improving students' confidence in their ability to perform specific communicative behaviours and increasing patient-centredness relative to a traditional curriculum.

eHealth research from the user's perspective

The application of information technology (IT) to issues of healthcare delivery has had a long and tortuous history in the United States. Within the field of eHealth, vanguard applications of advanced computing techniques, such as applications in artificial intelligence or expert systems, have languished in spite of a track record of scholarly publication and decisional accuracy. The problem is one of purpose, of asking the right questions for the science to solve. Historically, many computer science pioneers have been tempted to ask "what can the computer do?" New advances in eHealth are prompting developers to ask "what can people do?" How can eHealth take part in national goals for healthcare reform to empower relationships between healthcare professionals and patients, healthcare teams and families, and hospitals and communities to improve health equitably throughout the population? To do this, eHealth researchers must combine best evidence from the user sciences (human factors engineering, human-computer interaction, psychology, and usability) with best evidence in medicine to create transformational improvements in the quality of care that medicine offers. These improvements should follow recommendations from the Institute of Medicine to create a healthcare system that is (1) safe, (2) effective (evidence based), (3) patient centered, and (4) timely. Relying on the eHealth researcher's intuitive grasp of systems issues, improvements should be made with considerations of users and beneficiaries at the individual (patient-physician), group (family-staff), community, and broad environmental levels.

Patient participation in the medical specialist encounter: does physicians' patient-centred communication matter?

OBJECTIVE

Physicians' patient-centred communication is assumed to stimulate patients' active participation, thus leading to more effective and humane exchange in the medical consultation. We investigated the relationship between physicians' patient-centred communication and patient participation in a medical specialist setting.

METHODS

Participants were 30 residents and specialists in internal medicine, and 323 of their patients. Participants completed a questionnaire prior to a (videotaped) follow-up consultation. Physicians' patient-centred communication was assessed by coding behaviours that facilitate or rather inhibit patients to express their perspective. Patient participation was determined by assessing (a) their relative contribution to the conversation, and (b) their active participation behaviour. Analyses accounted for relevant background characteristics.

RESULTS

Physicians' facilitating behaviour was found to be positively associated with patients' relative contribution to the conversation as well as patients' active participation behaviour. Physicians' inhibiting behaviour was not related to patients' relative contribution, and was, unexpectedly, positively associated with patients' active participation behaviour. Physicians' behaviour was particularly associated with patients' expression of concerns and cues.

CONCLUSIONS

Physicians in internal specialist medicine appear to be able to facilitate patients' active participation in the visit. The findings indicate that inhibiting behaviour may not have the expected blocking effect on patient participation: patients voiced their perspectives just the same and expressed even more concerns. Showing inhibiting behaviour may, alternatively, be a physician's response to the patient's increased participation in the encounter.

PRACTICE IMPLICATIONS

The results may give directions for future medical education and specialist training.

Ratings of physician communication by real and standardized patients

PURPOSE

Patient ratings of physician's patient-centered communication are used by various specialty credentialing organizations and managed care organizations as a measure of physician communication skills. We wanted to compare ratings by real patients with ratings by standardized patients of physician communication.

METHODS

We assessed physician communication using a modified version of the Health Care Climate Questionnaire (HCCQ) among a sample of 100 community physicians. The HCCQ measures physician autonomy support, a key dimension in patient-centered communication. For each physician, the questionnaire was completed by roughly 49 real patients and 2 unannounced standardized patients. Standardized patients portrayed 2 roles: gastroesophageal disorder reflux symptoms and poorly characterized chest pain with multiple unexplained symptoms. We compared the distribution, reliability, and physician rank derived from using real and standardized patients after adjusting for patient, physician, and standardized patient effects.

RESULTS

There were real and standardized patient ratings for 96 of the 100 physicians. Compared with standardized patient scores, real-patient-derived HCCQ scores were higher (mean 22.0 vs 17.2), standard deviations were lower (3.1 vs 4.9), and ranges were similar (both 5-25). Calculated real patient reliability, given 49 ratings per physician, was 0.78 (95% confidence interval [CI], 0.71-0.84) compared with the standardized patient reliability of 0.57 (95% CI, 0.39-0.73), given 2 ratings per physician. Spearman rank correlation between mean real patient and standardized patient scores was positive but small to moderate in magnitude, 0.28.

CONCLUSION

Real patient and standardized patient ratings of physician communication style differ substantially and appear to provide different information about physicians' communication style.