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

Personality and perceived health in older adults: the five factor model in primary care

Responses to specific questions tapping perceived health are associated with morbidity, mortality, and the use of health services, yet there has been little research on their personality correlates. We examined the associations between Five Factor Model personality traits and responses to four items extracted from the Medical Outcomes Study Short Form-36 in 266 primary care patients who were 65 years of age or older. Multivariate analyses controlling for age, gender, depressive symptoms, and physical disease burden showed that having a higher Neuroticism score was associated with worse perceived health in response to all items except "I am as healthy as anybody I know." Having a lower Extraversion score was associated with worse perceived health in response to the item "I expect my health to get worse." We discuss implications for understanding personality influences on morbidity, mortality, and health services utilization.

Exploring and validating patient concerns: relation to prescribing for depression

PURPOSE

This study examined moderating effects of physician communication behaviors on relationships between patient requests for antidepressant medications and subsequent prescribing.

METHODS

We conducted a secondary analysis of a randomized trial. Primary care physicians (N = 152) each had 1 or 2 unannounced visits from standardized patients portraying the role of major depression or adjustment disorder. Each standardized patient made brand-specific, general, or no requests for antidepressants. We coded covert visit audio recordings for physicians' exploration and validation of patient concerns (EVC). Effects of communication on prescribing (the main outcome) were evaluated using logistic regression analysis, accounting for clustering and for site, physician, and visit characteristics, and stratified by request type and standardized patient role.

RESULTS

In the absence of requests, high-EVC visits were associated with higher rates of prescribing of antidepressants for major depression. In low-EVC visits, prescribing was driven by patient requests (adjusted odds ratio [AOR] for request vs no request = 43.54, 95% confidence interval [CI], 1.69-1,120.87; P < or = .005), not clinical indications (AOR for depression vs adjustment disorder = 1.82; 95% CI, 0.33-9.89; P = NS). In contrast, in high-EVC visits, prescribing was driven equally by requests (AOR = 4.02; 95% CI, 1.67-9.68; P < or = .005) and clinical indications (AOR = 4.70; 95% CI, 2.18-10.16; P < or = .005). More thorough history taking of depression symptoms did not mediate these results.

CONCLUSIONS

Quality of care for depression is improved when patients participate more actively in the encounter and when physicians explore and validate patient concerns. Communication interventions to improve quality of care should target both physician and patient communication behaviors. Cognitive mechanisms that link patient requests and EVC to quality of care warrant further study.

The clinical context and patient participation in post-diagnostic consultations

OBJECTIVE

Although patient participation is an important feature of patient-centered health care, few studies have examined how the clinical context affects patient involvement in medical encounters. This investigation examined the way patients communicate with physicians in two diverse post-diagnostic settings, post-angiogram consultations and initial lung cancer visits.

METHODS

From transcripts and audiorecordings of post-angiogram consultations (n=88) and initial lung cancer visits (n=62) within a VA hospital in the United States, three measures of patient participation were coded--number of active participation behaviors (questions, acts of assertiveness, and expressions of concern), proportion of patients' utterances in the form of active participation, and conversational involvement (ratio of patient utterances to physician plus patient utterances). Mixed linear regression procedures assessed the independent effects of the clinical setting, physicians' facilitative communication (partnership-building and supportive talk), and patients' age, education, and ethnicity on patient participation.

RESULTS

Not only was their less talk in the post-angiogram consultations compared with the lung cancer visits, heart patients also were less conversationally involved (accounted for 25% of the talk) than were lung cancer patients (45% of the talk) and their doctors used proportionally less facilitative talk than did the lung cancer physicians. In both settings, patients were more conversationally engaged when proportionally more of the physicians' talk was facilitative.

CONCLUSIONS

The clinical context has a profound effect on patient participation. However, within individual settings, physicians can increase patient involvement by using partnering and supportive communication.

PRACTICE IMPLICATIONS

Clinicians and administrators should assess clinical practices that restrict patient involvement in ways that could affect quality of decision-making.

'Breaking it down': patient-clinician communication and prenatal care among African American women of low and higher literacy

PURPOSE

Low literacy has been associated with poor medical adherence, but its role in maternal care utilization has not been explored.

METHODS

We undertook a concurrent mixed methods study among 202 African American women of low (< or = 6th grade) and higher literacy receiving Medicaid. Poor use of prenatal care was defined by (1) starting care after the first trimester and (2) inadequate care utilization according to the Adequacy of Prenatal Care Utilization Index (APNCU). Participant-derived themes regarding prenatal care and care utilization were identified and explored through individual interviews (free listing and cultural consensus analysis; n = 40), and 4 confirmatory focus groups stratified by literacy.

RESULTS

Thirty-three women (16%) had low-literacy levels, 120 (61%) women started prenatal care after the first trimester, and 101 (50%) had inadequate utilization of prenatal care. Neither measure varied by literacy (P >.05). Cultural consensus analysis identified a single prenatal care factor that was comprised of 9 items, shared by women of low and higher literacy (eigenvalue 0.881, SD 0.058). Focus groups confirmed these items among participants from both literacy groups. Communication with clinicians was a central theme linking all of the factor items. Effective communication, exemplified by "breaking it down," was described as encouraging, whereas ineffective communication discouraged use of care.

CONCLUSION

Women who had both low- and higher-literacy skills had high rates of poor prenatal care utilization and reported that communication with clinicians influenced their use of prenatal care. Improving the clarity of communication by breaking down information into simple parts should be a priority for prenatal clinicians.

Determinants of physicians' patient-centred behaviour in the medical specialist encounter

It has been suggested that patient-centred communication does not necessarily translate into a 'one-size fits all' approach, but rather that physicians should use a flexible style and adapt to the particular needs of their patients. This paper examines variability in physicians' patient-centred behaviour in medical specialist encounters, and determines whether patient, visit, and physician characteristics influence this variability. Participants were 30 residents and specialists in internal medicine at an academic teaching hospital in The Netherlands, and 323 patients having a (videotaped) outpatient follow-up appointment. Physicians and patients completed a questionnaire prior to the encounter. Consultations were coded using the Patient-centred Behaviour Coding Instrument (PBCI); physicians' patient-centred behaviour was determined by behaviours that facilitated rather than inhibited the patient's expression of his/her perspective. The results show that physicians differ in their communicative behaviour (i.e. inter-individual variability): some internists had a more 'patient-centred' communication style and others less so. At the same time, physicians show intra-individual variation; apparently they adjust their style according to the situation. Physicians displayed more facilitating behaviour when patients were older, reported more physical symptoms, when they rated patients' health condition as more severe and when the physician was a woman. Physicians also displayed more inhibiting behaviour when patients reported more physical symptoms and when the physician rated patients' health condition as more severe. Apparently, sicker patients were targets of both greater facilitation and greater inhibition. Variability in physicians' facilitating and inhibiting behaviour was explained by patient characteristics, i.e. patients' age and health condition, and-with the exception of physician gender-not by physician or visit characteristics. This indicates that physician patient-centred behaviour is related to the type of patient visiting, especially in relation to the seriousness of symptoms.

Physicians' responses to patients' medically unexplained symptoms

OBJECTIVE

To understand how physicians communicate may contribute to the mistrust and poor clinical outcomes observed in patients who present with medically unexplained symptoms (MUS).

METHODS

After providing informed consent, 100 primary care physicians in greater Rochester, New York, were visited by two unannounced covert standardized patients (actors, or SPs) portraying two chest pain roles: classic symptoms of gastroesophageal reflux disease (GERD) with nausea and insomnia (the GERD role) and poorly characterized chest pain with fatigue and dizziness (the MUS role). The visits were surreptitiously audiorecorded and analyzed using the Measure of Patient-Centered Communication (MPCC), which scores physicians on their exploration of the patients' experience of illness (component 1) and psychosocial context (component 2), and their attempts to find common ground on diagnosis and treatment (component 3).

RESULTS

In multivariate analyses, MUS visits yielded significantly lower scores on MPCC component 1 (p = .01). Subanalysis of component 1 scores showed that patients' symptoms were not explored as fully and that validation was less likely to be used in response to patient concerns in the MUS than in the GERD visits. Component 2 and component 3 were unchanged.

CONCLUSION

Physicians' inquiry into and validation of symptoms in patients with MUS was less common compared with more medically straightforward patient presentations. Further research should study the relationship between communication variables and poor clinical outcomes, misunderstandings, mutual distrust, and inappropriate healthcare utilization in this population, and test interventions to address this problem.

Emerging trends and future directions in patient communication skills training

Despite several reviews of research on the effects of patient communication skills interventions, relatively few new studies on the topic have been published recently. The purpose of this article is to identify areas of needed research into patient communication skills training, with the intent of stimulating further investigation. Several topics are discussed, including longitudinal research, issues for studying underserved populations, the role of patients' preference for involvement with their health care, and the assessment of the effects of patient communication skills training on health outcomes.

Patient-centered communication and diagnostic testing

PURPOSE

Although patient-centered communication is associated with improved health and patient trust, information about the impact of patient-centered communication on health care costs is limited. We studied the relationship between patient-centered communication and diagnostic testing expenditures.

METHODS

We undertook an observational cross-sectional study using covert standardized patient visits to study physician interaction style and its relationship to diagnostic testing costs. Participants were 100 primary care physicians in the Rochester, NY, area participating in a large managed care organization (MCO). Audio recordings of 2 standardized patient encounters for each physician were rated using the Measure of Patient-Centered Communication (MPCC). Standardized diagnostic testing and other expenditures, adjusted for patient demographics and case-mix, were derived from the MCO claims database. Analyses were adjusted for demographics and standardized patient detection.

RESULTS

Compared with other physicians, those who had MPCC scores in the lowest tercile had greater standardized diagnostic testing expenditures (11.0% higher, 95% confidence interval [CI], 4.5%-17.8%) and greater total standardized expenditures (3.5% higher, 95% CI, 1.0%-6.1%). Whereas lower MPCC scores were associated with shorter visits, adjustment for visit length and standardized patient detection did not affect the relationship with expenditures. Total (testing, ambulatory and hospital care) expenditures were also greater for physicians who had lower MPCC scores, an effect primarily associated with the effect on testing expenditures.

CONCLUSIONS

Patient-centered communication is associated with fewer diagnostic testing expenditures but also with increased visit length. Because costs and visit length may affect physicians' and health systems' willingness to endorse and practice a patient-centered approach, these results should be confirmed in future randomized trials.

Studying physician effects on patient outcomes: physician interactional style and performance on quality of care indicators

Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.

Wintner L, Sztankay M, Tomaszewski K, Hofmeister D, Costantini A, Bredart A, Young T, Kuljanic K, M. Tomaszewska I, Kontogianni M, Chie WC, Kullis D, Greimel E, Zarandona U. La comunicación entre el paciente oncológico y los profesionales. El cuestionario de comunicación de la EORTC

Este trabajo pretende introducir el área de la comunicación entre el paciente oncológico y los profesionales, y destacar el impacto que tiene en el paciente. Además, se presenta el cuestionario de comunicación de la EORTC. La comunicación entre el paciente y los profesionales es uno de los elementos claves del soporte que se ofrece a dichos pacientes. En dicha comunicación participan un rango importante de profesionales. Hay una necesidad de realizar más investigación sobre la comunicación. Se presentan dos modelos principales de atención al paciente: el Paternalista y el de Atención Centrada en el Paciente con cáncer. Este último lleva asociada la Comunicación Centrada en el Paciente - CCP. Se revisa la relación entre comunicación y otros PRO: Calidad de Vida, información, y Satisfacción con los Cuidados. Existen diferencias culturales en comunicación que pueden estar relacionadas con el modelo de atención al paciente. El Grupo de Calidad de Vida de la Organización Europea para la Investigación y Tratamiento del Cáncer-EORTC está desarrollando una escala de comunicación entre el paciente oncológico y los profesionales. La mayoría del contenido de dicho cuestionario se centra en las conductas de los profesionales. Los aspectos culturales tienen un papel fundamental en el desarrollo del instrumento. El cuestionario se basa en el modelo de Comunicación Centrada en el Paciente – CCP. Se presenta el cuestionario EORTC QLQ-COMU26, que consta de seis escalas y cuatro ítems individuales. Se describen las tres primeras fases que se han dado en su creación. En la actualidad su funcionamiento psicométrico se está valorando en un estudio internacional.