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

The Predictive Individual Effect for Survival Data

BACKGROUND

The call for patient-focused drug development is loud and clear, as expressed in the twenty-first Century Cures Act and in recent guidelines and initiatives of regulatory agencies. Among the factors contributing to modernized drug development and improved health-care activities are easily interpretable measures of clinical benefit. In addition, special care is needed for cancer trials with time-to-event endpoints if the treatment effect is not constant over time.

OBJECTIVE

To quantify the potential clinical survival benefit for a new patient, would he/she be treated with the test or control treatment.

METHODS

We propose the predictive individual effect which is a patient-centric and tangible measure of clinical benefit under a wide variety of scenarios. It can be obtained by standard predictive calculations under a rank preservation assumption that has been used previously in trials with treatment switching.

RESULTS

We discuss four recent Oncology trials that cover situations with proportional as well as non-proportional hazards (delayed treatment effect or crossing of survival curves). It is shown that the predictive individual effect offers valuable insights beyond p-values, estimates of hazard ratios or differences in median survival.

CONCLUSION

Compared to standard statistical measures, the predictive individual effect is a direct, easily interpretable measure of clinical benefit. It facilitates communication among clinicians, patients, and other parties and should therefore be considered in addition to standard statistical results.

Development and implementation of a tool for measuring the training effectiveness of the patient-centered consultation model

Background: The patient-centered consultation model comprises four elements: exploring health, illness and disease experiences, understanding the whole person, finding common ground, and enhancing the patient-doctor relationship. This method is taught at the course in general practice at Copenhagen University. The aim of the study was to develop a simple tool consisting of a questionnaire about the patient-centered elements and a test video consultation. The outcome is the change in the students' ability to identify these elements. Used as a pre-course and post-course test it can inform the teachers which elements of the patient-centered consultation need intensifying in the teaching. Methods: The students from a course in general practice volunteered to participate in all steps of the development. They took part in individual interviews to select items from an already existing questionnaire (DanSCORE). The preliminary questionnaire was tested for face and content validity, pilot-tested and tested for test-retest reliability. All video consultations were transcribed and assessed for patient-centered elements through a conversation analysis. The videos showed medical students seeing real patients. Results: The preliminary version of the questionnaire (called DanOBS) had 23 items. In the subsequent interviews, items were reduced to 17, each with three response options. After a pilot test, the questionnaire was further reduced to 13 items, all strictly relevant to the model and with two response options. The final questionnaire had acceptable test-retest reliability. The number of test consultation videos underwent a reduction from six videos to one. Conclusions: The DanOBS combined with a test video consultation, used as a pre-and post-course test demonstrates for teachers which elements in the patient-centered consultation need to be intensified in the teaching.

Observable indicators of person-centred care: an interview study with patients, relatives and professionals

OBJECTIVE

To identify key observable indicators of person-centred care (PCC) from interviews with patients, relatives and professionals with experience of receiving or working with PCC.

DESIGN

A qualitative interview study using deductive content analysis.

SETTING

Primary and hospital care settings in Western Sweden.

PARTICIPANTS

Twelve participants with extensive experience of receiving or working with PCC were interviewed: two patients, two patients representative with long-term conditions, one relative and informal carer, three registered nurses, one physician, two occupational therapists and one social worker/researcher.

RESULTS

Nine observable indicators were identified and subsumed under three predetermined categories: initiating, working and safeguarding the partnership. The first category comprised three subcategories: welcoming, interested and courteous reception; agreeing on structure and aims of the conversation; and eliciting patients' wishes for involvement of significant others. The second category comprised four subcategories: attentive, empathic and encouraging manner; promoting mutual understanding; promoting patient engagement; and encouraging and friendly body language. The last category consisted of two subcategories: collaboration and transparency in documentation and verifying that patient's and professional's views, goals and wants are correctly documented.

CONCLUSION

Our results underline the need for health professionals to actively and conscientiously convey to patients their interest in and respect for the patient as a person and their willingness to collaborate as partners in their care from the very outset of the interaction. Non-verbal behaviours were seen to play a major role in shaping patients' impressions of health professionals. Given that patients' first impressions were considered to impact the content, course and outcomes of the interaction, more research attention should be given to their implications for the effective delivery of PCC.

Relationships between Key Functions of Patient-Provider Communication, Trust, and Motivation across White, African American, and Hispanic/Latino Patients with Asthma

Patient-provider communication is essential for providing effective care for asthma patients. However, little is known about key functions of communication and their relationships with outcomes in asthma patients across racial/ethnic groups. This study assessed asthma patients' perceptions of key functions of patient-provider communication, and examined associations between key functions, trust, and motivation across racial/ethnic groups. In this study, a sample of 470 US adults responded to an assessment of patient-provider communication, trust, and motivation through an electronically administered survey. Key functions of patient-provider communication included: exchanging information, responding to emotions, making decisions, enabling self-management, managing uncertainty, and fostering relationships. Results showed no differences in the mean scores of key functions of communication across racial/ethnic groups. The key function fostering relationships was positively associated with trust and motivation in both Whites and African Americans. However, the key function making decisions was associated with trust, and the key function managing uncertainty was associated with motivation only for Hispanic/Latinos. Results suggest different cultures may place different values on key functions of communication which may engender trust and motivation. Practical implications and suggestions for future research are discussed.

Why Do Patients Seek Diagnose Dis-accordance With Hierarchical Medical System Related Policies in Tertiary Hospitals? A Qualitative Study in Shanghai From the Perspective of Physicians

Background

Although the Hierarchical Medical System has been utilized in China for many years, it is inadequate for guiding patients in adopting appropriate diagnose-seeking behaviors in accordance with related policies. This study examined how patients' diagnose-seeking behavior in tertiary hospitals that is dis-accordance with Hierarchical Medical System related policy (“DSB-dis-accordance”) arise and ways to guide patients away from such behaviors, both from the perspective of physicians.

Methods

A qualitative study based on a mixed method including in-depth interviews and grounded theory. Twenty-seven physicians with more than 2 years of experience serving in tertiary hospitals of Shanghai were involved after reviewing the related purposes and requirements. Patients' “DSB-dis-accordance” was studied from the perspective of physicians.

Results

Patient-related factors (habits, trust, and knowledge), physician-related factors (conservative preference, risk avoidance), and system-related factors (accessibility, operability) affected patients' diagnose-seeking behavior.

Conclusions

Patient-related, physician-related, and system-related factors affecting patients' diagnose-seeking behaviors in tertiary hospitals should be addressed by investing more health resources in lower-level hospitals, enhancing dissemination of health-related and policy-related knowledge, refining the classification of diseases, incentivizing physicians, and developing appropriate follow-up measures. Physicians could then become more involved in guiding patients' “DSB-dis-accordance,” thereby benefitting development of the Hierarchical Medical System in China.

Development and implementation of a tool for measuring the training effectiveness of the patient-centered consultation model

Background: The patient-centered consultation model comprises four elements: exploring health, illness, and disease experiences, understanding the whole person, finding common ground, and enhancing the patient-doctor relationship. This method is taught at the course in general practice at Copenhagen University. The aim of the study was to develop a simple tool consisting of a questionnaire about the patient-centered elements and a test video consultation. The outcome is the change in the students’ ability to identify these elements. Used as a pre-course and post-course test it can inform the teachers which elements of the patient-centered consultation need intensifying in the teaching. Methods: The students from a course in general practice volunteered to participate in all steps of the development. They took part in individual interviews to select items from an already existing questionnaire (DanSCORE). The preliminary questionnaire was tested for face and content validity, pilot-tested and tested for test-retest reliability. All video consultations were transcribed and assessed for patient-centered elements through a conversation analysis. The videos showed medical students seeing real patients. Results: The preliminary version of the questionnaire (called DanOBS) had 23 items. In the subsequent interviews, items were reduced to 17, each with three response options. After the pilot test, the questionnaire was further reduced to 13 items, all strictly relevant to the model and with two response options. The final questionnaire had acceptable test-retest reliability. The number of test consultation videos underwent a reduction from six videos to one. Conclusions: The DanOBS combined with a test video consultation, used as a pre-and post-course test demonstrates for teachers which elements in the patient-centered consultation need to be intensified in the teaching.

Applying Theory of Planned Behavior to Understand Physicians' Shared Decision-Making With Patients With Acute Respiratory Infections in Primary Care: A Cross-Sectional Study

Background: To understand the physicians’ shared decision-making behavior (SDM) with patients with acute respiratory infections (ARIs) based on the theory of planned behavior (TPB) and identify barriers to the implementation of SDM in primary care.

Methods: A cross-sectional study of 617 primary care physicians was conducted in primary facilities in Hubei province, China from December 2019 to January 2020. A self-administered questionnaire based on TPB theory was applied for measuring the physicians’ SDM behavior with patients presenting with ARIs.

Results: The proposed TPB model revealed that attitude and subjective norms predicted behavior intention, and behavior intention was one significant predictor of SDM behavior (p < 0.001). After controlling for physicians’ demographic characteristics, receiving training regarding antibiotics was significantly associated with physicians’ attitudes toward SDM, while educational level and gender were significantly associated with physicians’ intention of engaging in SDM (p < 0.05). Physicians’ perceptions of patients’ expectations and incapability of making decisions were the most frequently reported barriers to the implementation of SDM.

Conclusion: The TPB theory provides insights for understanding physicians’ SDM behavior with patients with ARIs in primary care. Since attitudes, subjective norms, and behavior intention were demonstrated as significant predictors of SDM behavior, these may be a promising focus of SDM interventions based on TPB theory. The results of the TPB model and potential barriers of SDM behavior would help determine future directions for SDM training and educating the public.

The interactive work of narrative elicitation in person-centred care: Analysis of phone conversations between health care professionals and patients with common mental disorders

INTRODUCTION

Narratives play a central part in person-centred care (PCC) as a communicative means of attending to patients' experiences. The present study sets out to explore what activities are performed and what challenges participants face in the interactive process of narrative elicitation, carried through in patient-professional communication in a remote intervention based on PCC.

METHODS

Data were gathered from a randomized controlled trial (RCT) in a Swedish city where health care professionals (HCPs) conducted remote PCC for patients on sick leave due to common mental disorders. A sample of eleven audio-recorded phone conversations between HCPs and patients enroled in the RCT were collected and subjected to conversation analysis.

RESULTS

Three interactive patterns in narrative elicitation were identified: Completed narrative sequences driven by the patient, question-driven narrative sequences guided by the HCP, and narrative sequences driven as a collaborative project between the patient and the HCP. In the question-driven narrative sequences, communication was problematic for both participants and they did not accomplish a narrative. In the other two patterns, narratives were accomplished but through various collaborative processes.

CONCLUSION

This study provides insight into what challenges narrative elicitation may bring in the context of a remote PCC intervention and what interactive work patients and HCP need to engage in. Importantly, it also highlights tensions in the ethics of PCC and its operationalization, if the pursuit of a narrative is not properly balanced against the respect for patients' integrity and personal preferences. Our findings also show that narrative elicitation may represent an interactive process in PCC in which illness narratives are jointly produced, negotiated and transformed.

PATIENT OR PUBLIC CONTRIBUTION

Stakeholders, including patient representatives, were involved in the design of the main study (the RCT). They have been involved in discussions on research questions and dissemination throughout the study period. They have not been involved in conducting the present study.

The Association Between Patient-Centered Communication and Primary Care Quality in Urban China: Evidence From a Standardized Patient Study

Background

Effective patient-physician communication has been considered a central clinical function and core value of health system. Currently, there are no studies directly evaluating the association between patient-centered communication (PCC) and primary care quality in urban China. This study aims to investigate the association between PCC and primary care quality.

Methods

The standardized patients were used to measure PCC and the quality of health care. We recruited 12 standardized patients from local communities presenting fixed cases (unstable angina and asthma), including 492 interactions between physicians and standardized patients across 63 CHCs in Xi'an, China. PCC was scored on three dismissions: (1) exploring disease and illness experience, (2) understanding the whole person, and (3) finding common ground. We measured the quality of the primary care by (1) accuracy of diagnosis, (2) consultation time, (3) appropriateness of treatment, (4) unnecessary exams; (5) unnecessary drugs, and (6) medical expenditure. Ordinary least-squares regression models with fixed effects were used for the continuous variables and logistic regression models with fixed effects were used for the categorical variables.

Results

The average score of PCC1, PCC2, and PCC3 was 12.24 ± 4.04 (out of 64), 0.79 ± 0.64 (out of 3), and 10.19 ± 3.60 (out of 17), respectively. The total score of PCC was 23.22 ± 6.24 (out of 84). We found 44.11% of the visits having a correct diagnosis, and 24.19% of the visits having correct treatment. The average number of unnecessary exams and drugs was 0.91 ± 1.05, and 0.45 ± 0.82, respectively. The average total cost was 35.00 ± 41.26 CNY. After controlling for the potential confounding factors and fixed effects, the PCC increased the correct diagnosis by 10 percentage points (P < 0.01), the correct treatment by 7 percentage points (P < 0.01), the consultation time by 0.17 min (P < 0.01), the number of unnecessary drugs by 0.03 items (P < 0.01), and the medical expenditure by 1.46 CNY (P < 0.01).

Conclusions

This study revealed pretty poor communication between primary care providers and patients. The PCC model has not been achieved, which could be one source of the intensified physician-patient relationship. Our findings showed the PCC model in the primary care settings has positive associations with the quality of the primary care. Interactions with a higher score of PCC were more likely to have a correct diagnosis and correct treatment, more consultation time, more unnecessary drugs, and higher medical expenditure. To improve PCC, the clinical capacity and communication skills of primary care providers need to be strengthened. Also, strategies on reforming the pay structure to better reflect the value of physicians and providing a stronger motivation for performance improvement are urgently needed.

Association of Physician Referrals with Timely Cancer Care Using Tumor Registry and Claims Data

More Americans are being screened for and more are surviving colorectal cancer due to advanced treatments and better quality of care; however, these benefits are not equitably distributed among diverse or older populations. Differential care delivery outcomes are driven by multiple factors, including access to timely treatment that comes from high-quality care coordination. Providers help ensure such coordinated care, which includes timely referrals to specialists. Variation in referrals between providers can also result in differences in treatment plans and outcomes. Patients who are more often referred between the same diagnosing and treating providers may benefit from more timely care compared to those who are not. Our objective is to examine patterns of referral, or patient-sharing networks (PSNs), and our outcome, treatment delay of 30-days (yes/no). We hypothesize that if a patient is in a PSN they will have lower odds of a 30-day treatment initiation delay. Our observational population-based analysis using the National Cancer Institute (NCI)-linked tumor registry and Medicare claims database includes records for 27,689 patients diagnosed with colorectal cancer from 2001 to 2013, and treated with either chemotherapy, radiotherapy, or surgery. We modeled the adjusted odds of a delay and found 17.04% of patients experienced a 30-day delay in initial treatment. Factors that increased odds of a delay were lack of membership in a PSN (adjusted odds ratio [AOR]: 2.20; 95% confidence interval [CI]: 1.71-2.84), racial/ethnic minority status, and having multiple comorbidities. Provider characteristics significantly associated with greater odds of a delay were if dyads were not in the same facility (AOR: 1.95; 95% CI: 1.81-2.10), if providers were different genders, most notably male (diagnosing) and female (treating) [AOR: 1.23; 95% CI: 1.08-1.40, p = 0.0015]. PSNs appear to be associated with reduced of a care delay. The associations observed in our study address the demand for developing multilevel interventions to improve the delivery and coordination of high-quality of care for older cancer patients.

Hodgkin lymphoma survivor perspectives on their engagement in treatment decision-making and discussion of late effects

BACKGROUND

Hodgkin lymphoma has a bimodal age distribution with the first peak occurring within young adulthood and the second, among older adults. Although current therapy provides excellent disease control, survivors are at risk of developing treatment-related late effects (LEs). We sought to understand how survivors in active survivorship care perceived their role in treatment decision-making and when they acquired an understanding of LEs.

METHODS

Semi-structured interviews were conducted until saturation was reached. Themes were identified through direct content analysis and consensus coding by a multidisciplinary team of coders, including hematology/oncology providers, patient navigators, and survivor stakeholders.

RESULTS

Seventeen interviews were conducted. Role in initial treatment decision-making fluctuated between passive and active engagement with providers identified as being crucial to this process. Half of interviewees (53%) expressed unmet information needs. Survivors reported having learned about LEs at multiple time points, spanning from before treatment commenced through when a LE was diagnosed. The majority (71%) expressed a desire to have learned about LEs before initial treatment ended. The impact of cancer and fertility discussions were also disclosed.

DISCUSSION

Participants highlighted the importance of discussions on LEs early in the care continuum. These preliminary data will be incorporated in a planned treatment decision-making tool that incorporates information on potential LEs.

IMPLICATIONS FOR CANCER SURVIVORS

Patient-centered communication approaches should be embraced to assist in treatment decision-making, while considering long-term health consequences. Survivors must be educated on their risk of LEs and encouraged to disclose their perspectives and preferences with their providers to optimize outcomes.

Addressing Hidden Curricula That Subvert the Patient-Centeredness "Hub" of the Pharmacists' Patient Care Process "Wheel"

Objective. This systematic review's purpose is to improve clarity for the meaning of patient-centered care in the JCPP Pharmacists' Patient Care Process and to provide an initial foothold for faculty to address "hidden curricula" that undermine the concept. Our corresponding objectives were to identify and describe the conceptualizations defining patient-centered care from the pharmacy literature; and compare the meaning of patient-centeredness in the pharmacy literature with the construct's seminal conceptualizations from other professional groups.Findings. The search protocol produced 61 unique sources from the pharmacy literature. More than two-thirds of these results lacked precise use of terminology consistent with the literature or operational depth or theoretical exploration of the term's meaning. The remaining sources yielded two separate conceptualizations of patient-centeredness with three commonalities but key differences between their grounding in the construct's seminal sources in the broader health care literature.Summary. The pharmacy literature clarifies the meaning of patient-centered care in the patient-pharmacist encounter, but additional understanding is needed at meso- (ie, health care) and macro-levels (ie, legislation, accreditation, payment, workforce dynamics) of care. This expansion of understanding may reduce dissonance between the formal and hidden curricula on patient-centeredness associated with health professional student disillusionment, contempt for faculty and institutions, and reductions in empathy and ethics. Increasing use of integrative case-based training, equitably blending patient-centeredness considerations with other curricular content, represents one strategy for reducing the presence and negative impact of hidden curricula.

Impact of Patient Communication Preferences on the Patient Trust in Physicians: A Cross-Sectional Study in Iranian Outpatient's Clinics

There are widely emerging concerns that patient confidence in physicians is diminishing as physician-patient communication is threatened globally. This study aimed to assess patient communication preferences and their impact on patient trust in physicians. A cross-sectional study was conducted among outpatient clinics of 2 public and private hospitals in Tabriz, Iran. A total of 704 patients were selected conveniently. Of the 704 patients, 6.39% had low trust, 36.79% moderate trust, 35.37% had a high trust, and 21.45% had blind trust in physicians. Overall patient communication preference score was more in a private clinic rather than a public one (P = .008). Patients of private hospitals and those who were living in rural areas have been shown to have more trust in physicians. Patients' trust in physicians showed a significant association with patient communication preference (B = 0.58; 95% CI: 0.53-0.63, P < .001).

The meaning of rapport for patients, families, and healthcare professionals: A scoping review

OBJECTIVE

Rapport is considered fundamental to clinical relationships but is a concept which is rarely defined. This review explores how rapport is defined, characterised, and operationalised in healthcare.

METHODS

A scoping review methodology was used. Data were synthesised using thematic analysis. The review process adhered to the Preferred Reporting System for Meta-Analysis for Scoping reviews (PRISMA-ScR).

RESULTS

Medline, CINAHL, and psychINFO were searched with thirty-four studies meeting inclusion criteria. Results were presented in two themes: The meanings of rapport and the implications for building rapport.

CONCLUSIONS

This scoping review found rapport has no commonly shared definition or conceptualisation in the reviewed research. At the same time rapport is operationalised and characterised. Factors that facilitate, and hinder rapport-building were identified. Having a consistently used definition and conceptualisation will benefit the research that is needed into patient and family experiences and outcomes of rapport.

PRACTICE IMPLICATIONS

It is crucial for health professionals to incorporate simple kind gestures into practice to facilitate rapport. Equally it is necessary for health professionals to review their practice for dismissive, avoiding behaviours that impede rapport-building and consider how they spend their time with patients.

Analyzing Expert Criteria for Authentic Resident Communication Skills

Phenomenon: Training and assessing communication skills requires flexible and holistic approaches, including feedback practices. Historically, assessing communication skills has predominantly relied on itemized scoring, which is less useful for providing meaningful feedback to learners. Even more troublesome, theoretical scoring criteria tend to become a refractive lens allowing observation of only the conduct that aligns with the theory. Few skills assessment efforts have embraced a holistic understanding of how physician-patient communication skills are enacted in real patient care. Therefore, this study focused on what experts refer to when they speak about physicians' communication skills and what they treat as important when evaluating these skills enacted during real patient encounters.Approach: This qualitative study was based on observations and grounded theory. Residents' encounters with real patients were recorded as part of a formative communication skills assessment program from July 2015 to June 2016. Evaluation panels with diverse backgrounds (e.g., medicine, education, communication, conversation analysis, and layperson) listened to these recordings and jointly developed feedback comments for the resident from January 2016 to July 2017. For this study, we recorded forty-one panel discussions to observe their consensus evaluation. We conducted open and axial coding using a constant comparison approach to generate themes from the data.Findings: Elements of communication skills were connected and interdependent around the concepts of thoroughness and natural flow, which were not addressed by formative assessment criteria. Themes included (1) thoroughness within a boundary via agenda-setting; (2) natural yet, controlled flow: authentic conversation by active listening and questioning; (3) making agenda setting explicit to all parties in the beginning; (4) designing questions using both open-ended and closed questions; (5) pre-/post-conditions for patient education: patient contextual factors and teach-back; (6) preconditions for shared decision-making: patient education and patient contextual factors; and (7) multifaceted empathy demonstrated in multiple ways.Insights: The main message of the study findings is that communication skills criteria should be treated as organically interrelated and connected in assessing physicians' communication skills. Current communication skills assessment practice should be revisited as it itemizes physicians' communication skills as distinct and separate constructs rather than mutually affecting dynamics. Rather than imposing a theoretical rubric, assessment criteria should evolve through naturalistic observations of physician-patient communication.

Screening and Psycho-Oncological Support for Patients With Head and Neck Cancer and Brain Malignancies Before Radiotherapy With Mask Fixation: Results of a Feasibility Study

This single-center, single-arm trial investigates the feasibility of a psycho-oncological care program, which aims to reduce psychological distress and improve compliance with radiotherapy with mask fixation in patients with head and neck cancer or brain malignancies. The care program comprised (1) a screening/needs assessment and (2) the provision of a psycho-oncological intervention using imaginative stabilization techniques for distressed patients (distress due to anxiety ≥5) or in a case of subjective interest in the psycho-oncological intervention. Another allocation path to the intervention was directly through the radiation oncologist in charge who classified the patient as: in need of support to tolerate the immobilization device. Of a total of 1,020 screened patients, 257 (25.2%) patients indicated a distress ≥5 and 141 (13.8%) patients reported panic attacks. 25% of the patients reported a subjective interest in psycho-oncological support. A total of 35 patients received the psycho-oncological intervention, of which 74% were assigned by radiation oncologists. In this small patient cohort, no significant pre-post effects in terms of depression, anxiety, distress, and quality of life (mental and physical component scores) could be detected. Our results indicate a good feasibility (interdisciplinary workflow and cooperation, allocation by physicians in charge) of the psycho-oncological care program for this cohort of patients before radiotherapy with mask fixation. The screening results underline the high psychological distress and demand for psycho-oncological support. However, since the utilization of our intervention was low, future studies should reduce the barriers and improve compliance to psycho-oncological services by these patients.Clinical Trial Registration: https://www.drks.de/drks_web/setLocale_EN.do #DRKS00013493

"If it's the time, it's the time": Existential communication in naturally-occurring palliative care conversations with individuals with advanced cancer, their families, and clinicians

OBJECTIVE

To explore how patients with advanced cancer, their families, and palliative care clinicians communicate about existential experience during palliative care conversations.

METHODS

We analyzed data from the Palliative Care Communication Research Initiative (PCCRI) - a multisite cohort study conducted between 2014 and 2016 involving hospitalized adults with advanced cancer who were referred for inpatient palliative care consultations at two academic medical centers. We used a qualitative descriptive approach paired with inductive content analysis to analyze a random subsample of 30 patients from the PCCRI study (contributing to 38 palliative care conversations).

RESULTS

We found existential communication to be woven throughout palliative care conversations, with key themes related to: 1) time as a pressing boundary; 2) maintaining a coherent self; and 3) connecting with others.

CONCLUSION

Communication about existential experience is omnipresent and varied in palliative care conversations between individuals with advanced cancer, their families, and clinicians.

PRACTICE IMPLICATIONS

Clinicians can recognize that discussion of time, routines of daily life, and relationships in the clinical context may hold profound existential relevance in palliative care conversations. Understanding how patients and families talk about existential experience in conversation can create opportunities for clinicians to better meet these needs.

In Orthopaedic Speciality Care, Longer Explanations Are Not More Caring or More Satisfying

BACKGROUND

Research consistently documents no correlation between the duration of a musculoskeletal specialty care visit and patient experience (perceived empathy of the specialist and satisfaction with care). Based on a combination of clinical experience and other lines of research, we speculate that longer visits are often related to discordance between specialist and patient interpretation of symptoms and weighting of available test and treatment options. If this is true, then the specific duration of time discussing the specialist's interpretations and options with the patient (expertise transfer) might correlate with satisfaction with care and perceived empathy of the clinician even if the total visit time does not.

QUESTIONS/PURPOSES

(1) What demographic or mental health factors are associated with the duration of expertise transfer? (2) What factors, including the duration of expertise transfer, are associated with the patient's satisfaction with the visit and perceived clinician empathy?

METHODS

In a cross-sectional study, 128 new and returning English-speaking adult outpatients seeking care from one of three orthopaedic specialists in two urban practices between September and November 2019 were enrolled and agreed to audio recording of the visit. A total of 92% (118) of patients completed the questionnaire and had a usable recording. Participants completed a sociodemographic survey, the Patient-Reported Outcome Measure Information System Depression computer adaptive test (PROMIS Depression CAT; a measure of symptoms of depression), the Short Health Anxiety Index (SHAI-5; a measure of symptoms of hypochondriasis, a form of symptoms misinterpretation), the Pain Catastrophizing Scale (PCS-4; a measure of misinterpretation of symptoms), an ordinal measure of patient satisfaction (dichotomized into satisfied or not because of strong ceiling effects), and the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE; a measure of perceived clinician empathy). The duration of expertise transfer and the total duration of the visit were measured by two raters with acceptable reliability using software that facilitates segmentation of the visit audio recording. To determine factors associated with the duration of expertise transfer, satisfaction, and empathy, we planned a multivariable analysis controlling for potential confounding variables identified in exploratory bivariable analysis. However, there were insufficient associations to merit multivariable analysis.

RESULTS

A longer duration of expertise transfer had a modest correlation with catastrophic thinking (r = 0.24; p = 0.01). Complete satisfaction with the visit was associated with less health anxiety (6 [interquartile range 5 to 7] for complete satisfaction versus 7 [5 to 7] for less than complete satisfaction; p = 0.02) and catastrophic thinking (4 [1 to 7] versus 5 [3 to 11]; p = 0.02), but not with the duration of expertise transfer. Greater perceived clinician empathy had a slight correlation with less health anxiety (r = -0.19; p = 0.04).

CONCLUSION

Patients with greater misinterpretation of symptoms experience a slightly less satisfying visit and less empathetic relationship with a musculoskeletal specialist despite a longer duration of expertise transfer. This supports the concept that directive strategies (such as teaching healthy interpretation of symptoms) may be less effective then guiding strategies (such as nurturing openness to alternative, healthier interpretation of symptoms using motivational interviewing tactics, often over more than one visit or point of contact).

LEVEL OF EVIDENCE

Level II, therapeutic study.

Communication Skills Training: A Means to Promote Time-Efficient Patient-Centered Communication in Clinical Practice

Purpose

We hypothesized that health care providers would behave in a more patient-centered manner after the implementation of communication skills training, without causing the consultation to last longer.

Methods

This study was part of the large-scale implementation of a communication skills training program called "Clear-Cut Communication With Patients" at Lillebaelt Hospital in Denmark. Audio recordings from real-life consultations were collected in a pre-post design, with health care providers' participation in communication skills training as the intervention. The training was based on the Calgary-Cambridge Guide, and audio recordings were rated using the Observation Scheme-12.

Results

Health care providers improved their communication behavior in favor of being more patient-centered. Results were tested using a mixed-effect model and showed significant differences between pre- and postintervention assessments, with a coefficient of 1.3 (95% Cl: 0.35-2.3; P=0.01) for the overall score. The consultations did not last longer after the training.

Conclusions

Health care providers improved their communication in patient consultations after the implementation of a large-scale patient-centered communication skills training program based on the Calgary-Cambridge Guide. This did not affect the length of the consultations.

Conversational stories & self organizing maps: Innovations for the scalable study of uncertainty in healthcare communication

BACKGROUND

Understanding uncertainty in participatory decision-making requires scientific attention to interaction between what actually happens when patients, families and clinicians engage one another in conversation and the multi-level contexts in which these occur. Achieving this understanding will require conceptually grounded and scalable methods for use in large samples of people representing diversity in cultures, speaking and decision-making norms, and clinical situations.

DISCUSSION

Here, we focus on serious illness and describe Conversational Stories as a scalable and conceptually grounded framework for characterizing uncertainty expression in these clinical contexts. Using actual conversations from a large direct-observation cohort study, we demonstrate how natural language processing and unsupervised machine learning methods can reveal underlying types of uncertainty stories in serious illness conversations.

CONCLUSIONS

Conversational Storytelling offers a meaningful analytic framework for scalable computational methods to study uncertainty in healthcare conversations.

Patient-reported Outcomes Among Vulnerable Populations in the Medicare Bundled Payments for Care Improvement Initiative

BACKGROUND

The Centers for Medicare & Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative tested whether episode-based payment models could reduce Medicare payments without harming quality. Among patients with vulnerabilities, BPCI appeared to effectively reduce payments while maintaining the quality of care. However, these findings could overlook potential adverse patient-reported outcomes in this population.

RESEARCH DESIGN

We surveyed beneficiaries with 4 characteristics (Medicare-Medicaid dual eligibility; dementia; recent institutional care; or racial/ethnic minority) treated at BPCI-participating or comparison hospitals for congestive heart failure, sepsis, pneumonia, or major joint replacement of the lower extremity. We estimated risk-adjusted differences in patient-reported outcomes between BPCI and comparison respondents, stratified by clinical episode and vulnerable characteristic.

MEASURES

Patient care experiences during episodes of care and patient-reported functional outcomes assessed roughly 90 days after hospitalization.

RESULTS

We observed no differences in self-reported functional improvement between BPCI and comparison respondents with vulnerable characteristics. Patient-reported care experience was similar between BPCI and comparison respondents in 11 of 15 subgroups of clinical episode and vulnerability. BPCI respondents with congestive heart failure, sepsis, and pneumonia were less likely to indicate positive care experiences than comparison respondents for at least 1 subgroup with vulnerabilities.

CONCLUSIONS

As implemented by hospitals, BPCI Model 2 was not associated with adverse effects on patient-reported functional status among beneficiaries who may be vulnerable to reductions in care. Hospitals participating in heart failure, sepsis or pneumonia bundled payment episodes should focus on patient care experience while implementing changes in care delivery.

Examining the impact of video-based outpatient education on patient demand for a rheumatology CNS service

BACKGROUND

Patient demand for education and access to the clinical nurse specialists (CNSs) during the rheumatology clinic at one hospital in Ireland was increasing. Alternative methods of providing patient education had to be examined.

AIMS

To explore the efficacy of video-based outpatient education, and its impact on demand for the CNSs.

METHODS

A video was produced to play in a rheumatology outpatient department. A representative sample of 240 patients (120 non-exposed and 120 exposed to the video) attending the clinic was selected to complete a questionnaire exploring the effect of the video. Data were analysed using chi-square tests with Yates' continuity correction.

FINDINGS

Demand for the CNSs was six times higher in the non-exposed group compared with the exposed group (non-exposed: 25%, exposed: 4.8%) (χ²=15.7, P=0.00007), representing a significant decrease in resource demand.

CONCLUSION

High-quality educational videos on view in the rheumatology outpatient department provide patients with information sufficient to meet their educational needs, thus releasing CNS resources.

Unknown unknowns: can bringing patients' lived experience of long term conditions into curriculum design help our future doctors offer more holistic, socially accountable care?

Understanding the holistic impact of long-term conditions (LTCs) on a patient, due to their high prevalence, morbidity, mortality and cost, is an important part of the primary care undergraduate medicine curriculum. Increasingly, we set learning outcomes for our students anticipating what the patient would want them to know. But are our expectations congruent with what patients would want them to know? In this leading article, we propose that patient involvement in curriculum design remains inadequate. We base our argument on (1) an existing strong theoretical premise that increasing patient incorporation enhances the delivery of medical education, (2) recommendations from major health organisations, our regulator and leading healthcare educationalists and (3) a growing body of evidence that what is important to physicians may not reflect what is important to patients. We advocate that patient involvement in curriculum design will result in a better understanding of how LTCs affect their physical, psychological and social health and of their journey through health care and community support services. This learning is essential, but unfortunately often overlooked, if we are to ensure that students in their future roles plan patient care using an empathic, holistic, patient-centred and socially accountable approach.

Participative development and evaluation of a communication skills-training program for oncologists-patient perspectives on training content and teaching methods

Background

Using the 6-step approach to curriculum development for medical education, we developed a communication skills training (CST) curriculum for oncology and evaluated this curriculum from the perspective of cancer patients.

Methods

We conducted a qualitative interview study with cancer patients, collecting data using semi-structured face-to-face or telephone interviews with a short standardized survey. We fully transcribed the audiotaped interviews and conducted the content analysis using MAXQDA 2020. We analyzed the quantitative sociodemographic data descriptively.

Results

A total of 22 cancer patients participated, having a mean age of 60.6 (SD, 13.2) years and being predominantly female (55%). The patients believed that the CST curriculum addressed important aspects of patient-centered communication in cancer care. They emphasized the importance of physicians acquiring communication skills to establish a trusting relationship between doctor and patient, show empathy, inform patients, and involve them in treatment decisions. The patients had some doubts concerning the usefulness of strict protocols or checklists (e.g., they feared that protocol adherence might disturb the conversation flow).

Discussion

Although it was a challenge for some participants to take the perspective of a trainer and comment on the CST content and teaching methods, the patients provided a valuable perspective that can help overcome blind spots in CST concepts.

Direct-Care Staff Perceptions of Patient Engagement and Treatment Planning in Detox

As the prevalence of substance use disorders and drug-related deaths continue to rise, addiction treatment facilities are charged with providing effective and efficient services to curb the national substance use crisis. Direct-care staff in treatment service facilities play a crucial role in whether or not evidence-based practices are incorporated. Without their understanding and utilization of patient engagement best practices, an organization risks maintaining the status quo rather than actively pursuing improved outcomes through empirically supported approaches. Through in-depth interviews (N=13) with nurses, counselors, and behavioral health technicians in an inpatient detoxification facility, this study evaluates the perspectives and experiences of direct-care staff through a lens of patient engagement in treatment planning. The findings from these interviews elucidate how participants' personal characteristics and values, perspectives of patient engagement, understanding of treatment planning, and organizational culture and operations facilitate or inhibit the integration of patient engagement for treatment planning in detox.

Paradox of Patient-Centered Care and the Implications for Patient Involvement in Continuing Professional Development

INTRODUCTION

Patient-centered care (PCC) is widely considered as essential in chronic disease management. As the underlying rationale for engaging patients in continuing professional development (CPD) is commonly described as fostering care that is more patient-centered, we hoped to understand the discursive conditions for how educators and health professionals can (or cannot) learn with, from, and about patients.

METHODS

Using diabetes as a case, we conducted a Foucauldian discourse analysis of an archive of relevant policy documents, professional and educational texts, to explore different conceptualizations of practice and the implications for PCC. We also conducted in-depth interviews with a purposive sample of physicians to understand their experiences in providing and teaching PCC. We sought to understand: How has PCC been discursively constructed? Whose interests does advocating PCC serve? What are the implications for patient involvement in CPD?

RESULTS

We describe three discursive constructions of PCC, each extending the reach of biomedical power. PCC as a disease intervention emphasizes knowing and relating to patients to normalize laboratory test results. PCC as a form of confession promotes patients to come to their own realizations to become responsible for their own health, but through the lens and evaluation of physicians. PCC as a disciplinary technique makes visible the possibility of using a checklist to judge physician competency in providing PCC.

DISCUSSION

PCC may be constructed in ways that paradoxically reinforce rather than challenge conventional, provider-centric paradigms. Our results challenge educators to acknowledge the existence and effects of discourses when involving patients in the planning and delivery of CPD.

Co-creation and collaboration: A promising approach towards successful implementation. Experience from an integrated communication and mental health skills training programme for Japanese General Practice

INTRODUCTION

This paper describes the co-creation and delivery of an integrated training programme in communication and depression assessment & management for Japanese GPs.

METHODS

Experts in communication and depression from EACH and WONCA developed a framework and filled it with content. Through iterative discussions with the Japanese participants and experts during delivery, the training was further adjusted to match local needs. It included didactic and experiential training methods with an emphasis on practicing and feedback. A "train-the-trainer" component helped participants develop their own trainer skills to enhance dissemination of the training in Japan.

RESULTS

Six Japanese GPs participated in two one week training-modules in May and November 2018. To aid implementation participants received online supervision on depression management and on teaching between the two modules and after the second module. Evaluation of the content of the training, the teaching methods and the participatory approach was positive. More than two years after the training, many elements of the training continue to be used in daily practice with the GPs teaching communication as well as depression management skills.

CONCLUSION

The method of co-creation is promising. Research is needed to confirm that it is effective in transfer to clinical practice.

Associations Between Patient-Provider Secure Message Content and Patients' Health Care Visits

Background: Between-visit communications can play a vital role in improving intermediate patient outcomes such as access to care and satisfaction. Secure messaging is a growing modality for these communications, but research is limited about the influence of message content on those intermediate outcomes. We examined associations between secure message content and patients' number of health care visits. Methods: Our study included 2,111 adult patients with hypertension and/or diabetes and 18,309 patient- and staff-generated messages. We estimated incident rate ratios (IRRs) for associations between taxonomic codes assigned to message content, and the number of office, emergency department, and inpatient visits. Results: Patients who initiated message threads in 2017 had higher numbers of outpatient visits (p < 0.001) compared with patients who did not initiate threads. Among patients who initiated threads, we identified an inverse relationship between outpatient visits and preventive care scheduling requests (IRR = 0.92; 95% confidence interval [CI]: 0.86-0.98) and requests for appointments for new conditions (IRR = 0.95; 95% CI: 0.92-0.99). Patients with higher proportions of request denials or more follow-up appointment requests had more emergency department visits compared with patients who received or sent other content (IRR = 1.18; 95% CI: 1.03-1.34 and IRR = 1.14; 95% CI: 1.07-1.23, respectively). We identified a positive association between outpatient visits and the proportion of threads that lacked a clinic response (IRR = 1.02; 95% CI: 1.00-1.03). Discussion: We report on the first analyses to examine associations between message content and health care visits. Conclusions: Our findings are relevant to understanding how to better use secure messaging to support patients and their care.

Theories of self-care and self-management of long-term conditions by community-dwelling older adults: A systematic review and meta-ethnography

RATIONALE

The proportion of older adults living with long-term conditions (LTCs) is increasing. Self-care and self-management approaches are seen as valuable in helping older people with LTCs to manage their health and care, yet the theoretical overlaps and divergences are not always clear.

OBJECTIVES

The objectives of this review were to: (1) systematically identify and appraise studies of self-care or self-management of LTCs by community-dwelling older adults (aged ≥60 years) either informed by, applying, creating, or testing theory; (2) explore similarities or points of convergence between the identified theories; and (3) use a meta-ethnographic approach to synthesise the theories and group related concepts into core constructs.

METHODS

We conducted a systematic theory synthesis, searching six electronic databases. Three reviewers independently screened titles and abstracts followed by full texts and two reviewers appraised study quality. Theoretical data were synthesised within and across individual theories using meta-ethnographic line-of-argument synthesis.

RESULTS

A total of 141 articles (138 studies) and 76 theories were included in the review. Seven core constructs were developed: (1) temporal and spatial context; (2) stressors; (3) personal resources; (4) informal social resources; (5) formal social resources; (6) behavioural adaptations; and (7) quality of life outcomes. A line of argument was developed that conceptualised older adults' self-care and self-management as a dynamic process of behavioural adaptation, enabled by personal resources and informal and formal social resources, aimed at alleviating the impacts of stressors and maintaining quality of life.

CONCLUSION

This synthesis provides an overview of theories used in research on older adults' LTC self-care and self-management. Our synthesis describes the complex interplay of intrinsic and extrinsic factors influencing self-care and self-management behaviours and provides considerations for future research, intervention design, and implementation. The utility of the constructs in research and practice requires further attention and empirical validation.

Patient-Centeredness in Older Adults With Multimorbidity: Results of an Online Expert Delphi Study

BACKGROUND AND OBJECTIVES

Older adults suffering from multimorbidity represent a priority target group for patient-centeredness (PC). We aimed to investigate the transferability of an existing integrated model of PC comprising 15 dimensions on the care of older adults with multimorbidity from an expert perspective.

RESEARCH DESIGN AND METHODS

A total of 242 experts were invited to participate in a 2-round online Delphi study. In round 1, they were asked to (a) individually rate relevance and clarity of the dimensions, (b) add missing dimensions, and (c) prioritize the dimensions. In round 2, experts received results of round 1 and were asked to rerate their ratings.

RESULTS

Forty-eight experts participated in round 1 and 39 in round 2. Ten dimensions were rated as sufficiently relevant and clear, including one new dimension ("prognosis and life expectancy, burden of treatment"). Four dimensions were rated as relevant but insufficiently clear. One dimension failed to reach our validation threshold on both criteria. The 5 dimensions rated as most important were: "patient as a unique person," "clinician-patient communication," "patient involvement in care," "physical, cognitive, and emotional support," and "involvement of family and friends."

DISCUSSION AND IMPLICATIONS

The experts' ratings were higher regarding relevance than regarding clarity, which emphasizes the still existing conceptual uncertainty of PC. Our results give further directions regarding the operationalization of PC in older adults with multimorbidity, which is essential for its implementation in routine care. Further refined using focus groups with geriatric patients, our adapted model serves as a basis for a systematic review of assessment instruments.

The Social Construction of Gender in Medical Interactions: A Case for the Perpetuation of Stereotypes?

This paper focuses on the ways in which gender, conceived as the product of an ongoing social and cultural construction in and through communication processes, is accomplished during medical encounters and through the narratives produced within these interactions. The main objective is to examine: (1) when and by what devices gender becomes interactionally relevant; (2) the participants' narratives on 'gender issues'; (3) the interplay between the narratives produced and the forms of communication created, also considering which form may be more effective in challenging gender stereotypes and bias. Data are drawn from a corpus of self-administered audio-recorded interactions between a female gynecologist/midwife and pregnant patients. The consultations (half of them mediated, half not) took place in a city of North Italy; the patients (sometimes accompanied by the husband) are migrant women from North and West Africa. The main results show that: (1) at each stage of the examinations, an orientation to gender emerges, mainly through questions that display categorizations, category-bound activities, and cultural assumptions about gender: when referred to the patient, these devices often reproduce the traditional cultural model of femininity and, connected to this, the 'normal' (heterosexual and stable) intimate relationship as socially expected; (2) medical dialogue as patient-centered approach is the most recurrent form of interaction and often leads to a co-construction of narratives in which personal uniqueness is more relevant than gender roles, expectations, and stereotyped representations; when husbands are involved, however, the interactions seem to shift toward doctor-centered forms of communication, and this usually leads to asymmetrical and directive constructions of narratives about differentiated and traditional gender roles.

Psychometric evaluation of the Arabic version of the patient-centered communication instrument for adult cancer patients

BACKGROUND

This study aimed to examine the validity and reliability of the Arabic version of the patient-centered communication instrument.

METHODS

A self-administered instrument was used over 4 months by 318 participants living with cancer in Saudi Arabia. The instrument contained 36 items assessing patient-centered communication (PCC-36) experiences. The PCC-36 instrument was translated into Arabic following the World Health Organization guidelines for translating instruments before undergoing psychometric evaluation. This involved confirmatory factor analysis for each of the PCC-36 functions and testing the reliability and internal consistency of the PCC-36 measures.

RESULTS

The Arabic-translated PCC-36 version demonstrated a good correlation between items, with confirmatory factor analysis showing a good fit of the data (comparative fit index = 0.922, Tucker-Lewis index = 0.910, root mean square error approximation = 0.059, ${\chi ^2}$ = 1214.4, df = 579, P < 0.001). Internal consistency of the total six PCC-36 functions was confirmed by a Cronbach's alpha of 0.97.

CONCLUSIONS

The study proved that the PCC-36 Arabic version is a valid and reliable instrument for the measurement of patient communication experiences in cancer care in Saudi Arabia, with similar properties to the original, and that this instrument may be used in 22 different Arab countries to measure and improve cancer patients' communication experiences.

Improving Communications With Patients and Families in Geriatric Care. The How, When, and What

There has been little published literature examining the unique communication challenges older adults pose for health care providers. Using an explanatory mixed-methods design, this study explored patients’ and their family/caregivers’ experiences communicating with health care providers on a Canadian tertiary care, inpatient Geriatric unit between March and September 2018. In part 1, the modified patient–health care provider communication scale was used and responses scored using a 5-point scale. In part 2, one-on-one telephone interviews were conducted and responses transcribed, coded, and thematically analyzed. Thirteen patients and 7 family/caregivers completed part 1. Both groups scored items pertaining to adequacy of information sharing and involvement in decision-making in the lowest 25th percentile. Two patients and 4 family/caregivers participated in telephone interviews in part 2. Interview transcript analysis resulted in key themes that fit into the “How, When, and What” framework outlining the aspects of communication most important to the participants. Patients and family/caregivers identified strategic use of written information and predischarge family meetings as potentially valuable tools to improve communication and shared decision-making.

Doctor-Patient Communication in Primary Health Care: A Mixed-Method Study in Fiji

From a clinical perspective, effective and efficient communication is part of a strategy to ensure doctors are providing high-quality care to their patients. Despite the positive impact of effective doctor-patient communication on health outcomes, limited information is available on this in Fiji. This study was carried out to determine the current patients' perception of doctors' communication behaviour and identify factors affecting the doctor-patient communication in Fiji. This mixed-method study was conducted in the outpatient setting of three randomly selected health centres in the Suva Subdivision, Fiji. For the quantitative phase, systematic random sampling was used to select the 375 participants who completed the structured questionnaire; of those, 20 participants were selected for the qualitative interview. From the patients' perception, 45.6% of them perceived doctors' communication behaviour as good, 53.6% as fair, and 0.8% as poor communication behaviour. Qualitative findings highlight factors such as the attitude of the doctors, their approach, their interaction with the patients, and them providing an explanation as important factors during doctor-patient communication. In Fiji, the majority of patients perceived doctors' communication behaviour as fair to good and the doctors' skills were important for effective doctor-patient communication. This study highlighted the importance of doctor-patient communication and suggested that doctors might not be practicing patient-centred care and communication; thus, they need to upgrade their patient-centred communication skills.

What do patients expect? Assessing patient-centredness from the patients' perspective: an interview study

OBJECTIVE

Although there has been much conceptual work on patient-centredness (PC), patients' perspectives on PC were neglected. In a previous study, participating patients rated the relevance of 16 dimensions of an integrative model of PC as high to very high. However, it remained unclear which specific behaviours described in the dimensions were considered most relevant. Thus, the aim of the current study was to further explore which of the specific behaviours described in the model are especially relevant for the high ratings in the previous study.

METHODS AND DESIGN

We conducted semistructured interviews with 20 patients with chronic diseases (16 females, 4 males, mean age: 52 years). Patients answered questions regarding their experiences in the German healthcare system and how optimal healthcare would look like from their perspective. Furthermore, patients were asked to reflect on the most important aspects which they had mentioned in the interview before. Data were analysed via content analysis.

RESULTS

Participants addressed many different aspects of PC, but mostly focused on three major themes: (1) time appropriate access to care, (2) competence, empathy and being taken seriously by HCPs, (3) HCPs' individual consideration of each patient's situation (eg, wishes and needs). Minor themes were: (1) taking a holistic perspective of the patient, (2) patient-centred communication, (3) integration of multidisciplinary treatment elements, (4) transparency regarding waiting time and (5) reduction of unequal access to care.

CONCLUSION

This study enriches the construct of PC by depicting essential aspects of PC from the patients' perspective. The results allow prioritising strategies to implement patient-centred care. Thus, this study helps to pursue the ultimate goal of fostering patient-centred healthcare delivery in Germany.

Investigating Patient Trust in Doctors: A Cross-Sectional Survey of Out-Patient Departments in Fiji

Despite evidence on the positive impact of trust in a doctor-patient relationship on health outcomes, there are limited studies conducted in Pacific Island Countries including Fiji. This study was conducted to assess the current level of patient trust in doctors and investigate its determinants in Fiji. Method: A random sample of 410 participants attending the outpatient services completed the self-administered structured questionnaire. The response rate was 91% (N=375) and data was analyzed using descriptive statistics and analytic analysis using logistic regression. Result: Mean age of participants was 38years (±15yrs). The majority of patients had partial trust in their doctors compared to full trust (61.6% vs 38.4%). More than half of the participants perceived doctor's communication behavior as fair rather than good (53.6% vs 45.6%). Those over 50 years (OR 1.96; p=0.007, 95% CI: 1.198-3.226) and those who perceived doctors' communication behavior as good (OR 8.48; p=0.0001, 95% CI: 5.257-13.709) were significantly more likely to have full trust in the doctors. Conclusion: This study reveals that age and communication are determinants of trust in Fiji. In view of the current perception of the doctors' communication behavior, Fiji's Ministry of Health and Medical Services should implement policies to give equal importance to the communication skills of the doctors together with their clinical skills and enforce it in the medical schools.

Variance components of ratings of physician-patient communication: A generalizability theory analysis

BACKGROUND

The ratings of physician-patient communication are an important indicator of the quality of health care delivery and provide guidance for many important decisions in the health care setting and in health research. But there is no gold standard to assess physician-patient communication. Thus, depending on the specific measurement condition, multiple sources of variance may contribute to the total score variance of ratings of physician-patient communication. This may systematically impair the validity of conclusions drawn from rating data.

OBJECTIVE

To examine the extent to which different measurement conditions and rater perspectives, respectively contribute to the variance of physician-patient communication ratings.

METHODS

Variance components of ratings of physician-patient communication gained from 32 general practitioners and 252 patients from 25 family practices in Germany were analyzed using generalizability theory. The communication dimensions "shared decision making", "effective and open communication" and "satisfaction" were considered.

RESULTS

Physician-patient communication ratings most substantially reflect unique rater-perspective and communication dimension combinations (32.7% interaction effect). The ratings also represented unique physician and rater-perspective combinations (16.3% interaction effect). However, physicians' communication behavior and the observed communication dimensions revealed only a low extent of score variance (1% physician effect; 3.7% communication dimension effect). Approximately half of the variance remained unexplained (46.2% three-way interaction, confounded with error).

CONCLUSION

The ratings of physician-patient communication minimally reflect physician communication skills in general. Instead, these ratings exhibit primarily differences among physicians and patients in their tendency to perceive shared decision making and effective and open communication and to be satisfied with communication, regardless of the communication behavior of physicians. Rater training and assessing low inferential ratings of physician-patient communication dimensions should be considered when subjective aspects of rater perspectives are not of interest.

Negative stance towards treatment in psychosocial assessments: The role of personalised recommendations in promoting acceptance

People presenting to the emergency department with self-harm or thoughts of suicide undergo a psychosocial assessment involving recommendations for e.g. contact with other practitioners, charity helplines or coping strategies. In these assessments, patients frequently adopt a negative stance towards potential recommendations. Analysing 35 video-recorded liaison psychiatry psychosocial assessments from an emergency department in England (2018-2019), we ask how these practitioners transform this negative stance into acceptance. We show that practitioners use three steps to anticipate and address negative stance (1) asking questions about the patient's experience/understanding that help the patient to articulate a negative stance (e.g., "what do you think about that"); (2) accepting or validating the reasons underlying the negative stance (e.g., "that's a very real fear and thought to have"); and (3) showing the patient that their reasons were incorporated in the recommendation (e.g., "it's telephone support if you're a bit more uncomfortable with face to face"). These steps personalise the recommendation based on the patient's specific experiences and understanding. When practitioners followed all three of these steps, the patient moved from a negative stance to acceptance in 84% of cases. When practitioners made a recommendation but did not follow all three steps, the patient moved from a negative stance to acceptance in only 14% of cases. It is not the case that each communication practice works on its own to promote patient acceptance, rather Steps 1 and 2 build on each other sequentially to develop and demonstrate shared understanding of the patient's negative stance. In this way, acceptance and validation play an indispensable role in addressing a patient's concerns about treatment.

Improv to improve medical student communication

BACKGROUND

Effective patient provider communication skills can be difficult and time-consuming to teach. Deliberate practice of communication skills through improvisational theatre exercises, with structured debriefing, can provide a solution for teaching patient-centred communication skills in time-limited settings. The objective of this study was to determine if improvisational theatre exercises improved the ratings of patient satisfaction and empathetic communication by standardised patients.

METHODS

This was a randomised controlled trial looking at the effect of improvisational theatre exercises on ratings of patient satisfaction and empathetic communication. Third-year medical students (n = 188) participated in a formative team-based standardised patient (SP) experience. Prior to the SP experience, teams of students were randomly assigned to receive a 45-minute communication-focused improvisation intervention (immediately before the SP experience) or to a control arm without intervention. All teams then participated in the SP experience; the SPs (blinded to team randomisation assignment) then assessed each team's empathetic communication and completed patient satisfaction questions focused on physician behaviours derived from Press GaneyTM and the Hospital Consumer Assessment of Healthcare Providers and System SurveysTM . Fifty teams of three or four students participated; 20 teams in the intervention arm and 30 teams in the control arm.

RESULTS

Student teams in the improvisation intervention group had increased measures of empathetic communication (p = 0.04) compared to the control group. The intervention group had increased patient satisfaction survey ratings of 'ability to listen carefully' (p = 0.001) and of 'physician skills' compared to control groups (p = 0.03).

DISCUSSION

Improv exercises with students increased students' empathetic communication and patient satisfaction as assessed by standardised patients.

Scoping review of the person-centered literature in adult physical rehabilitation

PURPOSE

To describe the amount, range, and key characteristics (e.g., publication years, methods, topics) of the person-centered rehabilitation literature in adults with physical impairments.

METHOD

Following the published scoping review protocol, papers were identified through: three major databases, snowball searches and expert consultation. Two independent reviewers have identified English-language papers on adult person-centered rehabilitation according to six pre-defined inclusion categories - theoretical, quantitative and qualitive research papers are included; and then have extracted their key characteristics (e.g., aims, methods, participants). Descriptive statistics, regression and content analyses were used to synthesize the results.

RESULTS

Of 5912 deduplicated records initially screened, 170 papers were included: 136 empirical, including 13 systematic reviews. Empirical papers had data from 15264 clients and 4098 providers, in total. Yearly publications grew significantly from 2009 to 2018 (r2 = 0.71; b = 1.98: p < 0.01). Publications were unevenly distributed by countries (e.g., United States' publications per population was 44 times lower than New Zealand's). Most papers focused in more than one profession, setting-type or health conditions. Finally, many empirical papers (n = 67) studied implementation of person-centered rehabilitation approaches, including its effect.

CONCLUSION

This scoping review synthesizes key characteristics and publication trends in the person-centered rehabilitation literature on adults with physical impairments, a growing but unchartered territory thus far. This large and diverse body of literature can ground further person-centered rehabilitation practices and research, including toward building a transdisciplinary, trans-service model of person-centered rehabilitation.Implications for rehabilitationThe person-centered rehabilitation literature on adults with physical impairments, especially the empirical one, has been growing significantly over time, despite inequitably distributed per countries.Rehabilitation stakeholders, including practitioners, have a growing amount of literature in which they can rely for the operationalization and implementation of person-centered rehabilitation approaches into routine practice.Based on our work, person-centered rehabilitation emerges as a practice requirement that cuts across professional and other rehabilitation silos.

Improving secure messaging: A framework for support, partnership & information-giving communicating electronically (SPICE)

BACKGROUND

Patient-centered communication benefits patients and is widely endorsed. However, it is primarily associated with face-to-face contexts, although patients are increasingly using electronic platforms, such as secure messaging in patient portals, to communicate with providers.

PURPOSE

Given the popularity of secure messaging and its ability to impact the patient-provider relationship, this study aimed to determine which attributes of patient-centered communication are most desired by cancer patients using secure messaging.

METHODS

A 2⁶ balanced incomplete block design discrete choice experiment was conducted using the best-worst scaling technique. Respondents were asked to select their most and least preferred attributes of two simulated patient-provider exchanges within each of eight choice sets.

RESULTS

210 respondents indicated that either level of partnership (high and low) and either level of information-giving (high and low) were most preferred, while response times greater than 24 hours and low levels of support were least favored.

CONCLUSIONS

Similar to face-to-face communication, patients value aspects of patient-centered communication in the secure messaging setting and desire them to be included in provider replies.

PRACTICE IMPLICATIONS

Patient-centered communication is important to patients using secure messaging. Providers should incorporate SPICE (Support, Partnership, and Information-giving while Communicating Electronically).

'It's not magic': A qualitative analysis of geriatric physicians' explanations of cardio-pulmonary resuscitation in hospital admissions

BACKGROUND

Discussing patient preferences for cardio-pulmonary resuscitation (CPR) is routine in hospital admission for older people. The way the conversation is conducted plays an important role for patient comprehension and the ethics of decision making.

OBJECTIVE

The objective was to examine how CPR is explained in geriatric rehabilitation hospital admission interviews, focussing on circumstances in which physicians explain CPR and the content of these explanations.

METHOD

We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR was discussed. Data were analysed in French with thematic and conversation analysis, and the extracts used for publication were translated into English.

RESULTS

Mean patient age was 83.7 years; 53.5% were admitted for rehabilitation after surgery or traumatism. CPR was explained in 53.8% of the conversations. Most explanations were brief and concerned the technical procedures, mentioning only rarely potential outcome. With one exception, medical indication and prognosis of CPR did not feature in these explanations. Explanations occurred either before the patient's answer (as part of the question about CPR preferences) or after the patient's answer, generated by patients' indecision, misunderstanding and by the need to clarify answers.

DISCUSSION AND CONCLUSIONS

The scarcity and simplicity of CPR explanations highlight a reluctance to have in-depth discussions and reflect the assumption that CPR does not need explaining. Providing patients with accurate information about the outcomes and risks of CPR is incremental for reaching informed decisions and patient-centred care.

PATIENT CONTRIBUTION

Patients were involved in the data collection stage of the study.

Collegiate Student-Athletes' Perceptions of Patient-Centered Care Delivered by Athletic Trainers

CONTEXT

The health care core competencies indicate that all medical professionals should provide patient-centered care (PCC), which is defined as care that is respectful and responsive to the patient's values and preferences, during each encounter.

OBJECTIVE

To identify collegiate student-athletes' definitions of PCC and measure their perceived level of PCC from an athletic trainer (AT).

DESIGN

Cross-sectional study.

SETTING

Mixed-methods survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 610 (age = 19 ± 1 year) National Collegiate Athletic Association student-athletes completed the survey.

MAIN OUTCOME MEASURE(S)

The survey consisted of 1 open-ended question that prompted the participant to define PCC in his or her own words. The quantitative data were gathered using the Global Perceptions of Athletic Trainer PCC tool, which explores the overall agreement with the AT's use of PCC constructs. Finally, those participants who had received care from an AT completed the validated Patient Perception of Patient-Centeredness instrument. Qualitative analysis was completed through Text IQ technology with a mean sentiment score attributed to each of the coded statements. We calculated descriptive statistics for all quantitative data.

RESULTS

The qualitative analysis revealed 13 topics, with the most used being individual, priority, and best. Other topics were inconsistent with how the medical community has defined PCC. On the Global Perceptions of Athletic Trainer PCC tool, the participants expressed strong agreement (mode = 4) with 12 of the 15 statements. On the Patient Perception of Patient-Centeredness instrument, participants expressed that the AT was completely (mode = 4) patient centered for all dimensions during their most recent encounter. However, PCC behaviors, as defined by the medical community, may not be directly expressed according to collegiate student-athletes.

CONCLUSIONS

Student-athletes defined PCC as individualized and prioritized health care. They perceived that ATs provided care that kept their best interest in mind and practiced PCC during their encounters.

Treatment satisfaction mediates the association between perceived physician empathy and psychological distress in a community sample of individuals with chronic pain

OBJECTIVE

While the benefits of patient-centered care have been consistently demonstrated in the health literature, there exists a dearth of pathway research within health outcome research, especially within the chronic pain context. This study examined the relationship between perceived physician empathy and patient psychological distress and its underlying mechanism.

METHODS

A community sample of 259 adults with chronic pain completed online questionnaires measuring patient-perceived physician empathy, treatment satisfaction, depressive and anxiety symptoms. Analyses were conducted using correlational and mediation analyses.

RESULTS

Results revealed perceived empathy to be positively and strongly correlated with treatment satisfaction (r = .72, p < .001). A significant negative correlation was also demonstrated between perceived empathy and depressive symptoms (r = -.13, p < .05), but not between perceived empathy and anxious symptoms (r = .03, p = .65). Results revealed significant mediation models between perceived empathy and patient depressive symptoms (indirect effect: B = -.19, SE =.06, 95 % CI [-.31, -.09]) and anxious symptoms (indirect effect: B = -.24, SE = .06, 95 % CI [-.35, -.14]), via treatment satisfaction as mediator and including covariates.

CONCLUSION

Chronic pain patients who perceive greater levels of physician empathy experience fewer depressive and anxious symptoms, as mediated by treatment satisfaction.

PRACTICE IMPLICATIONS

Clinical training and practice should promote empathetic components of health communication within chronic pain treatment.

Seeing the Elephant: A Systematic Scoping Review and Comparison of Patient-Centeredness Conceptualizations from Three Seminal Perspectives

"Patient-Centeredness" (PC) is a theoretical construct made up of a diverse constellation of distinct concepts, processes, practices, and outcomes that have been developed, arranged, and prioritized heterogeneously by different communities of professional healthcare practice, research, and policy. It is bound together by a common ethos that puts the holistic individual at the functional and symbolic center of their care, a quality deemed essential for chronic disease management and health promotion. Several important contributions to the PC research space have adeptly integrated seminal PC conceptualizations to improve conceptual clarity, measurement, implementation, and evaluation in research and practice. This systematic scoping review builds on that work, but with a purpose to explicitly identify, compare, and contrast the seminal PC conceptualizations arising from the different healthcare professional groups. The rationale for this work is that a deeper examination of the underlying development and corresponding assumptions from each respective conceptualization will lead to a more informed understanding of and meaningful contributions to PC research and practice, especially for healthcare professional groups newer to the topic area like pharmacy. The literature search identified four seminal conceptualizations from the healthcare professions of Medicine, Nursing, and Health Policy. A compositional comparison across the seminal conceptualizations revealed a shared ethos but also six distinguishing features: (1) organizational structure; (2) predominant level of care; (3) methodological approach; (4) care setting origin; (5) outcomes of interest; and (6) language. The findings illuminate PC's stable theoretical foundations and distinctive nuances needed to appropriately understand, apply, and evaluate the construct's operationalization in contemporary healthcare research and practice. These considerations hold important implications for future research into the fundamental aims of healthcare, how it should look when practiced, and what should reasonably be required of it.

Application of the Spanish-Language Consultation and Relational Empathy (CARE) Measure to Assess Patient-Centered Care Among Latino Populations

INTRODUCTION

Reliable and valid measures are needed to assess the patient-centeredness of clinical care among Latino populations.

METHODS

We translated the Consultation and Relational Empathy (CARE) measure from English to Spanish and assessed its psychometric properties using data from 349 Latino parents/guardians visiting a pediatric clinic. Using confirmatory factor analysis, we examined the psychometric properties of the Spanish CARE measure.

RESULTS

Internal reliability of the Spanish CARE measure was high (Omega coefficient = 0.95). Similar to the English-language CARE measure, factor analysis of the Spanish CARE measure yielded a single domain of patient-centeredness with high item loadings (factor loadings range from 0.79 to 0.96).

CONCLUSION

This preliminary analysis supports the reliability and validity of the Spanish version of the CARE measure among Latinos in pediatric care settings. With further testing, the Spanish CARE measure may be a useful tool for tracking and improving the health care delivered to Latino populations.

UK Dietitians' views on communication skills for behaviour change: A 10 year follow-up survey

BACKGROUND

In 2007, a survey of UK dietitians identified that dietitians were positive about the use of Communication Skills for Behaviour Change (CSBC) in practice, although barriers to the implementation of skills were acknowledged. This follow-up survey aimed to explore current perceptions of CSBC and compare them with the previous survey.

METHODS

A cross-sectional online survey of British Dietetic Association (BDA) members' views of CSBC was undertaken. The results for full members are presented. Quantitative data were analysed descriptively. Qualitative data were subject to either content, or inductive thematic analysis.

RESULTS

A response rate of 9.4% (n = 729) was achieved. Respondents were predominately female (n = 684; 95.1%) and worked in the National Health Service (n = 634; 87.4%). They were positive about the importance of CSBC in practice (n = 714; 99.5%). Pre-registration training had been completed by 346 respondents (48.7%). Post-registration training had been undertaken by 520 (74.7%) respondents and 514 of these (99.6%) had implemented training into practice, with few barriers identified. Perception of ability to use skills had increased, with 513 (83.6%) respondents rating their skills as excellent/very good compared to 62% previously. The majority (n = 594; 93.7%) reported that post-registration training was necessary, with the need for skills to be regularly reviewed (n = 456; 74.5%), and 235 (51.9%) respondents suggested this be mandatory. By contrast, some suggested that a skill review was not a priority, and would be difficult to administer and stressful.

CONCLUSIONS

Perception of the importance of CSBC remains high. Although the perceived ability to apply CSBC has increased, the perceived need for post-registration training is high, with respondents' favouring mandatory training.

Analyzing models of patient-centered care in Canada through a scoping review and environmental scan

Aim

The objective of this study was to identify and synthesize models of patient-centered care in Canada and compare them with the normative models described in the literature.

Subject and methods

Patient-centered care has gained momentum in the twenty-first century as a component of quality care. During the Covid-19 pandemic, the crisis often shifts the focus to the disease rather than the patient. The multiplicity of Canadian systems, including the federal, provincial, and territorial contexts, made a good case to search for a variety of models. This study was conducted using a scoping review method supported by an environmental scan to identify patient-centered care models in Canada.

Results

The study identified 19 patient-centered interventions across Canada. The interventions included bedside interventions, patient-engagement projects at the organizational level, and citizen advisory panels at the system level. The organizational model was the most common. The goals of interventions ranged from enhancing the patient's experience of care to identifying ways to cut costs. In most organizational-level projects, there was a marked tendency to engage patients as members of quality improvement committees. Respecting patient dignity and autonomy in one-on-one clinical interactions was minimally addressed in the models.

Conclusion

Health systems are not only technical, biomedical organizations but also socio-political institutions with goals of financial protection, the fair distribution of services and resources, and the meaningful inclusion of the citizens in the system, and thus patients need to be respected as individuals and as collectives within the healthcare system.