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Lawton AJ, Daubman BR, Natarajan S, Zehm A, Rosenberg LB. Making Every Minute Matter: Practical Strategies to Enhance High-Quality, Time-Efficient Hospice and Palliative Care Visits. J Palliat Med 2024. [PMID: 39235346 DOI: 10.1089/jpm.2024.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024] Open
Abstract
Therapeutic clinical relationships and skilled communication are foundational elements of high-quality hospice and palliative care. Both require that we draw on the most valuable, yet limited, resource in our practice: clinician time. As the demand for serious illness care continues to outpace the supply of trained palliative care clinicians, we must consider time-efficiency as a key component of clinical effectiveness. Equally, many skilled interventions, including serious illness communication, can occur during time-efficient encounters, which still preserve compassion and authentic presence. This report invites clinicians to reevaluate the meaning and use of time in modern palliative care practice and offers six strategies to enhance time-efficiency in daily clinical care.
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Affiliation(s)
- Andrew J Lawton
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany-Rose Daubman
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sudha Natarajan
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - April Zehm
- Division of Geriatric and Palliative Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Leah B Rosenberg
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Nelson RE, Kanjee Z, Freed J, Cichon CJ, Ricotta DN. BEDSIDE 2-R: A framework for team-based, patient-centered bedside rounds. J Hosp Med 2024. [PMID: 39104045 DOI: 10.1002/jhm.13481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/07/2024]
Affiliation(s)
- Ryan E Nelson
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Zahir Kanjee
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Freed
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Catherine J Cichon
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Daniel N Ricotta
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts, USA
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Houchens N, Engle JM, Palanjian R, Saint S, Townsend WA, Nasrallah M, Gupta A. Effect of Clinician Posture on Patient Perceptions of Communication in the Inpatient Setting: A Systematic Review. J Gen Intern Med 2024:10.1007/s11606-024-08906-4. [PMID: 39020229 DOI: 10.1007/s11606-024-08906-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 06/17/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Nonverbal communication plays a pivotal role in the provision of effective patient care and has been associated with important patient health outcomes. Clinician posture, a nonverbal form of communication, may influence the patient experience and satisfaction. The relationship between clinician posture (i.e., standing or at the patient's eye level) and patient perceptions of clinician communication in the hospital-a setting with heightened power dynamics between patient and clinician-is currently unknown. METHODS We conducted searches of Ovid MEDLINE, EBSCO CINAHL Complete, EBSCO PsycInfo, Elsevier Embase/Embase Classic, Elsevier Scopus, and Web of Science Core Collection up to May 2023. English language studies were included if they compared clinician posture (eye-level or standing) during adult inpatient (including emergency department) interactions. Two authors independently abstracted data from included studies and assessed risk of bias or quality of evidence. A third author arbitrated any disagreements. Studies reported adherence to the posture intervention and/or patient perception outcomes. The latter included encounter duration, preferences for posture type, perceptions of interaction quality and clinician communication and compassion, and standardized assessments of patient satisfaction. RESULTS Fourteen studies (six randomized controlled trials, four quasi-experimental studies, four observational studies) assessed clinician posture at the bedside. Ten noted at least one favorable outcome for clinicians who communicated at the patient's eye level, three revealed no differences in patient perceptions between standing and sitting, and one noted higher patient ratings for standing clinicians. Findings were limited by variation in interventions and outcomes, generally high risk of bias, and relatively low adherence to assigned posture groups. DISCUSSION Compared to standing, eye-level communication by clinicians appears beneficial. The magnitude and types of benefits clinicians and patients may gain from this behavior remain unclear given heterogeneity and generally high risk of bias in available studies. With its relatively easy implementation and potential for benefit, clinicians should consider communicating with their hospitalized patients at eye level. REGISTRATION PROSPERO, CRD42020199817.
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Affiliation(s)
- Nathan Houchens
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jason M Engle
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Rita Palanjian
- University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Urology, University of Arizona, Tucson, AZ, USA
| | - Sanjay Saint
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Whitney A Townsend
- University of Michigan Taubman Health Sciences Library, Ann Arbor, MI, USA
| | - Mariam Nasrallah
- University of Michigan Medical School, Ann Arbor, MI, USA
- Beaumont Health Family Medicine, Wayne, MI, USA
| | - Ashwin Gupta
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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Golden BP, Tackett S, Kobayashi K, Nelson TS, Agrawal AM, Zhang J, Jackson NA, Mills G, Lorigiano TJ, Hirpa M, Lin JS, Johnson T, Sajja A, Disney S, Huang S, Nayak J, Lautzenheiser M, Berry SA. Wall-mounted folding chairs to promote resident physician sitting at the hospital bedside. J Hosp Med 2024; 19:356-367. [PMID: 38243720 PMCID: PMC11065620 DOI: 10.1002/jhm.13271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/11/2023] [Accepted: 12/26/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Sitting at the bedside may improve patient-clinician communication; however, many clinicians do not regularly sit during inpatient encounters. OBJECTIVE To determine the impact of adding wall-mounted folding chairs inside patient rooms, beyond any impact from a resident education campaign, on the patient-reported frequency of sitting at the bedside by internal medicine resident physicians. DESIGN, SETTING, AND PARTICIPANTS Prospective, controlled pre-post trial between 2019 and 2022 (data collection paused 2020-2021 due to COVID-19) at an academic hospital in Baltimore, Maryland. Folding chairs were installed in two of four internal medicine units and educational activities were delivered equally across all units. MAIN OUTCOME AND MEASURES Patient-reported frequency of sitting at bedside, assessed as means on Likert-type items with 1 being "never" and 5 being "every single time." We also examined the frequency of other patient-reported communication behaviors. RESULTS Two hundred fifty six and 206 patients enrolled in the pre and post-intervention periods, respectively. The mean frequency of patient-reported sitting by resident physicians increased from 1.8 (SD 1.2) to 2.3 (1.2) on education-only units (absolute difference 0.48 [95% CI: 0.21-0.75]) and from 2.0 (1.3) to 3.2 (1.4) on units receiving chairs (1.16, [0.87-1.45]). Comparing differences between groups using ordered logistic regression adjusting for clustering within residents, units with added chairs had greater increases in sitting (odds ratio 2.05 [1.10-3.82]), spending enough time at the bedside (2.43 [1.32-4.49]), and checking for understanding (3.04 [1.44-6.39]). Improvements in sitting and other behaviors were sustained on both types of units. CONCLUSIONS Adding wall-mounted folding chairs may help promote effective patient-clinician communication.
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Affiliation(s)
- Blair P Golden
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sean Tackett
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kimiyoshi Kobayashi
- Department of Medicine and Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worchester, Massachusetts, USA
| | | | - Alison M Agrawal
- Central Billing Office, University of Maryland Medical System, Baltimore, Maryland, USA
| | - Jerry Zhang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Geron Mills
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ting-Jia Lorigiano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Meron Hirpa
- City of Cincinnati Health Department, Cincinnati, Ohio, USA
| | - Jessica S Lin
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Trent Johnson
- Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aparna Sajja
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sarah Disney
- Johns Hopkins Surgery Centers Series, Baltimore, Maryland, USA
| | - Shanshan Huang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Juhi Nayak
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew Lautzenheiser
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephen A Berry
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Yan X, Li J. Better doctor-patient relationships start with the small things. BMJ 2023; 383:2935. [PMID: 38101920 DOI: 10.1136/bmj.p2935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Xuemin Yan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun Li
- Department of Language and Culture in Medicine, Peking University School of Health Humanities, Beijing, China
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Golden BP, Gilmore-Bykovskyi A. "Nudging" clinicians to communicate more effectively with patients in hospital. BMJ 2023; 383:2678. [PMID: 38101921 DOI: 10.1136/bmj.p2678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Blair P Golden
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Andrea Gilmore-Bykovskyi
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
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Iyer R, Park D, Kim J, Newman C, Young A, Sumarsono A. Effect of chair placement on physicians' behavior and patients' satisfaction: randomized deception trial. BMJ 2023; 383:e076309. [PMID: 38101923 PMCID: PMC10726223 DOI: 10.1136/bmj-2023-076309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To evaluate the effect of chair placement on length of time physicians sit during a bedside consultation and patients' satisfaction. DESIGN Single center, double blind, randomized controlled deception trial. SETTING County hospital in Texas, USA. PARTICIPANTS 51 hospitalist physicians providing direct care services, and 125 observed encounters of patients who could answer four orientation questions correctly before study entry, April 2022 to February 2023. INTERVENTION Each patient encounter was randomized to either chair placement (≤3 feet (0.9 m) of patient's bedside and facing the bed) or usual chair location (control). MAIN OUTCOME MEASURES The primary outcome was the binary decision of the physician to sit or not sit at any point during a patient encounter. Secondary outcomes included patient satisfaction, as assessed with the Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, time in the room, and both physicians' and patients' perception of time in the room. RESULTS 125 patient encounters were randomized (60 to chair placement and 65 to control). 38 of the 60 physicians in the chair placement group sat during the patient encounter compared with five of the 65 physicians in the control group (odds ratio 20.7, 95% confidence interval 7.2 to 59.4; P<0.001). The absolute risk difference between the intervention and control groups was 0.55 (95% confidence interval 0.42 to 0.69). Overall, 1.8 chairs needed to be placed for a physician to sit. Intervention was associated with 3.9% greater TAISCH scores (effect estimate 3.9, 95% confidence interval 0.9 to 7.0; P=0.01) and 5.1 greater odds of complete scores on HCAHPS (95% confidence interval 1.06 to 24.9, P=0.04). Chair placement was not associated with time spent in the room (10.6 minutes v control 10.6 minutes) nor perception of time in the room for physicians (9.4 minutes v 9.8 minutes) or patients (13.1 minutes v 13.5 minutes). CONCLUSION Chair placement is a simple, no cost, low tech intervention that increases a physician's likelihood of sitting during a bedside consultation and resulted in higher patients' scores for both satisfaction and communication. TRIAL REGISTRATION ClinicalTrials.gov NCT05250778.
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Affiliation(s)
- Ruchita Iyer
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Do Park
- Department of Internal Medicine, University of Texas - Southwestern Medical Center, Dallas, TX 75390, USA
| | - Jenny Kim
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Courtney Newman
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Avery Young
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Andrew Sumarsono
- Department of Internal Medicine, University of Texas - Southwestern Medical Center, Dallas, TX 75390, USA
- Division of Hospital Medicine, Parkland Health, Dallas, TX, USA
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