How do patients view the role of the primary care physician in inpatient care?

Primary care physician involvement during hospitalisation: a qualitative analysis of perspectives from frequently hospitalised patients

OBJECTIVE

To explore frequently hospitalised patients' experiences and preferences related to primary care physician (PCP) involvement during hospitalisation across two care models.

DESIGN

Qualitative study embedded within a randomised controlled trial. Semistructured interviews were conducted with patients. Transcripts were analysed using qualitative template analysis.

SETTING

In the Comprehensive Care Programme (CCP) Study, in Illinois, USA, Medicare patients at increased risk of hospitalisation are randomly assigned to: (1) care by a CCP physician who serves as a PCP across both inpatient and outpatient settings or (2) care by a PCP as outpatient and by hospitalists as inpatients (standard care).

PARTICIPANTS

Twelve standard care and 12 CCP patients were interviewed.

RESULTS

Themes included: (1) Positive attitude towards PCP; (2) Longitudinal continuity with PCP valued; (3) Patient preference for PCP involvement in hospital care; (4) Potential for in-depth involvement of PCP during hospitalisation often unrealised (involvement rare in standard care; in CCP, frequent interaction with PCP fostered patient involvement in decision making); and (5) PCP collaboration with hospital-based providers frequently absent (no interaction for standard care patients; CCP patients emphasising PCP's role in interdisciplinary coordination).

CONCLUSION

Frequently hospitalised patients value PCP involvement in the hospital setting. CCP patients highlighted how an established relationship with their PCP improved interdisciplinary coordination and engagement with decision making. Inpatient-outpatient relational continuity may be an important component of programmes for frequently hospitalised patients. Opportunities for enhancing PCP involvement during hospitalisation should be considered.

Craving Empathy: Studying the Sustained Impact of Empathy Training on Clinicians

Evidence is sparse when it comes to the longitudinal impact of educational interventions on empathy among clinicians. Additionally, most available research on empathy is on medical trainee cohorts. We set out to study the impact of empathy and communication training on practicing clinicians' self-reported empathy and whether it can be sustained over six months. An immersive curriculum was designed to teach empathy and communication skills, which entailed experiential learning with simulated encounters and didactics on the foundational elements of communication. Self-reported Jefferson Scale of Empathy (JSE) was scored before and at two points (1-4 weeks and 6 months) after the training. Overall, clinicians' mean self-empathy scores increased following the workshop and were sustained at six months. Specifically, the perspective taking domain of the empathy scale, which relates to cognitive empathy, showed the most responsiveness to educational interventions. Our analysis shows that a structured and immersive training curriculum centered on building communication and empathy skills has the potential to positively impact clinician empathy and sustain self-reported empathy scores among practicing clinicians.

Role of Kindness in Cancer Care

The wonders of high-tech cancer care are best complemented by the humanity of high-touch care. Simple kindnesses can help to diffuse negative emotions that are associated with cancer diagnosis and treatment—and may even help to improve patients’ outcomes. On the basis of our experience in cancer care and research, we propose six types of kindness in cancer care: deep listening , whereby clinicians take the time to truly understand the needs and concerns of patients and their families; empathy for the patient with cancer, expressed by both individual clinicians and the care culture, that seeks to prevent avoidable suffering; generous acts of discretionary effort that go beyond what patients and families expect from a care team; timely care that is delivered by using a variety of tools and systems that reduce stress and anxiety; gentle honesty, whereby the truth is conveyed directly in well-chosen, guiding words; and support for family caregivers, whose physical and mental well-being are vital components of the care their loved ones receive. These mutually reinforcing manifestations of kindness—exhibited by self-aware clinicians who understand that how care is delivered matters—constitute a powerful and practical way to temper the emotional turmoil of cancer for patients, their families, and clinicians themselves.

A majority of family physicians use a hospitalist service when their patients require inpatient care

BACKGROUND

The hospitalist movement in the United States has risen in prominence over the past 2 decades with more physicians practicing as hospitalists. Our objective was to examine different strategies used by family physicians when their patients require inpatient care.

METHODS

Secondary analysis of a cross-sectional survey of physicians accessing the American Board of Family Medicine Web site in 2011 and the 2011 Area Resource File. Logistic regression assessed for associations between using hospitalists, managing inpatients personally, or with a group partner, and then comparing and contrasting these physicians with health care market characteristics.

RESULTS

A total of 3857 physicians had data on practice characteristics and could be geocoded to their county of residence. Compared with other physicians meeting inclusion criteria in the American Board of Family Medicine database, our sample was slightly older and more likely to be female. In all, 54% of respondents reported using hospitalist services while 18% reported managing hospitalized patients themselves. Respondents more likely to use hospitalist services were female and resided in urban areas. However, one third of these physicians living in isolated rural areas reported using hospitalist services. Respondents more likely to personally manage their patients in the hospital were more likely to be male and an international medical graduate. The likelihood of using hospitalist services increased with higher availability of hospitalist services.

CONCLUSIONS

Overall, a majority of family physicians are using hospitalist services. Family physicians seem more likely to use hospitalist services when they are available which may lead to fragmentation of care.

Seriously ill hospitalized patients' perspectives on the benefits and harms of two models of hospital CPR discussions

OBJECTIVE

To describe seriously ill patients' perspectives on expert-endorsed approaches for hospital cardiopulmonary resuscitation (CPR) discussions.

METHODS

We created two videos depicting a hospital doctor discussing CPR with a seriously ill patient. One depicted a values-based approach with a doctor's recommendation, and one an information-focused approach without a recommendation. During semi-structured interviews, 20 seriously ill hospitalized patients viewed and commented on both videos. We conducted a thematic analysis to describe benefits and harms of specific discussion components.

RESULTS

Half of participants reported no preference between the videos; 35% preferred the information-focused, and 15% the values-based. Participants' reactions to the discussion components varied. They identified both benefits and harms with components in both videos, though most felt comfortable with all components (range, 60-65%) except for the doctor's recommendation in the values-based video. Only 40% would feel comfortable receiving a recommendation, while 65% would feel comfortable with the doctor eliciting their CPR preference as in the information-focused video, p=0.03.

CONCLUSION

Participants' reactions to expert-endorsed discussion components varied. Most would feel uncomfortable receiving a doctor's recommendation about CPR.

PRACTICE IMPLICATIONS

Participants' varied reactions suggest the need to tailor CPR discussions to individual patients. Many patients may find doctor's recommendations to be problematic.

Decision-making process reported by Medicare patients who had coronary artery stenting or surgery for prostate cancer

BACKGROUND

Patients facing decisions should be told about their options, have the opportunity to discuss the pros and cons, and have their preferences reflected in the final decision.

OBJECTIVES

To learn how decisions were made for two major preference-sensitive interventions.

DESIGN

Mail survey of probability samples of patients who underwent the procedures.

PARTICIPANTS

Fee-for-service Medicare beneficiaries who had surgery for prostate cancer or elective coronary artery stenting in the last half of 2008.

MAIN MEASUREMENTS

Patients' reports of which options were presented for serious consideration, the amount of discussion of the pros and cons of the chosen option, and if they were asked about their preferences.

RESULTS

The majority (64%) of prostate cancer surgery patients reported that at least one alternative to surgery was presented as a serious option. Almost all (94%) said they and their doctors discussed the pros, and 63% said they discussed the cons of surgery "a lot" or "some". Most (76%) said they were asked about their treatment preferences. Few who received stents said they were presented with options to seriously consider (10%). While most (77%) reported talking with doctors about the reasons for stents "a lot" or "some", few (19%) reported talking about the cons. Only 16% said they were asked about their treatment preferences.

CONCLUSIONS

While prostate cancer surgery patients reported more involvement in decision making than elective stent patients, the reports of both groups document the need for increased efforts to inform and involve patients facing preference-sensitive intervention decisions.

Gaps in continuity of care at the interface between primary care and specialized care: general practitioners' experiences and expectations

Introduction

Discontinuity of care at the interface between inpatient and outpatient management can lead to increased morbidity and mortality. Appropriate communication and flow of information is indispensable to ensure continuity of care. Consequently, the aim of this study was to assess general practitioners’ (GPs) experiences of cooperation with a university hospital, as well as their needs and obvious barriers regarding an optimized information flow.

Methods

A qualitative study was performed. In March 2011, 300 GPs from the Zurich Canton were invited to participate in two focus group meetings. Based on a review of the literature, an interview guide was created addressing two main issues. In the first part, experiences and barriers regarding cooperation with the university were explored. In the second part, needs and suggestions to improve cooperation were addressed.

Results

Fifteen GPs participated in two focus groups. GPs complained that they have often not been adequately informed about ongoing treatments or appointments for their patients. GPs feel responsible for the continuity of care and wish to be more involved, especially in long-term treatment decisions or at the end of life. By not involving them, they stated, important information concerning patients’ medical history and social setting was not taken into account. Improvements are also required at discharge: GPs often do not receive important information about treatments in the hospital and further requirements within a reasonable time.

Conclusion

Exchange of information between the hospital and the GP at admission and discharge is essential. However, at present, involvement during hospitalization of the patient is lacking. This includes the exchange of information after an unexpected clinical procedure and input from GPs when difficult clinical decisions are made, such as at the beginning or termination of long-term therapies.

Assessment of patient's experiences across the interface between primary and secondary care: Consumer Quality Index Continuum of care

OBJECTIVE

Development and validation of a questionnaire that measures patients' experiences of collaboration between general practitioners (GPs) and specialists.

METHODS

A questionnaire was developed using the method of the consumer quality index and validated in a cross-sectional study among a random sample of patients referred to medical specialists in the Netherlands. Validation included factor analysis, ascertain internal consistency, and the discriminative ability.

RESULTS

The response rate was 65% (1404 patients). Exploratory factor analysis indicated that four domains could be distinguished (i.e. GP Approach; GP Referral; Specialist; Collaboration). Cronbach's alpha coefficients ranged from 0.51 to 0.93 indicating sufficient internal consistency to make comparison of groups of respondents possible. The Pearson correlation coefficients between the domains were <0.4, except between the domains GP Approach and GP Referral. All domains clearly produced discriminating scores for groups with different characteristics.

CONCLUSIONS

The Consumer Quality Index (CQ-index) Continuum of Care can be a useful instrument to assess aspects of the collaboration between GPs and specialists from patients' perspective.

PRACTICE IMPLICATIONS

It can be used to give feedback to both medical professionals and policy makers. Such feedback creates an opportunity for implementing specific improvements and evaluating quality improvement projects.

Transition of care: experiences and preferences of patients across the primary/secondary interface - a qualitative study

BACKGROUND

Coordination between care providers of different disciplines is essential to improve the quality of care, in particular for patients with chronic diseases. The way in which general practitioners (GP's) and medical specialists interact has important implications for any healthcare system in which the GP plays the role of gatekeeper to specialist care. Patient experiences and preferences have proven to be increasingly important in discussing healthcare policy. The Dutch government initiated the development of a special website with information for patients on performance indicators of hospitals as well as information on illness or treatment.In the present study we focus on the transition of care at the primary - secondary interface with reference to the impact of patients' ability to make choices about their secondary care providers. The purpose of this study is to (a) explore experiences and preferences of patients regarding the transition between primary and secondary care, (b) study informational resources on illness/treatment desired by patients and (c) determine how information supplied could make it easier for the patient to choose between different options for care (hospital or specialist).

METHODS

We conducted a qualitative study using semi-structured focus group interviews among 71 patients referred for various indications in the north and west of The Netherlands.

RESULTS

Patients find it important that they do not have to wait, that they are taken seriously, and receive adequate and individually relevant information. A lack of continuity from secondary to primary care was experienced. The patient's desire for free choice of type of care did not arise in any of the focus groups.

CONCLUSION

Hospital discharge information needs to be improved. The interval between discharge from specialist care and the report of the specialist to the GP might be a suitable performance indicator in healthcare. Patients want to receive information, tailored to their own situation. The need for information, however, is quite variable. Patients do not feel strongly about self-chosen healthcare, contrary to what administrators presently believe.

Patients' perspectives on ideal physician behaviors

We incorporated the views of patients to develop a comprehensive set of ideal physician behaviors. Telephone interviews were conducted in 2001 and 2002 with a random sample of 192 patients who were seen in 14 different medical specialties of Mayo Clinic in Scottsdale, Ariz, and Mayo Clinic in Rochester, Minn. Interviews focused on the physician-patient relationship and lasted between 20 and 50 minutes. Patients were asked to describe their best and worst experiences with a physician in the Mayo Clinic system and to give specifics of the encounter. The interviewers independently generated and validated 7 ideal behavioral themes that emerged from the interview transcripts. The ideal physician is confident, empathetic, humane, personal, forthright, respectful, and thorough. Ways that physicians can incorporate clues to the 7 ideal physician behaviors to create positive relationships with patients are suggested.

Interpersonal continuity of care and patient satisfaction: a critical review

PURPOSE

We wanted to review the medical literature regarding the relationship between interpersonal continuity of care and patient satisfaction and suggest future strategies for research on this topic.

METHODS

A search of the MEDLINE database from 1966 through April 2002 was conducted to find articles focusing on interpersonal continuity of patient care. The resulting articles were screened to select those focusing on the relationship between interpersonal continuity in the doctor-patient relationship and patient satisfaction. These articles were systematically reviewed and analyzed for study method, measurement technique, and the quality of evidence.

RESULTS

Thirty articles were found that addressed the relationship between interpersonal continuity and patient satisfaction with medical care. Twenty-two of these articles were reports of original research. Nineteen of the 22, including 4 clinical trials, reported significantly higher satisfaction when interpersonal continuity was present.

CONCLUSIONS

Although the available literature reflects persistent methodologic problems, a consistent and significant positive relationship exists between interpersonal continuity of care and patient satisfaction. Future research in this area should address whether the same is true for all patients or only for those who seek ongoing relationships with physicians in primary care.

Defining and measuring interpersonal continuity of care

BACKGROUND

In an effort to learn more about the importance of continuity of care to physicians and patients, I reviewed the medical literature on continuity of care to define interpersonal continuity and describe how it has been measured and studied.

METHODS

A search of the MEDLINE database from 1966 through April 2002 was conducted to find articles focusing on the keyword "continuity of patient care," including all subheadings. Titles and abstracts of the resulting articles were screened to select articles focusing on interpersonal continuity in the physician-patient relationship or on the definition of continuity of care. These articles were systematically reviewed and analyzed for study method, measurement technique, and research theme.

RESULTS

A total of 379 original articles were found that addressed any aspect of continuity as an attribute of general medical care. One hundred forty-two articles directly related to the definition of continuity or to the concept of interpersonal continuity in the physician-patient relationship. Although the available literature reflects little agreement on how to define continuity of care, it is best defined as a hierarchy of 3 dimensions; informational, longitudinal, and interpersonal continuity. Interpersonal continuity is of particular interest for primary care. Twenty-one measurement techniques have been defined to study continuity, many of which relate to visit patterns and concentration rather than the interpersonal nature of the continuity relationship.

CONCLUSIONS

Future inquiry in family medicine should focus on better understanding the interpersonal dimension of continuity of care.