Time and the patient-physician relationship

The efficacy of postoperative visits for detecting complications in pediatric patients

BACKGROUND

Long wait times for new patient visits can delay necessary care and lead to patient dissatisfaction. Minimizing nonessential scheduled follow-up visits may increase surgeons' availability to see new patients. Postoperative clinic visits are typically scheduled to detect complications. However, there is limited data on how often postoperative complications are diagnosed during scheduled follow-up visits versus during other encounters. We examined whether complications were routinely detected during scheduled follow-up visits after low-risk procedures in healthy children.

METHODS

A single-center observational study was performed using Current Procedural Terminology/International Classification of Diseases codes and a chart review. Our cohort included patients who underwent appendectomy, inguinal hernia repair, pyloromyotomy, or circumcision between 2016 and 2023. A scheduled follow-up visit was defined as a postoperative clinic visit with a surgeon that was made ≥3 days before the clinic visit date and within 8 weeks of surgery. A complication that was diagnosed at an encounter other than the scheduled follow-up visit was defined as an "uncaptured complication." The primary exposure was provider scheduled follow-up visit rate, and the primary outcome was rate of uncaptured complications.

RESULTS

In total, 2,676 patients were included. Surgeon scheduled follow-up visit rate was categorized as low versus high based on the mean scheduled follow-up visit rate of 63%. The median rate of uncaptured complications for physicians with both a low scheduled follow-up visit rate and a high scheduled follow-up visit was 1.4% (P = .99). Even on adjusted analysis, high scheduled follow-up visit rate was not protective against uncaptured complications. Only procedure type and younger age were predictive of incidence of uncaptured complications.

CONCLUSION

Routine scheduled follow-up visits after low-risk operations in healthy children do not effectively capture postoperative complications. Implementing a culture of follow-up as needed could increase surgeon availability to see new patients in ambulatory clinics.

"The doctor will see you now… but not for long": Linking physicians' racial attitudes and patients' discrimination experiences to racial disparities in the duration of medical consultations

OBJECTIVE

To investigate the relationship between non-Black physicians' racial attitudes, Black patients' discrimination experiences, and consultation duration in diverse clinical settings.

METHODS

Secondary analyses were conducted on data from three prior studies involving non-Black primary care physicians (Study 1: n = 14, Study 2: n = 5) and their Black patients (Study 1: n = 118, Study 2: n = 31), as well as 15 non-Black oncologists and their 72 Black patients (Study 3). Data included physician and patient surveys, along with video-recorded consultations.

RESULTS

Study 1 revealed that, relative to other physicians, physicians whose racial attitudes fit an aversive racist profile (i.e., low explicit racial bias, high implicit bias) had longer consultations with Black patients who reported more (vs. fewer) discrimination experiences. Study 2 and 3 found that physicians' implicit racial bias is negatively associated with consultation duration. Finally, a meta-analysis supported the effects of aversive racism and patients' discrimination experiences on consultation duration.

DISCUSSION

These findings demonstrate how physicians' racial attitudes and patients' discrimination experiences can affect medical consultation duration-an important aspect of patient-provider communication quality.

PRACTICAL VALUE

These results provide initial evidence for the importance of helping physicians manage the negative consequences of their implicit bias within the current structural constraints of limited medical consultation time and empowering Black patients to advocate for their healthcare needs.

Information Overload-Do We Read All the Posters Displayed Across the Walls on Hospital Wards?

BACKGROUND AND OBJECTIVES

To establish whether posters displayed across the walls on hospital wards are read, what information is important, and how the information should be received.

METHODS

Sixty-eight staff and 32 patients' relatives were interviewed across 3 older people's medical wards followed by 20 follow-up secondary questionnaires postintervention.

RESULTS

Only 23% of those interviewed were able to recall any of the posters displayed, and of those, 34% did not find the information useful. Those interviewed were enthusiastic about utilizing alternative media. A quarter felt the walls across the hospitals wards should be for artwork. Among patients' relatives interviewed, common information requests were "the discharge pathway," "delirium," and "falls." Based on the initial findings, a targeted information board was installed and a mural was painted across the wall in one of the wards. Further post-intervention interviews with patients' relatives showed that the board was well received, but further unmet information needs were uncovered. Despite the new mural, 45% called for more paintings.

CONCLUSIONS

Most people ignore the posters displayed across the walls of hospital wards, and unmet information needs are rife. An appetite exists for alternative media. Paintings were earnestly called for, highlighting how a comforting environment could be part of the holistic care we offer patients in hospital.

Interactional competencies in medical student admission- what makes a "good medical doctor"?

Doctors' interactional competencies play a crucial role in patient satisfaction, well-being, and compliance. Accordingly, it is in medical schools' interest to select candidates with strong interactional abilities. While Multiple Mini Interviews (MMIs) provide a useful context to assess such abilities, the evaluation of candidate performance during MMIs is not always based on a solid theoretical framework. The newly developed selection procedure "Interactional Competencies - Medical Doctors (IC-MD)" uses an MMI circuit with five simulation patient scenarios and is rated based on the theoretically and empirically grounded construct of emotional availability. A first validation study with N = 70 first-semester medical students took place in 2021. In terms of convergent validity, IC-MD ratings showed strong correlations with simulation patients' satisfaction with the encounter (r =.57) but no association with emotional intelligence measures. IC-MD ratings were not related to high school performance or a cognitive student aptitude test, indicating divergent validity. Inter-rater reliability (ICC = 0.63) and generalizability (Eρ2 = 0.64) were satisfactory. The IC-MD proved to be fair regarding participants' age and gender. Participants with prior work experience in healthcare outperformed those without such experience. Participant acceptance of the procedure were good. The IC-MD is a promising selection procedure capable of assessing interactional competencies relevant to the medical setting. Measures of interactional competencies can complement the use of cognitive selection criteria in medical student admission. The predictive validity of the IC-MD needs to be addressed in future studies.

Patient-physician communication of health and risk information in the management of cardiovascular diseases and diabetes: a systematic scoping review

BACKGROUND

The communication of health and risk information is an integral part of patient-physician interaction. Effective communication of risk information for cardiovascular diseases and diabetes has been shown to improve medication adherence, increase physical activity levels, and improve dietary control. Patients who understand their risk profile are better able to work towards modifying their lifestyle behaviours as part of a shared decision-making process with physicians. This scoping review examines the evidence on patient-physician risk communication strategies, approaches and interventions for CVDs and diabetes management in primary care and secondary outpatient settings.

METHODS

A comprehensive database search for quantitative and qualitative studies was conducted in PubMed, Embase, Web of Science, Scopus, CINAHL, PsycINFO, and Cochrane Library from 1st January 2000 to 3rd October 2023. Two reviewers independently performed the screening of articles. Studies that report on patient-physician risk communication processes were included. Data were extracted and analysed using descriptive summaries and narrative synthesis. Results are reported in accordance with PRISMA-ScR guidelines. Included articles were appraised for quality following JBI critical appraisal and MMAT tools.

RESULTS

A total of 8378 articles published between 1st Jan 2000 to 3rd October 2023 were screened. After a full-text review of 88 articles, a total of 30 articles, consisting of 15 qualitative, 14 quantitative and 1 mixed method studies were included. Common areas of inquiry among articles include: (1) understanding and recalling risk information, (2) strategies and approaches used by physicians to communicate risk, and (3) interventions to improve the communication of risk. Studies reveal how physicians use a range of strategies, approaches and interventions to discuss risk with patients. We present and discuss each theme narratively in detail.

CONCLUSIONS

There is a critical need for further research into risk communication strategies for cardiovascular diseases (CVDs) and diabetes, with a focus on developing targeted approaches that enhance patients' understanding of their risk profiles. Evidence-based guidelines should assist healthcare professionals improve risk communication within clinical settings, with the goal of facilitating patient comprehension of health risks that can sustain lifestyle changes. Misalignment in communication may lead to dissatisfaction and confusion, which may impede the effective management of chronic conditions.

A socio-ecological model of the management of leprosy reactions in Indonesia and India using the experiences of affected individuals, family members and healthcare providers

BACKGROUND

Leprosy reactions (LR) are immune-mediated complications of leprosy that may be associated with severe and irreversible nerve damage. Non-medical aspects, such as financing, service provision, and healthcare resources in the management of LR are generally overlooked as studies tend to concentrate on clinical features and treatment. Barriers to accessing care and services are a major cause of suboptimal care for people with leprosy. This study aims to explore the barriers to and facilitators of high-quality care and management of LR in two leprosy-endemic countries with different health care models - Indonesia and India - and identify areas for improvement.

METHODS

A socio-ecological model was adopted. Data were obtained from 66 interviews with individuals who experienced LR and were seeking care at the two study sites. In addition, immediate family members of individuals with LR and healthcare workers attending to people with leprosy participated in seven focus group discussions (FGDs).

RESULTS

This study highlights the significant impact of public health insurance regulations and uptake at the macrosystem level on the provision of healthcare services, clinical decision-making, care expenditure, and the psychological well-being of individuals with LR in Indonesia and India. Lack of specialized health professionals and communication challenges were identified in both study populations. Indonesian participants encounter additional challenges due to a fragmented information system and drug shortages. This study identifies key facilitators in providing high-quality care for LR-affected individuals, including financial assistance, availability of corticosteroid alternatives, timely provision of care, and counselling. It found that the high coverage of public health insurance cards in the Indonesian model has increased access to care among individuals affected by LR, despite the challenges. Conversely, the Indian model of care offers treatment subsidies. The advantage of the Indonesian model is its ability to provide wider access to high-quality care, whereas the Indian model focuses on those in most need. This study emphasizes the importance of addressing these challenges through improved communication strategies, education aimed at the affected individuals, and accessible medical care. Furthermore, variations in care-seeking behaviour and self-care practices were observed in both sites, underscoring the need for culturally sensitive and comprehensive approaches to the management of LR.

CONCLUSION

The study findings demonstrate that the factors identified at the four systemic levels are interrelated and have an impact on the access, acceptability, and management of LR services. Despite its accessibility and wider coverage of public health insurance, the integrated service model in Indonesia faces challenges associated with complex regulations and the availability of medication. India's care model offers intensive, specialised care but has difficulties in ensuring sufficient health personnel, resources, and public health insurance coverage. These findings highlight the need to address these challenges to ensure timely, effective, and comprehensive care for individuals with LR.

Instruments evaluating the duration and pace of clinical encounters: A scoping review

OBJECTIVE

Hurried encounters in clinical settings contribute to dissatisfaction among both patients and clinicians and may indicate and contribute to low-quality care. We sought to identify patient- or clinician-reported instruments concerning this experience of time in clinical encounters.

METHODS

We searched multiple databases from inception through July 2023. Working in duplicate without restrictions by language or clinical context, we identified published instruments or single items measuring perceptions of time adequacy in clinical encounters. We characterized these by time domain (perceived duration or pace of the encounter), responder (patient or clinician), and reference (experience of care in general or of a particular encounter).

RESULTS

Of the 96 instruments found, none focused exclusively on perception of time adequacy in clinical encounters. Nonetheless, these instruments contained 107 time-related items. Of these, 81 items (77 %) measured the perception of the encounter duration, assessing whether there was adequate consultation time overall or for specific tasks (e.g., listening to the patient, exploring psychosocial issues, formulating the care plan). Another 19 (18 %) assessed encounter pace, and 7 (7 %) assessed both duration and pace. Pace items captured actions perceived as rushed or hurried or the perception that patients and clinicians felt pressed for time or rushed. Patients were the respondents for 76 (71 %) and clinicians for 24 (22 %) items. Most patient-reported items (48 of 76) referred to the patient's general care experience.

CONCLUSION

There are existing items to capture patient and clinician perceptions of the duration and/or pace of clinical encounters. Further work should ascertain their ability to identify hurried consultations and to detect the effect of interventions to foster unhurried encounters.

PRACTICE IMPLICATIONS

The available items assessing patient and clinician perceptions of duration and pace can illuminate the experience of time adequacy in clinical encounters as a target for quality improvement interventions. These items may capture unintended consequences on perceived time for care of interventions to improve healthcare access and efficiency.

How Much More Time Neurologic Examination Adds to Outpatient Visits: A Study of Cross-Sectional Data

Background and Objectives

The neurologic examination is a key part of neurologist visits. The neurologic examination leads to more accurate diagnoses, avoidance of unnecessary tests and procedures, and a stronger doctor-patient relationship. However, the neurologic examination takes time to perform, leading to longer visits with neurologists than with other specialists. We hypothesize that the neurologic examination adds quantifiable time to patient visits to a neurologist.

Methods

We examined a 5-year cross-section of the National Ambulatory Medical Care Survey, 2012-2016, selecting visits to a neurologist. We extracted an indicator for neurologic examination, time spent with the patient in minutes, patient demographics, new or established visit, reasons for visit, new vs chronic problems, insurance status, geographic region, collection year, and survey design variables. We report descriptive statistics among patient visits with and without neurologic examinations and built a generalized linear model of visit time and neurologic examination with patient and visit information as covariates and interaction terms between neurologic examination and new/established visits. A subgroup analysis was conducted by reasons for visit. All analyses incorporated survey design variables for accurate standard errors.

Results

There were 4,009 patient visits among 211 neurologists, comprising 11.3 million annual visits in the weighted sample. Neurologic examination was reported in 58%, with no difference in demographics, geographic regions, or reasons for visit between those who did or did not receive a neurologic examination. The mean time spent with the patient in visits with a neurologic examination was 29.9 minutes, compared with 25.0 minutes without (p = 0.002). In the adjusted model, new visits with a neurologic examination were associated with 4.1 minutes greater time spent with the patient (95% CI + 0.6 minutes, +7.7 minutes, p = 0.02) and established visits with a neurologic examination were 4.6 minutes longer (95% CI + 1.5 minutes, +7.5 minutes, p = 0.006.) In subgroup analysis, association of neurologic examination with time spent with the patient was greatest for visits for pain (+6.7 minutes, 95% CI + 0.7 minutes, +12.9 minutes, p = 0.03) and known neurologic diagnoses (+7.5 minutes, 95% CI + 4.2 minutes, +10.7 minutes, p < 0.001).

Discussion

This study demonstrates the association of neurologic examinations with increased time spent with the patient in ambulatory care. Further work is needed to assess the effects on medical decision making, costs of care, and patient access to neurologists.

Developing and Evaluating SEE-Diabetes: A Patient-Centered Educational Decision Support System for Diabetes Care

OBJECTIVES

This feasibility study evaluated the effectiveness of Support-Engage-Empower-Diabetes (SEE-Diabetes), a patient-centered educational tool designed to promote shared decision-making of diabetes management in older adults. We aimed to assess SEE-Diabetes's ability to facilitate patient engagement and collaborative goal setting, as measured by the Observational Patient Involvement (OPTION) scale and Shared Decision-Making Questionnaire (SDM-Q-Doc). We hypothesized that these instruments would effectively differentiate between healthcare providers who actively leveraged SEE-Diabetes to guide patient-centric conversations and set goals compared to those who did not.

METHODS

SEE-Diabetes, developed through a 4-year user-centered design process, was employed in simulated clinical encounters at the University of Missouri Health Care. We conducted an analysis of 12 clinical encounters using video recordings. This analysis involved three simulated patients and four providers, two internals and two externals, utilizing a mixed-methods approach. We assessed the decision-making process using SEE-Diabetes by SDM-Q-Doc, OPTION scale, and conversation analysis.

RESULTS

The average scores for the SDM-Q-Doc and the OPTION scale, out of a possible 100, were 52.6 and 75.9, respectively. Our findings revealed that active provider engagement with SEE-Diabetes during patient interactions served as an effective medium to facilitate shared decision-making and to set patient-centered goals. Providers who actively utilized SEE-Diabetes to guide conversations, ask open-ended questions, and incorporate patient input into goal setting demonstrated significantly higher OPTION and SDM-Q-Doc scores compared to those who used the tool less frequently or primarily for documentation purposes. Providers expressed positive feedback, highlighting its conciseness, patient-centricity, and optimism about integrating SEE-Diabetes into their future practices.

CONCLUSION

SEE-Diabetes showed considerable promise in improving interactions between patients and providers, presenting an innovative approach to diabetes management for older adults. This tool has the potential to not only close communication gaps but also enable patients to take a more active role in their healthcare decisions.

Computer-assisted medical history taking prior to patient consultation in the outpatient care setting: a prospective pilot project

BACKGROUND

Feeding patients' self-reported medical history into the diagnostic care process may accelerate workflows in clinical routine.

METHODS

We prospectively piloted a novel medical history documentation system in a German cardiological outpatient practice and evaluated its feasibility and perceived usefulness. Based on a generic software that allows to record structured information, a customized solution for the cooperating practice was developed and implemented. Prior to the consultation of the physician, the patient used a tablet that guided the user through a structured comprehensive workflow to document the medical history. The retrieved information was arranged by the software into a ready-to-use text format, presented to the physician in an editable form and added to her report. Three user-centered endpoints were explored: i) Appropriateness-measured by the duration of a patient interview; ii) Patient acceptance-assessed by three questions to patients; iii) Usefulness-operationalized by multiple ratings of the physician.

RESULTS

A total of 2,513 patients were approached of which 2,415 provided complete histories. The system was assessed as appropriate for the practical workflow in terms of time and workflows. The patient-system interaction was rated favourably by patients including elderly ones. The system was regarded useful by the physician, reducing her daily workload by about one hour.

CONCLUSIONS

Automated history-taking tools deployed before consultation could support physicians in obtaining patients' medical histories, thereby reducing professionals' perceived workload. The technical and methodological limitations of our study should be respected, calling for additional future evaluations.

Factors influencing diabetes treatment satisfaction in the INtegrating DEPrEssioN and Diabetes treatmENT randomized clinical trial: A multilevel model analysis

AIMS

Patient satisfaction is associated with positive diabetes outcomes. However, there are no identified studies that evaluate both patient- and clinic-level predictors influencing diabetes care satisfaction longitudinally.

METHODS

Data from the INtegrating DEPrEssioN and Diabetes treatmENT trial was used to perform the analysis. We used fixed and random effects models to assess whether and how changes in patient-level predictors (treatment assignment, depression symptom severity, systolic blood pressure, body mass index, LDL cholesterol, and haemoglobin A1C) from 0 to 24 months and clinic-level predictors (visit frequency, visit cost, number of specialists, wait time, time spent with healthcare provider, and receiving verbal reminders) measured at 24 months influence diabetes care satisfaction from 0 to 24 months.

RESULTS

Model 1 (patient-level predictors) accounted for 7% of the change in diabetes satisfaction and there was a significant negative relationship between change in depressive symptoms and care satisfaction (β = -0.23, SE = 0.12, p < 0.05). Within Model 1, 2% of the variance was explained by clinic-level predictors. Model 2 included both patient- and clinic-level predictors and accounted for 18% of the change in diabetes care satisfaction. Within Model 2, 9% of the variance was attributed to clinic-level predictors. There was also a cross-level interaction where the change in depression had less of an impact on the change in satisfaction for those who received a verbal reminder (β = -0.11, SE = 0.21, p = 0.34) compared with those who did not receive a reminder (β = -0.62, SE = 0.08, p < 0.01).

CONCLUSIONS

Increased burden of depressive symptoms influences diabetes care satisfaction. Clinic-level predictors also significantly influence diabetes care satisfaction and can reduce dissatisfaction in primary care, specifically, reminder calls from clinic staff.

BREAST-Q Analysis of Reduction Mammaplasty: Do Postoperative Complications of Breast Reduction Surgery Negatively Affect Patient Satisfaction?

BACKGROUND

Reduction mammaplasty can provide symptomatic relief to patients suffering from macromastia; however, complications such as dehiscence are common. It is unknown if the presence of complications affects patient-reported outcomes.

OBJECTIVES

The aim of this study was to determine the risk factors for the development of complications, and to examine the correlation between postoperative complications and patient-reported outcomes in reduction mammaplasty.

METHODS

A single-center retrospective chart review was undertaken of patients who received reduction mammaplasties (CPT 19318), performed by 13 surgeons, between January 2017 and February 2023. Breast cancer cases and oncoplastic reconstructions were excluded. Patients with >1 complication were grouped into the complications cohort. Satisfaction was assessed by administering the BREAST-Q survey.

RESULTS

A total of 661 patients were included for analysis, 131 of whom developed at least 1 complication. Patients in the group with complications had significantly higher average ages and BMIs, and a higher likelihood of hypertension and diabetes (P < .01). Among 180 BREAST-Q responders, 41 had at least 1 complication. There were no significant differences between the 2 groups (complications vs no complications) across survey outcomes. Although obese patients were more likely to develop infection and require revisions (P < .01), no significant differences in subgroup analysis of patient-reported outcomes focusing on obese patients were observed.

CONCLUSIONS

Obesity, hypertension, and diabetes were associated with postoperative complications of reduction mammaplasty. Patients with complications had similar postoperative BREAST-Q satisfaction to patients without complications. Although risk optimization is critical, patients and surgeons should be reassured that satisfaction may be achieved even in the event of a complication.

LEVEL OF EVIDENCE: 3

A Community-Informed Maternal and Infant Health Needs Assessment in Alabama

BACKGROUND

Maternal mortality is a global clinical and public health crisis. Researchers and leading organizations have highlighted the need for local partnerships to implement evidence-based strategies to mitigate poor outcomes. Alabama has the third highest maternal mortality rate in the nation. Research on the complexity of maternity mortality is strengthening, but poor outcomes in Alabama persist and there is limited data highlighting the perspectives of those on the frontlines of providing and receiving care.

PURPOSE

We conducted a qualitative, statewide, community-informed, maternal and infant health research assessment with physicians, providers, professionals, and birthing persons to identify challenges and solutions to addressing the states' poor perinatal health outcomes.   METHODS: Data were collected using a four-phase, research design that included semi-structured interviews, focus groups, one state-wide data sharing event, and five regional data sharing events. Data were collected between January 2020 and October 2021. The data were analyzed using consensus coding and thematic analysis.

MAIN FINDINGS

Fifty-nine (N = 59) individuals participated. Three themes emerged: 1) "They were making me feel so overlooked.": A disconnect between perinatal healthcare services and patient needs; 2) "That shouldn't be something you have to ask for.": Limitations to providing respectful perinatal healthcare; and 3) "If they work together, they can have all the tools they need.": Building a case for collaborative care.

CONCLUSIONS

Participants advocated for a collaborative perinatal healthcare model that focuses on the provision of respectful, quality perinatal healthcare. Our approach can be applied across contexts and used to support the effective implementation of contextually relevant maternity care practices.

Dangerous Knowledge and Proxy-Reasons: A Kurdish Woman's Therapeutic Attempts

Jihan, a former Kurdish guerilla fighter, struggles to gain medical treatment for the health problems she suffers as a result of war and trauma. The provision of care in Turkey has been motivated by ethno-political security concerns. Therefore, medical encounters are characterized by silences, not-knowing and of averting danger. Based on theories of ignorance, I explore how experiences of war and torture constitute dangerous knowledge that are difficult to share in a context, without a guaranteed therapeutic safe space. Patient and doctor navigate mistrust, silences and proxy-reasons in an attempt to deal with the traumata and violent experiences left unsaid.

Effectiveness of static, dynamic and combined dry needling techniques in the management of myofascial pain syndrome: A three-group study

Objectives

This study aims to evaluate and compare the therapeutic effectiveness of static dry needling (S-DN), dynamic dry needling (D-DN), and a combined technique (CT) for managing myofascial pain syndrome (MPS).

Patients and methods

Between January 1, 2023 and April 15, 2023, a total of 38 patients (9 males, 29 females; mean age: 40.5±12.7 years; range, 22 to 63 years) with MPS who experienced neck pain for less than six months and had at least one painful myofascial trigger point in the trapezius, rhomboids, or levator scapula muscle were included in the study. The patients were divided into three groups: D-DN, S-DN, and CT. Measurements included the Visual Analog Scale (VAS), range of motion (ROM), Neck Disability Index (NDI), and the European Quality of Life 5 Dimensions 3 Level Version (EQ5D3L). All measurements were made at baseline (T0), after the first treatment session (T1), after the final session (T2), and one-month post-treatment (T3).

Results

The group treated with S-DN showed less significant improvement in ROM scores compared to other treatment methods. Both the D-DN and S-DN groups showed decreased VAS scores at rest and during motion across all time points, compared to the CT group. The NDI scores decreased in all groups, while the EQ5D3L scores exhibited no variations between groups or across any time point irrespective of the treatment method employed.

Conclusion

Our study results suggest that all three methods are effective in treating MPS, with D-DN potentially being the preferred method over S-DN and CT due to its time efficiency.

[Patient survey on the use of video consultation in the outpatient treatment of chronic pruritus]

BACKGROUND

Analyses of patient evaluations and barriers to the implementation of teledermatology procedures are still rare. The aim of this study was to determine whether administrative processes have an influence on the patient evaluation of telephone and video consultations.

METHODS

With the help of a patient survey, assessments of the processes and organisation surrounding the outpatient appointment were asked. These were then compared to the assessment of whether the telephone or video consultation is an alternative to on-site consultation.

RESULTS

In all, 1538 patients took part in the survey. Significant correlations were found between the evaluation of the telephone or video consultation and the distance between the place of residence and the outpatient clinic, whether the patient had already been seen several times or for the first time, as well as the evaluation of the waiting time for the appointment, the organisation before the appointment and the waiting time in the outpatient clinic.

CONCLUSIONS

The study shows that even after the Coronavirus pandemic, telephone and video consultations remain an important tool for patients to contact their physician. However, patients' perceptions of the processes around the outpatient appointment have an influence on their willingness to participate in a digital consultation.

Real-World Use of Inhaled COPD Medications: the Good, the Bad, the Ugly

Patients with chronic obstructive pulmonary disease (COPD) rely primarily on inhaled medications to control and treat symptoms. Although the medications delivered by inhaler devices are often quite efficacious when delivered to the lung, the real-world effectiveness of these inhaler devices often falls short. Barriers to effective inhaler use include inhaler misuse and cost-related nonadherence. Inhaler misuse can be reduced with appropriate education which leads to improved outcomes. Education can be provided in multiple settings by a wide array of clinicians and clinical team members including pharmacists, respiratory therapists, nurses, physicians, advanced practice nurses, physician assistants, and community health workers, among others. However, despite decades of research and existing effective strategies across settings and types of educators, overall not much progress has been made with respect to effective inhaler technique among populations of patients with COPD in nearly half a century. Similarly, cost-related nonadherence is a long-standing and critical barrier to effective control of COPD, with limited improvements, especially until very recently. This perspective reviews the current promising directions for inhaler-based therapies, ongoing challenges, and critical issues requiring urgent attention.

Intergroup time bias and aversive racism in the medical context

Time is fundamental to organizing all aspects of human life. When invested in relationships, it has a psychological meaning as it indicates how much individuals value others and their interest in maintaining social relationships. Previous research has identified an intergroup time bias (ITB) in racialized social relations, defined as a discriminatory behavior in which White individuals invest more time in evaluating White than Black individuals. This research proposes an aversive racism explanation for the ITB effect and examines its consequences in the medical context. In four experimental studies (N = 434), we found that White medical trainees invested more time in forming impressions of White (vs. Black) male patients. Study 5 (N = 193) further revealed more time investment in diagnosing, assessing pain, and prescribing opioids for White than Black male patients. This biased time effect mediated the impact of patients' skin color on health care outcomes, leading to greater diagnostic accuracy and pain perception, and lower opioid prescriptions. A meta-analytical integration of the results (Study 6) confirmed the ITB effect reliability across experiments and that it is stronger in participants with an aversive racist profile (vs. consistently prejudiced or nonprejudiced). These findings provide the first evidence that bias in time investment favoring White (vs. Black) patients is associated with aversive racism and impacts medical health care outcomes. Furthermore, these results offer insights into the sociopsychological meaning of time investment in health care and provide a theoretical explanation for an understudied insidious form of discrimination that is critical to comprehending the persistency of racial health care disparities. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Asking patients if they have any questions can help improve patient satisfaction with medical team communication in the emergency department

BACKGROUND

It is well known that patient satisfaction with medical communication in the emergency department (ED) improves patient experience. Investing in good communication practices is highly desirable in the emergency setting. In the literature, very few studies offer evidence of effective interventions to achieve this outcome. Aim of the study is to evaluate whether encouraging emergency physicians to ask if patients have questions at the end of the visit would improve patient satisfaction with medical communication.

METHODS

The physicians of two EDs in Lugano, Switzerland, were invited by various methods (mailing, newsletter, memo pens and posters, coloured bracelets etc.) to implement the new practice of asking patients if they had questions before the end of the visit. Patients discharged were consecutively enrolled. Participants completed the modified CAT-T questionnaire rating their satisfaction with medical communication from 1 (very poor) to 5 (excellent). Data such as age, means of arrival, seniority of the physician etc. were also collected. Statistical analysis was performed with Bayesian methodology. The results were compared with those of a similar study conducted one year earlier.

RESULTS

517 patients returned the questionnaire. Overall, patients' satisfaction with communication in the ED was very good and improved from the previous year (percentage of fully satisfied patients: 68% vs. 57%). The result is statistically significant (C: I: 51.8 - 61.3% vs. 63.9 - 71.8% p = 0.000). Younger patients (< 30 ye22ars old) were slightly less satisfied. Waiting time did not affect perception of communication.

CONCLUSION

This study implements a concrete way to improve patients' satisfaction with medical communication in the ED. The intervention targeted only one item of the CAT-T ("Encouraged me to ask questions") but it generated an overall perception of better communication from patients discharged from the ED. The study also confirms that there are some objective elements that can alter perception of quality of medical communication by patients (age, seniority of the physician), in agreement with the literature. In conclusion, focusing physicians' attention on asking patients whether they have questions before discharge helps improving overall patient satisfaction with medical communication in the ED. This may lead to changes in physicians' clinical practice.

Patients' expectations of primary health care from both patients' and physicians' perspectives: a questionnaire study with a qualitative approach

BACKGROUND

Patients' ideas, concerns, and expectations are three important concepts in consultation techniques. Limited studies on these concepts include responses from both health care providers and care recipients of the same consultation. Highlighting both perspectives provides an increased understanding of the consultation. This study aims to explore the perspectives of patients and health care professionals about patients' expectations of primary health care during consultations with primary care physicians and compare the two sets of perspectives.

METHODS

A cross-sectional study. Patients (n = 113) and physicians (n = 67) from five primary health care centers completed a questionnaire after planned consultations. Their responses to open-ended questions about patients' expectations, from patients' and physicians' perspectives were analyzed with qualitative content analyses.

RESULTS

The patients expected a personal journey, through the primary health care system where they were the subject of interest. A journey, with ready access to a health care provider followed by a consultation with the physician, medical measures administered, their outcomes discussed, and a plan developed for continued health care. The physicians observed patients' expectations to concern the responsibilities placed on primary health care where patients were the object of interest. Patients' short-term expectations were described in a similar way by both patients and physicians. Patients expressed their long-term expectations as more personal and interpersonal whereas physicians observed them from a more professional and organizational standpoint.

CONCLUSIONS

Patients and physicians have different views of what patients expect of primary health care. While patients' short-term expectations were perceived by physicians, their long-term expectations were not. Patients expected more of a personal journey through the primary health care system while physicians observed patients' expectations to concern the responsibilities placed on primary health care. Identifying and meeting patients' expectations is an important part of patient-centered care, and a better understanding of patients' expectations is needed to improve health professionals' consultation skills.

Patient Time Spent With Professional Medical Interpreters and the Care Experiences of Patients With Limited English Proficiency

INTRODUCTION/OBJECTIVES

More time spent with interpreters may support clinician-patient communication for patients with limited English proficiency (LEP), especially when interpreter support before and after clinical encounters is considered. We assessed whether more time spent with interpreters is associated with better patient-reported experiences of clinician-patient communication and interpreter support among patients with LEP.

METHODS

Patients with LEP (n = 338) were surveyed about their experiences with both the clinician and interpreter. Duration of interpreter support during the encounter (in min) and auxiliary time spent before and after encounters supporting patients (in min) were documented by interpreters. Multivariable linear regression models were estimated to assess the association of the time duration of interpreter support and patient experiences of (1) clinician-patient communication, and (2) interpreter support, controlling for patient and encounter characteristics.

RESULTS

The average encounter duration was 47.7 min (standard deviation, SD = 25.1), the average auxiliary time was 43.8 min (SD = 16.4), and the average total interpreter time was 91.1 min (SD = 28.6). LEP patients reported better experiences of interpreter support with a mean score of 97.4 out of 100 (SD = 6.99) compared to clinician-patient communication, with a mean score of 93.7 out of 100 (SD = 14.1). In adjusted analyses, total patient time spent with an interpreter was associated with better patient experiences of clinician-patient communication (β = 7.23, P < .01) when auxiliary time spent by interpreters supporting patients before and after the encounter was considered, but not when only the encounter time was considered.

CONCLUSIONS

Longer duration of time spent with an interpreter was associated with better clinician-patient communication for patients with LEP when time spent with an interpreter before and after the clinician encounter is considered. Policymakers should consider reimbursing health care organizations for time interpreters spend providing patient navigation and other support beyond clinical encounters.

Patient perception of attributes of primary care: a study of Aam Aadmi Mohalla Clinics in Delhi, India

BACKGROUND

Aam Aadmi Mohalla Clinics (AAMC) are the community level public primary care facilities recently introduced to strengthen primary care in Delhi, India by bringing affordable healthcare close to home.

OBJECTIVES

This study looks at the primary care attributes of AAMC from a patient perspective, to assess their features, strengths and weaknesses.

METHODS

Using a primary care survey tool, a cross-sectional survey of 360 users was conducted at 18 facilities across 9 districts of Delhi to gather information on six dimensions of primary care delivery. Thematic analysis of responses to quantitative, multiple-choice and Likert scale questions using percentage of respondents in each category; and a strengths, weaknesses, opportunities and suggestions (SWOS) framework, was used to examine the primary care attributes.

RESULTS

AAMCs have done well in improving proximity, availability, physical and financial access to primary care with respondents reporting their residence within 1 kilometre of AAMCs (95%), physician being available (100%), free drugs in stock (99%). Service delivery is however not comprehensive with missing preventive care. Respondents reported missing gatekeeping, weak referral mechanism (6-19%), and low physician's familiarity with their overall health (2%).

CONCLUSION

AAMCs have brought affordable healthcare with free medicines and diagnostics to neighbourhood. There is an opportunity for attaining universal healthcare that is responsive to user needs through provision of comprehensive care. Compulsory enrolment of neighbourhood population with an electronic database of patients has an immense potential to improve longitudinality and coordination of care.

Archetypes of incomplete stories in chronic illness medical encounters

OBJECTIVE

During encounters, patients and practitioners engage in conversations to address health concerns. Because these interactions are time-pressured events, it may be inevitable that any story exchanged during these encounters will be incomplete in some way, potentially jeopardizing how quality and safety of care is delivered. In this study, we explored how and why incomplete stories might arise in health interactions.

METHODS

Constructivist grounded theory methodology was used to explore how patients and practitioners approach their interactions during encounters. In this two-phase study, we interviewed patients (n = 21) then practitioners (n = 12).

RESULTS

We identified three distinct archetypes of incomplete storytelling - the hidden story, the interpreted story, and the tailored story. Measured information sharing, triadic encounters and pre-planned agendas influenced these storylines, respectively.

CONCLUSION

Both patient and practitioner participants focused on what each considered important, appropriate, and useful for productive encounters. While incomplete stories may be a reality, educating practitioners about how incomplete stories come about from both sides of the conversation creates new opportunities to optimize interactions at medical encounters for in-depth patient practitioner storytelling.

Artificial Intelligence Versus Expert Plastic Surgeon: Comparative Study Shows ChatGPT "Wins" Rhinoplasty Consultations: Should We Be Worried?

Introduction: Large language models, such as ChatGPT, hold tremendous promise to bridge gaps in patient education and enhance the decision-making resources available online for patients seeking nasal surgery. Objective: To compare the performance of ChatGPT in answering preoperative and postoperative patient questions related to septorhinoplasty. Methods: Two sets of responses were collected for the questions: one from an expert rhinoplasty surgeon with over two decades of experience, and the other from ChatGPT-3.5. Seven expert rhinoplasty surgeons, blinded to the source of responses, independently assessed the responses using a 5-point Likert scale in four performance areas: empathy, accuracy, completeness, and overall quality. Results: ChatGPT outperformed physician responses in three of the four performance areas, earning significantly higher ratings in accuracy, completeness, and overall quality (p < 0.001). In addition, ChatGPT was overwhelmingly preferred over physician responses (p < 0.001), with evaluators favoring ChatGPT in 80.95% of instances. Conclusions: ChatGPT has demonstrated its remarkable ability to deliver accurate, complete, and high-quality responses to preoperative and postoperative patient questions. Although certain improvements are warranted, this artificial intelligence tool has shown its potential to effectively counsel and educate prospective septorhinoplasty patients at a level comparable with or exceeding that of an expert surgeon.

Perceptions of conflicting information about long-term medications: a qualitative in-depth interview study of patients with chronic diseases in the Swiss ambulatory care system

OBJECTIVE

Patients with multiple long-term conditions visit various healthcare professionals and are exposed to medication information from various sources causing an increased risk of patients perceiving contradictory medication information. The aims of this study are to: (1) characterise conflicting medication information perceived by patients with long-term conditions, (2) better understand the related impact on patients' medication self-management and healthcare system navigation and (3) explore ways in which such events could be prevented.

DESIGN

This study was conducted through qualitative semistructured interviews. Data were analysed using thematic analysis.

SETTING

Community pharmacies and medical centres in Geneva, Switzerland.

PARTICIPANTS

This study included outpatients from April 2019 to February 2020. Patients were included after participating in a quantitative survey of perceived conflicting information about medications for long-term diseases.

METHODS

Semistructured audiotaped interviews of 20 to 60 min following a pre-established interview guide to explore participants' perceptions of conflicting information. Interviews were transcribed verbatim, and a thematic analysis was conducted with inductive and deductive coding using MAXQDA (2018, Release 18.2.3).

RESULTS

Twenty-two patients were interviewed, until data saturation, mentioning indication or need for a medication as the main topic of conflicting information between two healthcare professionals. Perceived conflicting information often resulted from insufficient information provided and poor communication leading to confusion, doubts and medication non-adherence. Patients expected more information and more interprofessional communication on their medications. As a result of conflicting information, most participants learnt or were learning to take an active role and become partners of the healthcare providers.

CONCLUSION

The need to strengthen and improve communication and interprofessional collaborative practice among healthcare professionals and with the patient is emerging to increase the quality and consistency of information about medications, and consequently, to ensure better use and experience of medications.

Time management practice and associated factors among employees working in public health centers, Northwest Ethiopia: a mixed method study

BACKGROUND

While progressing towards universal health coverage, poor time management in the healthcare system had significant effect on an individual such as imbalance, job dissatisfaction, and work ineffectiveness and finally poor productivity of the organization will be resulted. Information about time management practice in the healthcare system is limited. Therefore, the objective of this study was to assess time management practice and associated factors among employees working in public health centers, Dabat District, Northwest Ethiopia.

METHODS

A facility-based cross-sectional mixed methods (quantitative and qualitative) study was conducted in Dabat District from May 27 to June 22, 2022. A simple random sampling technique was used to select 413 study subjects and for the qualitative data, six key informants were selected. Self-administered questionnaire was used for the quantitative study, and an interview guide was employed for the qualitative study. Epi-data version 4.6 and SPSS 26 software were used for data entry and analysis, respectively. Open Code 4.6 software was used for qualitative data analysis. Variables with p-value of < 0.05 in multivariable analysis were considered as significant associated factors.

RESULTS

A total of 396 employees participated in the study with a response rate of 95.8%. The result showed that overall, 54.8% (95% CI: 49.5-59.6) of health employees had practiced good time management. The likelihood of good time management was higher among those health workers who had planning experience (AOR = 2.04, 95% CI: 1.22-3.4), low procrastination habit (AOR = 1.65 95% CI: 1.04-2.65), satisfied with performance appraisal (AOR: 1.7, 95% CI: 1.05-2.81), and satisfied with organizational policy and strategy (AOR: 2.6, 95% CI: 1.6-4.3). The qualitative result also showed that the existing performance appraisal practices were not linked to rewards or sanction planning.

CONCLUSION

The overall time management practice of public health center employees was low compared with prior studies. Organizational policies, prior planning experience, procrastination, and performance appraisal were all significantly associated factors with time management practice. Therefore, health center managers need to set an intervention to address all of the following factors to enhance employees' time management skills at public health centers like evidence-based performance appraisals, sharing organizational policies, and engaging in capacity building activities such as training in time management and planning.

A window of opportunity: Adverse childhood experiences and time alone with a provider in the United States

BACKGROUND

To date, there is limited literature on the relationship between Adverse Childhood Experiences (ACEs) and the quality of health care provider encounters. This is key, as people with a history of ACEs have a greater burden of illness.

METHODS

This study uses data from the 2020-2021 National Survey of Children's Health to examine relationships between ACEs and (1) spending less than ten minutes with a health care provider, and (2) spending time alone with a health care provider.

RESULTS

In general, our results suggested most ACEs were associated with higher odds of a provider spending <10 min with a child during their last preventative care visit, while ACEs were inconsistently related to spending time alone with a provider. Each additional ACE was found to be associated with higher odds of both outcomes.

CONCLUSIONS

This work emphasizes the importance of ACEs screening in a health care setting and may set the groundwork for future research investigating mechanisms within these associations. Given the established link between health care quality and patient-provider trust, and health outcomes, intervention work is needed to develop healthcare practices that may encourage the length and quality of health care provider visits.

Factors and Barriers to Goals-of-Care Conversations for Patients With Cancer and Inpatient Mortality

PURPOSE

Conversations about personal values and goals of care (GOC) at the end of life are essential in caring for patients with advanced cancer. However, GOC conversations may be influenced by patient and oncologist factors during transitions of care.

METHODS

We electronically administered surveys to medical oncologists of inpatients who died from May 1, 2020, to May 31, 2021. Primary outcomes included oncologists' knowledge of inpatient death, anticipation of patient death, and recollection of GOC discussions. Secondary outcomes, including GOC documentation and advance directives (ADs), were collected retrospectively from electronic health records. Outcomes were analyzed for association with patient, oncologist, and patient-oncologist relationship factors.

RESULTS

For 75 patients who died, 104/158 (66%) surveys were completed by 40 inpatient and 64 outpatient oncologists. Eighty-one oncologists (77.9%) were aware of patients' deaths, 68 (65.4%) anticipated patients' deaths within 6 months, and 67 (64.4%) recalled having GOC discussions before or during the terminal hospitalization. Outpatient oncologists were more likely to report knowledge of patient death (P < .001), as were those with longer therapeutic relationships (P < .001). Inpatient oncologists were more likely to correctly anticipate patient death (P = .014). Secondary outcomes revealed 21.3% of patients had documented GOC discussions before admission and 33.3% had ADs; patients with a longer duration of cancer diagnosis were more likely to have ADs (P = .003). Oncologist-reported barriers to GOC included unrealistic expectations from patients or family (25%) and decreased patient participation because of clinical conditions (15%).

CONCLUSION

Most oncologists recalled having GOC discussions for patients with inpatient mortality, yet documentation of serious illness conversations remained suboptimal. Further studies are needed to examine barriers to GOC conversations and documentation during transitions of care and across health care settings.

Image-Based Communication for Strengthening Patient Health Education in Rural and Underserved Settings

Effective communication is the cornerstone of efficient patient care. It is vital to obtain a thorough history, build the patient's trust, and ensure compliance to treatment. Image-based communication (IBC) using comic-like strips is better than the conventional verbal and written modes, as it is inexpensive, less human resource dependent, and diversity agnostic. Strips based on local and socioculturally relevant issues and characters grab readers' attention, are relatable and entertaining, and utilize a storyline that invigorates thinking. The medical advice delivered by an ideal IBC strip is easy to comprehend, has a better recall, and promotes patient adherence. With an idea that IBC strips can serve as a vital supportive tool in underserved and overburdened clinics, we have described the nuances of adapting them into the existing physician-patient experience. We utilize a prototype IBC of an elderly woman helping a family whose child developed acute fever, possibly malaria. Various elements of an IBC strip, namely, panels, gutters, background, characters, bubbles, captions, and visual effects, are illustrated, and their variations are described later. Once designed, an IBC strip must be critically evaluated for the accuracy of the educational message, and errors, if any, must be corrected. The images are then subjected to a series of local field tests to ensure that they serve their purpose and have the desired cultural competence. Once ready, IBC strips can be posted in public spaces and outside clinics or distributed to healthcare workers or patients. Here, they serve as educational and health literacy tools. The strips can significantly reduce caregiver-patient interaction time and improve the quality of communication, especially when patients are illiterate or understand a different language. It is easier to develop rapport and partnership with a patient when the communication is presented through a pictorial tool. An IBC strip can be used to train grassroot workers, who subsequently train patients, thereby serving a dual purpose. To obtain tangible clinical and epidemiologic benefits from IBC strips, rigorous evidence building and standardization are a crucial long-term goal.

Factors within A Veterinarian-Cattle Farmer Relationship That May Impact on Biosecurity Being Carried out on Farms: An Exploratory Study

Veterinarians (vets) appear to be one of the main gateways to biosecurity information for cattle farmers, and therefore are likely to affect the implementation of these measures. The aim of this study was to explore factors within the vet-farmer relationship that may impact on biosecurity being carried out on cattle farms in England. Interviews were conducted with cattle farmers and large-animal vets, with a focus on individuals deemed to implement good levels of biosecurity or those working with said individuals. The questions explored how each stakeholder felt the communication occurred between the groups and the perceived consequential influence each had on the other. Inductive Thematic analysis was used to explore participants' experience of vet-farmer interactions with a focus on areas of reciprocity between the two groups. Five primary themes were identified. Factors within the vet-cattle farmer relationship, such as trust and familiarity, which were interconnected with time spent with each other, appeared to influence the uptake of biosecurity measures on cattle farms. These factors purportedly impacted the ability of vet-farmer pairs to have cooperative discussions and enter into shared decision-making. In order to enhance animal and human health and welfare, these relationship factors might be key to the development of sustainable optimisation frameworks.

Assessing Barriers and Facilitators to Lung Cancer Screening: Initial Findings from a Patient Navigation Intervention

Low-dose computed tomography-based lung cancer screening represents a complex clinical undertaking that could require multiple referrals, appointments, and time-intensive procedures. These steps may pose difficulties and raise concerns among patients, particularly minority, under-, and uninsured populations. The authors implemented patient navigation to identify and address these challenges. They conducted a pragmatic randomized controlled trial of telephone-based navigation for lung cancer screening in an integrated, urban safety-net health care system. Following standardized protocols, bilingual (Spanish and English) navigators educated, motivated, and empowered patients to traverse the health system. Navigators made systematic contact with patients, recording standardized call characteristics in a study-specific database. Call type, duration, and content were recorded. Univariable and multivariable multinomial logistic regression was performed to investigate associations between call characteristics and reported barriers. Among 225 patients (mean age 63 years, 46% female, 70% racial/ethnic minority) assigned navigation, a total of 559 barriers to screening were identified during 806 telephone calls. The most common barrier categories were personal (46%), provider (30%), and practical (17%). System (6%) and psychosocial (1%) barriers were described by English-speaking patients, but not by Spanish-speaking patients. Over the course of the lung cancer screening process, provider-related barriers decreased 80% (P = 0.008). The authors conclude that patients undergoing lung cancer screening frequently report personal and health care provider-related barriers to successful participation. Barrier types may differ among patient populations and over the course of the screening process. Further understanding of these concerns may increase screening uptake and adherence. Clinical Trial Registration number: (NCT02758054).

The psychological impact of adult-onset craniopharyngioma: A qualitative study of the experience of patients and clinicians

PURPOSE

Individuals who experience social and emotional difficulties struggle to maintain successful social relationships and incur an increased risk of developing mood disorders. These, in turn, have a significant impact on psychological and physical wellbeing. A small number of medical studies suggest that patients with adult-onset craniopharyngioma (AoC) report poorer quality of life, however, no in-depth psychological research has been carried out. The present study aimed to capture a rich understanding of whether patients with AoC experience a psychological impact from their diagnosis and whether psychological factors may contribute to a poorer quality of life.

METHOD

Both patients with AoC and clinicians with experience of working with patients with AoC were invited to take part in a semi-structured interview. Participants were recruited from three geographically disperse National Health Service (NHS) units across the United Kingdom (UK). Eight patients and 10 clinicians took part in the study. Interviews were recorded and transcribed verbatim and analysed using inductive thematic analysis.

RESULTS

Two key themes, with multiple subthemes, were identified: 1) Patients experience psychological impacts of AoC; and 2) Patients also experience common physical symptoms.

CONCLUSIONS

Patients and clinicians recognised significant psychological impact as a result of AoC, and these impacts contributed to overall poorer quality of life. Crucially, both parties also felt that further research into psychological impact of AoC was both interesting and useful.

Patient Perspectives on Perioperative Supportive Care Needs Surrounding Major Abdominal Operations for Cancer

PURPOSE

The development of supportive care interventions delivered by surgeons for their patients is a major research priority. Designing such interventions requires understanding patients' supportive care needs for major operations. This qualitative analysis aimed to determine the supportive care needs of patients undergoing major abdominal operations for cancer.

METHODS

We conducted semi-structured interviews with a subset of participants in a randomized, controlled trial of a specialist palliative care intervention for patients undergoing abdominal resections for cancer (NCT03436290). Sampling was designed to balance the population by sex, age (older vs. younger than 65 years), and treatment group assignment (intervention vs. control). The interview guide was developed to elicit patient perceptions of their supportive care needs from diagnosis to the time of interview, about 1 month after their operation. Two coders used an iterative, inductive method to identify recurring themes in the interviews.

RESULTS

Analysis of interview transcripts revealed five primary themes: preoperative preparation, postoperative recovery, expectation setting, coordination of care, and provider characteristics. Cutting across these themes were patients' focus on time, timeliness, and timelines, as well as their desires for information both from their surgeons and other sources. Surgeons inspired trust through the quality of their communication and their responsiveness to questions. Patients were sensitive to perceived deviations from their expectations and spoke of the need to develop patience and to expect the unexpected.

CONCLUSIONS

Patients expressed several needs for supportive care that surgical teams can potentially address to improve the experience of major cancer surgery.

Implementation of Patient-Centered Care by Athletic Training Students during Clinical Experiences: A Report from the Association of Athletic Training Education Research Network

Patient-centered care (PCC) is a core competency that should be required by all healthcare education programs, but little is known about its implementation in athletic training clinical experiences. Therefore, we examined characteristics of patient encounters documented by athletic training students implementing PCC behaviors. A multisite panel design was used to recruit 363 students from twelve professional athletic training programs (five undergraduate, seven graduate). Over 1.5 years, clinical experience patient encounter data were logged in E*Value Case Logs, including student role during the encounter, length of encounter, and clinical site. Generalized estimating equations models characterized the likelihood students included PCC behaviors in 30,522 encounters. Discussing patient goals was associated with student role (χ²(2) = 40.6, p < 0.001) and length of encounter (χ²(4) = 67.6, p < 0.001). Using patient-reported outcome measures was associated with student role (χ²(2) = 21.6, p < 0.001), length of encounter (χ²(4) = 34.5, p < 0.001), and clinical site (χ²(3) = 17.3, p = 0.001). Implementing clinician-rated outcome measures was affected by length of encounter (χ²(4) = 27.9, p < 0.001) and clinical site (χ²(3) = 8.6, p = 0.04). PCC behaviors were largely associated with student role and length of encounters; clinical site had less impact. Athletic training educators should emphasize progressive autonomous supervision with preceptors and encourage students to facilitate slightly longer patient visits, when possible, to incorporate more PCC behaviors.

Primary healthcare competencies needed in the management of person-centred integrated care for chronic illness and multimorbidity: Results of a scoping review

BACKGROUND

Chronic disease management is important in primary care. Disease management programmes focus primarily on the respective diseases. The occurrence of multimorbidity and social problems is addressed to a limited extent. Person-centred integrated care (PC-IC) is an alternative approach, putting the patient at the centre of care. This asks for additional competencies for healthcare professionals involved in the execution of PC-IC. In this scoping review we researched which competencies are necessary for healthcare professionals working in collaborative teams where the focus lies within the concept of PC-IC. We also explored how these competencies can be acquired.

METHODS

Six literature databases and grey literature were searched for guidelines and peer-reviewed articles on chronic illness and multimorbidity in primary care. A data synthesis was carried out resulting in an overview of the competencies that healthcare professionals need to deliver PC-IC.

RESULTS

Four guidelines and 21 studies were included and four core competencies could be derived through the synthesis: 1. interprofessional communication, 2, interprofessional collaborative teamwork, 3. leadership and 4. patient-centred communication. Included papers mostly lack a clear description of the competencies in terms of knowledge, skills and attitudes which are necessary for a PC-IC approach and on how these competencies can be acquired.

CONCLUSION

This review provides insight on competencies necessary to provide PC-IC within primary care. Research is needed in more depth on core concepts of these competencies which will then benefit educational programmes to ensure that healthcare professionals in primary care are better equipped to deliver PC-IC for patients with chronic illness and multimorbidity.

Structural violence and the uncertainty of viral undetectability for African, Caribbean and Black people living with HIV in Canada: an institutional ethnography

Biomedical advances in healthcare and antiretroviral treatment or therapy (ART) have transformed HIV/AIDS from a death sentence to a manageable chronic disease. Studies demonstrate that people living with HIV who adhere to antiretroviral therapy can achieve viral suppression or undetectability, which is fundamental for optimizing health outcomes, decreasing HIV-related mortality and morbidity, and preventing HIV transmission. African, Caribbean, and Black (ACB) communities in Canada remain structurally disadvantaged and bear a disproportionate burden of HIV despite biomedical advancements in HIV treatment and prevention. This institutional ethnography orients to the concept of 'structural violence' to illuminate how inequities shape the daily experiences of ACB people living with HIV across the HIV care cascade. We conducted textual analysis and in-depth interviews with ACB people living with HIV (n = 20) and health professionals including healthcare providers, social workers, frontline workers, and health policy actors (n = 15). Study findings produce a cumulative understanding that biomedical HIV discourses and practices ignore structural violence embedded in Canada's social fabric, including legislation, policies and institutional practices that produce inequities and shape the social world of Black communities. Findings show that inequities in structural and social determinants of health such as food insecurity, financial and housing instability, homelessness, precarious immigration status, stigma, racial discrimination, anti-Black racism, criminalization of HIV non-disclosure, health systems barriers and privacy concerns intersect to constrain engagement and retention in HIV healthcare and ART adherence, contributing to the uncertainty of achieving and maintaining undetectability and violating their right to health. Biomedical discourses and practices, and inequities reduce Black people to a stigmatized, pathologized, and impoverished detectable viral underclass. Black people perceived as nonadherent to ART and maintain detectable viral loads are considered "bad" patients while privileged individuals who achieve undetectability are considered "good" patients. An effective response to ending HIV/AIDS requires implementing policies and institutional practices that address inequities in structural and social determinants of health among ACB people.

Hand Grip Strength Relative to Waist Circumference as a Means to Identify Men and Women Possessing Intact Mobility in a Cohort of Older Adults with Type 2 Diabetes

Possessing intact mobility in older adults assures their continued independence. The early identification of reduced mobility in older adults with type 2 diabetes (T2DM) is paramount for preventing their future physical deterioration. Hand grip strength (HGS), relative to body size, is associated with mobility in older T2DM patients. This study aims to identify an HGS index that best identifies mobilityintact older T2DM patients, along with its optimal cut-off point. The baseline data are from a cohort of 122 older T2DM patients (59% women) (mean age of 70.2 ± 4.4 years). Three mobility tests encompassing three main mobility domains were measured, including usual gait speed (UGS), timed up and go (TUG), and a two-minute walk test (2MWT). Passing scores were defined as those either above the established cut-off points or above the 25th percentile of population norms. Passing all three tests was considered as possessing intact mobility. Receiver operating characteristic (ROC) curves of the most relevant HGS indices were constructed to determine the area under the curve (AUC) that best identifies patients with intact mobility. In a sample of 122 older adults with T2DM, 63.9% of women and 60% of men were found to possess intact mobility. HGS relative to waist circumference (WC) was found to have the strongest association with intact mobility, presenting the highest AUC in both men (0.78) and women (0.72) for discriminating mobility status, with an optimal cut-off of 0.355 (kg/cm) and 0.245 (kg/cm) in men and women, respectively. HGS relative to WC best differentiated between mobility-intact older adults with T2DM and those with mobility limitations, especially in men. Using HGS/WC as a simple and safe screening mode for mobility in a clinical setting could potentially identify older patients with T2DM that require therapeutic interventions.

Patient Experiences with a Tertiary Care Post-COVID-19 Clinic

Post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PASC) is a complex condition with multisystem involvement. We assessed patients' experience with a PASC clinic established at University of Iowa in June 2020. A survey was electronically mailed in June 2021 asking about (1) symptoms and their impact on functional domains using the Patient-Reported Outcomes Measurement Information System (PROMIS) measures (Global Health and Cognitive Function Abilities) (2) satisfaction with clinic services, referrals, barriers to care, and recommended support resources. Survey completion rate was 35% (97/277). Majority were women (67%), Caucasian (93%), and were not hospitalized (76%) during acute COVID-19. As many as 50% reported wait time between 1 and 3 months, 40% traveled >1 h for an appointment and referred to various subspecialities. Participants reported high symptom burden-fatigue (77%), "brain fog" (73%), exercise intolerance (73%), anxiety (63%), sleep difficulties (56%) and depression (44%). On PROMIS measures, some patients scored significantly low (≥1.5 SD below mean) in physical (22.7%), mental (15.9%), and cognitive (17.6%) domains. Approximately 61% to 93% of participants were satisfied with clinical services. Qualitative analysis added insight to their experience with healthcare. Participants suggested potential strategies for optimizing recovery, including continuity of care, a co-located multispecialty clinic, and receiving timely information from emerging research. Participants appreciated that physicians validated their symptoms and provided continuity of care and access to specialists.

Hypertension in an Emergency Department Population in Moshi, Tanzania; A Qualitative Study of Barriers to Hypertension Control

BACKGROUND

Sub-Saharan Africa has a high prevalence of hypertension with a low rate of awareness, treatment adherence, and control. The emergency department (ED) may represent a unique opportunity to improve hypertension screening, awareness, and linkage to care. We conducted a qualitative study among hypertensive patients presenting to the ED and their healthcare providers to determine barriers to hypertension care and control.

METHODS

In northern Tanzania, between November and December 2017, we conducted three focus group discussions among patients with hypertension presenting to the emergency department and three in-depth interviews among emergency department physicians. In our study, hypertension was defined as a single blood pressure of ≥160/100 mm Hg or a two-time average of ≥140/90 mm Hg. Barriers to care were identified by thematic analysis applying an inductive approach within the framework method.

RESULTS

We enrolled 24 total patients into three focus groups and performed three in-depth interviews with individual providers. Thematic analysis identified two major domains: 1) patient knowledge, attitudes, and practices, and 2) structural barriers to hypertension care. Four major themes emerged within the knowledge, attitudes, and practices domain, including disease chronicity, provider communication, family support, and fear-based attitudes. Within the structural domain, several themes emerged that identified barriers that impeded hypertension follow-up care and self-management, including cost, access to care, and transportation and wait time.

CONCLUSION

Patients and physicians identified multiple barriers and facilitators to hypertension care. These perspectives may be helpful to design emergency department-based interventions that target blood pressure control and linkage to outpatient care.

Integrating primary palliative care into hidradenitis suppurativa management

Hidradenitis suppurativa (HS) is a chronic, often debilitating skin condition that disproportionately impacts women in the United States and other Western nations. Dermatologists should consider incorporating palliative care principles into HS management to optimize care. Primary palliative care principles include utilizing evidence-based frameworks in serious illness communication, acknowledging and addressing physical and psychosocial suffering, recognizing and validating the burden of disease in partners, families, and caregivers, and engaging in collaborative care coordination. Certain patients may also benefit from outpatient, or sometimes inpatient, palliative care specialist collaboration, such as those with refractory HS and superimposed challenging psychosocial dynamics and symptom burden. Through integration of these palliative care domains into HS care, dermatologists can optimize their ability to provide comprehensive and compassionate care for patients suffering with this disease.

Knowledge, Attitude, and Practice regarding Narrative Medicine among Chinese Medical Personnel: An Online Cross-Sectional Survey

Background

Narrative medicine has been applied as a model for humane medical practice in many countries. However, it was not introduced in China until 2011 and there has been no standardized assessment of Chinese medical personnel regarding their perception and application of narrative medicine-related theories. This study is aimed at investigating Chinese medical personnel's knowledge, attitude, and practice regarding narrative medicine and the factors that influence it.

Methods

An online questionnaire based on the knowledge, attitude, and practice model was distributed among Chinese medical personnel from December 2021 to March 2022. All in-service medical personnel across China who had access to the Internet were eligible. Two independent samples t-tests, one-way analysis of variance, Pearson's correlation analysis, and multivariate linear regression were conducted for data analyses.

Results

The participants' scoring rates for knowledge, attitude, and practice were 49.62%, 47.18%, and 41.43%, respectively. Significant influencing factors for knowledge were education level, religious belief, professional role, title, working years, and institution categories; those for attitude were education level, religious belief, professional role, and working years; and those for practice were professional title, religious belief, working years, and institution categories.

Conclusions

Chinese medical personnel have generally good knowledge of, attitudes towards, and practice of narrative medicine; however, there remain deficiencies in their understanding of certain important concepts, their attitude towards narrative medicine, and the application of narrative skills in their daily work. Thus, to improve narrative medicine practice in China, the application of strategies based on theoretical, educational, and institutional aspects is warranted.

They "Don't Know How to Deal with People Like Me": Assessing Health Care Experiences of Gender Minorities in Indiana

Purpose

Within the LGBTQ+ community, the transgender and nonbinary (TGNB) population experience a disproportionate amount of discrimination when seeking health care. Such disparities may arise from lack of proper medical training and resources for providers or biases. In this study, we examine the health care experiences of TGNB individuals living in Southern Indiana.

Methods

We analyzed responses from TGNB respondents to an LGBTQ+ health care needs assessment survey in Southern Indiana. Respondents were asked about demographic data, their self-assessed health status, quality of health care received, whether they have a provider with whom they feel comfortable sharing their gender identity with, and if they have to commute to see their provider. Finally, respondents were asked an open-ended question about their health care experiences while living in Southern Indiana. Responses were coded and several themes emerged and were analyzed.

Results

Eighty-five TGNB individuals completed our survey. Less than half of respondents indicated that they had an LGBTQ+-welcoming provider (44.7%). Individuals with an LGBTQ+-welcoming provider were more likely to report their self-assessed health as excellent/good (p=0.02) and quality of health as excellent/very good (p=0.03) compared to individuals without an LGBTQ+-welcoming provider. Five themes emerged from the write-in responses (n=64): discrimination (34.4%), invalidation (32.8%), distrust (28.1%), logistic concerns (35.9%), and positive experiences (35.9%).

Conclusion

The TGNB community living in Southern Indiana reports numerous barriers related to provider attitudes when obtaining health care. Additional training is needed to address provider biases and improve LGBTQ+ community health disparities.

An innovative 5-Step Patient Interview approach for integrating mental healthcare into primary care centre services: a validation study

Background

Mental health problems are prevalent among patients seeking primary healthcare. However, traditional patient interviews often fail to identify and manage these problems. Therefore, an improved patient interview process is needed to assess and treat mental health problems in primary care settings.

Aims

To assess the validity, reliability, sensitivity and specificity of a 5-Step Patient Interview approach for the screening, diagnosis and treatment of mental health problems.

Design and setting

This study compared a 5-Step Patient Interview approach (AlKhathami approach) with expert psychiatric interviews based on the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fifth edition, the Patient Health Questionnaire-9 (PHQ-9) and the Generalised Anxiety Disorder-7 (GAD-7) questionnaire from 1 January 2020 to 30 April 2020 in family practice or primary healthcare centres.

Methods

A total of 760 participants from five Saudi Arabian regions were selected using a multiclustered random sample of every third patient aged ≥18 years, drawn from the clinics’ patient list.

Results

A total of 732 patients agreed to participate, with a response rate of 96.3%; 396 (54.1%) were women; the mean (Standard Deviation) age was 41.28 (14.30) years (ranging from 18 to 84 years). Mental health problems were suspected in 40% of the participants. The 5-Step Patient Interview approach was shown to be comparable to an expert interview by a psychiatrist. Moreover, it was more accurate than the PHQ-9 and GAD-7 self-administered questionnaires in screening for stress and classifying it as mild, moderate to severe or severe. Additionally, the 5-Step Patient Interview approach improved physician-patient communication by encouraging the exploration of patients’ perspectives.

Conclusions

The 5-Step Patient Interview approach is a valid, reliable tool that can aid the integration of mental healthcare into primary healthcare and family practice. Future studies should evaluate the implementation outcomes of the 5-Step Patient Interview approach.

A cross sectional study on patient satisfaction and its association with length of consultation at the University Malaya Medical Centre Primary Care Clinic

INTRODUCTION

Patient satisfaction has been found to be a determinant of patient compliance to medical advice and treatment, medical service utilisation, the doctor-patient relationship, and continuity of care. Assessment of patient satisfaction can be used to evaluate health care services and identify areas to target for quality improvement.

METHODS

A cross-sectional study was conducted to determine the satisfaction level of patients attending a primary care clinic and its associated factors. Participants' experience of time at the clinic, socio-demographic data, and personal health information were collected. The 18-Item Patient Satisfaction Questionnaire was used to determine patient satisfaction. Univariate and multivariate analyses were employed to identify the factors associated with patient satisfaction.

RESULTS

We recruited 327 participants and 50.46% reported satisfaction. The highest satisfaction was reported in the communication domain (80.80% of the maximum score) and the lowest score was reported in the accessibility and convenience domain (66.40%). The only significant positive correlation with total patient satisfaction score was the difference between perceived and expected length of consultation.

CONCLUSION

The only independently associated factor was the difference between perceived and expected length of consultation; therefore, changing how time is spent during consultations may prove useful in improving patient satisfaction.

Evaluation of Payment Transformation in Hawai'i Based on Physician Perspective

The Hawai'i Medical Service Association's (HMSA) Population-based Payments for Primary Care (3PC) system has been in effect since 2016. There is limited literature regarding physician opinions on this payment transformation policy change. The objective of this study was to evaluate physician responses to a survey regarding the 3PC payment transformation system and identify methods to support physicians in Hawai'i. An online survey was sent to 2478 Hawai'i physicians and yielded 250 responses. A total of 77% respondents reported being unhappy with payment transformation, while 12.9% and 10.1% reported being indifferent and happy, respectively. Of responding physicians, 60.6% reported a decrease in overall income, whereas 24.9% and 14.5% reported no change or an overall increase, respectively. Open-ended responses were categorized into theme clusters: negative impact on primary care, increased administrative burdens, decreased quality of patient care, decreased physician reimbursement, preference to treat healthier patients, harm to private practice, harm to newer practices, ignored physician sentiments, and worsened physician shortage in Hawai'i. Respondents, especially those working in primary care, are dissatisfied with payment transformation. Future research is needed to compare the thematic clusters identified in the current study with relevant literature.