Intention to discontinue care among primary care patients: influence of physician behavior and process of care

The quality of primary care performance in private sector facilities in Nairobi, Kenya: a cross-sectional descriptive survey

Background

Integrated health services with an emphasis on primary care are needed for effective primary health care and achievement of universal health coverage. The key elements of high quality primary care are first-contact access, continuity, comprehensiveness, coordination, and person-centredness. In Kenya, there is paucity of information on the performance of these key elements and such information is needed to improve service delivery. Therefore, the study aimed to evaluate the quality of primary care performance in private sector facilities in Nairobi, Kenya.

Methods

A cross-sectional descriptive study using an adapted Primary Care Assessment Tool for the Kenyan context and surveyed 412 systematically sampled primary care users, from 13 PC clinics. Data were analysed to measure 11 domains of primary care performance and two aggregated primary care scores using the Statistical Package for Social Sciences.

Results

Mean primary care score was 2.64 (SD=0.23) and the mean expanded primary care score was 2.68 (SD=0.19), implying an overall low performance. The domains of first contact-utilisation, coordination (information system), family-centredness and cultural competence had mean scores of >3.0 (acceptable to good performance). The domains of first contact-access, coordination, comprehensiveness (provided and available), ongoing care and community-orientation had mean scores of < 3.0 (poor performance). Older respondents (p=0.05) and those with higher affiliation to the clinics (p=0.01) were more likely to rate primary care as acceptable to good.

Conclusion

These primary care clinics in Nairobi showed gaps in performance. Performance was rated as acceptable-to-good for first-contact utilisation, the information systems, family-centredness and cultural competence. However, patients rated low performance related to first-contact access, ongoing care, coordination of care, comprehensiveness of services, community orientation and availability of a complete primary health care team. Performance could be improved by deploying family physicians, increasing the scope of practice to become more comprehensive, incentivising use of these PC clinics rather than the tertiary hospital, improving access after-hours and marketing the use of the clinics to the practice population.

Advanced CKD Care and Decision Making: Which Health Care Professionals Do Patients Rely on for CKD Treatment and Advice?

Rationale & Objective

Chronic kidney disease (CKD) care is often fragmented across multiple health care providers. It is unclear whether patients rely mostly on their nephrologists or non-nephrologist providers for medical care, including CKD treatment and advice.

Study Design

Cross-sectional study.

Setting & Participants

Adults receiving nephrology care at CKD clinics in Pennsylvania.

Predictors

Frequency, duration, and patient-centeredness (range, 1 [least] to 4 [most]) of participants’ nephrology care.

Outcome

Participants’ reliance on nephrologists, primary care providers, or other specialists for medical care, including CKD treatment and advice.

Analytical Approach

Multivariable logistic regression to quantify associations between participants’ reliance on their nephrologists (vs other providers) and their demographics, comorbid conditions, kidney function, and nephrology care.

Results

Among 1,412 patients in clinics targeted for the study, 676 (48%) participated. Among these, 453 (67%) were eligible for this analysis. Mean age was 71 (SD, 12) years, 59% were women, 97% were white, and 65% were retired. Participants were in nephrology care for a median of 3.8 (IQR, 2.0-6.6) years and completed a median of 4 (IQR, 3-5) nephrology appointments in the past 2 years. Half (56%) the participants relied primarily on their nephrologists, while 23% relied on primary care providers, 18% relied on all providers equally, and 3% relied on other specialists. Participants’ adjusted odds of relying on their nephrologists were higher for those in nephrology care for longer (OR, 1.08 [95% CI, 1.02-1.15]; P = 0.02), those who completed more nephrology visits in the previous 2 years (OR, 1.16 [95% CI, 1.05-1.29]; P = 0.005), and those who perceived their last interaction with their nephrologists as more patient-centered (OR, 2.63 [95% CI, 1.70-4.09]; P < 0.001).

Limitations

Single health system study.

Conclusions

Many nephrology patients relied on non-nephrologist providers for medical care. Longitudinal patient-centered nephrology care may encourage more patients to follow nephrologists’ recommendations.

Mental well-being and job satisfaction in general practitioners in Denmark and their patients' change of general practitioner: a cohort study combining survey data and register data

OBJECTIVES

Low job satisfaction and poor well-being (eg, stress and burnout) among physicians may have negative consequences for patient experienced healthcare quality. In primary care, this could manifest in patients choosing another general practitioner (GP). The objective of this study was to examine change of GP (COGP) (unrelated to change of address) among patients in relation to their GPs' job satisfaction, well-being and self-assessed work-ability.

DESIGN AND SETTING

Data from a nationwide questionnaire survey among Danish GPs in May 2016 was combined with register data on their listed patients. Associations between patients' COGP in the 6-month study period (from May 2016) and the job satisfaction/well-being of their GP were estimated as risk ratios (RRs) at the individual patient level using binomial regression analysis. Potential confounders were included for adjustment.

PARTICIPANTS

The study cohort included 569 776 patients aged ≥18 years listed with 409 GPs in single-handed practices.

RESULTS

COGP was significantly associated with occupational distress (burnout and low job satisfaction) in the GP. This association was seen in a dose-response like pattern. For burnout, associations were found for depersonalisation and reduced sense of personal accomplishment (but not for emotional exhaustion). The adjusted RR was 1.40 (1.10-1.72) for patients listed with a GP with the lowest level of job satisfaction and 1.24 (1.01-1.52) and 1.40 (1.14-1.72) for patients listed with a GP in the most unfavourable categories of depersonalisation and sense of personal accomplishment (the most favourable categories used as reference). COGP was not associated with self-assessed work-ability or domains of well-being related to life in general.

CONCLUSIONS

Patients' likelihood of changing GP increased with GP burnout and decreasing job satisfaction. These findings indicate that patients' evaluation of care as measured by COGP may be influenced by their GPs' work conditions and occupational well-being.

Modelling the impact of new patient visits on risk adjusted access at 2 clinics

OBJECTIVE

To evaluate the effect new outpatient clinic visits has on the availability of follow-up visits for established patients when patient visit frequency is risk adjusted.

DATA SOURCES

Diagnosis codes for patients from 2 Internal Medicine Clinics were extracted through billing data.

STUDY DESIGN

The HHS-HCC risk adjusted scores for each clinic were determined based upon the average of all clinic practitioners' profiles. These scores were then used to project encounter frequencies for established patients, and for new patients entering the clinic based on risk and time of entry into the clinics.

PRINCIPAL FINDINGS

A distinct mean risk frequency distribution for physicians in each clinic could be defined providing model parameters. Within the model, follow-up visit utilization at the highest risk adjusted visit frequencies would require more follow-up slots than currently available when new patient no-show rates and annual patient loss are included. Patients seen at an intermediate or lower visit risk adjusted frequency could be accommodated when new patient no-show rates and annual patient clinic loss are considered.

CONCLUSIONS

Value-based care is driven by control of cost while maintaining quality of care. In order to control cost, there has been a drive to increase visit frequency in primary care for those patients at increased risk. Adding new patients to primary care clinics limits the availability of follow-up slots that accrue over time for those at highest risk, thereby limiting disease and, potentially, cost control. If frequency of established care visits can be reduced by improved disease control, closing the practice to new patients, hiring health care extenders, or providing non-face to face care models then quality and cost of care may be improved.

Patients satisfaction with consultation at primary health care centers in Abha City, Saudi Arabia

Aim of Study

This study aims to assess patients satisfaction regarding consultations at the General Clinics of primary health-care (PHC) centers, in Abha City.

Patients and Methods

This cross-sectional study design was conduct among adult patients attending training PHC centers in Abha City, Saudi Arabia during September 2016. The researcher designed a data collection sheet that comprised patients' personal characteristics and the consultation satisfaction questionnaire, which contained 18 questions within four dimensions, i.e., general satisfaction; professional care; depth of relationship; and length of consultation.

Results

The total number of the patient included in this study was 400, more than half of them were male (54%). Most of them were Saudi (90%), married (79%), and educated (93%). More than half 53% were dissatisfied, 20% were satisfied with consultation while 27% were natural. The most important factor affecting satisfaction with consultation was age, education level and income.

Conclusions

Patients satisfaction toward their consultation experience at general clinics of training PHC centers in Abha City was suboptimal. Total consultation scores differ significantly according to their age groups, education level, and monthly income.

Recommendations

PHC physicians should be more concerned with improving medical consultations provided to their patients. Continuing medical education and training of PHC physicians about provision of medical consultation.

Medical Care Avoidance Among Older Adults

Objective: To examine factors and reasons associated with medical care avoidance among older adults in the United States. Method: Analysis of data on 2,155 adults aged 65 and older, who completed the 2008 Health Information National Trends Survey. Results: Nearly one fourth of older adults reported medical care avoidance ( n = 449; weighted % = 22.5%). Of these, more than one third reported doing so because of feeling uncomfortable when their body is examined (34.5%) or fearing a serious illness (35.9%) and with fewer reporting avoiding care because it made them think of dying (14.3%). Likelihood of avoidance was higher among those with worse self-reported health status, severe psychological distress, lower health self-efficacy, lower confidence in obtaining health information, lower trust in doctors, less patient-centered communication, lower perceived health care quality, and those who were current smokers. Qualitative reasons for avoidance corroborated quantitative results. Conclusion: Avoidance by older adults appears to be largely associated with evaluations of the quality of care and provider communication.

Difficult relationships between parents and physicians of children with cancer: A qualitative study of parent and physician perspectives

BACKGROUND

Previous work on difficult relationships between patients and physicians has largely focused on the adult primary care setting and has typically held patients responsible for challenges. Little is known about experiences in pediatrics and more serious illness; therefore, we examined difficult relationships between parents and physicians of children with cancer.

METHODS

This was a cross-sectional, semistructured interview study of parents and physicians of children with cancer at the Dana-Farber Cancer Institute and Boston Children's Hospital (Boston, Mass) in longitudinal primary oncology relationships in which the parent, physician, or both considered the relationship difficult. Interviews were audiotaped, transcribed, and subjected to a content analysis.

RESULTS

Dyadic parent and physician interviews were performed for 29 relationships. Twenty were experienced as difficult by both parents and physicians; 1 was experienced as difficult by the parent only; and 8 were experienced as difficult by the physician only. Parent experiences of difficult relationships were characterized by an impaired therapeutic alliance with physicians; physicians experienced difficult relationships as demanding. Core underlying issues included problems of connection and understanding (n = 8), confrontational parental advocacy (n = 16), mental health issues (n = 2), and structural challenges to care (n = 3). Although problems of connection and understanding often improved over time, problems of confrontational advocacy tended to solidify. Parents and physicians both experienced difficult relationships as highly distressing.

CONCLUSIONS

Although prior conceptions of difficult relationships have held patients responsible for challenges, this study has found that difficult relationships follow several patterns. Some challenges, such as problems of connection and understanding, offer an opportunity for healing. However, confrontational advocacy appears especially refractory to repair; special consideration of these relationships and avenues for repairing them are needed. Cancer 2017;123:675-681. © 2016 American Cancer Society.

Health and Social Needs in Three Migrant Worker Communities around La Romana, Dominican Republic, and the Role of Volunteers: A Thematic Analysis and Evaluation

Objective. For decades, Haitian migrant workers living in bateyes around La Romana, Dominican Republic, have been the focus of short-term volunteer medical groups from North America. To assist these efforts, this study aimed to characterize various health and social needs that could be addressed by volunteer groups. Design. Needs were assessed using semistructured interviews of community and professional informants, using a questionnaire based on a social determinants of health framework, and responses were qualitatively analysed for common themes. Results. Key themes in community responses included significant access limitations to basic necessities and healthcare, including limited access to regular electricity and potable water, lack of health insurance, high out-of-pocket costs, and discrimination. Healthcare providers identified the expansion of a community health promoter program and mobile medical teams as potential solutions. English and French language training, health promotion, and medical skills development were identified as additional strategies by which teams could support community development. Conclusion. Visiting volunteer groups could work in partnership with community organizations to address these barriers by providing short-term access to services, while developing local capacity in education, healthcare, and health promotion in the long-term. Future work should also carefully evaluate the impacts and contributions of such volunteer efforts.

Physicians' perceptions of quality of care, professional autonomy, and job satisfaction in Canada, Norway, and the United States

Background

We lack national and cross-national studies of physicians’ perceptions of quality of patient care, professional autonomy, and job satisfaction to inform clinicians and policymakers. This study aims to compare such perceptions in Canada, the United States (U.S.), and Norway.

Methods

We analyzed data from large, nationwide, representative samples of physicians in Canada (n = 3,083), the U.S. (n = 6,628), and Norway (n = 638), examining demographics, job satisfaction, and professional autonomy.

Results

Among U.S. physicians, 79% strongly agreed/agreed they could provide high quality patient care vs. only 46% of Canadian and 59% of Norwegian physicians. U.S. physicians also perceived more clinical autonomy and time with their patients, with differences remaining significant even after controlling for age, gender, and clinical hours. Women reported less adequate time, clinical freedom, and ability to provide high-quality care. Country differences were the strongest predictors for the professional autonomy variables. In all three countries, physicians’ perceptions of quality of care, clinical freedom, and time with patients influenced their overall job satisfaction. Fewer U.S. physicians reported their overall job satisfaction to be at-least-somewhat satisfied than did Norwegian and Canadian physicians.

Conclusions

U.S. physicians perceived higher quality of patient care and greater professional autonomy, but somewhat lower job satisfaction than their colleagues in Norway and Canada. Differences in health care system financing and delivery might help explain this difference; Canada and Norway have more publicly-financed, not-for-profit health care delivery systems, vs. a more-privately-financed and profit-driven system in the U.S. None of these three highly-resourced countries, however, seem to have achieved an ideal health care system from the perspective of their physicians.

Racial disparities in changing to a high-volume urologist among men with localized prostate cancer

BACKGROUND

Patients who receive surgery from high-volume surgeons tend to have better outcomes. Black patients, however, are less likely to receive surgery from high-volume surgeons.

OBJECTIVE

Among men with localized prostate cancer, we examined whether disparities in use of high-volume urologists resulted from racial differences in patients being diagnosed by high-volume urologists and/or changing to high-volume urologists for surgery.

RESEARCH DESIGN

Retrospective cohort study from Surveillance, Epidemiology, and End Results-Medicare data.

SUBJECTS

A total of 26,058 black and white men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with localized prostate cancer from 1995 to 2005 that underwent prostatectomy. Patients were linked to their diagnosing urologist and a treating urologist (who performed the surgery).

MEASURES

Diagnosis and receipt of prostatectomy by a high-volume urologist, and changing between diagnosing and treating urologist

RESULTS

After adjustment for confounders, black men were as likely as white men to be diagnosed by a high-volume urologist; however, they were significantly less likely than white men to be treated by a high-volume urologist [odds ratio 0.76; 95% confidence interval (CI), 0.67-0.87]. For men diagnosed by a low-volume urologist, 46.0% changed urologists for their surgery. Black men were significantly less likely to change to a high-volume urologist (relative risk ratio 0.61; 95% CI, 0.47-0.79). Racial differences appeared to reflect black and white patients being diagnosed by different urologists and having different rates of changing after being diagnosed by the same urologists.

CONCLUSIONS

Lower rates of changing to high-volume urologists for surgery among black men contribute to racial disparities in treatment by high-volume surgeons.

Healthcare mistreatment and continuity of cancer screening among Latino and Anglo American women in southern california

The aim of this research was to examine the relation of perceptions of healthcare mistreatment and related emotions to continuity of cancer screening care among women who reported healthcare mistreatment. The structure of relations among cultural beliefs about healthcare professionals, perceptions of mistreatment, mistreatment-related emotions, and continuity of screening was investigated. Participants included 313 Anglo and Latino American women of varying demographic characteristics from southern California who were recruited using multi-stage stratified sampling. Structural equation modeling confirmed the relation of perceptions of mistreatment to continuity of care for both Anglo and Latino American women, with ethnicity moderating this association. For Anglo Americans, greater perceptions of mistreatment were negatively related to continuity of screening. However, for Latinas the relation was indirect, through mistreatment-related anger. While greater perceptions of mistreatment were associated with higher levels of anger for both ethnic groups, anger was negatively related to continuity of care for Latino but not for Anglo women. Furthermore, cultural beliefs about professionals were indirectly related to continuity of screening through perceptions of mistreatment and/or mistreatment-related anger. These findings highlight the importance of the role of cultural and psychological factors in research and interventions aimed at improving patient-professional relations with culturally diverse women.

Recruitment of representative samples for low incidence cancer populations: do registries deliver?

Background

Recruiting large and representative samples of adolescent and young adult (AYA) cancer survivors is important for gaining accurate data regarding the prevalence of unmet needs in this population. This study aimed to describe recruitment rates for AYAs recruited through a cancer registry with particular focus on: active clinician consent protocols, reasons for clinicians not providing consent and the representativeness of the final sample.

Methods

Adolescents and young adults aged 14 to19 years inclusive and listed on the cancer registry from January 1 2002 to December 31 2007 were identified. An active clinician consent protocol was used whereby the registry sent a letter to AYAs primary treating clinicians requesting permission to contact the survivors. The registry then sent survivors who received their clinician's consent a letter seeking permission to forward their contact details to the research team. Consenting AYAs were sent a questionnaire which assessed their unmet needs.

Results

The overall consent rate for AYAs identified as eligible by the registry was 7.8%. Of the 411 potentially eligible survivors identified, just over half (n = 232, 56%) received their clinician's consent to be contacted. Of those 232 AYAs, 65% were unable to be contacted. Only 18 AYAs (7.8%) refused permission for their contact details to be passed on to the research team. Of the 64 young people who agreed to be contacted, 50% (n = 32) completed the questionnaire.

Conclusions

Cancer registries which employ active clinician consent protocols may not be appropriate for recruiting large, representative samples of AYAs diagnosed with cancer. Given that AYA cancer survivors are highly mobile, alternative methods such as treatment centre and clinic based recruitment may need to be considered.

Approaches to the difficult patient/parent encounter

Most pediatricians have experienced uneasy interactions involving patients and/or their parents. The majority of literature on this topic reflects encounters in adult medicine, without providing much information for pediatricians who also face this challenge. Unique to the pediatric approach is the added quotient of the parent/family dynamic. Patients or their parents may have personality disorders or subclinical mental health issues, physicians may be overworked or have a lack of experience, and the health care system may be overburdened, fragmented, and inundated with poor communication. Recognizing the physical or emotional responses triggered by challenging patients/families may allow the provider to effectively partner with, instead of confront, the patient or the family. In this article we review existing literature on this subject and describe possible strategies for the pediatrician to use during a difficult encounter.

Patient dissatisfaction as a determinant of voluntary disenrollment in a managed care organization

An unsatisfactory patient experience during care may lead to a higher probability of disenrollment from a managed care organization (MCO). Compared with previous studies of general dissatisfaction, we examined the effects of specific outpatient visit dissatisfaction on subsequent voluntary disenrollment of 18 809 MCO subscriber units that had at least 1 completed postvisit satisfaction survey in 2000, 2001, or 2002. Subscriber units that reported dissatisfaction with care access, practitioner interaction, or overall visit experience had significantly increased likelihood of voluntary disenrollment from this MCO compared with subscriber units with a satisfactory visit experience.

A systematic review of the literature reporting on studies that examined the impact of interactive, computer-based patient education programs

OBJECTIVE

To evaluate studies that examined the impact of interactive, computer-based education (ICBE) programs on patient education.

METHODS

The Medline and CINAHL databases were searched to identify randomized controlled studies that evaluated the impact of ICBE programs.

RESULTS

The 25 studies that met the selection criteria generally supported the ability of ICBE programs to promote knowledge gains. Results related to economic or clinical outcomes were less consistent. Significant variations were noted across studies in program features, implementation and integration strategies, and in comparison program attributes and quality. It is likely that these differences contributed to the disparity in findings across studies.

CONCLUSION

Although significant inconsistencies in results were noted, the research provided collective evidence that ICBE programs had the potential to add great value to the patient education process. Programs must be properly designed and implementation and integration processes effectively planned in order to achieve consistently positive outcomes.

PRACTICE IMPLICATIONS

Consideration of the "best practices" derived from the research and noted in this report will assist healthcare providers in designing, selecting, and implementing effective ICBE programs.

Are medical students agreeable? An exploration of personality in relation to clinical skills training

BACKGROUND

Clinical competencies like trust, empathy, and cooperation are emphasized in medical school curricula. Agreeableness, a personality domain, reflects these competencies. It is unclear, however, whether medical student personality is intrinsically agreeable.

AIM

We explored whether medical student personality reflects Agreeableness, and compared student Agreeableness with that of police officer recruits, a group in which high Agreeableness is not preferred.

METHODS

Students and recruits completed the Revised NEO Personality Inventory, which measures domains of the five-factor model: Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness.

RESULTS

Medical student Agreeableness was at average levels. Students were high in Extraversion and Openness, reflecting personal growth, leadership, problem solving, and influencing. Relative to recruits, students had higher Neuroticism and Openness and lower Conscientiousness. Agreeableness and Extraversion did not differ. Using discriminant analysis, Neuroticism, Openness, and Conscientiousness accurately classified 77% of students and recruits.

CONCLUSION

Medical students were not inordinately agreeable. They were ambitious, intellectually-creative problem solvers with a preference to direct/influence. Clinical skills training that acknowledges this style may enhance clinical education processes. Model-based methods for clinical skills--including agenda-setting, conflict resolution, and alliance making - that require mastery of techniques and have evidence-based relevance to patient care may be useful adjuncts to conventional clinical training.

The Ontario Mother and Infant Study (TOMIS) III: a multi-site cohort study of the impact of delivery method on health, service use, and costs of care in the first postpartum year

BACKGROUND

The caesarean section rate continues to rise globally. A caesarean section is inarguably the preferred method of delivery when there is good evidence that a vaginal delivery may unduly risk the health of a woman or her infant. Any decisions about delivery method in the absence of clear medical indication should be based on knowledge of outcomes associated with different childbirth methods. However, there is lack of sold evidence of the short-term and long-term risks and benefits of a planned caesarean delivery compared to a planned vaginal delivery. It also is important to consider the economic aspects of caesarean sections, but very little attention has been given to health care system costs that take into account services used by women for themselves and their infants following hospital discharge.

METHODS AND DESIGN

The Ontario Mother and Infant Study III is a prospective cohort study to examine relationships between method of delivery and maternal and infant health, service utilization, and cost of care at three time points during the year following postpartum hospital discharge. Over 2500 women were recruited from 11 hospitals across the province of Ontario, Canada, with data collection occurring between April 2006 and October 2008. Participants completed a self-report questionnaire in hospital and structured telephone interviews at 6 weeks, 6 months, and 12 months after discharge. Data will be analyzed using generalized estimating equation, a special generalized linear models technique. A qualitative descriptive component supplements the survey approach, with the goal of assisting in interpretation of data and providing explanations for trends in the findings.

DISCUSSION

The findings can be incorporated into patient counselling and discussions about the advantages and disadvantages of different delivery methods, potentially leading to changes in preferences and practices. In addition, the findings will be useful to hospital- and community-based postpartum care providers, managers, and administrators in guiding risk assessment and early intervention strategies. Finally, the research findings can provide the basis for policy modification and implementation strategies to improve outcomes and reduce costs of care.

How strategies for managing patient visit time affect physician job satisfaction: a qualitative analysis

BACKGROUND

There is much physician discontent regarding policies that limit time for patient visits and contribute to physician dissatisfaction with the medical profession as a whole. Yet little is known about how physician strategies for managing time limits correspond to job satisfaction.

OBJECTIVE

The goal of this study was to identify strategies physicians use for managing time with patients and the effects these strategies have on job satisfaction.

DESIGN

In-depth interviews with primary care providers in various clinical settings (academic medical centers, community-based centers, solo practices, nonacademic group practices) were audiorecorded.

PARTICIPANTS

Primary care physicians (n = 25).

APPROACH

Transcribed audiorecordings of physician interviews were coded using a modified grounded theory approach. An open coding process was used to identify major themes, subthemes, and the interrelationships among them.

RESULTS

Three main themes emerged. (1) Study physicians disregarded time limits despite the known financial consequences of doing so and justified their actions according to various ethical- and values-based frameworks. (2) Disregarding time limits had a positive impact on job satisfaction in the realm of direct patient care. (3) The existence of time limits had a negative impact on overall job satisfaction.

CONCLUSION

For the study physicians, disregarding time limits on patient visits is an adaptive short-term strategy that enhances satisfaction with direct patient care. It is unlikely that such a strategy alone will help physicians cope with their broader- and growing-dissatisfaction with the profession.

Can teaching agenda-setting skills to physicians improve clinical interaction quality? A controlled intervention

BACKGROUND

Physicians and medical educators have repeatedly acknowledged the inadequacy of communication skills training in the medical school curriculum and opportunities to improve these skills in practice. This study of a controlled intervention evaluates the effect of teaching practicing physicians the skill of "agenda-setting" on patients' experiences with care. The agenda-setting intervention aimed to engage clinicians in the practice of initiating patient encounters by eliciting the full set of concerns from the patient's perspective and using that information to prioritize and negotiate which clinical issues should most appropriately be dealt with and which (if any) should be deferred to a subsequent visit.

METHODS

Ten physicians from a large physician organization in California with baseline patient survey scores below the statewide 25th percentile participated in the agenda-setting intervention. Eleven physicians matched on baseline scores, geography, specialty, and practice size were selected as controls. Changes in survey summary scores from pre- and post-intervention surveys were compared between the two groups. Multilevel regression models that accounted for the clustering of patients within physicians and controlled for respondent characteristics were used to examine the effect of the intervention on survey scale scores.

RESULTS

There was statistically significant improvement in intervention physicians' ability to "explain things in a way that was easy to understand" (p = 0.02) and marginally significant improvement in the overall quality of physician-patient interactions (p = 0.08) compared to control group physicians. Changes in patients' experiences with organizational access, care coordination, and office staff interactions did not differ by experimental group.

CONCLUSION

A simple and modest behavioral training for practicing physicians has potential to positively affect physician-patient relationship interaction quality. It will be important to evaluate the effect of more extensive trainings, including those that work with physicians on a broader set of communication techniques.

Teaching the medical interview: methods and key learning issues in a faculty development course

OBJECTIVE

To describe the American Academy on Communication in Healthcare's (AACH) Faculty Development Course on Teaching the Medical Interview and report a single year's outcomes.

DESIGN

We delivered a Faculty Development course on Teaching the Medical Interview whose theme was relationship-centered care to a national and international audience in 1999. Participants completed a retrospective pre-post assessment of their perceived confidence in performing interview, clinical, teaching, and self-awareness skills.

PARTICIPANTS AND SETTING

A total of 79 participants in the 17th annual AACH national faculty development course at the University of Massachusetts Medical School in June 1999.

INTERVENTION

A 5-day course utilized the principles of learner-centered learning to teach a national and international cohort of medical school faculty about teaching the medical interview.

MEASUREMENTS AND MAIN RESULTS

The course fostered individualized, self-directed learning for participants, under the guidance of AACH faculty. Teaching methods included a plenary session, small groups, workshops, and project groups all designed to aid in the achievement of individual learning goals. Course outcomes of retrospective self-assessed confidence in interview, clinical, teaching, self-awareness, and control variables were measured using a 7-point Likert scale. Participants reported improved confidence in interview, clinical, teaching, and self-awareness variables. After controlling for desirability bias as measured by control variables, only teaching and self-awareness mean change scores were statistically significant (p < .001).

CONCLUSIONS

The AACH Faculty Development course on Teaching the Medical Interview utilized learner-centered teaching methods important to insure learning with experienced course participants. Perceived teaching and self-awareness skills changed the most when compared to other skills.

Voluntary physician switching by human immunodeficiency virus-infected individuals: a national study of patient, physician, and organizational factors

OBJECTIVE

We sought to assess which patient, physician, and organizational factors are related to voluntary physician switching among human immunodeficiency virus (HIV)-infected patients.

DESIGN

We analyzed the results from a 3-wave survey of patients conducted by the HIV Cost and Services Utilization Study (HCSUS), a longitudinal study of a nationally representative sample of noninstitutionalized HIV-infected individuals receiving care in the contiguous United States. Physicians providing care and care site directors were surveyed once. Relationships of interpersonal aspects of care, access and continuity, technical quality of care, and physician and site characteristics to voluntary switching were analyzed using multilevel logistic regression models that nested repeated observations within patients, patients within clinicians, and clinicians within region.

RESULTS

Approximately 15% of patients voluntarily changed their usual clinicians during the 2-year study period. In a multivariate model, lower voluntary switching was predicted by patient trust (odds ratio [OR]=0.74; 95% confidence interval [95% CI]=0.61-0.90), physician antiretroviral knowledge (OR=0.26; 95% CI 0.13-0.53), moderate (rather than low or high) HIV patient volume at a care site (OR=0.09; 95% CI=0.03-0.31), and Ryan White Care Act funding (OR=0.27, 95% CI=0.14-0.52).

CONCLUSIONS

Patients with chronic illnesses may use several markers of specialization and technical quality to make decisions about their care. These results challenge the notion that patients cannot assess the quality of care they receive.

Ratings of physician communication by real and standardized patients

PURPOSE

Patient ratings of physician's patient-centered communication are used by various specialty credentialing organizations and managed care organizations as a measure of physician communication skills. We wanted to compare ratings by real patients with ratings by standardized patients of physician communication.

METHODS

We assessed physician communication using a modified version of the Health Care Climate Questionnaire (HCCQ) among a sample of 100 community physicians. The HCCQ measures physician autonomy support, a key dimension in patient-centered communication. For each physician, the questionnaire was completed by roughly 49 real patients and 2 unannounced standardized patients. Standardized patients portrayed 2 roles: gastroesophageal disorder reflux symptoms and poorly characterized chest pain with multiple unexplained symptoms. We compared the distribution, reliability, and physician rank derived from using real and standardized patients after adjusting for patient, physician, and standardized patient effects.

RESULTS

There were real and standardized patient ratings for 96 of the 100 physicians. Compared with standardized patient scores, real-patient-derived HCCQ scores were higher (mean 22.0 vs 17.2), standard deviations were lower (3.1 vs 4.9), and ranges were similar (both 5-25). Calculated real patient reliability, given 49 ratings per physician, was 0.78 (95% confidence interval [CI], 0.71-0.84) compared with the standardized patient reliability of 0.57 (95% CI, 0.39-0.73), given 2 ratings per physician. Spearman rank correlation between mean real patient and standardized patient scores was positive but small to moderate in magnitude, 0.28.

CONCLUSION

Real patient and standardized patient ratings of physician communication style differ substantially and appear to provide different information about physicians' communication style.

Life on the receiving end: A qualitative analysis of health providers' illness narratives

PURPOSE

Clinical empathy is integral to forging therapeutic patient-physician relationships. Illness narratives are a potentially rich source of insight into what it feels like to be a patient or patient's family member. The authors performed a qualitative analysis of illness narratives to develop an explicit framework for understanding what it feels like to be a health care recipient and to explore how providers' behaviors influence that experience.

METHOD

The authors used consensual qualitative research, a methodology based on principles of grounded theory, to analyze 24 illness narratives found in that number of essays from the Annals of Internal Medicine's "On Being a Patient" series published between January 1, 1999, and December 31, 2003. Trustworthiness was demonstrated via essayists' feedback on the analysis.

RESULTS

Patients and their families faced formidable physical and psychosocial challenges. Providers' behaviors influenced the illness experience in profoundly positive and negative ways, independent of the technical quality of care. Consistent with previous studies of patient-physician relationships, providers' advocacy for patients and expressions of compassion were prominent determinants of patients' satisfaction. The experience of simultaneously being a health care provider and consumer was an additional source of stress for essayists, but it positively influenced their subsequent practice.

CONCLUSIONS

Illness narratives vividly illustrate fundamental aspects of the illness experience and are a potentially rich resource for cultivating empathy. The authors' analysis provides a framework for enhancing trainees' and practitioners' ability to understand and meet patients' and families' psychosocial needs. The experiences of health care recipients with medical backgrounds are uniquely challenging and beneficial.

Improving the effectiveness of the medical visit: a brief visit-structuring workshop changes patients' perceptions of primary care visits

OBJECTIVE

To teach visit-structuring strategies to primary care clinicians with a 1.5-h experiential workshop and assess its effect on patient perceptions of their medical visits.

METHODS

We developed and conducted a 90 min workshop for 75 clinicians from seven primary care clinics, and evaluated the effectiveness of the workshop by assessing changes in patients' ratings of visit qualities from 1 week prior (n=301) to 1 week after (n=322) the workshop. Patients rated their physicians' visit-structuring skills as well as satisfaction with their medical visits.

RESULTS

Patients were highly satisfied with their visits both before and after the workshop. Post-workshop ratings of medical visits were more likely to indicate that all problems were addressed during the visit.

CONCLUSIONS

A brief workshop had a positive measurable effect on patients' perception of their medical visits. Future research should address the utility of patient rated assessments of visit characteristics.

PRACTICE IMPLICATIONS

Physicians' ability to establish and maintain a productive structure in primary care office visit is an important skill that can improve the quality of care, and some changes in physician visit-structuring behavior can be measured using patient perceptions.

The Newcastle Satisfaction with Nursing Scales: a valid measure of maternal satisfaction with inpatient postpartum nursing care

AIM

To test the validity of The Newcastle Satisfaction with Nursing Scales as measures of patient satisfaction with nursing care in an inpatient postpartum unit.

BACKGROUND

The Newcastle Satisfaction with Nursing Scales (Experience of Nursing Care Scale and Satisfaction with Nursing Care Scale) were developed to measure the satisfaction of medical-surgical inpatients with nursing care.

METHODS

The Newcastle Satisfaction with Nursing Scales were administered by interviewers to 189 postpartum women prior to hospital discharge. We tested the construct validity of the scales by making five a priori predictions: mothers who were more satisfied would be more likely to have one nurse caring for them and to recommend the postpartum unit to a friend. We also predicted that the Experience of Nursing Care and Satisfaction with Nursing Care Scales would be positively correlated with each other, with a global question about satisfaction with nursing care, and with a global question about satisfaction with overall postpartum stay.

RESULTS

Four of the five a priori predictions were supported by the data. The mean Newcastle Satisfaction with Nursing Scale scores of mothers who would recommend the unit to a friend were higher (more satisfied) than those who would not (P < 0.001). The Experience of Nursing Care Scale and Satisfaction with Nursing Care Scale were positively and significantly correlated with each other (r = 0.9, P < 0.001). There was a positive and significant correlation between the scales and global ratings of nursing care (Experience Scale r = 0.79, P < 0.001; Satisfaction Scale r = 0.82, P < 0.001) and overall postpartum stay (Experience Scale r = 0.64, P < 0.001; Satisfaction Scale r = 0.68, P < 0.001).

CONCLUSION

The Newcastle Satisfaction with Nursing Scales are valid measures of maternal satisfaction with inpatient postpartum nursing care.

Evaluations of care by adults following a denial of an advertisement-related prescription drug request: the role of expectations, symptom severity, and physician communication style

As patients continue to take a more active role in their health care, an understanding of patient requests of health care providers, including what happens when requests are not fulfilled, is becoming more important. Although its merits have been debated, direct-to-consumer advertising of prescription drugs generates patient requests. The objective of this study was to assess the influence of physician communication style, respondents' expectations of receiving a requested prescription, and perceived symptom severity on respondents' evaluations of care following a physician denial of a prescription drug request stimulated by direct-to-consumer advertising. A 2 x 2 x 2, between-subjects experimental design was used. The respondents were made up of employees of the University of Mississippi. Physician communication style, respondents' expectations, and respondents' perceived symptom severity were manipulated using vignettes. Respondents' post-visit evaluations of care were assessed by measuring trust in the physician, visit-based satisfaction with the physician, and commitment toward the physician. Factorial analysis of variance procedures for a three-way design were used to test the hypotheses and assess the research questions. Manipulation checks suggested that the independent variables were appropriately manipulated. No significant first-order or second-order interactions were noted in any of the analyses. Post-visit evaluations of care were significantly associated with physician communication style (a partnership response led to better evaluations of care). There were no significant effects of either prior expectation of request fulfillment or perceived symptom severity. However, non-significant trends in mean scores suggested a potential role of these variables in the evaluation process following request denial. The manner in which a physician communicates with an individual is an important determinant of the evaluation of care following the denial of a request. The results suggest that health care providers attempting to minimize the effect of request denials on patient evaluations should make an effort to involve the patient in the decision-making process.

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

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

Managed care, physician job satisfaction, and the quality of primary care

OBJECTIVE

To determine the associations between managed care, physician job satisfaction, and the quality of primary care, and to determine whether physician job satisfaction is associated with health outcomes among primary care patients with pain and depressive symptoms.

DESIGN

Prospective cohort study.

SETTING

Offices of 261 primary physicians in private practice in Seattle.

PATIENTS

We screened 17,187 patients in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms; 2,004 patients completed a 6-month follow-up survey.

MEASUREMENTS AND RESULTS

For each patient, managed care was measured by the intensity of managed care controls in the patient's primary care office, physician financial incentives, and whether the physician read or used back pain and depression guidelines. Physician job satisfaction at baseline was measured through a 6-item scale. Quality of primary care at follow-up was measured by patient rating of care provided by the primary physician, patient trust and confidence in primary physician, quality-of-care index, and continuity of primary physician. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days. Pain and depression patients of physicians with greater job satisfaction had greater trust and confidence in their primary physicians. Pain patients of more satisfied physicians also were less likely to change physicians in the follow-up period. Depression patients of more satisfied physicians had higher ratings of the care provided by their physicians. These associations remained after controlling statistically for managed care. Physician job satisfaction was not associated with health outcomes.

CONCLUSIONS

For primary care patients with pain or depressive symptoms, primary physician job satisfaction is associated with some measures of patient-rated quality of care but not health outcomes.

Psychosocial factors in medical and psychological treatment avoidance: the role of the doctor-patient relationship

A community sample of 1106 adults was examined to assess the impact of the doctor-patient relationship on participants' avoidance of treatment for a recognized medical or psychological problem. Of five aspects of participants' previous experience with their physicians, all but waiting time predicted participants' self-reported treatment avoidance. In two logistic regression models participants who felt their physicians listened more to their concerns were less likely to avoid treatment for both medical and psychological problems during the previous 12 months. These findings suggest that patients' perceptions of how they are treated by physicians may help explain why many people delay or avoid healthcare treatment, even when faced with a significant health problem.

Teaching communication in clinical clerkships: models from the macy initiative in health communications

Medical educators have a responsibility to teach students to communicate effectively, yet ways to accomplish this are not well-defined. Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. To address these problems the New York University School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School collaborated to develop, establish, and evaluate a comprehensive communication skills curriculum. This work was funded by the Josiah P. Macy, Jr. Foundation and is therefore referred to as the Macy Initiative in Health Communication. The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills. In a controlled trial this cross-institutional curriculum project proved effective in improving communication skills of third-year students as measured by a comprehensive, multistation, objective structured clinical examination. In this paper the authors describe the development of this unique, collaborative initiative. Grounded in a three-school consensus on the core skills and critical components of a communication skills curriculum, this article illustrates how each school tailored the curriculum to its own needs. In addition, the authors discuss the lessons learned from conducting this collaborative project, which may provide guidance to others seeking to establish effective cross-disciplinary skills curricula.