Understanding healing relationships in primary care

Cancer Patient Perspectives on the Meaning of Healing and the Clinician as a Healer

BACKGROUND

The experience of living with cancer is marked by suffering and loss, which creates a need for healing. Understanding what healing means to patients and how clinicians can play a role in the healing process is essential to holistic cancer care.

OBJECTIVE

The aim of this study was to explore the perspectives of cancer patients on the meaning and experiences of healing and the qualities of a clinician and the clinician-patient relationship that are healing.

METHODS

A qualitative study was conducted using semi-structured interviews with 14 cancer patients. Participants were asked about their illness experience, definition of healing, qualities of a healer, and relationships with clinicians that were healing. Interview transcripts were coded, and qualitative analysis was conducted to identify major themes.

RESULTS

Participants defined the nature of healing as comprising aspects of physical, mental, emotional, and spiritual well-being. Participants described healing as alleviating pain and symptoms; promoting mental strength, emotional comfort, and spiritual connection; restoring and adapting to losses; and improving quality of life. The qualities of a clinician that contributed to a healing relationship included listening, empathy and compassion, understanding patients' values and goals, and caring for the patient as a whole person.

CONCLUSION

Participants viewed healing as physical, psychosocial, and spiritual in nature and an important part of their cancer experience with an emphasis on quality of life. Clinicians played an important role beyond treating the cancer by helping in the healing process through their humanistic qualities and holistic approach to patient care.

Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review

Background

Nurses, midwives and paramedics are the largest collective group of clinical staff in the National Health Service and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves.

Aim

To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions.

Methods

Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards' reporting guidelines.

Data sources

First round database searching in Medical Literature Analysis and Retrieval System Online Database ALL (via Ovid), cumulative index to nursing and allied health literature database (via EBSCO) and health management information consortium database (via Ovid), was undertaken between February and March 2021, followed by supplementary searching strategies (e.g. hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied.

Results

We built on seven key reports and included 75 papers in the first round (26 nursing, 26 midwifery, 23 paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 context mechanism and outcome configurations. The key findings identified the following: (1) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; (2) it is difficult to promote staff psychological wellness where there is a blame culture; (3) the needs of the system often override staff well-being at work ('serve and sacrifice'); (4) there are unintended personal costs of upholding and implementing values at work; and (5) it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors.

Conclusions

Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological well-being. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to (1) rebalance the working environment to enable healthcare professionals to recover and thrive; (2) invest in multi-level system approaches to promote staff psychological well-being; and use an organisational diagnostic framework, such as the NHS England and NHS Improvement Health and Wellbeing framework, to self-assess and implement a systems approach to staff well-being.

Future work

Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with front-line staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs.

Limitations

The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder/expert suggestions to augment our sample.

Study registration

This study is registered as PROSPERO CRD42020172420. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172420.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129528) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

Extra/ordinary medicine: Toward an anthropology of primary care

Primary care is at the forefront of healthcare delivery. It is the site of disease prevention and health management and serves as the bridge between communities and the health care system As ethnographers of primary care, in this article we discuss what is gained by situating anthropological inquiry within primary care. We articulate how anthropologists can contribute to a better understanding of the issues that emerge in primary care. We provide a review of anthropological work in primary care and offer empirical data from two ethnographic case studies based in the United States, one focused on social risk screening in primary care and the other examining the diagnosis and care of people with dementia in primary care. Through these cases, we demonstrate how research of and within primary care can open important avenues for the study of the multidimensionality of primary care. This multidimensionality is apparent in the ways the medical field addresses the social and structural experiences of patients, scope of practice and disciplinary boundaries, and the intersection of ordinary and extraordinary medicine that emerge in the care of patients in primary care.

Where the joy comes from: a qualitative exploration of deep GP-patient relationships

BACKGROUND

Relationship-based, whole person care is foundational to quality general practice. Previous research has identified several characteristics of deep General Practitioner (GP)-patient relationships and their association with improved patient concordance, satisfaction and perceived health outcomes. Psychological attachment theory has been used to understand therapeutic relationships, but has only been explored to a limited extent in the general practice context. Additionally, evolving changes in sociocultural and commercial practice contexts may threaten relationship-based care. In view of this, we aimed to explore the nature and experience of deep GP-patient relationships, as identified by patients, from GP and patient perspectives.

METHODS

Semi-structured interview design. An initial survey assessed patients' perceived depth of their relationship with their GP, using the Health Care Provider Attachment Figure Survey and Patient-Doctor Depth of Relationship Scale. Patients who reported a deep relationship, and their GPs, were purposively selected for individual interviews exploring their experience of these relationships. A post-interview survey assessed interviewees' attachment styles, using the Modified and Brief Experiences in Close Relationships Scale. Patient interviewees also rated the patient-centredness of their GP's clinic using the Person-Centred Primary Care Measure. Transcripts were analysed using thematic analysis.

RESULTS

Thirteen patients and five GPs were interviewed. Four themes characterised deep relationships: the 'professional'; human connection; trust; and 'above and beyond'. Patient, GP and practice team all contributed to their cultivation.

CONCLUSIONS

We present a revised conceptual framework of deep GP-patient relationships. Deep relationships come to the fore in times of patient trouble. Like attachment relationships, they provide a sense of safety, caring and support for patients experiencing vulnerability. They can stretch GP boundaries and capacity for self-care, but also provide joy and vocational satisfaction. Patients may not always desire or need deep relationships with their GP. However, findings highlight the importance of enabling and cultivating these for times of patient hardship, and challenges of doing so within current healthcare climates.

The impact of patient-provider relationships on choosing between VA and VA-purchased care: A qualitative study of health care decision-making among rural veterans

PURPOSE

Since the Choice Act in 2014, many Veterans have had greater options for seeking Veteran Affairs (VA)-purchased care in the community. We investigated factors that influence rural Veterans' decisions regarding where to seek care.

METHODS

We utilized semi-structured telephone interviews to query Veterans living in rural or highly rural areas of Midwestern states about their health care options, preferences, and experiences. Interviews were recorded and transcribed, thematically coded, and deductively analyzed using a socioecological approach.

FINDINGS

Forty rural Veterans (20 men/20 women) ages 28-76 years completed interviews in 2019. We found that rural Veterans often spoke about their relationships and interactions with providers as an important factor in deciding where to seek care. They expressed three socioecological qualities of patient-provider relationships that affected their decisions: (1) personal level-rural Veterans traveled longer distances for more compatible patient-provider relationships; (2) interpersonal level-they sought stable patient-provider relationships that encouraged familiarity, trust, and communication; and (3) organizational level-they emphasized shared identities and expertise that fostered a sense of belonging with their provider. Participants also described how impersonal interactions, status differences, and staff turnover impacted their choice of provider and were disruptive to patient-provider relationships.

CONCLUSIONS

Rural Veterans' interview responses suggest exploring innovative ways to measure socioecological dimensions (i.e., personal, interpersonal, and organizational) of access-related decisions and patient-provider relationships to better understand health care barriers and needs. Such measures align with the VA's Whole Health approach that emphasizes person-centered care and the value of social relationships to Veterans' health.

The Role of Primary Care in Improving Population Health

Policy Points Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure. Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges. Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.

The Craft of Generalism clinical skills and attitudes for whole person care

RATIONALE, AIMS AND OBJECTIVES

Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism.

METHODS

The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research.

RESULTS

The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent.

CONCLUSIONS

Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.

Effect of Daily Multidisciplinary Team Reflection in Ambulatory Care: A Qualitative Analysis

Purpose

Participants and Methods

Results

Conclusion

Heard, known and safe in general practice? An interview study with patients with severe and persistent mental illness

Background

Although GPs provide care to many patients with severe and persistent mental illness, the role and skillset of the GP in this space are contested. Patients are less satisfied with GP care of mental health than physical health issues.

Aim

To explore patient expectations and experiences of GP roles in their mental health, and identify opportunities for improving mental health care in general practice.

Design & setting

Patient participants were recruited from community mental health clinics in Brisbane, Australia.

Method

Individual semi-structured interviews were conducted with a convenience sample of patients. Interviews were audio-recorded and transcribed professionally. The authors conducted an inductive thematic analysis, attending to participant vulnerability and reflexivity.

Results

Sixteen interviews were conducted by one author (RW), with an average duration of 29 minutes. Three overarching themes were identified: being heard, being known, and being safe. Participants greatly valued ‘good GPs’ who were able to detect early signs of relapse, and with whom they came to feel heard, known, and safe over time. Experiences of perfunctory, hurried care and avoidance of mental health issues were also reported. Many participants were uncertain whether GP training in mental health was sufficient to keep them safe. Patients may suspect GPs who predominantly engage with their physical health to have negative attitudes to mental illness.

Conclusion

Some GPs play central roles in patients’ mental health care. Barriers for others need further exploration, and may include time, confidence, and/or expertise. Findings challenge GPs to engage more actively and effectively with these patients in their general practice consultations.

Qualitative Investigation of Health Information Resources for Caregivers and Individuals Living With Spinal Cord Injury

Objectives: To identify the information networks of caregivers and individuals with spinal cord injury (SCI) and how the health information is accessed and used. Methods: For this qualitative study, participants from the United States were recruited through hospital listservs, websites, social media, and word of mouth to participate in a phone interview. Fourteen individuals living with a traumatic SCI and 18 caregivers of individuals living with a traumatic SCI were interviewed using a semi-structured interview guide. The interviews were transcribed verbatim, coded using NVivo, and analyzed using qualitative thematic methods. Results: Participants reported that medical resources such as SCI specialists were considered the most reliable sources, but due to accessibility barriers the Internet was used the most. The Internet and social resources, such as online and in-person support groups, provided beneficial content information and emotional support, but they posed credibility concerns and left participants feeling unsure of reliability. Information gaps such as lack of education on basic care practices during the transition from acute to chronic care were identified by the participants. Conclusion: Because SCI is an overwhelming experience, it is difficult for patients to retain information in the initial acute care phase, leading to gaps in knowledge about long-term care. Patients are concerned about the reliability of online sources of information; therefore, there is a need for new methods of SCI information dissemination. Potentially, using primary care providers as conduits for information distribution might improve access to reliable long-term SCI information for caregivers and patients.

The Meaning of the Empathetic Nurse-Patient Communication: A Qualitative Study

Nurse-patient communication is the foremost step in providing professional care. Nurses can use effective communication as a simple and powerful tool to create comfort, happiness, and vitality to reduce the patient's grief and suffering. This study aimed to explain the nurses' perception of empathetic nurse-patient communication. This qualitative study was conducted with a content analysis method in 2020. Seventeen hospital nurses were recruited with maximum variation from the educational hospitals affiliated to Qom University of Medical Sciences, Qom, Iran, and semi-structured interviews were conducted until data saturation was reached. Data analysis was performed using Graneheim and Lundman approach. Nurses establish empathetic communication with patients through three main categories of: (1) having humanistic and unique behaviors with the patients; (2) providing a calm and happy environment for the patients; and (3) reducing the patients' fear and consolation to them. These findings indicate empathetic communication that is appropriate to the conditions and needs of hospitalized patients. The three main categories were accomplished through 14 subcategories. The finding of this study can help to develop a training framework of empathetic nurse-patient communication and design instruments for measuring it.

Beyond multimorbidity: What can we learn from complexity science?

Multimorbidity - the occurrence of two or more long-term conditions in an individual - is a major global concern, placing a huge burden on healthcare systems, physicians, and patients. It challenges the current biomedical paradigm, in particular conventional evidence-based medicine's dominant focus on single-conditions. Patients' heterogeneous range of clinical presentations tend to escape characterization by traditional means of classification, and optimal management cannot be deduced from clinical practice guidelines. In this article, we argue that person-focused care based in complexity science may be a transformational lens through which to view multimorbidity, to complement the specialism focus on each particular disease. The approach offers an integrated and coherent perspective on the person's living environment, relationships, somatic, emotional and cognitive experiences and physiological function. The underlying principles include non-linearity, tipping points, emergence, importance of initial conditions, contextual factors and co-evolution, and the presence of patterned outcomes. From a clinical perspective, complexity science has important implications at the theoretical, practice and policy levels. Three essential questions emerge: (1) What matters to patients? (2) How can we integrate, personalize and prioritize care for whole people, given the constraints of their socio-ecological circumstances? (3) What needs to change at the practice and policy levels to deliver what matters to patients? These questions have no simple answers, but complexity science principles suggest a way to integrate understanding of biological, biographical and contextual factors, to guide an integrated approach to the care of people with multimorbidity.

Pediatric Preventive Care: Population Health and Individualized Care

Well-child care is a near-universal service for young children toward which a great deal of time and professional resources are devoted but for which there is scant evidence of effectiveness in routine practice. It is composed of many components, the value of which likely varies with the quality of their provision and the needs and priorities of the children and families who receive them. Achieving more efficient and effective preventive care will require that pediatric practices segment the population they serve and design schedules and staffing to match patients' health, well-being, personal and social circumstances, and service needs. Care should be individualized and include essential screening, tests, procedures, and education on the basis of assessment of patients' and families' needs and priorities. The traditional schedule of individual, comprehensive preventive care visits should be reconsidered and replaced with a schedule that allows complete care to be provided over a series of visits, including those for acute and chronic care. Preventive pediatric care should be provided in family-centered, team-based practices with strong linkages to other providers in the community who serve and support children and families. Care should make use of the wide variety of modalities that exist, and face-to-face time should be reserved for those services that are both important and uniquely responsive to in-office intervention. This model of preventive care will require changes in training, responsibilities and reimbursement of health care team members, and enhanced communication and collaboration among all involved, especially with families.

Dealing with Discontinuity in Cancer Care Trajectories: Patients' Solutions

Introduction

Patients with cancer require specialized care from different care providers, challenging continuity of care in terms of information, relationships, and/or management. The recognition of discontinuity of care has led to different initiatives by the healthcare system over the years. Yet, making use of the theory on boundary objects and brokers, this research explores the active role of patients themselves in resolving discontinuity along their care trajectories.

Methods

Semi-structured interviews were conducted with 33 patients to unravel the discontinuities that they experience and their attempts to resolve these. Interview data were analyzed using directed-content analysis informed by concepts from boundary crossing literature (i.e., data were searched for potential boundary objects and brokers).

Results

To re-establish continuity of care, patients actively use the objects and people provided by the healthcare system when these meet their needs. Patients also introduce own objects and people into the care trajectory. As such, information and management discontinuity can typically be resolved. Relational continuity appears to be more difficult to resolve, in some cases leaving patients to take drastic measures, such as changing care providers.

Discussion

The use of boundary crossing theory in improving care from a patient perspective is relatively novel. When patients and providers together address the objects and people that support establishing continuity of care, a continuous care process may be encouraged. We advocate an integrated approach, rather than provider or healthcare system initiatives exclusively, to patient care and continuity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00535-x.

Reimagining Relationship-Based Health Care in a Post-COVID World

The US health care system has a long history of discouraging the creation and maintenance of meaningful relationships between patients and providers. Fee-for-service payment models, the 1-directional, paternalistic approach of care providers, electronic health records, anddocumentation requirements, all present barriers to the development of meaningful relationships in clinic visits. As patients and providers adopt and experiment with telemedicine and other systems changes to accommodate the impact of Coronavirus disease 2019, there is an opportunity to reimagine visits entirely—both office-based and virtual—and leverage technology to transform a unidirectional model into one that values relationships as critical facilitators of health and well-being for both patients and providers.

Physical Distancing With Social Connectedness

In light of concerns over the potential detrimental effects of declining care continuity, and the need for connection between patients and health care providers, our multidisciplinary group considered the possible ways that relationships might be developed in different kinds of health care encounters.We were surprised to discover many avenues to invest in relationships, even in non-continuity consultations, and how meaningful human connections might be developed even in telehealth visits. Opportunities range from the quality of attention or the structure of the time during the visit, to supporting relationship development in how care is organized at the local or system level and in the use of digital encounters. These ways of investing in relationships can exhibit different manifestations and emphases during different kinds of visits, but most are available during all kinds of encounters.Recognizing and supporting the many ways of investing in relationships has great potential to create a positive sea change in a health care system that currently feels fragmented and depersonalized to both patients and health care clinicians.The current COVID-19 pandemic is full of opportunity to use remote communication to develop healing human relationships. What we need in a pandemic is not social distancing, but physical distancing with social connectedness.

It's time to bring human factors to primary care policy and practice

Primary health care is a complex, highly personal, and non-linear process. Care is often sub-optimal and professional burnout is high. Interventions intended to improve the situation have largely failed. This is due to a lack of a deep understanding of primary health care. Human Factors approaches and methods will aid in understanding the cognitive, social and technical needs of these specialties, and in designing and testing proposed innovations. In 2012, Ben-Tzion Karsh, Ph.D., conceived a transdisciplinary conference to frame the opportunities for research human factors and industrial engineering in primary care. In 2013, this conference brought together experts in primary care and human factors to outline areas where human factors methods can be applied. The results of this expert consensus panel highlighted four major research areas: Cognitive and social needs, patient engagement, care of community, and integration of care. Work in these areas can inform the design, implementation, and evaluation of innovations in Primary Care. We provide descriptions of these research areas, highlight examples and give suggestions for future research.

The Role of Health Consciousness, Patient-Physician Trust, and Perceived Physician's Emotional Appraisal on Medical Adherence

Poor adherence to medical recommendations is a well-recognized catalyst for public health consequences worldwide. The literature highlights health consciousness as a likely antecedent to patient-physician trust, which in turn promotes medical adherence. Nevertheless, principles of patient-centered care suggest that patient perceptions of their doctor's appraisal of their emotions may influence the path between trust and medical adherence. Accordingly, this study tested the mediating role of patient-physician trust in the relation between health consciousness and medical adherence and assessed whether patient ratings of their doctor's appraisal of their own and their patients' emotions moderated the mediated relation. Data were collected via self-report questionnaires from two culturally and economically diverse countries: Bosnia-Herzegovina (N = 262) and the United States (N = 314). Participants were young, healthy adults who visited their primary care physician in the past year. The study employed confirmatory factor analysis, mediation, and moderated mediation analyses. The results indicate that health consciousness positively related to patient-physician trust, which was in turn related to higher medical adherence and which mediated 28% of the total effect of health consciousness. Nevertheless, among patients who rated their physicians to have low appraisal for their patients' emotions but high appraisal for their own emotions, the path from trust to adherence was not significant. These results highlight the importance of promoting health consciousness among young individuals, all while training practitioners to be attuned to their patients' emotions and circumstances above their own. However, additional findings indicate that the interrelation between doctors' emotional attributes and adherence is not necessarily one directional and warrants further investigation.

Developing a New Measure of Primary Care Using the Medical Expenditure Panel Survey

OBJECTIVE

To develop and assess the reliability of a measure of primary care using items from the Medical Expenditure Panel Survey (MEPS), a US representative survey of community-dwelling persons.

METHODS

On the basis of the domains from the literature on primary care characteristics, we identified relevant items within the 2013-2014 MEPS family of surveys. In a sample of primary survey respondents with at least 1 office-based physician visit in the last 12 months, we conducted exploratory factor analysis, retaining items with a factor loading of 0.30 and factors ≥3 items. Using a hold-out sample, internal consistency, reproducibility, and confirmatory factor analyses were performed.

RESULTS

On the basis of 16 care domains, we found 32 candidate items in the MEPS. Factor analyses of data from 4549 persons meeting inclusion criteria (27.6% of the total sample), yielded 3 unique factors involving 24 items. We named these subscales Relationship, Comprehensiveness, and Health Promotion, displaying internal consistency reliability of 0.86, 0.78, and 0.69, respectively. Confirmatory factor analysis corroborated the stability of the exploratory findings in the hold out sample. Sensitivity analyses showed robustness to differences in underlying correlation structure, alternative approach to missing data, and extension to indirect survey respondents.

CONCLUSIONS

The MEPS Primary Care measure with 3 subscales is reliable and may be useful in conducting primary care health services and outcomes research in the rich MEPS dataset. Further validation is needed, and is described in a companion paper.

Primary care of adults with severe and profound intellectual and developmental disabilities: Family physicians' perspectives on patient-physician relationships

OBJECTIVE

To explore family physicians' perspectives on the development of the patient-physician relationship with adult patients living with severe or profound intellectual and developmental disabilities (IDD).

DESIGN

Constructivist grounded theory.

SETTING

St John's, NL, and across Canada.

PARTICIPANTS

Fifteen family physicians currently caring for patients with severe or profound IDD.

METHODS

Data were collected via in-depth, semistructured interviews conducted in-person or by telephone. Interviews were audiorecorded and transcribed verbatim. Field notes were documented immediately by the interviewer and discussed with the research team. Memos in the form of reflective notes served as additional sources of data.

MAIN FINDINGS

From the perspective of family physicians, the core process in the development of the patient-physician relationship was acceptance. This acceptance was bidirectional. With respect to family physicians accepting patients, family physicians had to accept that their patients with severe and profound IDD were as equally deserving of their respect as any other patient-as unique individuals with their own goals and potential. With respect to patients accepting their family physicians, family physicians had to seek out signs of acceptance from their patients to fully appreciate and develop a trusting relationship. This bidirectional process of acceptance required family physicians to adapt the way they practised (eg, by spending more time with the patient and finding alternate forms of communication). It also required family physicians to define their role (eg, building trust and being an advocate) in a relationship that had the patient as the primary focus but simultaneously acknowledged the important involvement of the caregiver.

CONCLUSION

For family physicians, the process of acceptance seems to underpin the development of the patient-physician relationship with adult patients with severe or profound IDD. Findings highlight the need for family physicians to adapt the way they deliver care to these patients and define their role in these complex relationships. Ultimately, this study highlights family physicians' acceptance of their patients' humanity regardless of the nature of the relationship that was created between them.

Questionnaires that measure the quality of relationships between patients and primary care providers: a systematic review

Background

International guidance on models of care stress the importance of good quality, continuous patient-provider relationships to support high quality and efficient care and hospital avoidance. However, assessing the quality of patient-provider relationships is challenging due to its experiential nature. The aim of this study was to undertake a systematic review to identify questionnaires previously developed or used to assess the quality of continuous relationships between patients and their provider in primary care.

Methods

MEDLINE, PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and SCOPUS databases were searched for English language studies published between 2009 and 2017. Key terms used identified studies conducted in the primary care setting examining relationships between patients and providers. Studies that focused on the conceptualisation, development, testing or review of a questionnaire, or studies that used a questionnaire for assessing the quality of continuous relationships between patients and providers were eligible. Studies that did not assess quality via a questionnaire, only assessed single aspects of relationships, only assessed single encounters, assessed transitions between settings or assessed relationships using an index were excluded. Information on validity testing of each relevant questionnaire identified from articles was reviewed to inform recommendations for future research and evaluation.

Results

Twenty-seven studies met the eligibility criteria, including 14 unique questionnaires. The questionnaires were diverse in length, scope, focus and level of validity testing. Five questionnaires were considered not feasible for future use due to size and lack of development work. Three questionnaires were considered strongest candidates for use in future work based on being relevant to the topic and primary care setting, freely available in English and not needing additional pilot work prior to use. These three questionnaires were the Care Continuity Across Levels of Care Scale, the Nijmegan Continuity Questionnaire and the Patient-Doctor Depth of Relationship Tool.

Conclusions

This study provides an overview of 14 unique questionnaires that have been used to assess the quality of continuous relationships between patients and primary care providers. The decision to use one of the questionnaires in future work requires careful consideration, including the scope, length, validation testing, accessibility of the questionnaires and their alignment with the initiative being evaluated.

Perceptions of Value and Cost of HIV Care Engagement Following Diagnosis in South Africa

Understanding the role of contextual factors beyond individual behavioural determinants is critical to identify strategies to achieve engagement in HIV clinical care. We sought to examine how subjective and objective evaluations of clinic-level costs and value placed on allopathic care influenced HIV care engagement. We used repeat in-depth interviews over 6 months among newly HIV diagnosed adults in South Africa. Data were analysed using thematic analyses and framework matrices to explore individual trajectories over time. Three main patterns of care engagement emerged: failure to enrol in care within 3 months, disengagement after enrolment, and early enrolment with sustained engagement. Findings show that burdensome health systems coupled with low perceptions of the future value of HIV care, compromise HIV care engagement. Without addressing these costs and enhancing perceptions of value on clinical care, the number of people engaging in HIV care is likely to fall short of goals.

Healing the heart of recovery

BACKGROUND AND AIM:

Medicine is traditionally considered a healing profession, yet concepts of healing are rarely applied to mental illness, recovery being the dominant discourse. This article reports one aspect of the results of a broader exploration, through a service user lens, of aspects of place that facilitate healing in mental health care, with a resulting conceptualisation of healing.

METHOD:

The research material comprised the author's historical writings of her experience of mental illness and recovery and in-depth individual interviews with 10 mental health service users. Analysed thematically, emerging ideas were further developed through an autoethnographically informed, reflexive and iterative process.

RESULTS:

Healing is necessary when there has been a disruption of integrity and wholeness, experienced as suffering. Offering opportunities for connection, integration and transformation, and acquiring wisdom along the way, healing is a journey of exploration that takes time and is hard work.

DISCUSSION:

Healing is conceptualised as the intensely personal experience at the heart of recovery, reminding us of the fundamental personal processes at the heart of our journeys. As a universal human experience, healing potentially removes the sense of othering that is at the heart of mental illness stigma.

A Narrative Approach to Healing Chronic Illness

Many clinicians may feel poorly prepared to manage patient suffering resulting from the travails of chronic illness. This essay explores the thesis that chronically and terminally ill patients can be holistically healed by transcending the suffering occasioned by the degradations of their illnesses. Suffering is conveyed as a story and clinicians can encourage healing by co-constructing patients' illness stories. By addressing the inevitable existential conflicts uncovered in patients' narratives and helping them edit their stories to promote acceptance and meaning, suffering can be transcended. This requires that clinicians be skilled in narrative medicine and open to engaging the patient's existential concerns. By helping patients transcend their suffering, clinicians claim their heritage as healers.

Efficacy of Solution-Focused Brief Therapy for Distress among Parents of Children with Congenital Heart Disease in China

Chinese parents of children with congenital heart disease (CHD) experience significant psychological distress due to the child's illness and hospitalization. Unfortunately, there are few psychosocial interventions for parental distress in China. This pilot study aimed to examine the efficacy of solution-focused brief therapy (SFBT) in a Chinese hospital for parental distress using a randomized controlled trial design. The participants included 40 Chinese parents of a currently hospitalized child diagnosed with CHD who were assessed to have psychological distress. Parents were randomized into either the intervention (n = 25) or the hospital medical social work treatment as usual (TAU) (n = 28) group. The Chinese Brief Symptom Inventory-18 and Chinese version of Herth Hope Index were administered before and after the interventions. Results of the intent-to-treat analysis indicated a significant decrease in parental distress and increase in parents' levels of hope in the intervention group compared with the TAU group. This study supported SFBT administered in a hospital setting as a promising intervention for reducing distress among Chinese parents with children diagnosed with CHD.

Grip on health: A complex systems approach to transform health care

This article addresses the urgent need for a transition in health care to deal with the increasing prevalence of chronic diseases and associated rapid rise of health care costs. Chronic diseases evolve and are predominantly related to lifestyle and environment. A shift is needed from a reductionist repair mode of thinking, toward a more integrated biopsychosocial way of thinking about health. The aim of this article is to discuss the opportunities that complexity science offer for transforming health care toward optimal treatment and prevention of chronic lifestyle diseases. Health and health care is discussed from a complexity science perspective. The benefits of concepts developed in the field of complexity science for stimulating transitions in health care are explored. Complexity science supports the elucidation of the essence of health processes. It provides a unique perspective on health with a focus on the relationships within networks of dynamically interacting factors and the emergence of health out of the organization of those relationships. Novel types of complexity science-based intervention strategies are being developed. The first application in practice is the integrated obesity treatment program currently piloted in the Netherlands, focusing on health awareness and healing relationships. Complexity science offers various theories and methods to capture the path toward unhealthy and healthy states, facilitating the development of a dynamic integrated biopsychosocial perspective on health. This perspective offers unique insights into health processes for patients and citizens. In addition, dynamic models driven by personal data provide simulations of health processes and the ability to detect transitions between health states. Such models are essential for aligning and reconnecting the many institutions and disciplines involved in the health care sector and evolve toward an integrated health care ecosystem.

Healing journey: a qualitative analysis of the healing experiences of Americans suffering from trauma and illness

OBJECTIVES

To elucidate pathways to healing for people having suffered injury to the integrity of their function as a human being.

METHODS

A team of physician-analysts conducted thematic analyses of in-depth interviews of 23 patients who experienced healing, as identified by six primary care physicians purposefully selected as exemplary healers.

RESULTS

People in the sample experienced healing journeys that spanned a spectrum from overcoming unspeakable trauma and then becoming healers themselves to everyday heroes functioning well despite ongoing serious health challenges.The degree and quality of suffering experienced by each individual is framed by contextual factors that include personal characteristics, timing of their initial or ongoing wounding in the developmental life cycle and prior and current relationships.In the healing journey, bridges from suffering are developed to healing resources/skills and connections to helpers outside themselves. These bridges often evolve in fits and starts and involve persistence and developing a sense of safety and trust.From the iteration between suffering and developing resources and connections, a new state emerges that involves hope, self-acceptance and helping others. Over time, this leads to healing that includes a sense of integrity and flourishing in the pursuit of meaningful goals and purpose.

CONCLUSION

Moving from being wounded, through suffering to healing, is possible. It is facilitated by developing safe, trusting relationships and by positive reframing that moves through the weight of responsibility to the ability to respond.

The Chief Primary Care Medical Officer: Restoring Continuity

The year 2016 marked the 20th anniversary of the hospitalist profession, with more than 50,000 physicians identifying as hospitalists. The Achilles heel of hospitalist medicine, however, is discontinuity. Despite many current payment and delivery systems rewarding this discontinuity and severing long-term relationships between patient and primary care teams at the hospital door, primary care does not stop being important when a person is admitted to the hospital. The notion of a broken primary care continuum is not an academic construct, it causes real harm to patients. As a step toward fixing the discontinuity in our health care systems, we propose that every hospital needs a Chief Primary Care Medical Officer (CPCMO), an expert in practice across the spectrum of care. The CPCMO can lead hospital efforts to create systems that ensure primary care's continuum is complete, while strengthening physician collaboration across specialties, and moving toward achieving the Quadruple Aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers. For hospitals operating on value-based payment structures, anticipated improvement in measurable outcomes such as decreased length of stay, decreased readmission rates, improved transitions of care, improved patient satisfaction, improved access to primary care, and improved patient health, will enhance the rate of return on the hospital's investment. The speciality of family medicine should reevaluate our purpose, and reembrace our mission as personal physicians by championing the creation of Chief Primary Care Medical Officers.

Consequences of the presence and absence of empathy during consultations in primary care: A focus group study with patients

OBJECTIVE

There is general consensus that explicit expression of empathy in patient-GP communication is highly valued. Yet, little is known so far about patients' personal experiences with and expectations of empathy. Insight into these experiences and expectations can help to achieve more person-centeredness in GP practice care.

METHODS

Participants were recruited by a press report in local newspapers.

INCLUSION CRITERIA

adults, a visit to the GP in the previous year. Exclusion criterion: a formal complaint procedure. Five focus groups were conducted. The discussions were analyzed using constant comparative analysis.

RESULTS

In total 28 participants took part in the focus group interviews. Three themes were identified: (1) Personalized care and enablement when empathy is present; (2) Frustrations when empathy is absent; (3) Potential pitfalls of empathy. Participants indicated that empathy helps build a more personal relationship and makes them feel welcome and at ease. Furthermore, empathy makes them feel supported and enabled. A lack of empathy can result in avoiding a visit to the GP.

CONCLUSION

Empathy is perceived as an important attribute of patient-GP communication. Its presence results in feelings of satisfaction, relief and trust. Furthermore, it supports patients, resulting in new coping strategies. A lack of empathy causes feelings of frustration and disappointment and can lead to patients avoiding visiting their GP.

PRACTICE IMPLICATIONS

More explicit attention should be given to empathy during medical education in general and during vocational GP-training.

'Multimorbidity' as the manifestation of network disturbances

We argue that 'multimorbidity' is the manifestation of interconnected physiological network processes within an individual in his or her socio-cultural environment. Networks include genomic, metabolomic, proteomic, neuroendocrine, immune and mitochondrial bioenergetic elements, as well as social, environmental and health care networks. Stress systems and other physiological mechanisms create feedback loops that integrate and regulate internal networks within the individual. Minor (e.g. daily hassles) and major (e.g. trauma) stressful life experiences perturb internal and social networks resulting in physiological instability with changes ranging from improved resilience to unhealthy adaptation and 'clinical disease'. Understanding 'multimorbidity' as a complex adaptive systems response to biobehavioural and socio-environmental networks is essential. Thus, designing integrative care delivery approaches that more adequately address the underlying disease processes as the manifestation of a state of physiological dysregulation is essential. This framework can shape care delivery approaches to meet the individual's care needs in the context of his or her underlying illness experience. It recognizes 'multimorbidity' and its symptoms as the end product of complex physiological processes, namely, stress activation and mitochondrial energetics, and suggests new opportunities for treatment and prevention. The future of 'multimorbidity' management might become much more discerning by combining the balancing of physiological dysregulation with targeted personalized biotechnology interventions such as small molecule therapeutics targeting specific cellular components of the stress response, with community-embedded interventions that involve addressing psycho-socio-cultural impediments that would aim to strengthen personal/social resilience and enhance social capital.

Preventive health measures in inflammatory bowel disease

We aim to review the literature and provide guidance on preventive health measures in inflammatory bowel disease (IBD). Structured searches were performed in PubMed, MEDLINE, EMBASE, Web of Science and Cochrane Library from January 1976 to June 2016 using the following keywords: (inflammatory bowel disease OR Crohn’s disease OR ulcerative colitis) AND (health maintenance OR preventive health OR health promotion). Abstracts of the articles selected from each of these multiple searches were reviewed, and those meeting the inclusion criteria (that is, providing data regarding preventive health or health maintenance in IBD patients) were recorded. Reference lists from the selected articles were manually reviewed to identify further relevant studies. Patients with IBD are at increased risk of developing adverse events related to the disease course, therapeutic interventions, or non-adherence to medication. Recent studies have suggested that IBD patients do not receive preventive services with the same thoroughness as patients with other chronic diseases. Preventive health measures can avert morbidity and improve the quality of life of patients with IBD. Gastroenterologists and primary care physicians (PCPs) should have an up to date working knowledge of preventive health measures for IBD patients. A holistic approach and better communication between gastroenterologists and PCPs with explicit clarification of roles will prevent duplication of services and streamline care.

The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations

In the movement to improve the health of patients with multiple chronic conditions and vulnerabilities, while reducing the need for hospitalizations, care management programs have garnered wide attention and support. The qualitative data presented in this paper sheds new light on key components of successful chronic care management programs. By going beyond a task- and temporal-based framework, this analysis identifies and defines the importance of "authentic healing relationships" in driving individual and systemic change. Drawing on the voices of 30 former clients of the Camden Coalition of Healthcare Providers, the investigators use qualitative methods to identify and elaborate the core elements of the authentic healing relationship-security, genuineness, and continuity-a relationship that is linked to patient motivation and active health management. Although not readily found in the traditional health care delivery system, these authentic healing relationships present significant implications for addressing the persistent health-related needs of patients with frequent hospitalizations. (Population Health Management 2016;19:248-256).

A Framework to Inform Strategies to Improve the HIV Care Continuum in Low- and Middle-Income Countries

Reasons for attrition along the HIV care continuum are well described. However, improving patient engagement in care has been a challenge. New approaches to understanding and responding to reasons for attrition are required. Here, with a focus on low- and middle-income countries, we propose a framework that brings together an explanatory model with social ecological levels. Individual action may be based on a conscious or unconscious balance between perceived value and perceived costs. When the balance between value and cost favors value, engagement in care can be expected. Value and cost may be mediated by levels of the individual, interpersonal interactions, the clinic experience, community, society, and policy. We encourage the use of a framework for developing strategies to improve the care continuum and believe that this framework provides a rigorous approach.

Patient Perceptions of Expression of Empathy From Chinese Medicine Clinicians in a Chinese Population: A Cross-Sectional Study

This study aims to examine the level of empathy perceived by patients receiving care from herbalists, acupuncturists and massage therapists and to investigate the factors that influence levels of perceived empathy.Participants who were 18 years or above; able to provide written informed consent; and able to read and write in Chinese without assistance were included. A total of 514 participants sampled from charity and semipublic Chinese medicine (CM) clinics in Hong Kong were recruited to assess levels of empathy perceived during various length of consultations (1-20 minutes) by the Chinese Consultation and Relational Empathy Measure (Chinese CARE). Multiple linear regressions were conducted to evaluate the associations between perceived levels of empathy and the type of CM practitioner consulted and participants' demographic and health characteristics.The average Chinese CARE total score for participants consulting CM practitioners was 34.3 of a maximum of 50. After adjusting for participants' health and demographic characteristics, acupuncturists received the highest ratings (P < 0.001), whereas massage therapists (P < 0.001) scored the lowest of the 3 modalities. Participants receiving social benefits (P = 0.013), those with longer waiting times (P = 0.002), and those with shorter consultation durations (P = 0.020) scored significantly lower on the Chinese CARE.The level of empathy perceived by participants using CM was similar to results found for those in conventional care, in contrast to findings in other geographical settings, where a high level of perceived empathy was a major motivator for participants to choose complementary medicine.

Breast and prostate cancer survivors' experiences of patient-centered cancer follow-up care from primary care physicians and oncologists

PURPOSE

Patient-physician relationships impact health care seeking and preventive screening behaviors among patients. At the end of active treatment some cancer survivors report feeling disconnected from their care team. This study explores cancer survivors' experiences of patient-centered cancer follow-up care provided by primary care physicians (PCP) and oncologists (ONC).

METHODS

Three hundred five early stage, breast and prostate cancer survivors at least 2 years post treatment were surveyed from four community hospital oncology programs in New Jersey. Participants reported receipt of patient-centered care measured by care coordination, comprehensiveness of care, and personal relationship with PCPs and ONCs.

RESULTS

PCPs received higher ratings for coordination of care and comprehensive care than ONCs from all survivors (P < 0.01). However, prostate and breast cancer survivors rated strengths of their personal bonds with the physicians differently. While prostate cancer survivors rated PCPs significantly higher for all items (P < 0.028), breast cancer survivors rated ONCs significantly higher on four out of seven items including having been through a lot together, understanding what is important regarding health, knowing their medical history and taking their beliefs and wishes into account (P < 0.036).

CONCLUSIONS

Prostate and breast cancer survivors report different experiences with their PCPs and oncologists around the comprehensiveness and coordination of their cancer follow-up care in addition to the strength of their relationships with their physicians.

IMPLICATIONS FOR CANCER SURVIVORS

There are important differences in the experience of patient-centered care among cancer survivors that should be considered when planning care models and interventions for these different populations.

Achieving Value in Primary Care: The Primary Care Value Model

The patient-centered medical home (PCMH) model provides a compelling vision for primary care transformation, but studies of its impact have used insufficiently patient-centered metrics with inconsistent results. We propose a framework for defining patient-centered value and a new model for value-based primary care transformation: the primary care value model (PCVM). We advocate for use of patient-centered value when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research and development to better define primary care value-creating activities and their implementation; and for use of the model to support primary care organizations in transformation.

Auricular acupuncture to relieve health care workers' stress and anxiety: impact on caring

BACKGROUND

The caring relationship between individual health care providers and patients is a critical component of healing. However, caring can result in physical, emotional, psychological, and spiritual symptoms in providers that can interfere with their capacity to enter into these relationships.

PURPOSE

The aim of this study was to evaluate whether auricular acupuncture is an effective tool for reducing health care provider stress and anxiety and, second, to determine if auricular acupuncture impacts provider capacity for developing caring relationships with patients.

METHODS

Preintervention and postintervention surveys were evaluated to see if auricular acupuncture was associated with changes in State-Trait Anxiety Inventory (STAI), Professional Quality of Life, and Caring Ability Inventory scores.

RESULTS

Compared with baseline, participants had a significant reduction in state anxiety (STAI), trait anxiety (STAI), burnout, and secondary traumatic stress scores (Professional Quality of Life). Significant increases were noted in courage and patience, 2 dimensions of the Caring Ability Inventory.

CONCLUSIONS

Auricular acupuncture is an effective intervention for the relief of stress/anxiety in providers and supports heightened capacity for caring.