A Multifaceted Educational Intervention in the Doctor-Patient Relationship for Medical Students to Incorporate Patient Agendas in Simulated Encounters

From the beginning of their clinical training, medical students demonstrate difficulties when incorporating patient perspectives. This study aimed to assess if students, after an instructional programme, increased their sensitivity towards patients' needs and carried out bidirectional conversations. An observational study involving 109 medical students prior to their clerkships was designed. They attended a five-step training programme designed to encourage the use of communication skills (CSs) to obtain patients' perspectives. The course developed experiential and reflective educational strategies. The students improved their use of CSs throughout three sessions, and the overall score for these patient consultations went up in the opinions of both the external observer (EO) (5; 6.6; 7.5) and the simulated patients SPs (5.3; 6.6; 7.8). Most of the students (83.9%) considered that the CSs addressed were useful for clinical practice, particularly the interviews and the feedback received by the SP and the lecturer. The programme seems to help the students use CSs that facilitate a more bidirectional conversation in a simulated learning environment. It is feasible to integrate these skills into a broader training programme. More research is needed to assess whether the results are applicable to students in real settings and whether they influence additional outcomes.

Medical resilience and morality: a survey study on the opinions and actions of exemplary family physicians

Background

Studies conducted to understand how family doctors develop resilience and deal with the challenges posed by work-related stress, usually have focused on identifying the elements that generate resilience from psychological perspectives and their impact on coping strategies. Few have explored the role that personal qualities and values that traditionally motivate family physicians can play as drivers of well-being and resilience.

Objectives

To explore attributes that exemplary family physicians (EFP) consider important for their work and the elements that, for them, are source of gratification and resources in the face of the adversities they encounter in their practice.

Methods

This is an exploratory study carried out by online survey. Eighty six doctors regarded as exemplary by their colleagues answered 7 close and 4 open-ended questions that explored their job satisfaction, the elements of their work that reward them, the difficulties and problems they usually encounter, the resources they use to cope with those problems, and the personal qualities they consider central to their work. Four researchers conducted a thematic (deductive and inductive) analysis of the free text responses received. Based on the results obtained, and through an iterative discussion process, the researchers proposed an integrated set of qualities at the core of their professionalism.

Results

88.4% (76) of the doctors said they were satisfied with their work. However, they face problems (202 comments), including demanding patients, insensitive managers with unshared interests/care goals, excessive paperwork, work overload, or time pressures. Sources of gratification point to personal identity; clinical, relational, and collaborative efficiency; a holistic and comprehensive practice (centred on individuals); and a continuous search for excellence (149) and the root of their resources (135). These elements, in turn, corresponded to the attributes considered essential for the practice of family medicine (131).

Conclusions

For EFPs, certain professional values give meaning to their clinical practice and are a source of well-being and resources. This central focus on professional values and qualities can help for better understand the burnout nature and expand the type of action that promotes resilience. Further studies using a less structured qualitative research will be needed to confirm/expand these results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01555-0.

Multi-source evaluation of an educational program aimed at medical students for interviewing/taking the clinical history using standardized patients

Introduction: Simulations with standardized patients (SP) have long been used for teaching/assessing communication skills. The present study describes and evaluates an experiential training methodology aimed at medical students and based on interviews with standardized simulated patients. The training was focused on developing basic communication skills and taking medical histories. Methods: Longitudinal observational study of a cohort of third-year medical students. Three interviews with SP were carried out and videotaped. These interviews were assessed by the students, the SPs and the professors of the relevant subject areas. Results: 83 students conducted the interviews. The self-evaluations performed by the students showed an improvement between the first and third interviews, as demonstrated by the increase of 6.7% (CI 95%=3.6-10.0%) (p<0.001) in the percentage of detected items. The SPs stated an improvement of 8.5% (CI 95%=2.9-14.1) (p=0.003) from the first to the third interview regarding the percentage of students that showed a level of interest in, and ease with, the patients' concerns. Finally, the teachers found a mean percentage of items identified in the third written clinical history of 61.4% (CI 95%=59.1-63.7) of the total available. Conclusions: This educational program, carried out with standardized simulated patients, showed positive signs of improvement from the first to the third interview, in both the student self-evaluations and the level of interest and ease perceived by the SPs. Additionally, the mean level of information recorded in the written medical histories was considered to be acceptable.

Effectiveness of a communication skills training program for medical students to identify patients communicative clues

OBJECTIVE

This study explores whether an Experiential Training Programme (ETP) in communication skills (CS) improves students' ability to identify patients clues compared to those who follow a non-experiential training throughout their medical studies.

METHOD

Intervention Group (IG): 85 4th-year medical students who received the ETP and Control Group (CG): 67 recently graduated students who did not receive it. Their immediate (written) response was requested to three expressions offered by patients containing communicative clues. The answers were grouped into 2 categories: Clue recognised and response patient-centred and the opposite. Three researchers analysed the answers.

RESULTS

Responses 366 (65 from the CG and 77 from the IG): 280 did not recognise clues: 131 (62%) in IG and 149 (96%) in CG and 86 recognised them: 80 (37.9%) in IG and 6 (3.9%) in CG (p = 0.000). Some clues were more elusive than others (p = 0,003).

CONCLUSIONS

The students who received the ETP in CS showed greater ability to explore patients perspective taking advantage of different types of communicative clues than those who did not receive it in a non-relational context.

PRACTICE IMPLICATIONS

Further research is needed to assess whether this ability is maintained in simulated or real clinical situations.

Training health providers to address unhealthy alcohol use in primary care: a cross-sectional, multicenter study

BACKGROUND

Health professionals' training is a key element to address unhealthy alcohol use in Primary Care (PC). Education about alcohol use can be effective in improving PC provider's knowledge and skills addressing alcohol-related problems. The aim of the study was to evaluate the training of health professionals to address unhealthy alcohol use in PC.

METHODS

An observational, descriptive, cross-sectional, multicenter study was performed.

LOCATION

PC centres of the Spanish National Health System (SNHS).

PARTICIPANTS

Family physicians, residents and nurses completed an online questionnaire that inquired about their training (none, basic, medium or advanced), knowledge and preventive practices aimed at reducing unhealthy alcohol use. The study population was recruited via random sampling, stratified by the regions of the SNHS's PC centre, and by email invitation to members of two Spanish scientific societies of Family Medicine.

RESULTS

A total of 1760 professionals participated in the study. Sixty-seven percent (95% CI: 67.5-71.8) reported not having received specific training to address unhealthy alcohol use, 30% (95% CI: 27.4-31.7) reported having received basic training, and 3% (95% CI: 2.3-4.0) medium/advanced training. The training received was greater in younger providers (p < 0.001) who participated in the PAPPS (Preventive Activities and Health Promotion Programme) (p < 0.001). Higher percentages of providers with intermediate or advanced training reported performing screening for unhealthy alcohol use (p < 0.001), clinical assessment of alcohol consumption (p < 0.001), counselling of patients to reduce their alcohol intake (p < 0.001) or to abstain, in the cases of pregnant women and drivers (p < 0.001).

CONCLUSION

Our study reveals a low level of training among Spanish PC providers to address unhealthy alcohol use. A higher percentage of screening, clinical assessment and counselling interventions aimed at reducing unhealthy alcohol use was reported by health professionals with an intermediate or advanced level of training.

Barriers to teaching communication skills in Spanish medical schools: a qualitative study with academic leaders

BACKGROUND

In recent years, Spanish medical schools (MSs) have incorporated training in communication skills (CS), but how this training is being carried out has not yet been evaluated.

OBJECTIVE

To identify the barriers to the introduction and development of CS teaching in Spanish MSs.

METHODS

In a previous study, 34 MSs (83% of all MSs in Spain) were invited to participate in a study that explored the factual aspects of teaching CS in these schools. The person responsible for teaching CS at each school was contacted again for this study and asked to respond to a single open-ended question. Two researchers independently conducted a thematic analysis of the responses.

RESULTS

We received responses from 30 MSs (85.7% of those contacted and 73% of all MSs in Spain). Five main thematic areas were identified, each with different sub-areas: negative attitudes of teachers and academic leaders; organisation, structure and presence of CS training in the curriculum; negative attitudes of students; a lack of trained teachers; and problems linked to teaching methods and necessary educational logistics.

CONCLUSIONS

The identified barriers and problems indicate that there are areas for improvement in teaching CS in most Spanish MSs. There seems to be a vicious circle based on the dynamic relationship and interdependence of all these problems that should be faced with different strategies and that requires a significant cultural shift as well as decisive institutional support at the local and national levels. The incorporation of CS training into MS curricula represents a major challenge that must be addressed for students to learn CS more effectively and avoid negative attitudes towards learning CS.

Impact of a primary care training program on the prevention and management of unhealthy alcohol use: A quasi-experimental study

OBJECTIVE

To assess the impact of a training program targeted to Primary Care (PC) professionalson the acquisition of communication skills, attitudes, and knowledge about the prevention and management of unhealthy alcohol use.

METHODS

A quasi-experimental, pre- and post-intervention study was performed in PC centers of Cordoba (Spain). Family doctors, residents and nurses participated in the study. The intervention was based on a motivational interviewing training program, which consisted in a workshop on learning skills, attitudes and knowledge about the alcohol management. PC providers were videotaped with a standardized patient in order to check the clinical and communication competencies acquired. A descriptive, bivariate and multivariate analysis was carried out (p < 0.05).

RESULTS

PC providers' communication skills and attitudes showed significant improvements in the variables studied (p < 0.001), as well as in the clinical interview evaluation parameters.

CONCLUSION

The present study reveals the impact of a training program targeted to PC professionals on communication skills, attitudes, and knowledge about the prevention and management of patients with unhealthy alcohol use.

PRACTICE IMPLICATIONS

Training activities targeted to PC providers represent a valuable strategy to improve communication skills, attitudes and knowledge of these professionals in their clinical practice.

[Promoting Health Promotion: Medical students perceptions about an educational program on behavioral change in primary care]

Objetivo

Valorar si un programa formativo ofrecido por médicos de familia en el currículum oficial de medicina sobre principios y estrategias para ayudar a los pacientes a cambiar conductas de riesgo (APCCR) produce cambios en sus percepciones, opiniones y actitudes con relación a este tipo de intervenciones.

Diseño

Estudio cuasiexperimental antes-después.

Emplazamiento

Una facultad de medicina.

Participantes

Todos los alumnos de 4.^o curso de medicina (n = 110).

Intervenciones

Formación experiencial sobre estrategias comunicativas para APCCR.

Mediciones

Opiniones y percepciones evaluadas antes y después del curso mediante cuestionario ad hoc.

Resultados

Tras el curso, los estudiantes (n = 103) cambiaron sus ideas sobre la motivación como factor «interno» (15, 13%) a «interno-externo» (71, 61%) (p = 0,003), reforzando sus opiniones sobre la capacidad del médico para APCCR (alta: 72, 62%; baja: 10, 12%; p = 0,008). Los alumnos se consideraron más capaces de respetar la autonomía de los pacientes cuando estos toman decisiones o siguen conductas consideradas perjudiciales (fácil: 58, 50%; difícil: 28, 24%; p = 0,001) e incrementaron su percepción sobre su capacidad para afrontar este tipo de entrevistas (83, 72% vs. 1, 1%; p < 0,001).

Conclusiones

Esta formación parece contribuir a crear en estudiantes percepciones y actitudes positivas relacionadas con aspectos claves a la hora de afrontar una entrevista para APCCR, lo cual supone un aspecto preliminar clave para implementar este tipo de estrategias.

Medical students' attitudes toward communication skills learning: comparison between two groups with and without training

OBJECTIVE

The value students give to communication skills (CS), acquiring them, or other related matters can influence the effectiveness of educational programs. In this study, we explored first and fourth year medical students' attitudes toward CS and their learning, assessing the possible influence they have on programmed experiential training in a medical school.

SUBJECTS AND METHODS

Two hundred and twenty first and fourth year medical students completed the Communication Skills Attitudes Scale, analyzing the positive and negative, and affective and cognitive attitude subscales toward learning.

RESULTS

Fourth year students trained in CS showed less positive attitudes toward CS than first year untrained students. Cognitive and affective attitudes displayed different patterns in both groups; while affective attitudes decreased in fourth year students, cognitive attitudes did not vary significantly between groups. Accumulated learning experiences seem to be more influential than sex.

CONCLUSION

The findings suggest that students' attitudes toward CS could decline as a result of CS training. Nevertheless, students' attitudes at the cognitive and fundamental level stay fairly unchanged. Learning CS with experiential methods seems to be challenging for students at a personal level; so, educators should personalize these methods as much as possible. However, further studies using longitudinal research designs should be performed for exploring students' attitudes changes over time.

Effectiveness of motivational interviewing to improve therapeutic adherence in patients over 65 years old with chronic diseases: A cluster randomized clinical trial in primary care

OBJECTIVE

To evaluate the effectiveness of motivational interviewing (MI) in improving medication adherence in older patients being treated by polypharmacy.

METHODS

Cluster randomized clinical trial in 16 primary care centers with 27 health care providers and 154 patients. Thirty-two health care providers were assigned to an experimental (EG) or control group (CG).

INTERVENTIONS

MI training program and review of patient treatments. Providers in the EG carried out MI, whereas those in the CG used an "advice approach". Three follow-up visits were completed, at 15 days and at 3 and 6 months. Medication adherence in both groups was compared (p<0.05).

RESULTS

Patients recruited: 70/84 (EG/CG). Mean age: 76 years; female: 68.8%. The proportion of subjects changing to adherence was 7.6% higher in the EG (p<0.001). Therapeutic adherence was higher for patients in the EG (OR=2.84), women (OR=0.24) and those with high educational levels (OR=3.93).

CONCLUSION

A face-to-face motivational approach in primary care helps elderly patients with chronic diseases who are being treated by polypharmacy to achieve an improved level of treatment adherence than traditional strategies of providing information and advice.

PRACTICE IMPLICATIONS

MI is a patient-centered approach that can be used to improve medication adherence in primary care.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov (NCT01291966).

[Theory of action on patient relationships. A different way of representing and understanding the behaviour of the family doctor in the clinic]

Objetivo

Identificar la «teoría en la acción» según el concepto de Argyris y Schon de un grupo de médicos de familia y comprobar si esta «teoría» aparece como una representación válida de su comportamiento y congruente con otros estudios.

Diseño

Descriptivo transversal.

Emplazamiento

Atención Primaria.

Participantes

Diez médicos de familia con una experiencia mínima de 10 años de otros tantos centros de salud de una ciudad y su comarca.

Método

Selección por muestreo intencional en función de la antigüedad, sexo, características del centro de referencia y estilo de práctica. Grabación y trascripción de audiograbaciones y observación de consultas. Formulación y agrupación inductiva de las proposiciones a partir de la identificación de las conductas en la consulta y su contexto siguiendo las propuestas de Argyris y Schon. Comparación de las proposiciones de los participante entre sí y con la literatura.

Resultados y discusión

Las 84 proposiciones de los entrevistados se agrupan en 9 categorías temáticas que en orden del peso de su presencia son: confianza/interés, medicalización, dimensión subjetiva, dirección, negociación, distancia e información, calidad clínica, comunicación clínica. Las proposiciones de los dos primeros temas son básicamente coincidentes mientras que en el resto aparecen diferencias en la teoría en la acción de distintos médicos. Las proposiciones pueden ser integradas con los resultados de otros estudios.

Conclusión

Es factible formular la teoría en la acción de los MF que aparece como una representación global y coherente de su comportamiento en la consulta.

[Efficacy of motivational interviewing for reducing medication errors in chronic patients over 65 years with polypharmacy: Results of a cluster randomized trial]

BACKGROUND AND OBJECTIVE

To evaluate the effectiveness of an intervention based on motivational interviewing to reduce medication errors in chronic patients over 65 with polypharmacy.

PATIENTS AND METHOD

Cluster randomized trial that included doctors and nurses of 16 Primary Care centers and chronic patients with polypharmacy over 65 years. The professionals were assigned to the experimental or the control group using stratified randomization. Interventions consisted of training of professionals and revision of patient treatments, application of motivational interviewing in the experimental group and also the usual approach in the control group. The primary endpoint (medication error) was analyzed at individual level, and was estimated with the absolute risk reduction (ARR), relative risk reduction (RRR), number of subjects to treat (NNT) and by multiple logistic regression analysis.

RESULTS

Thirty-two professionals were randomized (19 doctors and 13 nurses), 27 of them recruited 154 patients consecutively (13 professionals in the experimental group recruited 70 patients and 14 professionals recruited 84 patients in the control group) and completed 6 months of follow-up. The mean age of patients was 76 years (68.8% women). A decrease in the average of medication errors was observed along the period. The reduction was greater in the experimental than in the control group (F=5.109, P=.035). RRA 29% (95% confidence interval [95% CI] 15.0-43.0%), RRR 0.59 (95% CI:0.31-0.76), and NNT 3.5 (95% CI 2.3-6.8).

CONCLUSION

Motivational interviewing is more efficient than the usual approach to reduce medication errors in patients over 65 with polypharmacy.

Patient participation in the discussions of options in Spanish primary care consultations

OBJECTIVES

To determine patients' participation in the discussion of options in primary care consultations. Identify the patients' wish to participate and their perceptions of their participation and explore the potential factors that may influence these.

DESIGN

Cross-sectional study. Setting. Ninety-seven general practices. Participants. six hundred and fifty-eight patients who went to their doctors for unselected reasons. Measurements. All the encounters were videoed, patient participation in decision making (DM) was assessed with two tools. After the consultation, GPs completed a questionnaire about biomedical and relational information. Patients' preferences and perception of participation was explored with different type of questions.

RESULTS

Encounters successfully videoed: 638. Of these, only 90 interviews clearly showed patient participation. In 161 other interviews, patient participation was considered possible. Questionnaires collected: 645. In 60% of the situations (390 encounters), patients wished they could have stated their views about the proposed option(s), but they perceived this did not happen. The degree of participation at the consultation did not relate significantly with the physician's ideas about the type of problem, evolution and treatment. Neither did any of the considered variables influence either the patients' wish to participate in the discussion of the suggested option or their perception of this.

CONCLUSIONS

GPs ask patients for their opinion and promote discussion about the suggested plan in few encounters. Patients perceive this, including many patients that previously had declared not to be interested in being involved in decisions. These results revealed an important mismatch between what patients wish and what they perceive.

[Preferences, satisfaction level of patient participation in making decisions in health centre nursing clinics]

AIMS

To assess patient preferences their satisfaction level and their participation in decision making with nurses.

METHODS

Cross-sectional and mixed quantitative-qualitative study carried out in people attending the nursing services of 9 Health Centres in Andalusia. Patients were interviewed immediately after receiving nursing treatment using two different questionnaires for assessing their opinions, satisfaction and perception of involvement in the decisional process. A descriptive analysis using the χ(2) test (P<.05) was performed to assess the differences among close-ended and open-ended questions. Qualitative analysis: Open-ended questions were grouped into categories by a process involving three researchers independently.

RESULTS

A total of 235 patients took part, of whom 59% (138) preferred a collaborative role with the nurse when making decisions. In the closed questions, 96.2% (228) of the surveyed patients declared to be satisfied or very satisfied with the decision making process; nevertheless 17.4% (41) made specific suggestions for improving this process. For them the main improvement areas were related to: general communication skills or a more specific one such as: strategies for helping them make decisions, reaching common ground or giving advice.

CONCLUSIONS

Nurses should be aware that most patients wish to be involved in decision making and in clinical practice this participation can be improved by obtaining specific communicational skills. Surveys that include open-ended questions are more useful to assess the quality of care.

[Spanish Family Medicine Trainee Portfolio-Book: The extent of its implementation and trainee and trainer opinions after two years experience]

AIMS

To find out to what extent The "Reflective Practice Guide" (RPG) (a semi-structured Portfolio guide) has been implemented in a Spanish Family Medicine Vocational Training Region (Unidad Docente Provincial) and the opinions of trainees and trainers after using it in actual conditions.

DESIGN

Cross-sectional study

SETTING

A Provincial Family Medicine Teaching Unit (a Spanish Vocational Training Region).

PARTICIPANTS

43 trainers and 70 residents (trainees).

METHODS

The participants carried out a formative assessment for 12 months on the competency areas described in the RPG. The information was collected by means of specific card notes. Trainers and Trainees filled in an ad hoc survey.

RESULTS

The trainees carried out 295 (80%) tasks and reflections out of those recommended in the GPR. First and third year trainees completed 81/108 (75%) and 65/108 (60%) of the tasks, respectively. Trainees and trainers considered that the new method is useful for reflecting on clinical practice, for knowing their own competencies better and for strengthening the trainer-trainee relationship.

CONCLUSIONS

The GPR is a formative tool that trainees carried out with their trainers even to a greater extent than that recommended by the GPR. Both groups perceive this tool as useful for effectively reflecting the trainees practice and for strengthening their relationship.

[Evaluation of the patient centered clinical relationship: analysis of psychometric properties using the CICAA scale]

OBJECTIVE

To analyse the psychometric properties by a scale for evaluating patient centered clinical communication.

DESIGN

Validation and observational study of a measurement tool.

SETTING

Health centres and hospital outpatient clinics.

PARTICIPANTS

Three researchers independently evaluated video recorded interviews of different sub-samples: health professionals (family medicine medical residents, family doctors, specialist care physicians, and primary care nurses), actual patients who consulted for chronic or acute health problems, and standardised patients.

PRIMARY MEASUREMENTS

Dimensionality (exploratory factor analysis), internal consistency (alpha de Cronbach), intra- and inter-observer agreement (Kappa index, intraclass correlation coefficient [ICC], generalisability), sensitivity to change (Student t test) and convergent validity with the GATHA questionnaire (Pearson correlation coefficient).

RESULTS

Six factors have been identified that explain 66.0% of the variance. The overall internal consistency of the test was alpha=0.94. The overall intra-observer agreement, measured with the ICC, varied between 0.94 and 0.97, whilst the inter-observer was between 0.82-0.90. The number of completed questionnaires required for the evaluator to obtain adequate reproducibility (generalisability) varied between 6 and 12. Statistical significance was not obtained when testing the sensitivity to change. The CICAA scale and the GATHA questionnaire had a correlation of 0.67.

CONCLUSIONS

The CICAA scale is a generic patient centered clinical communication evaluation tool that may be used in different clinical contexts and situations, since it has shown to be reliable, valid and efficient.

[Pilot study for the inclusion of the portfolio of the family medicine specialist book in training]

BACKGROUND

The Spanish Family Medicine National Commission is proposing a new portfolio-type Specialist Training Book (STB).

OBJECTIVE

To pilot its contents, structure, and implementation strategies.

DESIGN

Cross-sectional, descriptive study.

SETTING

A Provincial Family Medicine Teaching Unit.

PARTICIPANTS

Twenty-eight tutors and 36 residents.

METHODS

For 9 months the participants conducted a training assessment on diverse areas of competence by means of tasks at work. Tutors recorded information on the quality of reflection achieved by residents and the tasks they performed by means of the card model proposed in the STB. Residents filled in an ad hoc survey. A univariate analysis of quantitative data was conducted.

RESULTS

Thirty-three surveys were received from residents; 21 tutors handed in 67 evaluation reports (average: 3 per tutor). They dealt with all the areas of competence, particularly those of communication, teaching, and ethics. Tasks most used were clinical sessions, critical incidents and video-recording. Both tutors and residents thought that the new method could be useful for reflecting on clinical practice, understanding their own areas of competence better and for strengthening the tutor-trainee relationship, especially if some suggestions to improve its practical use and reduce time and effort involved were taken into account.

CONCLUSIONS

The new STB in its current version or with some modifications is a useful tool for residents' training assessment and is probably accepted well in our ambit.

[Stated theory of family doctors on their relationships with patients]

OBJECTIVE

To identify and analyse the "theory" expressed by family doctors on the essential features of an effective and functional doctor-patient relationship and on how to achieve one ("stated theory" of Argyris and Schon).

DESIGN

Qualitative, based on discourse analysis.

SETTING

Primary care.

METHOD

Interviews recorded with 10 family doctors selected by intentional sampling that were then transcribed. The propositions in the discourses were identified and conceptual maps were constructed. An inductive analysis classified the questions and positions that emerged and identified similarities and differences between subjects.

RESULTS

Confidence and absence of conflict were the main desirable features of the doctor-patient relationship. Patients with a "demanding" attitude and their dishonesty were the most quoted obstacles. Doctors accepted negotiation, but held a very limited view of patient participation. Differences were appreciated on distance, the biomedical versus psychosocial focus and health education. Doctors' communication skills and qualities were little cited. Technical terminology in this area appeared little in the discourses.

CONCLUSIONS

Discourses highlighted "health consumerism" and revealed disagreements on distance in the relationship and the psycho-social approach. These points, which should be prioritised in training, along with education, can serve to define family doctors distinct professional orientations. Training methodology must bear in mind that experience dominates "stated theory" in this area.

[Problems and solutions in health care for chronic diseases. A qualitative study with patients and doctors]

BACKGROUND

Chronic diseases represent a challenge for health systems and the professionals most involved in chronic care. Despite biomedical advances, the results of care for chronic problems are not as good as they should be.

OBJECTIVE

To find out what doctors and patients think of care for some of the main chronic illnesses; to detect concrete areas of deficit and lack of satisfaction felt by both sides and possible lines of improvement; to raise mutual understanding between patients and doctors.

PARTICIPANTS

Forty-one patients with fibromyalgia or diabetes mellitus, carers for people with Alzheimer's and breast cancer patients. Forty-three family doctors involved in health care delivery to this kind of patient.

METHODS

Four discussion groups. Transcription and syntactical, semantic and pragmatic contents analysis, with both pre-established and emerging categories of consensus.

RESULTS

Patients thought, with different nuances as a function of the problem put forward, that questions of respectful, human and integrated care, clear and suitable information, and consistent follow-up were important and insufficiently covered by doctors and health services. Doctors thought that many of their efforts in caring for these patients were useless, and thought it important to reconsider their clinical responsibilities and the patient-doctor relationship. Doctors highlighted the limitations in the health care resources available for working with these patients.

CONCLUSIONS

To tackle prevalent chronic problems requires, in the view of doctors and patients, important modifications that are related mainly to the kind of relationship between the two, with new clinical responsibilities and certain organisational care delivery features.

[Falls in the elderly in the community: prevalence, consequences, and associated factors]

OBJECTIVE

To find the prevalence, characteristics, and consequences of falls in the elderly and related factors. DESIGN. Cross-sectional, descriptive study using personal interviews.

SETTING

Three health districts in Cordoba city, Spain.

PARTICIPANTS

A stratified sample of 362 people over 70.

MAIN MEASUREMENTS

The assessment tools were the WHO questionnaire for the study of falls and the EuroQol-5D for the measurement of health-related quality of life. Uni-bivariate and multivariate analyses (P< .05) were run.

RESULTS

The prevalence of falls was 31.78% (95% CI, 26.99%-36.6%); 12.98% of subjects had more than one fall in the previous year; 55.3% of falls happened at home; 71.8% of the falls had physical consequences, with 7.8% fractures; 44.7% of the elderly studied were scared of having a new fall, and 22% limited their mobility after the fall. In 30% of cases there was contact with the health system, and 3.3% needed hospital admission. The factors related to a greater risk of falls were: being older, being a woman, widowed, uneducated, with difficulties in moving both arms, suffering space disorientation, high drug consumption, and having worse perceived health status.

CONCLUSIONS

Falls in the elderly living in the community are a frequent problem, with important physical, psychological and social consequences.

Effectiveness of a clinical interviewing training program for family practice residents: a randomized controlled trial

BACKGROUND AND OBJECTIVES

This study evaluated the effectiveness of a clinical interviewing training program for third-year family practice trainees and determined which other factors influence residents' training in clinical communication.

METHODS

This was a randomized, multicenter, educational trial involving 193 third-year family practice residents from eight centers in Spain. Centers were randomly assigned to two groups, one of which would undertake a communication skills training program and one of which would not. The program was resident centered, based on residents' practice experience, and provided structured feedback. The main outcome measures were residents' consultation behavior with six standardized patient encounters (three before and three after the training) as measured with the GATHA-RES rating scale by an observer blinded to group assignment of the residents.

RESULTS

The intervention group trainees displayed marginally better communication skills at the start of the study than those in the control group. At the end of the study, trainees who had received the training program did not show better communication skills than those who had not received the training program. Factors related to the training center environment, having a teacher trained in clinical interviewing, younger age, and a longer interview duration correlated with better communication skills.

CONCLUSIONS

The trial program did not appear to improve the global communication skills of trainees. This study highlights the importance of the trainee's teachers, the residency program environment, and earlier exposure to training in planning future programs to improve residents' communication skills.

Evaluation of a patient-centred approach in generalized musculoskeletal chronic pain/fibromyalgia patients in primary care

The aim of this paper is to assess whether patient-centred consultations are more effective than the usual style of consultations used by general practitioners with patients suffering from benign chronic musculoskeletal pain and fibromyalgia. It also seeks to evaluate the differential characteristics of these two clinical groups of symptoms. The study was designed as a cluster randomised and simple blind trial. Twenty general practitioners took part and 110 patients were recruited. Compared with patients who received the usual treatment from their family physician, those who received a patient-centred approach showed greater improvement after 1 year in terms of psychological distress (anxiety) and number of tender points, as well as showing positive trends in some important outcomes such as pain intensity. Significantly better results were observed in those patients suffering chronic pain than in those with fibromyalgia, particularly as regards associated symptoms, self-rated pain and physical mobility as measured by the Nottingham health profile.

Effectiveness of a learner-centred training programme for primary care physicians in using a patient-centred consultation style

OBJECTIVE

The aim of the present study was to find out if a training programme adapted to family physicians with several years of clinical experience changes their behaviour when they deal with fibromyalgic patients in the sense of introducing the communication skills that define the 'patient-centred' approach.

METHODS

A randomized, and simple blind, educative study was carried out. Twenty full-time family physicians were invited to participate. They were allocated randomly to two groups: an intervention and a control group. A total of 110 patients were recruited from people attending physicians' surgeries for the first time and who complained of generalized pain that finally fulfilled criteria for generalized musculoskeletal chronic pain/fibromyalgia. This was done for an entire year. The intervention group received an 18 hour intensive course. One week after the course, all doctors carried out a video-recorded encounter with a patient who played the part of a typical fibromyalgia clinical case. The interviews were coded by an observer blind to the training status of the participants, using the GATHARES-CP questionnaire. All patients were contacted by telephone during a 1-2-month period by a different interviewer who was 'blinded' to the patient's experimental status. They were asked to respond to three questions that represent the key components of patient-centred style.

RESULTS

The average score on the GATHARES-CP questionnaire was 11.3 +/- 0.9 and 9 +/- 2.3, for doctors from the intervention and control groups, respectively (P < 0.01). For 11 items, scores were higher in the intervention group. The patients' answers to all three questions showed statistically significant differences in a positive direction for the trained doctors.

CONCLUSIONS

The doctors improved the use of strategies and skills for carrying out patient-centred consultations after they had received an interactive course. The doctors' behaviour appeared to have changed as much in a more experimental situation as in the actual consultations. Moreover, the gain was observed immediately after the intervention was completed, and after having run for a variable period of time up to 1 year.