Trajectories of opioid consumption as predictors of patient-reported outcomes among individuals attending multidisciplinary pain treatment clinics

PURPOSE

This study aimed to identify opioid consumption trajectories among persons living with chronic pain (CP) and put them in relation to patient-reported outcomes 6 months after initiating multidisciplinary pain treatment.

METHODS

This study used data from the Quebec Pain Registry (2008-2014) linked to longitudinal Quebec health insurance databases. We included adults diagnosed with CP and covered by the Quebec public prescription drug insurance plan. The daily cumulative opioid doses in the first 6 months after initiating multidisciplinary pain treatment were transformed into morphine milligram equivalents. An individual-centered approach involving principal factor and cluster analyses applied to longitudinal statistical indicators of opioid use was conducted to classify trajectories. Multivariate regression models were applied to evaluate the associations between trajectory group membership and outcomes at 6-month follow-up (pain intensity, pain interference, depression, and physical and mental health-related quality of life).

RESULTS

We identified three trajectories of opioid consumption: "no or very low and stable" opioid consumption (n = 2067, 96.3%), "increasing" opioid consumption (n = 40, 1.9%), and "decreasing" opioid consumption (n = 39, 1.8%). Patients in the "no or very low and stable" trajectory were less likely to be current smokers, experience polypharmacy, use opioids or benzodiazepine preceding their first visit, or experience pain interference at treatment initiation. Patients in the "increasing" opioid consumption group had significantly greater depression scores at 6-month compared to patients in the "no or very low and stable" trajectory group.

CONCLUSION

Opioid consumption trajectories do not seem to be important determinants of most PROs 6 months after initiating multidisciplinary pain treatment.

The Contribution of Insomnia and Obstructive Sleep Apnea on the Transition from Acute to Chronic Painful Temporomandibular Disorders and their Persistence: A Prospective 3-Month Cohort Study

Background

Insomnia, and Excessive Daytime Sleepiness (EDS), a surrogate marker of Obstructive Sleep Apnea (OSA), are common sleep-related conditions among painful temporomandibular disorders (TMD) patients. OSA was found to increase the risk of chronic painful TMD.

Aims

This prospective cohort study aims to determine the contribution of insomnia and EDS on acute to chronic painful TMD transition as well as its persistence when chronic pain is defined by: (i) duration (> 3 months), and (ii) dysfunction (Graded Chronic Pain Scale [GCPS II-IV]).

Methods

From 456 patients recruited between 2015 to 2021, through four locations in Canada, 378 completed the follow-up. A diagnosis was obtained using the Research Diagnostic Criteria or the Diagnostic Criteria for TMD. Insomnia was assessed with the Insomnia Severity Scale (ISS), and OSA was assessed using the Epworth Sleepiness Scale (ESS) which measures EDS, both at baseline. Patients completed the GCPS form at baseline and 3-month follow-up.

Results

Borderline associations were found between EDS and the transition or persistence of chronic painful TMD when chronic pain was defined by pain duration (RR adjusted_duration = 1.11, P = 0.07) and dysfunction (RRadjusted_dysfunction =1.40, P = 0.051). Furthermore, EDS was specifically associated with persistent painful TMD when chronic pain was defined by pain duration (RR = 1.13, 95%CI: 1.00-1.26, P = 0.04). Insomnia was not related to the study outcomes (RRadjusted_duration = 0.94, P = 0.27, RRadjusted_dysfunction =1.00, P = 0.99).

Conclusion

Results indicate that EDS contrary to insomnia predicted the persistence of chronic painful TMD at a 3-month follow-up.

Reflecting back to move forward: Lessons learned about COVID-19 safety protocols from pediatric anesthesiologists

BACKGROUND

The COVID-19 pandemic brought about the immediate need for enhanced safety protocols in health care centers. These protocols had to evolve as knowledge and understanding of the disease quickly broadened.

AIMS

Through this study, the researchers aimed to understand the experiences of pediatric anesthesiologists at the Montreal Children's Hospital and the Shriners' Hospital Canada as they navigated the first wave of COVID-19 at their institutions.

METHODS

Nine participants from the Montreal Children's Hospital and the Shriners' Hospital were interviewed. Interviews were recorded, transcribed verbatim, and then analyzed using an applied philosophical hermeneutics approach.

FINDINGS

Participants expressed their wish for simple and easy-to-apply protocols while recognizing the challenge of keeping up with evolving knowledge on the disease and its transmission. They pointed to some limitations and unintended consequences of the safety protocols and the system-wide flaws that the COVID-19 pandemic helped bring to light. They described their frustrations with some aspects of the safety protocols, which they at times felt could be more efficient or better suited for their daily practice.

CONCLUSIONS

The findings of this study highlighted the importance of listening to and empowering anesthesiology staff working in the field during crises, the implications of shifting from patient-centered care to community-centered care, and the fine line between sharing as much emerging information as possible and overwhelming staff with information.

Experience and Management of the Adverse Effects of Analgesics After Surgery: A Pediatric Patient Perspective

After surgery, the adverse effects (AEs) of analgesics are common and critical factors influencing the postoperative experience of pediatric patients. Inadequate management of AEs has been found to prolong hospital stay, increase readmission rates and decrease satisfaction with care. The aim of this qualitative descriptive study was to better understand the AEs of analgesics from the perspective of adolescent patients with idiopathic scoliosis after spinal surgery. A total of 7 patients participated in the study. Semistructured interviews were conducted at discharge and 1 week after discharge. Transcribed data were analyzed using qualitative content analysis and themes were identified. Overall, participants most frequently reported gastrointestinal and cognitive AEs, with constipation being the most persistent and bothersome. The pediatric participants used a combination of 3 strategies to mitigate analgesic AEs, namely pharmacologic, nonpharmacologic, and reduction of analgesic intake. Participants demonstrated a lack of understanding of AEs and involvement in their own care. Future studies should be conducted to evaluate the efficacy of nonpharmacological strategies in managing analgesic AEs for pediatric patients after surgery.

Advice for Dentists from Temporomandibular Disorder Patients: A Phenomenological Study

BACKGROUND

Despite increased efforts to improve the health of those with temporomandibular disorder (TMD), the focus remains on medical knowledge rather than patients' opinions and needs regarding quality of treatment and pain management.

OBJECTIVES

We aimed to identify what TMD patients want their dentists to know and do.

METHODS

Open-ended questions were used to understand the perspectives of 6 TMD patients. Two researchers examined the transcripts using interpretive phenomenological analysis.

FINDINGS

TMD participants consistently stressed the need for their dentists to listen and provide them with more advice and information to cope with TMD conditions. They also noted the need for dentists to be skilled in communications, particularly maintaining respectful doctor-patient relations and interpersonal communication.

CONCLUSIONS

Health care providers must acquire practical communication skills and expand their knowledge of TMDs to better support their patients. Improving relations between doctors and their TMD patients could result in positive health outcomes. The implications of this study will be to decrease medical crises and expensive interventions, provide better assistance to patients and refer them to other necessary health care professionals, an approach that will lead to lower care costs, more satisfaction and higher quality of life.

Physical Constraint in Pediatric Dentistry: The Lived Experience of Parents

Background:

The use of physical constraint in pediatric dentistry is highly controversial. Papoose boards in particular, which envelop and immobilize children during treatment procedures, have been described as barbaric devices even though their goal is to protect the patient. In this debate, the voice of parents is important but still missing in the scientific literature.

Aim:

To understand how parents or caregivers experienced physical constraint and the use of the papoose board on their children during regular dental treatment.

Design:

We conducted qualitative research rooted in interpretive phenomenology. Accordingly, we performed in-depth individual interviews with a purposive sample of 7 parents or caregivers. The interviews took place in Montréal, Canada, after the children had been treated with a papoose board for nonemergency dental treatments. The discussions were audio recorded, transcribed, and thematically analyzed.

Results:

Two perspectives emerged among participants. Some explained that the papoose board calmed their children, helped the dentist to complete the procedures, and made their experience less stressful. For others, the papoose board was a horrible and traumatizing experience, leading to feelings of guilt toward their children. They expressed anger toward the dentists for not allowing them enough time to decide and for imposing use of the device.

Conclusion

Our study raises serious ethical concerns about this practice. We believe that using a papoose board should remain an extraordinary measure and, more generally, that dental professionals should reflect on the place of children and their families in clinical encounters.

Knowledge Transfer Statement:

The findings of this study should encourage policy makers, dental professionals and ethicists to consider the following points: 1) the traumatizing experiences described by parents raise serious ethical concerns about the use of papoose boards; 2) the dental profession should reflect on the place of children and their families in the clinical encounter and grapple with the importance of consent and how to ensure consent in encounters involving children and their parents.

Resilience in Adolescent Chronic Pain: An Exploration of Coping Mechanisms and Protective Psychological Factors

Introduction: Adolescents living with Chronic Pain (CP) are vulnerable to negative outcomes such as disability and impaired quality of life; they often miss schools, are unable to maintain social contacts, have sleep disturbances, and suffer from anxiety and depression. The continuation of avoidance coping behaviour beyond normal healing time had also been shown to result in negative consequences such as Disuse Syndrome—a state associated with physical deconditioning, sick role behaviour, psychosocial withdrawal, as well as negative and catastrophic beliefs.Objective: This study uses an interpretative phenomenological approach to explore individual positive thought processes, adaptation efforts, coping mechanisms, as well as resilience resources (beneficial social situations and solid family ties) that adolescents adopt to minimize the impact of pain and its consequences. The ultimate goal is to liaise with fellow physicians, allied researchers, and policy makers to modify, adapt, and improve current adolescent CP services. This way, we can help patients foster skills that will allow them to adapt positively, regain a balanced social life, and live successfully despite their pain.Results / Findings: Central to all accounts is a sense of interrupted life—phrases with negative connotations such as “couldn’t do” and “had to stop” are repeatedly used to express feelings of loss of control.To regain control over their situation, participants create within themselves a positive internal dialogue: they reconstruct the meaning of normalcy, practice acceptance, make downward social comparisons, and engage in daily positive affirmations. While chronic pain disrupts their career trajectories, the experience of living with pain has instilled in them the pursuit of significance. This pursuit is propelled by the imagery of a full life and seems to be particular to this age group. Ironically, some participants are seen to be grateful for their pain. Living with pain has gifted them with intuitive empathy for the suffering of others, as well as the emotional credibility to help.

The Gift of Pain with Transformative Possibilities

This personal narrative explores the experiences of pain metaphorically as a gift. The intention of this presentation is to offer alternative ways to reflect on chronic pain, life and taking risks to move from health literacy toward health agency with help. I will describe my approach to decision making using the hermeneutic wager which provides a means to imagine possibilities while mindfully assessing risk. Learning to manage pain and learning to live well with pain through self-empathy and self-compassion as a gift that we are not always aware is within our grasp. This approach was only essential for my own healing process but helped many others who have participated in our community project called HOMEBASE funded by the Movember Foundation to reduce social isolation for men living with chronic pain. 

What Does it Mean to Live with Thalassemia? An Interpretative Phenomenological Inquiry

Living with Thalassemia, means that the body is unable to produce normal levels of hemoglobin to carry oxygen throughout the body. Without sufficient levels of hemoglobin (due to inefficiency of bone-marrow to produce normal red blood cells), one can experience signs and symptoms, such as severe anemia, chronic fatigue and other serious health concerns. My interest in this topic is because, I live with this condition, but, also interested in the lived experience of the Thalassemia community. My research is a phenomenological exploration through interpretation of research participants’ narratives. The overarching goal of the proposed research is to investigate the contribution to the medical personnel who may use the findings from the study to improve the clinical care from not only from patient centered, but also from a whole person care perspective. There are various clinical and psycho-social challenges such as, academics, career, and family / friend relationship issues. Families address the treatment issues of Thalassemia on a continuum Extreme Drive - No Drive to improve their lives. Thalassemia was seen as a “fatal condition,” today it is a “manageable condition,” therefore, we need to learn, how best to thrive to lead a healthy lifestyle? Through this research I am hoping to share my story and with others to inspire people living with Thalassemia, to go beyond managing towards thriving.

Reconceptualizing patient engagement within research contexts through a relational approach

Currently within the Canadian research landscape, inclusion of patients as partners, research ambassadors have become part of the fabric for research funding;"nothing about me without me". My recent personal experiences at pain conferences and from research team meetings as a patient or more precisely, a person living with chronic pain (PLCP), who is also an academic researcher, suggest we need to evolve a philosophy of engagement that serves both the PLCPs as research ambassadors, rather than patent partners. This presentation is intended to open up conversations about the role of patient experience and the interconnections needed to build strong research communities, through a consideration of a whole person care relational model. In order to meaningfully locate and describe the role of the patient within the structure of a scientific research community I turn to Merleau-Ponty who aptly described the two main perspectives from which we research as, “[t]he world and man [human-beings] are accessible through two kinds of investigations, in the first case explanatory [scientific] and in the second case reflective [philosophical]”. Suggesting, that the language and relationships the emerge and nurtured within research communities need a shared understanding derived from a relational approach rather than a business model of efficiency, experts and teams. A relational approach works toward co-creating a sense of belonging and purpose rather than mere inclusion to meet research funding application criteria. The focus of this presentation is to explore how to co-create a relational approach for researchers with people living with chronic pain. 

A Phenomenologic Study About the Dietary Habits and Digestive Complications for People Living with Temporomandibular Joint Disorder

AIMS

To better understand the experiences of individuals who must alter the types of food they eat because of having a chronic temporomandibular joint disorder (TMD) and the digestive issues that these alterations produce.

METHODS

Six participants answered open-ended questions during semi-structured interviews about their experiences with TMD-related changes in diet and digestion. These interviews, held face-to-face with the participants in a nonclinical environment, were recorded and transcribed. Interpretive phenomenology was used to arrange and analyze the narrative data collected.

RESULTS

The authors identified three common themes among the participants: (1) constipation and bloating; (2) loss of chewing function; and (3) weight change. For each of these themes, participants expressed physiologic and psychologic complications, which were largely unaddressed by their health care providers.

CONCLUSION

These findings highlight the need for health care providers to establish nutritional guidelines for TMD individuals at risk of physiologic and psychologic comorbidities. Health care intervention programs to treat people living with chronic TMD pain and that provide nutritional guidance will help decrease medical crises and the need for expensive interventions and will better assist these patients.

A qualitative study on the oral health of humanitarian migrants in Canada

OBJECTIVES

There is limited evidence to guide oral health policy and services for the 25,000 refugees and asylum seekers who arrive in Canada yearly. The purpose of this study was to explore and understand the pre-migration use of dental services, oral health knowledge, and the effects of oral disease among newly arrived humanitarian migrants in order to inform policy and practice for the population.

METHODS

Using focused ethnography and the public health model of the dental care process, we conducted face-to-face interviews (50-60 minutes) with a purposive sample of humanitarian migrants who had indicated the need for dental care. We observed mobile dental clinics that provided care to underserved communities in Montreal. Data were analyzed using a thematic and contextual approach that combined inductive and deductive frameworks.

RESULTS

Participants included 25 humanitarian migrants from four global geographical regions. Five major thematic categories were explored: problem-based dental consultation, self-assessed oral health status, causes of oral diseases, personal oral hygiene, and good oral health for wellbeing. In their countries of origin, participants consulted a dentist when oral symptoms persisted. They cited excessive sugar consumption and inadequate oral hygiene as causes of oral diseases, and reported significant oral diseases impacts that limited their daily functions and wellbeing once in Canada.

CONCLUSIONS

Humanitarian migrants were knowledgeable about causes of oral disease and the importance of good oral health, yet poor oral health continued to affect their lives in Canada in important ways.

Understanding how Indigenous culturally-based interventions can improve participants' health in Canada

There is increasing recognition that culturally-based diabetes prevention programs can facilitate the adoption and maintenance of healthy behaviours in the communities in which they are implemented. The Kahnawake School Diabetes Prevention Project (KSDPP) is a health promotion, community-based participatory research project aiming to reduce the incidence of Type 2 diabetes in the community of Kahnawake (Mohawk territory, Canada), with a large range of interventions integrating a Haudenosaunee perspective of health. Building on a qualitative, naturalistic and interpretative inquiry, this study aimed to assess the outcomes of a suite of culturally-based interventions on participants' life and experience of health. Data were collected through semi-structured qualitative interviews of 1 key informant and 17 adult, female Kahnawake community members who participated in KSDPP's suite of interventions from 2007 to 2010. Grounded theory was chosen as an analytical strategy. A theoretical framework that covered the experiences of all study participants was developed from the grounded theory analysis. KSDPP's suite of interventions provided opportunities for participants to experience five different change processes: (i) Learning traditional cooking and healthy eating; (ii) Learning physical activity; (iii) Learning mind focusing and breathing techniques; (iv) Learning cultural traditions and spirituality; (v) Socializing and interacting with other participants during activities. These processes improved participants' health in four aspects: mental, physical, spiritual and social. Results of this study show how culturally-based health promotion can bring about healthy changes addressing the mental, physical, spiritual and social dimensions of a holistic concept of health, relevant to the Indigenous perspective of well-being.

Oral healthcare experiences of humanitarian migrants in Montreal, Canada

OBJECTIVE

To understand the oral healthcare experiences of humanitarian migrants in Montreal and their perceptions of ways to improve access to oral healthcare.

METHODS

We used focused ethnography informed by a public health model of the dental care process. The adapted McGill Illness Narrative Interview (MINI) guided interviews of a purposeful sample of humanitarian migrants who received or needed dental care in Montreal. Each interview (50-60 min) was audio-recorded for verbatim transcription. Observation of dental care episodes occurred during mobile dental clinics in underserved communities over the same period (2015-2016). Data analysis combined deductive codes from the theoretical frameworks and inductive codes from interview transcripts and field notes to inform themes.

RESULTS

We interviewed 25 participants (13 refugees and 12 asylum seekers) from 10 countries, who had been in Canada for a range of 1 month to 5 years. The dental care experiences of participants included delayed consultation, proximity to dental clinics, quality care, limited treatment choices, high cost, and long waiting times. A more inclusive healthcare policy, lower fees, integration of dental care into public insurance, and creation of community dental clinics were proposed strategies to improve access to dental care.

CONCLUSION

Humanitarian migrants in this study experienced inadequate oral healthcare. Their lived experiences help us to identify gaps in the provision of oral healthcare services, and suggestions of participants have great potential to improve access to oral healthcare.

Patient Experience of Living with Orofacial Pain: An Interpretive Phenomenological Study

This study investigated the experience of living with chronic orofacial pain. Participating in this study's individual in-depth interviews were 6 participants with chronic orofacial pain who were undergoing treatment at a pain clinic. In consideration of the empirical nature of the study, the interviews were transcribed verbatim and analyzed from an interpretive phenomenological approach. The participants in the study experienced various types of loss as a result of chronic pain, such as the loss of employment, self-identity, and the ability to enjoy eating and engaging in social activities. Other findings revealed a disbelief among the families and medical community in the pain reported by the participants in this study. In addition, the current study explores the dissatisfaction of these participants with their journey through the health care system. Previous studies have concentrated on chronic pain predominantly through quantitative methods based on measurements, such as questionnaires. The biomedical aspects of pain are essential to report, yet the emphasis on this can result in overlooking the experience of living with chronic pain. Qualitative methodologies are necessary for gaining a more profound understanding of and appreciation for the individual patient and his or her unique perspective. The present study may benefit those living with chronic pain, since this sharing of experiences can help sufferers feel less isolated in their agony. The current article's intention is to report these experiences in such a way that chronic pain sufferers and laypeople can comprehend and relate to them. In addition, the findings of this study should promote the knowledge and understanding of health care providers who deal with chronic pain sufferers, so that treatment is provided with more empathy and compassion. Knowledge Transfer Statement: The findings of the present study may assist health care professionals interacting regularly with sufferers of chronic pain to gain a deeper understanding of the chronic pain experience and how to best support these patients.

A novel source of patients' and families' written words to identify what they value in the doctor-patient encounter

Context:  The value and desirability of a positive doctor-patient relationship has traditionally been described using case histories and narratives, and less often with formal literature, art, movies, and theatre. To the detriment of this relationship some family physicians are facing pressure to engage in volume medicine, at the possible expense of personalized care. What patients appreciate in their care is at risk of being ignored. Objective: To understand what adult patients value in the clinical encounters with their family physicians.  Design: In this research, still in progress, we have adopted an interpretive hermeneutics approach to examine a collection of over 140 cards and letters received by an academic family doctor in practice for 39 years.  Participants:  The patients or their family members who sent the aforementioned notes. Findings: Preliminary analysis suggests that correspondence is not spontaneous, but initiated at holidays (Christmas, New Years, Chanukah); life cycle events (birth, recovery from illness, death); and transitions (leaving the practice because of geographical re-location). Notes are commonly  personalized through hand-written text written on behalf of oneself and/or ones family. Showing a wide variety of word selection they expresses appreciation for family physician care of oneself or a family member that was perceived as knowledgeable bio-medically, and experienced as available, authentic, supportive, professional, compassionate, offering hope, and sensitive to suffering. Conclusions: The writing of notes to ones doctors may serve many functions: catharsis, closure, and bearing witness to patients’ appreciation of care in which Hippocratic and Asclepian traditions overlap and complement each other.

Reflective practice and the role of transformational learning in healthcare

Among possible adult learning theories, transformative learning emerged in the 1990’s with the aim to provide learners an educational experience consistent with the purpose of changing perspectives. Transformational learning theory provides the opportunity to learn, confront, engage and reflect on the possibility of learning through changes in perspective and to explore new meanings, roles, relationships and actions contained within it.Perspective transformation is, therefore, not only intended to create ownership of new knowledge, but its re-integration into new or re-configured ways of everyday living. The readiness to apply new knowledge is triggered by confronting an event, or mode of thought, that moves individuals from experiencing knowledge as a series of facts disconnected from their meaning and context into a relevant context, or one that has a different significance for the learner. New understanding requires that learners assess the meanings behind words, the coherence, truth and appropriateness of what is being communicated as well as the truthfulness, credibility and authenticity of the presenter. Unlike focusing only on instrumental learning in which logical problem solving and inquiry dominate, transformative learning entails the use of metaphor, analogies and reflective dialogue so that learners revise their interpretations of knowledge. In these ways transformative learning might help healthcare providers to change their frame of reference and perceptions to accommodate new and different ways of learning and engaging within a multidisciplinary clinical team. 

What is preventing dentists from providing person-centred care?

Most healthcare professions have shifted the way they teach clinical approaches from a biomedical to a person-centred perspective. Yet, dentistry remains strongly anchored in a biomedical world.The objective of this project was to understand the barriers practicing dentists face to provide what we consider person-centred care. We conducted a qualitative descriptive study that comprised semi-structured interviews with dentists in private practice in the Greater Montreal area. After the analysis, we identified six barriers:•     Fear of interpersonal conflict: participants thought that engaging in genuine conversations with patients would lead to situations of disagreement and even conflicts.•     Fear of litigation: dentists considered that the legal and licensing infrastructure would judge the treatment they provide through a strict biomedical framework.•     Fear of loss of money: participants thought that providing person-centred care was more time consuming and thus financially penalizing. •    Pleasure to excel technically: some dentists did not consider offering interventions that provided less procedural pleasure than technical ones.•    Narrow interpretation of health: participants considered the biomedical dimension as the only important dimension.•    Lack of information: participants knew nothing or very little about person or patient-centred care. They seemed willing to integrate it into their practice had they had known more about it.These findings should help academic institutions to design their programs on person-centred care and respond to the fears expressed by professionals.Also, legal infrastructures must recognize the paradigm shift from the biomedical to the person-centred. 

General principles to consider when designing a clinical communication assessment program

OBJECTIVES

Assessment of clinical communication helps teachers in healthcare education determine whether their learners have acquired sufficient skills to meet the demands of clinical practice. The aim of this paper is to give input to educators when planning how to incorporate assessment into clinical communication teaching by building on the authors' experience and current literature.

METHODS

A summary of the relevant literature within healthcare education is discussed, focusing on what and where to assess, how to implement assessment and how to choose appropriate methodology.

RESULTS

Establishing a coherent approach to teaching, training, and assessment, including assessing communication in the clinical context, is discussed. Key features of how to implement assessment are presented including: establishing a system with both formative and summative approaches, providing feedback that enhances learning and establishing a multi-source and longitudinal assessment program.

CONCLUSIONS

The implementation of a reliable, valid, credible, feasible assessment method with specific educational relevance is essential for clinical communication teaching.

PRACTICE IMPLICATIONS

All assessment methods have strengths and limitations. Since assessment drives learning, assessment should be aligned with the purpose of the teaching program. Combining the use of different assessment formats, multiple observations, and independent measurements in different settings is advised.

Exploring the Relational Aspects of Patient and Doctor Communication

The alliance concept is an essential component of therapeutic relationships. Contrary to empirical evidence, its relevance is often not acknowledged in medical encounters. This circumstance invites the question, ‘‘How can the doctor and patient connect relationally with each other to improve the communication process and promote healing?’’ We propose that healing can be accomplished through dialog that emphasizes the collaborative nature of the partnership between the doctor and patient. The typical conversation in a medical encounter may be reduced to an information exchange and a medium for prescribing directives. This being-with approach can override patients’ involvement in the process. A positive doctor–patient relationship may be one of the most important, and most frequently overlooked, factors for predicting patient response to negative medical information. Receiving such news is potentially upsetting for the patient and may require the doctor to let go of the conversational medical agenda and adopt a being-for mode of relationship. We propose that this approach invites the doctor and patient to work together and negotiate how to manage the chronic illness eliciting patient-preferred treatment options. The authors propose the adoption of the being-for relationship as a way of enhancing the therapeutic potential of the doctor–patient relationship.

An exploration of the relationship between emotional intelligence (EI) and the Multiple Mini-Interview (MMI)

The present study explored the relationship between the Multiple Mini-Interview (MMI) admissions process and the Bar-On EQ-i emotional intelligence (EI) instrument in order to investigate the potential for the EQ-i to serve as a proxy measure to the MMI. Participants were 196 health science candidates who completed both the MMI and the EQ-i as part of their admissions procedure at the Michener Institute for Applied Health Sciences. Three types of analyses were conducted to examine the relationship between the two tools: reliability analyses, correlational analyses, and a t-test. The tools were found to be moderately reliable. No significant relationships were found between the MMI and the EQ-i at the total or subscale level. The ability of the EQ-i to discriminate between accepted and not-accepted students was also not supported. These findings do not support the use of the EQ-i as a potential pre-screening tool for the MMI, but rather highlight the need to exercise caution when using emotional intelligence instruments for high-stakes admissions purposes.

A look at nutritional supplement use in adolescents

PURPOSE

To examine the use of nutritional supplements by adolescents. Supplements examined were those purported to influence performance and body mass.

METHODS

333 adolescents (190 male, 139 female, 4 nonrespondents) between the ages of 13 and 19 years, from a midwestern province in Canada, completed a pencil-and-paper survey. Participants, who were enrolled in health and wellness/physical education classes, were requested to provide information about current and potential use of 10 readily available nutritional supplements, as well as their knowledge of these products as potentially performance enhancing. Differences in use, potential use, and knowledge, as a function of gender, age, and level of physical activity were examined using Chi-square analyses and ANOVA techniques.

RESULTS

The most popular dietary aids were multivitamin/mineral preparations (42.5%). More adolescent males than females reported that they currently used both creatine and diuretics. Female respondents indicated that they would consume herbal weight control products significantly more than males. Older students and students reporting high levels of physical activity were significantly more likely to be supplementing with creatine and protein. Males were more likely than females to believe that creatine and androsterone were performance-enhancing agents. Individuals highly involved in physical activity tended to believe that multivitamins, creatine, L-carnitine, energizers, and protein supplements could enhance their performance.

CONCLUSIONS

This study highlights the fact that many nutritional supplements fall within the spectrum of adolescent use, and that this use may be driven by misguided beliefs in their performance-enhancing abilities. Groups at particular risk, such as individuals involved in physical activity to a high degree, are highlighted and the need for gender-specific information is suggested.

Prospective evaluation of prostate specific antigen and prostate specific antigen density in the detection of carcinoma of the prostate: ethnic variations

PURPOSE

We evaluated prospectively the ethnic variations in prostate specific antigen (PSA) and prostate specific antigen density in the detection of carcinoma of the prostate.

MATERIALS AND METHODS

A total of 297 consecutive patients with an elevated serum PSA and/or abnormal digital rectal examination underwent transrectal ultrasound with lesion directed and systematic biopsy (6 if the prostatic volume was 50 cc or less and 12 if it was greater than 50 cc). Receiver operating characteristic curves, predictive values and likelihood ratios were calculated for PSA and PSA density for white and black patients. Ethnic analysis was performed for the entire group, patients with a normal digital rectal examination, and those with a normal digital rectal examination and PSA of 4 to 10 ng./ml.

RESULTS

Of the 297 patients 131 (44%) had cancer, including 48 of 97 black (50%) and 83 of 200 white (42%) patients. Median PSA, PSA density and prostate size did not differ between the positive or negative biopsy groups, or between the ethnic groups in any of the analyses. If all digital rectal examinations were considered PSA density was superior to PSA by receiver operating characteristic analysis for cancer detection in both ethnic groups when all values or PSA of 4 to 10 ng./ml. were considered. However, the significance was lost if only patients with a normal digital rectal examination were considered. In general, predictive values were greater in black patients. Likelihood ratios for a negative test result in black patients demonstrated significant changes in the post-test probability if a PSA density cutoff of 0.1 was used to determine the need for biopsy. Many unnecessary biopsies could be avoided and few cancers would be missed.

CONCLUSIONS

A PSA density cutoff of 0.1 may be warranted in determining the need for prostate biopsy in black men with a normal digital rectal examination.

Prospective evaluation of prostate specific antigen and prostate specific antigen density in the detection of nonpalpable and stage T1C carcinoma of the prostate

PURPOSE

We evaluated prospectively prostate specific antigen (PSA) and prostate specific antigen density in the detection of prostate cancer in patients with normal findings on digital rectal examination with and without normal transrectal ultrasound.

MATERIALS AND METHODS

Consecutive patients (184) with an elevated serum PSA and normal digital rectal examination underwent transrectal ultrasound with lesion directed and systematic biopsies (6 if prostatic volume was 50 cc or less and 12 if volume was more than 50 cc). Receiver operating characteristic curves, predictive values and likelihood ratios were calculated for PSA and PSA density.

RESULTS

Of the 184 patients 50 (27%) with a normal digital rectal examination had cancer compared to 30 of 112 (27%) with a normal digital rectal examination and transrectal ultrasound. Median PSA or PSA density did not differ between the positive and negative biopsy groups among patients with a normal digital rectal examination (8.4 versus 7.1 and 0.22 versus 0.14 ng./ml., respectively) or a normal digital rectal examination and transrectal ultrasound (8.2 versus 7.5 and 0.21 versus 0.14 ng./ml., respectively). PSA density was superior to PSA by receiver operating characteristic analysis for cancer detection when all PSA values or those between 4 and 20 ng./ml. were considered. However, the significance was lost for a PSA of 4 to 10 ng./ml. Likelihood ratios demonstrated insignificant changes in the post-test probability if PSA density was used to determine the need for biopsy and many cancers would have been missed.

CONCLUSIONS

PSA density should not be used to determine the need for biopsy in patients with a normal digital rectal examination and/or transrectal ultrasound.