Background

Excellent communication between surgeons and patients is critical to helping patients to make informed decisions and is a key component of both high quality of care and patient satisfaction. Understanding racial disparities in communication is essential to provide quality care to all patients.

Objective

To examine the content and process of informed decision-making (IDM) between orthopedic surgeons and elderly white versus African American patients. To assess the association of race and patient satisfaction with surgeon communication.

Research Design

Analysis of audiotape recordings of office visits between orthopedic surgeons and patients.

Participants

Eighty-nine orthopedic surgeons and 886 patients age 60 years or older in Chicago, Illinois.

Methods

Tapes were analyzed by coders for content using 9 elements of IDM and for process using 4 global ratings of the relationship-building component of communication (responsiveness, respect, listening, and sharing). Ratings by race were compared using χ2 analysis. Patients completed a questionnaire rating satisfaction with surgeon communication and the visit overall. Logistic analysis was used to assess the effect of race on satisfaction.

Results

Overall there were practically no significant differences in the content of the 9 IDM elements based on race. However, coder ratings of relationship were higher on 3 of 4 global ratings (responsiveness, respect, and listening) in visits with white patients compared with African American patients (P < 0.01). Patient ratings of communication and overall satisfaction with the visit were significantly higher for white patients.

Conclusions

The content of IDM conversations does not differ by race. Yet differences in the process of relationship building and in patient satisfaction ratings were clearly present. Efforts to enhance cultural communication competence of surgeons should emphasize the skills of building relationships with patients in addition to the content of IDM.

Objective

To explore older adults’ views of existing Informed Decision Making (IDM) elements and investigate the need for additional elements.

Methods

We recruited persons 65 and older to participate in six focus groups. Participants completed questionnaires about IDM preferences, and discussed videotapes of idealized patient-physician interactions in light of seven IDM elements: 1) discussion of the patient's role in decision-making; 2) discussion of the clinical issue; 3) discussion of alternatives; 4) discussion of benefits/risks; 5) discussion of uncertainties; 6) assessment of patient understanding; and 7) exploration of patient preference. We used a modified grounded theory approach to assess agreement with existing IDM elements and identify new elements.

Results

In questionnaires, 97–100% of 59 participants rated each IDM element as “somewhat” or “very” important. Qualitative analysis supported existing elements and suggested two more: opportunity for input from trusted others, and discussion of decisions’ impacts on patients’ daily lives. Elements overlapped with global communication themes.

Conclusion

Focus groups affirmed existing IDM elements and suggested two more with particular relevance for older patients.

Practice implications

Incorporation of additional IDM elements into clinical practice can enhance informed participation of older adults in decision-making.

Background

Disclosing harmful errors to patients is recommended, but appears to be uncommon. Understanding how trainees disclose errors and how those practices evolve during training could help educators design programs to address this gap.

Purpose

To determine how trainees would disclose medical errors.

Methods

A survey of 758 trainees (488 students and 270 residents) in internal medicine at two academic medical centers. Surveys depicted one of two harmful error scenarios that varied by how apparent the error would be to the patient. We measured attitudes and disclosure content using scripted responses.

Results

Trainees reported their intent to disclose the error as “definitely” (43%) “probably” (47%) “only if asked by patient” (9%), and “definitely not” (1%). Trainees were more likely to disclose obvious errors in comparison with ones patients were unlikely to recognize (55% vs. 30%, P<0.01). Respondents varied widely in what information they would disclose. Fifty percent of trainees chose statements explicitly stating an error occurred rather than only an adverse event. Regarding apologies, trainees were split between a general expression of regret (52%) and an explicit apology (46%). Respondents at higher levels of training were less likely to use explicit apologies (Trend P<0.01). Prior disclosure training was associated with increased willingness to disclose errors (OR 1.40, P=0.03).

Conclusions

Trainees may not be prepared to disclose medical errors to patients, and worrisome trends in trainee apology practices were observed across levels of training. Medical educators should intensify efforts to enhance trainees’ skills at meeting patients’ expectations for open disclosure of harmful medical errors.

Background

Prior studies show significant gaps in the informed decision-making process, a central goal of surgical care. These studies have been limited by their focus on low-risk decisions, single visits rather than entire consultations, or both. Our objectives were, first, to rate informed decision-making for major elective vascular surgery based on audiotapes of actual physician–patient conversations and, second, to compare ratings of informed decision-making for first visits to ratings for multiple visits by the same patient over time.

Methods

We prospectively enrolled patients for whom vascular surgical treatment was a potential option at a tertiary care outpatient vascular surgery clinic. We audio-taped all surgeon–patient conversations, including multiple visits when necessary, until a decision was made. Using an existing method, we evaluated the transcripts for elements of decision-making, including basic elements (e.g., an explanation of the clinical condition), intermediate elements (e.g., risks and benefits) and complex elements (e.g., uncertainty around the decision).

Results

We analyzed 145 surgeon–patient consultations. Overall, 45% of consultations contained complex elements, whereas 23% did not contain the basic elements of decision-making. For the 67 consultations that involved multiple visits, ratings were significantly higher when evaluating all visits (50% complex elements) compared with evaluating only the first visit (33% complex elements, p < 0.001.)

Conclusion

We found that 45% of consultations contained complex elements, which is higher than prior studies with similar methods. Analyzing decision-making over multiple visits yielded different results than analyzing decision-making for single visits.

Abstract

Objective

To gauge the public’s opinion of the College of Physicians and Surgeons of Ontario’s (CPSO’s) policy on how primary care physicians should accept new patients.

Design

Deliberative citizens’ council.

Setting

Toronto, Ont.

Participants

Twenty-five public members of the Toronto Health Policy Citizens’ Council.

Methods

A 2-day council session was held, during which the new policy was presented and council members heard from experts with various perspectives on the issues involved. Council members then deliberated and developed recommendations concerning the policy.

Main findings

Council members agreed that a first-come, first-served policy was an appropriate method for family physicians to use when accepting new patients. They thought the policy’s exception, which allows physicians not to accept patients based on a lack of clinical competency in an area, should be clarified in order to avoid it being used as an excuse to inappropriately screen patients. Counsel members also encouraged the CPSO to publicize its policy as widely as possible, so that potential patients undergoing screening in the future will recognize that this goes against the CPSO’s policy and can take appropriate action if they wish.

Conclusion

How family physicians accept new patients into their practices is a sensitive issue. The CPSO policy provides guidance on how new patients should be admitted, which, if it is appropriately enacted, seems reasonable to informed members of the public.

Objective

To determine the relationship between physicians’ communication behaviors and patients’ overall satisfaction with hospital care using a novel instrumental variable to address possible confounding of this association by patient attributes.

Data Sources/Study Setting

Administrative records and postdischarge survey data were obtained from patients discharged from the General Medicine service at an urban tertiary-care academic hospital between July 1, 1997 and June 30, 2000. Administrative data included comorbidities, demographic data, and payer status. In the discharge survey, patients rated their attending physician on four communication behaviors, other aspects of their hospital stay, and their overall hospital care.

Study Design

The primary outcome was patients’ ratings of their overall satisfaction with hospital care, and the primary independent variable was patients’ ratings of their physicians’ communication behaviors. To remove possible confounding of the association between patient ratings of physician communication and overall satisfaction by other patient-specific attributes, we created an instrumental variable (IV) in a two-stage linear regression. The IV was the mean of the communication ratings given to each physician by the other patients cared for by that physician.

Principle Findings/Conclusions

Three thousand one hundred and twenty-three patients were included in the analysis. In the ordinary least squares regression, there was a significant positive relationship between overall satisfaction and overall ratings of attendings’ communication behaviors, with an increase in overall satisfaction of 0.58 points on a 5-point scale for each 1-point increase in overall attendings’ communication behaviors, p<.001. This relationship was maintained but attenuated in the IV regression, with a coefficient of 0.40, p=.046. Although we find that the relationship between patient communication ratings and overall patient satisfaction may be confounded by patient-level factors, we nevertheless continue to find evidence of a statistically significant and sizable relationship between physicians’ communication behaviors and overall patient satisfaction after controlling for such factors.

Homeless individuals often suffer from serious health problems. It has been argued that the homeless are socially isolated, with low levels of social support and social functioning, and that this lack of social resources contributes to their ill health. These observations suggest the need to further explore the relationship between social networks, social support, and health among persons who are homeless. The purpose of this study was to examine the association between multidimensional (cognitive/perceived and behavioral/received) social support and health outcomes, including physical health status, mental health status, and recent victimization, among a representative sample of homeless individuals in Toronto, Canada. Multivariate regression analyses were performed on social support and health outcome data from a subsample of 544 homeless adults, recruited from shelters and meal programs through multistage cluster sampling procedures. Results indicated that participants perceived moderately high levels of access to financial, emotional, and instrumental social support in their social networks. These types of perceived social supports were related to better physical and mental health status and lower likelihood of victimization. These findings highlight a need for more services that encourage the integration of homeless individuals into social networks and the building of specific types of social support within networks, in addition to more research into social support and other social contextual factors (e.g., social capital) and their influence on the health of homeless individuals.

Background

Many countries have tried to reduce waiting times for health care through formal wait time reduction strategies. Our paper describes views of members of the public about a wait time management initiative - the Ontario Wait Time Strategy (OWTS) (Canada). Scholars and governmental reports have advocated for increased public involvement in wait time management. We provide empirically derived recommendations for public engagement in a wait time management initiative.

Methods

Two qualitative studies: 1) an analysis of all emails sent by the public to the (OWTS) email address; and 2) in-depth interviews with members of the Ontario public.

Results

Email correspondents and interview participants supported the intent of the OWTS. However they wanted more information about the Strategy and its actions. Interview participants did not feel they were sufficiently made aware of the Strategy and email correspondents requested additional information beyond what was offered on the Strategy's website. Moreover, the email correspondents believed that some of the information that was provided on the Strategy's website and through the media was inaccurate, misleading, and even dishonest. Interview participants strongly supported public involvement in the OWTS priority setting.

Conclusions

Findings suggest the public wanted increased communication from and with the OWTS. Effective communication can facilitate successful public engagement, and in turn fair and legitimate priority setting. Based on the study's findings we developed concrete recommendations for improving public involvement in wait time management.

Background:

Despite efforts to reduce wait times for computed tomography (CT) and magnetic resonance imaging (MRI) in Ontario, little is known about physicians' attitudes regarding contemporary patterns of CT and MRI scan use in this province.

Methods:

We interviewed 19 Ontario family physicians, specialists and radiologists from diverse settings between November 2006 and April 2007. Our detailed written notes were independently reviewed to identify major recurring themes.

Results:

Major themes were grouped under two categories: (a) non-clinical reasons for ordering CT and MRI (“defensive ordering,” indeterminate imaging reports, patient demand, supply-induced demand, marked variation in ordering practices) and (b) communication among groups of physicians (increasing isolation between clinicians and radiologists; specialists and family physicians working in silos).

Conclusion:

These interviews revealed infrequent communication among physician groups and marked variations in ordering practices that are often driven by a number of non-clinical factors, such as fear of litigation and patient demand. Recent increases in CT and MRI capacity may not be leading to better care for patients. Our findings, however, are very preliminary and require validation in other studies.

Background

The firsthand experience of physicians using computer-assisted health-risk assessment is salient for designing practical eHealth solutions.

Objective

The aim of this study was to enhance understanding about computer-assisted health-risk assessments from physicians’ perspectives after completion of a trial at a Canadian, urban, multi-doctor, hospital-affiliated family practice clinic.

Methods

A qualitative approach of face-to-face, in-depth, semi-structured interviews was used. All interviews were audio recorded and field notes taken. Analytic induction and constant comparative techniques were used for coding and analyses. Interpretation was facilitated by peer audit and insights gained from the social exchange theoretical perspective.

Results

Ten physicians (seven female and three male) participated in the interviews. Three overarching themes emerged in relation to computer-assisted health-risk assessments: (1) perceived benefits, (2) perceived concerns or challenges, and (3) feasibility. Physicians unanimously acknowledged the potential of computer-assisted health-risk assessments to open dialogue on psychosocial health risks. They also appreciated the general facilitative roles of the tool, such as improving time-efficiency by asking questions on health risks prior to the consultation and triggering patients’ self-reflections on the risks. However, in the context of ongoing physician-patient relationships, physicians expressed concerns about the impact of the computer-assisted health-risk assessment tool on visit time, patient readiness to talk about psychosocial issues when the purpose of the visit was different, and the suitability of such risk assessment for all visits to detect new risk information. In terms of feasibility, physicians displayed general acceptance of the risk assessment tool but considered it most feasible for periodic health exams and follow-up visits based on their perceived concerns or challenges and the resources needed to implement such programs. These included clinic level (staff training, space, confidentiality) and organizational level (time, commitment and finances) support.

Conclusions

Participants perceived computer-assisted health-risk assessment as a useful tool in family practice, particularly for identifying psychosocial issues. Physicians displayed a general acceptance of the computer tool and indicated its greater feasibility for periodic health exams and follow-up visits than all visits. Future physician training on psychosocial issues should address physicians’ concerns by emphasizing the varying forms of “clinical success” for the management of chronic psychosocial issues. Future research is needed to examine the best ways to implement this program in diverse clinical settings and patient populations.

Trial Registration

ClinicalTrials.gov NCT00385034; http://clinicaltrials.gov/ct2/show/NCT00385034 (Archived by WebCite at http://www.webcitation.org/5pV8AGRgt)

Background

Drug use is believed to be an important factor contributing to the poor health and increased mortality risk that has been widely observed among homeless individuals. The objective of this study was to determine the prevalence and characteristics of drug use among a representative sample of homeless individuals and to examine the association between drug problems and physical and mental health status.

Methods

Recruitment of 603 single men, 304 single women, and 284 adults with dependent children occurred at homeless shelters and meal programs in Toronto, Canada. Information was collected on demographic characteristics and patterns of drug use. The Addiction Severity Index was used to assess whether participants suffered from drug problems. Associations of drug problems with physical and mental health status (measured by the SF-12 scale) were examined using regression analyses.

Results

Forty percent of the study sample had drug problems in the last 30 days. These individuals were more likely to be single men and less educated than those without drug problems. They were also more likely to have become homeless at a younger age (mean 24.8 vs. 30.9 years) and for a longer duration (mean 4.8 vs. 2.9 years). Marijuana and cocaine were the most frequently used drugs in the past two years (40% and 27%, respectively). Drug problems within the last 30 days were associated with significantly poorer mental health status (-4.9 points, 95% CI -6.5 to -3.2) but not with poorer physical health status (-0.03 points, 95% CI -1.3 to 1.3)).

Conclusions

Drug use is common among homeless individuals in Toronto. Current drug problems are associated with poorer mental health status but not with poorer physical health status.

Background

Research funders, educators, investigators and decision makers worldwide have identified the need to improve the quality of health care by building capacity for knowledge translation (KT) research and practice. Peer-based mentorship represents a vehicle to foster KT capacity. The purpose of this exploratory study is to identify mentoring models that could be used to build KT capacity, consult with putative mentee stakeholders to understand their KT mentorship needs and preferences, and generate recommendations for the content and format of KT mentorship strategies or programs, and how they could be tested through future research.

Methods

A conceptual framework was derived based on mentoring goals, processes and outcomes identified in the management and social sciences literature, and our research on barriers and facilitators of academic mentorship. These concepts will inform data collection and analysis. To identify useful models by which to design, implement and evaluate KT mentorship, we will review the social sciences, management, and nursing literature from 1990 to current, browse tables of contents of relevant journals, and scan the references of all eligible studies. Eligibility screening and data extraction will be performed independently by two investigators. Semi-structured interviews will be used to collect information about KT needs, views on mentorship as a knowledge sharing strategy, preferred KT mentoring program elements, and perceived barriers from clinician health services researchers representing different disciplines. Qualitative analysis of transcripts will be performed independently by two investigators, who will meet to compare findings and resolve differences through discussion. Data will be shared and discussed with the research team, and their feedback incorporated into final reports.

Discussion

These findings could be used by universities, research institutes, funding agencies, and professional organizations in Canada and elsewhere to develop, implement, and evaluate mentorship for KT research and practice. This research will establish a theoretical basis upon which we and others can compare the cost-effectiveness of interventions that enhance KT mentorship. If successful, this program of research may increase knowledge about, confidence in, and greater utilization of KT processes, and the quality and quantity of KT research, perhaps ultimately leading to better implementation and adoption of recommended health care services.

Background

We sought to determine the lifetime prevalence of traumatic brain injury and its association with current health conditions in a representative sample of homeless people in Toronto, Ontario.

Methods

We surveyed 601 men and 303 women at homeless shelters and meal programs in 2004–2005 (response rate 76%). We defined traumatic brain injury as any self-reported head injury that left the person dazed, confused, disoriented or unconscious. Injuries resulting in unconsciousness lasting 30 minutes or longer were defined as moderate or severe. We assessed mental health, alcohol and drug problems in the past 30 days using the Addiction Severity Index. Physical and mental health status was assessed using the SF-12 health survey. We examined associations between traumatic brain injury and health conditions.

Results

The lifetime prevalence among homeless participants was 53% for any traumatic brain injury and 12% for moderate or severe traumatic brain injury. For 70% of respondents, their first traumatic brain injury occurred before the onset of homelessness. After adjustment for demographic characteristics and lifetime duration of homelessness, a history of moderate or severe traumatic brain injury was associated with significantly increased likelihood of seizures (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.8 to 5.6), mental health problems (OR 2.5, 95% CI 1.5 to 4.1), drug problems (OR 1.6, 95% CI 1.1 to 2.5), poorer physical health status (–8.3 points, 95% CI –11.1 to –5.5) and poorer mental health status (–6.0 points, 95% CI –8.3 to –3.7).

Interpretation

Prior traumatic brain injury is very common among homeless people and is associated with poorer health.

BACKGROUND

Despite the aging of the population, little is known about the sexual behaviors and sexual function of older people.

METHODS

We report the prevalence of sexual activity, behaviors, and problems in a national probability sample of 3005 U.S. adults (1550 women and 1455 men) 57 to 85 years of age, and we describe the association of these variables with age and health status.

RESULTS

The unweighted survey response rate for this probability sample was 74.8%, and the weighted response rate was 75.5%. The prevalence of sexual activity declined with age (73% among respondents who were 57 to 64 years of age, 53% among respondents who were 65 to 74 years of age, and 26% among respondents who were 75 to 85 years of age); women were significantly less likely than men at all ages to report sexual activity. Among respondents who were sexually active, about half of both men and women reported at least one bothersome sexual problem. The most prevalent sexual problems among women were low desire (43%), difficulty with vaginal lubrication (39%), and inability to climax (34%). Among men, the most prevalent sexual problems were erectile difficulties (37%). Fourteen percent of all men reported using medication or supplements to improve sexual function. Men and women who rated their health as being poor were less likely to be sexually active and, among respondents who were sexually active, were more likely to report sexual problems. A total of 38% of men and 22% of women reported having discussed sex with a physician since the age of 50 years.

CONCLUSIONS

Many older adults are sexually active. Women are less likely than men to have a spousal or other intimate relationship and to be sexually active. Sexual problems are frequent among older adults, but these problems are infrequently discussed with physicians.

Background

Women who are victims of domestic violence frequently seek care in an emergency department. However, it is challenging to hold sensitive conversations in this environment.

Objective

To describe communication about domestic violence between emergency providers and female patients.

Design

Analysis of audiotapes made during a randomized, controlled trial of computerized screening for domestic violence.

Setting

2 socioeconomically diverse emergency departments: one urban and academic, the other suburban and community-based.

Participants

1281 English-speaking women age 16 to 69 years and 80 providers (30 attending physicians, 46 residents, and 4 nurse practitioners).

Results

871 audiotapes, including 293 that included provider screening for domestic violence, were analyzed. Providers typically asked about domestic violence in a perfunctory manner during the social history. Provider communication behaviors associated with women disclosing abuse included probing (defined as asking ≥1 additional topically related question), providing open-ended opportunities to talk, and being generally responsive to patient clues (any mention of a psychosocial issue). Chart documentation of domestic violence was present in one third of cases.

Limitations

Nonverbal communication was not examined. Providers were aware that they were being audiotaped and may have tried to perform their best.

Conclusion

Although hectic clinical environments present many obstacles to meaningful discussions about domestic violence, several provider communication behaviors seemed to facilitate patient disclosure of experiences with abuse. Illustrative examples highlight common pitfalls and exemplary practices in screening for abuse and response to disclosures of abuse.

Twenty-five years ago, George Engel proposed a challenge to the biomedical model and its limited view of disease as biologically rooted. Building on Engel’s work, we present the Interactive Biopsychosocial Model (IBM). The IBM argues for a reorientation in biomedicine where research, education, and clinical practice: (1) address health in addition to illness; (2) aim to decipher interrelated biophysical, psychocognitive, and social processes in health and disease, rather than seek a single root cause; and (3) take into account the social networks of the individual to achieve, maintain, and maximize health and well-being for individuals, their significant others, and society. Based on an interdisciplinary collaboration of medical and social scientists, this paper demonstrates the application of the IBM to understanding and generating hypotheses about the longitudinal relationship between sexuality and health, and sexuality and chronic illness (diabetes mellitus) at older ages. The model provides a dynamic, dyadic, framework for building scientific hypotheses about the etiologies and consequences of health, well-being, and disease throughout the life course.

Background

As no health system can afford to provide all possible services and treatments for the people it serves, each system must set priorities. Priority setting decision makers are increasingly involving the public in policy making. This study focuses on public engagement in a key priority setting context that plagues every health system around the world: wait list management. The purpose of this study is to describe and evaluate priority setting for the Ontario Wait Time Strategy, with special attention to public engagement.

Methods

This study was conducted at the Ontario Wait Time Strategy in Ontario, Canada which is part of a Federal-Territorial-Provincial initiative to improve access and reduce wait times in five areas: cancer, cardiac, sight restoration, joint replacements, and diagnostic imaging. There were two sources of data: (1) over 25 documents (e.g. strategic planning reports, public updates), and (2) 28 one-on-one interviews with informants (e.g. OWTS participants, MOHLTC representatives, clinicians, patient advocates). Analysis used a modified thematic technique in three phases: open coding, axial coding, and evaluation.

Results

The Ontario Wait Time Strategy partially meets the four conditions of 'accountability for reasonableness'. The public was not directly involved in the priority setting activities of the Ontario Wait Time Strategy. Study participants identified both benefits (supporting the initiative, experts of the lived experience, a publicly funded system and sustainability of the healthcare system) and concerns (personal biases, lack of interest to be involved, time constraints, and level of technicality) for public involvement in the Ontario Wait Time Strategy. Additionally, the participants identified concern for the consequences (sustainability, cannibalism, and a class system) resulting from the Ontario Wait Times Strategy.

Conclusion

We described and evaluated a wait time management initiative (the Ontario Wait Time Strategy) with special attention to public engagement, and provided a concrete plan to operationalize a strategy for improving public involvement in this, and other, wait time initiatives.