To assess the reliability, applicability, and validity of a refined system (taxonomy of requests by patients [TORP]) for characterizing patient requests and physician responses in office practice.
Data were obtained from visits to six general internists practicing in North-Central California in 1994 and eight cardiologists practicing in the same region in 1998.
This was an observational study of patient requests and physician responses in two practice settings. Patients were surveyed before and after the visit. Physicians were surveyed immediately after the visit, and all visits were audio recorded for future study.
Data Collection/Extraction Methods
TORP was refined using input from a multidisciplinary panel. Audiotape recordings of 131 visits (71 in internal medicine and 60 in cardiology) were rated independently by two coders. Estimates of classifying reliability (intercoder agreement on the sorting of requests into categories) and unitizing reliability (intercoder agreement on the labeling of elements of discourse as “requests” and subsequent classification into categories) were calculated. Validity was assessed by testing three specific hypotheses concerning the antecedents and consequences of patient requests and request fulfillment.
The overall unitizing kappa for identifying patients' requests was 0.64, and the classification kappa was 0.73, indicating substantial agreement beyond chance. The average patient made 4.19 requests for information and 0.88 requests for physician action; there were few differences in the spectrum of requests between internal medicine and cardiology. Approximately 15 percent of visits included a direct request for completion of paperwork. Patients who were very or extremely worried about their health made more requests than those who were not (6.06 vs. 3.89, p < 0.05). Visits involving more patient requests took longer (p < 0.05) and were perceived as more demanding by the treating physician (p = 0.025). The vast majority of requests were fulfilled.
The refined TORP shows evidence of both unitizing and classification reliability and should be a useful tool for understanding the clinical negotiation. In addition the system appears applicable to both generalist and specialist practices. More experience with the system is necessary to appraise TORP's ability to predict important clinical outcomes.
This study examined the effect of a theoretically grounded, tailored education-coaching intervention to help patients more effectively discuss their pain-related questions, concerns, and preferences with physicians.
Grounded in social-cognitive and communication theory, a tailored education coaching (TEC) intervention was developed to help patients learn pain management and communication skills. In a RCT, 148 cancer patients agreed to have their consultations audio-recorded and were assigned to the intervention or a control group. The recordings were used to code for patients’ questions, acts of assertiveness, and expressed concerns and to rate the quality of physicians’ communication.
Patients in the TEC group discussed their pain concerns more than did patients in the control group. More active patients also had more baseline pain and interacted with physicians using participatory decision-making. Ratings of physicians’ information about pain were higher when patients talked more about their pain concerns.
The study demonstrates the efficacy of a theoretically grounded, coaching intervention to help cancer patients talk about pain control.
Coaching interventions can be effective resources for helping cancer patients communicate about their pain concerns if they are theoretically grounded, can be integrated within clinical routines, and lead to improve health outcomes.
Physician-patient communication; cancer; pain; patient participation
Cancer-related pain is common and under-treated. This article describes a study designed to test the effectiveness of a theory-driven, patient-centered coaching intervention to improve cancer pain processes and outcomes.
The Cancer Health Empowerment for Living without Pain (Ca-HELP) Study is an American Cancer Society sponsored randomized trial conducted in Sacramento, California. A total of 265 cancer patients with at least moderate pain severity (Worst Pain Numerical Analog Score >=4 out of 10) or pain-related impairment (Likert score >= 3 out of 5) were randomly assigned to receive tailored education and coaching (TEC) or educationally-enhanced usual care (EUC); 258 received at least one follow-up assessment. The TEC intervention is based on social-cognitive theory and consists of 6 components (assess, correct, teach, prepare, rehearse, portray). Both interventions were delivered over approximately 30 minutes just prior to a scheduled oncology visit. The majority of visits (56%) were audio-recorded for later communication coding. Follow-up data including outcomes related to pain severity and impairment, self-efficacy for pain control and for patient-physician communication, functional status and well-being, and anxiety were collected at 2, 6, and 12 weeks.
Building on social cognitive theory and pilot work, this study aims to test the hypothesis that a brief, tailored patient activation intervention will promote better cancer pain care and outcomes. Analyses will focus on the effects of the experimental intervention on pain severity and impairment (primary outcomes); self-efficacy and quality of life (secondary outcomes); and relationships among processes and outcomes of cancer pain care. If this model of coaching by lay health educators proves successful, it could potentially be implemented widely at modest cost.
[Clinical Trials Identifier: NCT00283166]
Effective communication is a critical component of quality health care, and to improve it we must understand its dynamics. This investigation examined the extent to which physicians' and patients' preferences for control in their relationship (e.g., shared control vs doctor control) were related to their communications styles and adaptations (i.e., how they responded to the communication of the other participant).
Stratified case-controlled study.
Twenty family medicine and internal medicine physicians and 135 patients.
Based on scores from the Patient-Practitioner Orientation Scale, 10 patient-centered physicians (5 male, 5 female) and 10 doctor-centered physicians (5 male, 5 female) each interacted with 5 to 8 patients, roughly half of whom preferred shared control and the other half of whom were oriented toward doctor control. Audiotapes of 135 consultations were coded for behaviors indicative of physician partnership building and active patient participation.
Patients who preferred shared control were more active participants (i.e., expressed more opinions, concerns, and questions) than were patients oriented toward doctor control. Physicians' beliefs about control were not related to their use of partnership building. However, physicians did use more partnership building with male patients. Not only were active patient participation and physician partnership building mutually predictive of each other, but also approximately 14% of patient participation was prompted by physician partnership building and 33% of physician partnership building was in response to active patient participation.
Communication in medical encounters is influenced by the physician's and patient's beliefs about control in their relationship as well as by one another's behavior. The relationship between physicians' partnership building and active patient participation is one of mutual influence such that increases in one often lead to increases in the other.
physician-patient communication; patient participation; control; gender
Tailoring to psychological constructs (e.g. self-efficacy, readiness) motivates behavior change, but whether knowledge tailoring alone changes healthcare preferences - a precursor of behavior change in some studies - is unknown. We examined this issue in secondary analyses from a randomized controlled trial of a tailored colorectal cancer (CRC) screening intervention, stratified by ethnicity/language subgroups (Hispanic/Spanish, Hispanic/English, non-Hispanic/English).
Logistic regressions compared effects of a CRC screening knowledge-tailored intervention versus a non-tailored control on preferences for specific test options (fecal occult blood or colonoscopy), in the entire sample (N = 1164) and the three ethnicity/language subgroups.
Pre-intervention, preferences for specific tests did not differ significantly between study groups (experimental, 64.5%; control 62.6%). Post-intervention, more experimental participants (78.6%) than control participants (67.7%) preferred specific tests (P <0.001). Adjusting for pre-intervention preferences, more experimental group participants than control group participants preferred specific tests post-intervention [average marginal effect (AME) = 9.5%, 95% CI 5.3-13.6; P <0.001]. AMEs were similar across ethnicity/language subgroups.
Knowledge tailoring increased preferences for specific CRC screening tests across ethnic and language groups.
If the observed preference changes are found to translate into behavior changes, then knowledge tailoring alone may enhance healthy behaviors.
We examined migration-related changes in smoking behavior in the transnational Mexican-origin population.
We combined epidemiological surveys from Mexico (Mexican National Comorbidity Survey) and the United States (Collaborative Psychiatric Epidemiology Surveys). We compared 4 groups with increasing US contact with respect to smoking initiation, persistence, and daily cigarette consumption: Mexicans with no migrant in their family, Mexicans with a migrant in their family or previous migration experience, migrants, and US-born Mexican-Americans.
Compared with Mexicans with a migrant in their family or previous migration experience, migrants were less likely to initiate smoking (odds ratio [OR] =0.56; 95% confidence interval [CI] =0.38, 0.83) and less likely to be persistent smokers (OR = 0.41; 95% CI = 0.26, 0.63). Among daily smokers, the US-born smoked more cigarettes per day than Mexicans with a migrant in their family or previous migration experience for men (7.8 vs 6.5) and women (8.6 vs 4.3).
Evidence suggests that smoking is suppressed among migrants relative to the broader transnational Mexican-origin population. The pattern of low daily cigarette consumption among US-born Mexican Americans, noted in previous research, represents an increase relative to smokers in Mexico.
To investigate provider opinions about responsibility for medication adherence and examine physician-patient interactions to illustrate how adherence discussions are initiated.
Focus group discussions with healthcare providers and audiotaped outpatient office visits with a separate group of providers.
Focus group participants were recruited from multi-specialty practice groups in New Jersey and Washington, D.C. Outpatient office visits were conducted in primary care offices in Northern California.
Twenty-two healthcare providers participated in focus group discussions. One hundred patients aged 65 and older and 28 primary care physicians had their visits audiotaped.
Inductive content analysis of focus groups and audiotaped encounters.
Focus group analyses indicated that providers feel responsible for assessing medication adherence during office visits and for addressing mutable factors underlying nonadherence. However, they believed that patients are ultimately responsible for taking medications and voiced reluctance about confronting patients about nonadherence. The 100 patients participating in audio taped encounters were taking a total of 410 medications. Of these, 254 (62%) were discussed in a way that might touch upon adherence; physicians made simple inquiries about current patient medication use for 31.5%, but they made in-depth inquiries about adherence for only 4.3%. Of 39 identified instances of nonadherence, patients spontaneously disclosed 51%.
The lack of intrusive questions about medication taking during actual office visits may reflect poor provider recognition of the questions needed to fully assess adherence. Alternatively, provider beliefs about patient responsibility for adherence may hinder detailed queries. A paradigm of joint provider-patient responsibility may be needed to better guide discussions about medication adherence.
medication adherence; patient-physician relationship; provider-patient communication; prescription medication
In Hirschman’s classic formulation, physicians can signal discontent with their conditions of work by “exiting” (leaving the profession or not entering it in the first place) or by giving “voice” to their concerns (e.g. complaining, protesting, bargaining collectively, or conducting work actions and strikes). This Commentary reviews the findings of a survey of Israeli neonatologists by Moshe et al. Survey respondents were satisfied with their careers but not with salary, patient care demands, and leisure time, a pattern that has been seen in other countries, particularly within “small, acute care specialties” (SACS). One question for policymakers is how to help physicians in SACS maintain work-life balance and avoid burnout while providing superb patient care. The Commentary considers several possible solutions while advocating for rigorous and comprehensive monitoring of physician satisfaction over time.
Martin Hickman† maneuvered his way into the office and pulled up his sleeve as the medical assistant put the brake on his wheelchair and attached the blood pressure cuff around his oversized upper arm. A bulky 56-year-old man with a heavy shock of gray hair teetering on the edge of his forehead, his problem list included type 2 diabetes, chronic obstructive pulmonary disease, hypertension, obesity, and hyperlipidemia. For the past 15 years he has used a wheelchair due to T4 paraplegia from a gunshot wound. He has also suffers from bouts of major depression that respond to sertraline but never fully remit. As the medical assistant inflated the cuff, Mr. Hickman smiled weakly and maintained a cheerful façade even after she informed him that his blood pressure was 164/88 mm Hg and his glucose was 267 mg/dl (both well above goal). Later, on more careful questioning by his primary care physician, Hickman admitted that he was feeling “more down than usual” and that he sometimes neglected to take his diabetes medicine and blood pressure pills. Thinking back over the years he had cared for this patient, the physician recalled that December tended to be a particularly bad month. Social isolation, tolerable for most of the year, became painful around the holidays. December also happened to mark the anniversary of Hickman's spinal cord injury.
The clock was running, the waiting room was full, and the physician realized he was already falling behind.
depression; comorbid; chronic medical conditions; primary care
In developing policies for use of expensive agents, such as those used for the treatment of rheumatoid arthritis, managed care organizations have invoked “stepped care,” in which physicians and patients must first try more established and less costly agents. N-of-1 clinical trials are multiple crossover trials in a single patient. In this cost-minimization analysis, we show that offering patients with rheumatoid arthritis the opportunity to participate in an n-of-1 trial comparing methotrexate with etanercept could save costs relative to open access while preserving clinical freedom relative to mandatory stepped care. In the primary model, the n-of-1 trial option was 15% more expensive than stepped care but 47% cheaper than open access to etanercept. More research is needed on the acceptability, safety, and generalizability of this promising approach.
Mobile phones and devices, with their constant presence, data connectivity, and multiple intrinsic sensors, can support around-the-clock chronic disease prevention and management that is integrated with daily life. These mobile health (mHealth) devices can produce tremendous amounts of location-rich, real-time, high-frequency data. Unfortunately, these data are often full of bias, noise, variability, and gaps. Robust tools and techniques have not yet been developed to make mHealth data more meaningful to patients and clinicians. To be most useful, health data should be sharable across multiple mHealth applications and connected to electronic health records. The lack of data sharing and dearth of tools and techniques for making sense of health data are critical bottlenecks limiting the impact of mHealth to improve health outcomes. We describe Open mHealth, a nonprofit organization that is building an open software architecture to address these data sharing and “sense-making” bottlenecks. Our architecture consists of open source software modules with well-defined interfaces using a minimal set of common metadata. An initial set of modules, called InfoVis, has been developed for data analysis and visualization. A second set of modules, our Personal Evidence Architecture, will support scientific inferences from mHealth data. These Personal Evidence Architecture modules will include standardized, validated clinical measures to support novel evaluation methods, such as n-of-1 studies. All of Open mHealth’s modules are designed to be reusable across multiple applications, disease conditions, and user populations to maximize impact and flexibility. We are also building an open community of developers and health innovators, modeled after the open approach taken in the initial growth of the Internet, to foster meaningful cross-disciplinary collaboration around new tools and techniques. An open mHealth community and architecture will catalyze increased mHealth efficiency, effectiveness, and innovation.
Mobile health; software tools; software engineering; open access to information; open architecture; open source; evaluation methodology; data analysis; data visualization
Healthcare providers’ attitudes toward sexual minorities influence patient comfort and outcomes. This study characterized medical student attitudes toward gay men, focusing on behavior, personhood, gay civil rights, and male toughness.
A cross-sectional web-based anonymous survey was sent to medical students enrolled at the University of California, Davis (N = 371) with a response rate of 68%.
Few respondents expressed negative attitudes toward gay men or would deny them civil rights. More negative responses were seen with respect to aspects of intimate behavior and homosexuality as a natural form of sexual expression. Men and students younger than 25 years old were more likely to endorse negative attitudes toward behavior as well as more traditional views on male toughness.
We show that an important minority of students express discomfort with the behavior of gay men and hold to a narrow construction of male identity. These findings suggest that competency training must move beyond conceptual discussions and address attitudes toward behaviors through new pedagogical approaches.
Homosexuality; Medical students; Bias
Given their prevalence and persuasive power in our culture, gender norms— commonly described as socially reinforced, learned expectations of what it means to be a man or a woman—likely contribute to sex differences in service utilization for depression. This study investigated whether sex differences in toughness, a gender-linked norm characterized by a desire to hide pain and maintain independence, were associated with a preference to wait for depression to resolve on its own without active professional treatment (``wait-and-see” approach).
Participants (N=1,051) in the California Behavioral Risk Factor Surveillance System (BRFSS) survey were contacted in a follow-on survey to assess toughness, the kind of treatment they would prefer were they to receive a diagnosis of depression, and current symptoms of depression. Participants who reported ever having been diagnosed as having a depressive disorder on the BRFSS were oversampled threefold. Analyses were conducted using linear and logistic regressions.
Men and women who scored higher on toughness had a greater preference for the wait-and-see approach (OR=1.14, p<.01). Women were less likely to prefer the wait-and-see approach (OR=.58, p<.04) and scored lower on toughness (B=−.70, p<.01). Men’s greater levels of toughness partially mediated the sex difference in treatment preferences (OR=.91, p<.05).
Men’s greater adherence to the toughness norm explained part of the sex difference observed in treatment-seeking preferences, but toughness undermined women’s treatment seeking as well. Findings could be used to inform novel public health communications intended to attract both men and women to psychiatric services.
Family and friends may help patients seek out and engage in depression care. However, patients’ social networks can also undermine depression treatment and recovery. In an effort to improve depression care in primary care settings, we sought to identify, categorize, and alert primary care clinicians to depression-related messages that patients hear from friends and family that patients perceive as unhelpful or detrimental.
We conducted 15 focus groups in 3 cities. Participants (n = 116) with a personal history or knowledge of depression responded to open-ended questions about depression, including self-perceived barriers to care-seeking. Focus group conversations were audio-recorded and analyzed using iterative qualitative analysis.
Four themes emerged related to negatively-received depression messages delivered by family and friends. Specifically, participants perceived these messages as making them feel labeled, judged, lectured to, and rejected by family and friends when discussing depression. Some participants also expressed their interpretation of their families’ motivations for delivering the messages and described how hearing these messages affected depression care.
The richness of our results reflects the complexity of communication within depression sufferers’ social networks around this stigmatized issue. To leverage patients’ social support networks effectively in depression care, primary care clinicians should be aware of both the potentially beneficial and detrimental aspects of social support. Specifically, clinicians should consider using open-ended queries into patients’ experiences with discussing depression with family and friends as an initial step in the process. An open-ended approach may avoid future emotional trauma or stigmatization and assist patients in overcoming self-imposed barriers to depression discussion, symptom disclosure, treatment adherence and follow-up care.
depression; disclosure; norms; patient-provider communication; social support; qualitative analysis