An accessible,relational, inclusive,and actionable (ARIA) model of genetic counseling compared with usual care: Results of a randomized controlled trial

PurposeEffective approaches to communicate genomic information are needed to ensure equitable care. In a randomized controlled superiority trial, we tested a novel practice model that aims to make genetic counseling inclusive, by making the communication accessible, relational, and actionable (ARIA).MethodsIn total, 696 English- and Spanish-speaking patients aged 18 to 49 years, enriched for individuals from historically underserved backgrounds, were randomized in 1:1 ratio to ARIA or usual care. Primary outcomes were accuracy of recall, communication satisfaction, and perceived understanding. In total, 33 participants completed qualitative interviews.ResultsRecall and understanding were high for all participants. ARIA participants scored higher on the relationship scale of communication satisfaction (mean difference = 0.09, 95% CI = <0.01 to 0.17). Moderator analyses of communication satisfaction showed that those with lower health literacy reported less communication difficulty in ARIA and those using medical interpreters reported greater communication ease in ARIA. No significant difference was found on other primary and secondary outcomes. Qualitative data enhanced understanding of how and why ARIA can be effective.ConclusionThis study provides evidence that a genetic counseling intervention that focuses on specific communication skills to enhance relationship-building, patient engagement, and comprehension can be effective with all patients and may be especially valuable for patients of lower health literacy and Spanish-speakers who use a medical interpreter.     

The active role of interpreters in medical discourse – An observational study in emergency medicine

ObjectiveTo study communicative tasks executed and related strategies used by patients, health professionals, and medical interpreters.MethodsEnglish proficient and limited English proficient emergency department patients were observed. The content of patient-hospital staff communication was documented via pen and paper. Key themes and differences across interpreter types were established through qualitative analysis. Themes and differences across interpreter type were vetted and updated through member checking interviews.Results6 English proficient and 9 limited English proficient patients were observed. Key themes in communicative tasks included: establishing, maintaining, updating, and repairing understanding and rapport. All tasks were observed with English proficient and limited English proficient patients. The difference with limited English proficient patients was that medical interpreters played an active role in completing communicative tasks. Telephone-based interpreters faced challenges in facilitating communicative tasks based on thematic comparisons with in-person interpreters, including issues hearing and lost information due to the lack of visual cues.ConclusionsProfessional interpreters play an important role in communication between language discordant patients and health professionals that goes beyond verbatim translation.Practical implicationsTraining for interpreters and health professionals, and the design of tools for facilitating language discordant communication, should consider the role of interpreters beyond verbatim translation.     

The professional interpreter’s effect on empathic communication in medical consultations: A qualitative analysis of interaction

ObjectiveTo investigate how empathic communication is expressed in interpreter-mediated consultations (IMCs) and the interpreter's effect on it.MethodsWe coded 20 authentic video-recorded IMCs by using the Empathic Communication Coding System (ECCS). We compared patient-initiated empathic opportunities (EOs) and doctors' responses as expressed by patients and doctors and as rendered by interpreters.ResultsWe identified 44 EOs. In 2 of the 44 EOs there was a close match in the way the EOs were expressed by the patient in the first place and in the way they were rendered by the interpreter. Twenty-four of the 44 EOs that were passed on by the interpreter to the doctor and presented the doctor with an opportunity to respond, came with a shift in meaning and/or intensity. Twenty of the 44 EOs were not passed on by the interpreter to the doctor.ConclusionIn IMCs, EOs are subject to the interpreter's renditions and the doctor's actions during interaction.Practice implicationsDoctors and interpreters require skills to detect patient cues, assess them correctly, render them completely and in an appropriate manner (interpreters) and display communicative behaviours that take into account the intricacies of interpreter-mediated clinical communication and facilitate each other’s communicative goals.     

Utility of mobile technology in medical interpretation: A literature review of current practices

ObjectivesLanguage barriers limit healthcare access. However, professional interpretation usage is infrequent due to high cost and poor interpreter availability. Healthcare-oriented mobile applications are becoming more accepted and may help alleviate this burden. This literature review aims to better understand the utility of mobile technology in healthcare interpretation. Specifically, the objective of this review is to synthesize the feasibility, outcome, and challenges of implementing technological medical interpretation services.Patient involvementNo patients were involved for this review.MethodsIn December 2019, MEDLINE (Ovid) was systematically searched according to PRISMA guidelines. All articles discussing the utility of technology in healthcare interpretation encounters were included.ResultsTwo major themes emerged: 1) comparing video and phone interpretation with in-person interpretation and 2) assessing direct translation software in healthcare settings. Phone and video interpretation help reduce overall patient wait-times. Both patients and clinicians preferred in-person or video interpretation over interpretation by phone. Chief benefits of using direct translation software include immediate access, low costs, and sustainability. Several studies discussed potential translation inaccuracies and the importance of having professional interpreters in medico-legal discussions.ConclusionMobile applications may be used to facilitate access to medical interpreters with high clinician and patient satisfaction. Direct in-app translations facilitate access but risk inaccuracies with important medico-legal considerations.Practical valueMobile applications are available at low costs and can improve access to interpreters though video and phone calls. Mobile software can also provide direct translation and facilitate clinical care. Clinicians should prioritize face-to-face encounters with professional medical interpreters, whenever possible. In a time of social distancing amidst the current COVID-19 pandemic, there is crucial value in elucidating the best telehealth interpretation practices.     

Determinants and outcomes of patient-centered care

Objective

This paper defines an interactional analysis instrument to characterize patient-centered care and identify associated variables.

Methods

In this study, 509 new adult patients were randomized to care by family physicians and general internists. An adaption of the Davis Observation Code was used to measure a patient-centered practice style. The main outcome measures were visit-specific satisfaction and healthcare resource utilization.

Results

In initial primary care visits, patient-centered practice style was positively associated with higher patient self-reported physical health status (p = 0.0328), higher educational level (p = 0.0050), and non-smoking status (p = 0.0108); it was also observed more often in the interactions of family physicians compared to internists (p = 0.0003). Controlling for patient sociodemographic variables, self-reported health status, pain, health risk behaviors (obesity, alcohol abuse, and smoking), and clinic assignment, patient satisfaction was not related to the provision of patient-centered care. Moreover, a higher average amount of patient-centered care recorded in visits throughout the one-year study period was significantly related to lower annual medical charges (p = 0.0003).

Conclusions

Patient-centered care was observed more often with family physician caring for healthier, more educated patients, and was associated with lower charges.

Practice implications

Reduced annual medical care charges are an important outcome of patient-centered medical visits.     

The importance of patient-centered care for various patient groups

Objectives

To assess differences in the importance ascribed to patient-centered care between various patient groups and demographic groups.

Methods

Survey data collected using questionnaires were analyzed for patients that underwent hip or knee surgery (n = 214), patients suffering from rheumatoid arthritis (n = 343), spinal disk herniation (n = 145), breast abnormalities (n = 596) or congestive heart failure (n = 118). A composite for patient-centered care priorities was constructed (α = 0.82) and compared to the average importance over all healthcare aspects in the surveys.

Results

All patient groups considered patient-centered care to be of above-average importance (p‘s < 0.001). Small but significant differences were observed: patient-centered care was more important for patients suffering from congestive heart failure (p < 0.001) and patients who were younger, female, well-educated and healthier (p‘s < 0.05). Patients who had undergone hip or knee surgery considered patient-centered care more important than patients with spinal disk herniation did (p < 0.05).

Conclusion

Patient-centered care is important to all patient groups. Differential policies regarding patient-centered care for patient subgroups do not seem required.

Practical implications

Given the importance attributed to patient-centered care, it is essential that elements of patient-centered care are included in surveys, indicators of quality of care, and the training of doctors and nurses.     

The EHR and building the patient’s story: A qualitative investigation of how EHR use obstructs a vital clinical activity

BackgroundRecent research has suggested that using electronic health records (EHRs) can negatively impact clinical reasoning (CR) and interprofessional collaborative practices (ICPs). Understanding the benefits and obstacles that EHR use introduces into clinical activities is essential for improving medical documentation, while also supporting CR and ICP.MethodsThis qualitative study was a longitudinal pre/post investigation of the impact of EHR implementation on CR and ICP at a large pediatric hospital. We collected data via observations, interviews, document analysis, and think-aloud/-after sessions. Using constructivist Grounded Theory’s iterative cycles of data collection and analysis, we identified and explored an emerging theme that clinicians described as central to their CR and ICP activities: building the patient’s story. We studied how building the patient’s story was impacted by the introduction and implementation of an EHR.ResultsClinicians described the patient’s story as a cognitive awareness and overview understanding of the patient’s (1) current status, (2) relevant history, (3) data patterns that emerged during care, and (4) the future-oriented care plan. Constructed by consolidating and interpreting a wide array of patient data, building the patient’s story was described as a vitally important skill that was required to provide patient-centered care, within an interprofessional team, that safeguards patient safety and clinicians’ professional credibility. Our data revealed that EHR use obstructed clinicians’ ability to build the patient’s story by fragmenting data interconnections. Further, the EHR limited the number and size of free-text spaces available for narrative notes. This constraint inhibited clinicians’ ability to read the why and how interpretations of clinical activities from other team members. This resulted in the loss of shared interprofessional understanding of the patient’s story, and the increased time required to build the patient’s story.ConclusionsWe discuss these findings in relation to research on the role of narratives for enabling CR and ICP. We conclude that EHRs have yet to truly fulfill their promise to support clinicians in their patient care activities, including the essential work of building the patient’s story.     

Nurses’ experiences of using an interactive tailored patient assessment tool one year past implementation

BackgroundDespite evidence of benefits, integration of patient-centered communication in clinical practice is challenging. Interactive tailored patient assessment (ITPA) tools can contribute to a more patient-centered care approach. However, little research has examined the impact of such tools on nursing care once they have been implemented.ObjectiveTo explore nurses’ experiences of the benefits of and barriers to using an ITPA called Choice, in cancer care one year after its implementation.MethodsThis investigation is a part of a larger study examining the use of Choice in cancer care. Four focus group interviews were conducted with 20 nurses experienced in using the Choice application. The data were analyzed using qualitative content analysis.ResultsThree themes and nine sub-themes emerged: (1) “Choice as facilitator for shared understanding and engagement in patients’ own care,” with three sub-themes: preparing both patient and nurse for communication, shared engagement in care planning, and giving the patients a voice; (2) “enhancing the patients’ strengths,” with two sub-themes: releasing patient's internal strengths and confirming “normalcy” for the patient; and (3) “new challenges for the nurse,” with four sub-themes: organizational challenges, interactions with technology, a need for training in communication skills, and new ethical challenges.ConclusionsFindings suggest that, from nurses’ perspectives, integration of ITPAs such as Choice in clinical practice offers many benefits that can contribute to patient-centered care. However, to reap these benefits, use of such tools must receive equal priority as other routines, and require sufficient time, space and competence. Choice also challenged nurses’ professional roles and created dilemmas such as nurses’ ambivalence regarding patients’ levels of disclosure of sensitive issues and the nurses’ ability to respond to them. Although patient-centered care is advocated as model for good clinical practice, this is not always internalized. Tools such as Choice may help to make such a shift happen.     

An evidence base for patient-centered cancer care: A meta-analysis of studies of observed communication between cancer specialists and their patients

ObjectiveIn the context of patients visiting cancer specialists, the objective is to test the association between both patient-centered communication (including Affective Behavior and Participation Behavior) and Instrumental Behavior and patients’ post-visit satisfaction with a variety of visit phenomena.MethodsMeta-analysis of 25 articles representing 10 distinct data sets.ResultsBoth patient-centered- and instrumental behavior are significantly, positively associated with satisfaction, with patient-centered communication having a relatively stronger association.ConclusionThere is an evidence base for the efficacy of patient-centered care.Practice implicationsCancer specialists need to train to improve their patient-centered communication.     

Physician's gender,communication style,patient preferences and patient satisfaction in gynecology and obstetrics: A systematic review

Objective

Review of studies published in the last 10 years about women seeking gynecological- or obstetrical care and physician's gender in relation to patient preferences, differences in communication style and patient satisfaction.

Methods

Studies were identified by searching the online databases PubMed, PsycINFO, Embase and the Cochrane Library. The search strategies ‘gender’; ‘obstetrics’ and ‘gynecology’ were combined with ‘communication’; ‘physician–patient relations’; ‘patient preference’ and ‘patient satisfaction’.

Results

After screening title and abstract, evaluating full text and quality assessment, 9 articles were included in this review. Most patients preferred a female rather than a male gynecologist–obstetrician. This was partly explained by a more patient-centered communication style used by female gynecologists–obstetricians. Also experience and clinical competence were important factors in choosing a gynecologist–obstetrician. It was not clear whether patient's age or ethnicity influenced patients gender preference. Patient satisfaction increased when gynecologists–obstetricians used a patient-centered communication style.

Conclusion

Preference for a female gynecologist–obstetrician might be explained by a more patient-centered communication style used by female gynecologists–obstetricians. Using a patient-centered communication style increases patient satisfaction.

Practice implications

To increase patient satisfaction, gynecologists–obstetricians should learn to integrate patient-centered communication style into the consultation.     

Agents of empathy: How medical interpreters bridge sociocultural gaps in genomic sequencing disclosures with Spanish-speaking families

ObjectivesTo describe how linguistic tools used by interpreters during return of genomic sequencing results may have impacted communication with Spanish-speaking families, and to discuss the implications for the role of medical interpreters.MethodsUsing discourse analysis, we identified and categorized the various ways hospital-based interpreters adapted clinicians’ language in 37 audio-recorded sessions in which Spanish-speaking parents participating in a clinical trial received their child’s genomic sequencing results from English-speaking clinicians.ResultsWe found that interpreters adapted clinicians’ statements using five empathic linguistic tools: contextualization, encouragement, checking comprehension, endearment, and softening. Interpreters used an average of four linguistic tools per session, with contextualization and encouragement being the most frequently used.ConclusionsInterpreters used empathic linguistic tools to alter clinicians’ statements when communicating genomic information to Spanish-speaking families. Our findings demonstrate the critical role of interpreters as cultural mediators and facilitators of understanding for Spanish-speaking families.Practice implicationsThis study expands upon the definition of clinical empathy in interpreter-mediated sessions. Our findings suggest that revisions of standards of medical interpretation practice may be warranted regarding interpreters’ ability to adapt clinicians’ language in a culturally sensitive manner during interpretation.     

Treatment satisfaction mediates the association between perceived physician empathy and psychological distress in a community sample of individuals with chronic pain

ObjectiveWhile the benefits of patient-centered care have been consistently demonstrated in the health literature, there exists a dearth of pathway research within health outcome research, especially within the chronic pain context. This study examined the relationship between perceived physician empathy and patient psychological distress and its underlying mechanism.MethodsA community sample of 259 adults with chronic pain completed online questionnaires measuring patient-perceived physician empathy, treatment satisfaction, depressive and anxiety symptoms. Analyses were conducted using correlational and mediation analyses.ResultsResults revealed perceived empathy to be positively and strongly correlated with treatment satisfaction (r = .72, p < .001). A significant negative correlation was also demonstrated between perceived empathy and depressive symptoms (r = -.13, p < .05), but not between perceived empathy and anxious symptoms (r = .03, p = .65). Results revealed significant mediation models between perceived empathy and patient depressive symptoms (indirect effect: B = -.19, SE =.06, 95 % CI [-.31, -.09]) and anxious symptoms (indirect effect: B = -.24, SE = .06, 95 % CI [-.35, -.14]), via treatment satisfaction as mediator and including covariates.ConclusionChronic pain patients who perceive greater levels of physician empathy experience fewer depressive and anxious symptoms, as mediated by treatment satisfaction.Practice implicationsClinical training and practice should promote empathetic components of health communication within chronic pain treatment.     

Challenges and approaches to involving family caregivers in primary care

ObjectiveOlder adults are commonly accompanied to routine medical visits. This study identifies challenges and explores approaches to managing patient-family interactions in primary care.MethodsSemi-structured interviews were conducted with primary care clinicians and staff (N = 30) as well as older adult patients and family caregivers (N = 40). Interviews were analyzed using content analysis.ResultsThree major challenges to patient-family interactions were identified: navigating patient autonomy and family motivation to participate; adjudicating patient-family disagreements; and minimizing obtrusive behaviors by caregivers. Three approaches to managing patient-family interactions were identified. Collaborating involved non-judgmental listening, consensus-building, and validation of different perspectives. Dividing involved separating the patient and family member to elicit confidential information from one member of the dyad. Focusing involved re-directing the conversation to either the patient or family member while minimizing input from the other. Approaches varied by patients’ cognitive status and overall health condition. In general, patients and caregivers expressed the most positive attitudes toward collaborating and patient-directed focusing approaches.ConclusionPrimary care clinicians use varied approaches to managing their interactions with patient-family dyads. Patients and caregivers generally prefer those approaches that involve collaborative rather than individual discussions.Practice implicationsFindings suggest the potential for the development of communication-focused interventions to promote positive clinician-patient-family interactions.     

A systematic review of interventions aiming to improve communication of prognosis to adult patients

ObjectiveOur objective was to describe interventions that aim to improve communication of prognosis to adult patients and to summarize the effect of interventions.MethodsWe included randomized controlled trials of interventions that included prognosis delivery. We excluded studies of decision aids. Our analysis was a narrative synthesis of interventions and outcomes.ResultsOur search identified 1151 unique records. After screening, and full text review we included 21 reports from 17 RCTs. Only 2 studies used a prediction model to generate prognostic estimates. Four studies used education, ten used patient mediated interventions, and 2 used coordination of care. In some studies education that includes prognosis improves patient reported outcomes, communication and treatment decisions, patient mediated interventions can increase the number of questions patients ask about prognosis. Coordination of care may improve satisfaction.ConclusionsEducation for clinicians that includes teaching about how to communicate prognosis may improve patient reported outcomes. Patient mediated interventions can increase the number of prognosis related questions asked by patients.Practice ImplicationsCommunication skills training that includes training on delivering prognosis may improve communication and patient reported outcomes, but the evidence is uncertain. Giving patients question prompt lists can help them ask more prognosis related questions.     

Physician gender,physician patient-centered behavior,and patient satisfaction: A study in three practice settings within a hospital

Objective

To compare male and female physicians on patient-centeredness and patients’ satisfaction in three practice settings within a hospital; to test whether satisfaction is more strongly predicted by patient-centeredness in male than female physicians.

Methods

Encounters between physicians (N = 71) and patients (N = 497) in a hospital were videotaped and patients’ satisfaction was measured. Patient-centeredness was measured by trained coders.

Results

In the outpatient setting, female physicians were somewhat more patient-centered than male physicians; patient satisfaction did not differ. In the inpatient and emergency room settings, female physicians were notably more patient-centered than male physicians; satisfaction paralleled these differences. Nevertheless, there was some, though mixed, evidence that patient-centeredness predicted satisfaction more strongly in male than female physicians, suggesting that patients valued patient-centered behavior more in male than female physicians.

Conclusion

Even though satisfaction mirrored the different behavior styles of male and female physicians in the inpatient and emergency room settings, in all settings male physicians got somewhat more credit for being patient-centered than female physicians did.

Practice implications

If female physicians do not consistently receive credit for high patient-centeredness in the eyes of patients, this could lead female physicians to reduce their patient-centered behavior.     

Patient satisfaction in Kazakhstan: Looking through the prism of patient healthcare experience

ObjectivesThis study aimed to explore the relationship between patient satisfaction and patient experience after exposure to inpatient hospitalization.MethodsA cross-sectional self-completed survey at the bedside in the Inpatient departments of the University Medical Center hospitals (UMC) in Nur-Sultan city, Kazakhstan was submitted. A total of 153 patients completed the survey from September 2017 to June 2018. The survey used the Picker Patient Experience questionnaire validated in Russian and Kazakh languages.ResultsThe majority of patients were satisfied with their hospital stay (90.8 %). Only self-rated health status was associated with overall satisfaction (OR 1.922, 95 % CI 1.09−3.37). Patient experience assessment revealed an association of physical comfort and respect for patient preferences with overall satisfaction (OR 0.101, 95 % CI 0.01−0.91 and OR 0.317, 95 % CI 0.11−0.92).ConclusionsStudy findings support that patient satisfaction is an exaggerated image of healthcare performance. Groups with negative experience have shown lower overall satisfaction in the dimensions ‘physical comfort’ and ‘respect for patient preferences’.Practice implicationsImproving patient centered communication and pain control in clinical practice may lead to the improvement in patient satisfaction.