“I just answer ‘yes’ to everything they say”: Access to health care for deaf people in Worcester,South Africa and the politics of exclusion

Objective

To explore whether there are other factors besides communication difficulties that hamper access to health care services for deaf patients.

Methods

Qualitative methodology using semi-structured interviews with 16 deaf participants from the National Institute for the Deaf in Worcester and 3 Key informants from the Worcester area, South Africa.

Results

Communication difficulties were found to be a prominent barrier in accessing health care services. In addition to this interpersonal factors including lack of independent thought, overprotectedness, non-questioning attitude, and lack of familial communication interact with communication difficulties in a way that further hampers access to health care services.

Conclusion

These interpersonal factors play a unique role in how open and accepting health services feel to deaf patients.

Practice implications

Health care services need to take cognizance of the fact that providing sign language interpreters in the health care setting will not necessarily make access more equitable for deaf patients, as they have additional barriers besides communication to overcome before successfully accessing health care services.     

Verbal communication among Alzheimer's disease patients, their caregivers, and primary care physicians during primary care office visits

Objective

Primary care visits of patients with Alzheimer's disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual's verbal participation in these triadic interactions.

Methods

To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty-three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed.

Results

PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver's own verbal participation.

Conclusion

Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less.

Practice implications

Encouraging verbal participation by AD patients and their caregivers may increase the AD patient's active role and caregiver satisfaction with primary care visits.     

Improving patient education by an in-service communication training for health care providers at a cancer ward: Communication climate,patient satisfaction and the need of lasting implementation

Objective

To show the effects of an in-service communication training for health care providers at a cancer ward, to improve the quality and quantity of the patient education, and patient satisfaction with the care received.

Methods

A 3-year in-service communication training was held at a cancer ward. Pre- and post-data were collected about the quality and quantity of the communication of nurses, physicians and other health care providers (HCPs) towards patients and colleagues (n = 22) as well as the satisfaction of the patients with the quality of care (n = 90).

Results

The communication training raised significantly the quality and quantity of the communication towards patients and with colleagues. Also patient satisfaction with the quality of care increased. However, the long-term implementation of the benefits was proved disappointing.

Conclusion

In-service communication training is an important means for the long-term improvement of the quality of patient education at nursing departments in hospitals. Lasting implementation of the benefits however requires attention to organizational obstacles, budgetary conditions, leadership factors at the ward, and the application of an organizationally oriented theoretical framework.

Practice implications

Improvement of patient education at nursing wards does not only require educational means, organizational facilities and professional training, but can be improved too by in-service communication training, which increases the quality of the patient-centered care. An organizational oriented change-strategy is needed to ensure the implementation produces lasting effects.     

Towards non-reductionistic medical anthropology,medical education and practitioner–patient-interaction: The example of Anthroposophic Medicine

Objective

To develop the hypothesis that reductionism in medical anthropology, professional education and health care influences empathy development, communication and patient satisfaction.

Method

We identified relevant literature and reviewed the material in a structured essay. We reflected our hypothesis by applying it to Anthroposophic Medicine (AM), an example of holistic theory and practice.

Results

Reductionism in medical anthropology such as in conventional medicine seems to lead to a less empathetic and less communicative health care culture than holism such as in CAM disciplines. However, reductionism can be transformed into a systemic, multi-perspective holistic view, when the emergent properties of the physical, living, psychic, spiritual and social levels of human existence and the causal relations between them are more carefully accounted for in epistemology, medical anthropology and professional education. This is shown by the example of AM and its possible benefits for communication with and satisfaction of patients.

Conclusion

A non-reductionistic understanding of the human being may improve communication with patients and enhance patient benefit and satisfaction.

Practice implications

Interdisciplinary qualitative and quantitative studies are warranted to test this hypothesis and to understand the complex relations between epistemology, medical anthropology, education, health care delivery and benefit for patients.     

Associations between patient–provider communication and socio-cultural factors in prostate cancer patients: A cross-sectional evaluation of racial differences

Objective

To examine the association between socio-cultural factors and patient–provider communication and related racial differences.

Methods

Data analysis included 1854 men with prostate cancer from a population-based study. Participants completed an assessment of communication variables, physician trust, perceived racism, religious beliefs, traditional health beliefs, and health literacy. A multi-group structural equation modeling approach was used to address the research aims.

Results

Compared with African Americans, Caucasian Americans had significantly greater mean scores of interpersonal treatment (p < 0.01), prostate cancer communication (p < 0.001), and physician trust (p < 0.001), but lower mean scores of religious beliefs, traditional health beliefs, and perceived racism (all p values <0.001). For both African and Caucasian Americans, better patient–provider communication was associated with more physician trust, less perceived racism, greater religious beliefs (all p-values <0.01), and at least high school education (p < 0.05).

Conclusion

Socio-cultural factors are associated with patient–provider communication among men with cancer. No evidence supported associations differed by race.

Practice implication

To facilitate patient–provider communication during prostate cancer care, providers need to be aware of patient education levels, engage in behaviors that enhance trust, treat patients equally, respect religious beliefs, and reduce the difficulty level of the information.     

Patient reported interpersonal processes of care and perceived social position: The Diabetes Study of Northern California (DISTANCE)

Objective

A patient's sense of his/her standing in the social hierarchy may impact interpersonal processes of care (IPC) within the patient–provider encounter. We investigated the association of perceived social position with patient-reported IPC.

Methods

We used survey data from the Diabetes Study of Northern California (DISTANCE), studying 11,105 insured patients with diabetes cared for in an integrated healthcare delivery system. Perceived social position was based on the MacArthur subjective social status ladder. Patient-reported IPC was based on a combined scale adapted from the Consumer Assessment of Health Plans Study provider communication subscale and the Trust in Physicians scale.

Results

Lower perceived social position was associated with poorer reported IPC (p < 0.001). The relationship remained statistically significant after controlling for age, sex, race/ethnicity, depressive symptoms, physical functioning, income and education.

Conclusion

Beyond objective measures of SES, patients’ sense of where they fall in the social hierarchy may represent a pathway between social position and patient satisfaction with the quality of patient–provider communication in chronic disease.

Practice implications

Interventions to address disparities in communication in primary care should incorporate notions of patients’ social position.     

A systematic review of surgeon–patient communication: Strengths and opportunities for improvement

Objective

Effective communication is critical to patient satisfaction, outcomes of care and malpractice prevention. Surgeons need particularly effective communication skills to discuss complicated procedures and help patients make informed choices. We conducted a systematic review of the literature on surgeon–patient communication.

Methods

Searches were conducted in MEDLINE, PsycINFO, and Sociological Abstract. Two reviewers screened citations and full-text articles. Quality was appraised using the Critical Appraisal Skills Program tool. Studies were categorized into content of communication, patient satisfaction, relationship of communication to malpractice, and duration of visits.

Results

2794 citations and 74 full-text articles, 21 studies and 13 companion reports were included. Surgeons spent the majority of their time educating patients and helping them to make choices. Surgeons were generally thorough in providing details about surgical conditions and treatments. Surgeons often did not explore the emotions or concerns of patients. Potential areas of improvement included discussing some elements of informed decision making, and expressing empathy.

Conclusion

Surgeons can enhance their communication skills, particularly in areas of relative deficiency. Studies in primary care demonstrate communication programs are effective in teaching these skills.

Practice implications

These can be adapted to surgical training and ultimately lead to improved outcomes and satisfaction with care.     

Delivery of telephone-based supportive care to people with cancer: An analysis of cancer helpline operator and cancer nurse communication

Objectives

Telephone-based supportive care presents a potentially highly accessible means of addressing unmet supportive care needs for people with cancer. Identification of behaviours that facilitate communication is essential for development of training for telephone-based supportive care. The aim of this study was to describe communication behaviours within supportive care telephone calls in two contexts (1) a telephone outreach intervention and (2) cancer helpline calls, to identify potential areas for further training.

Methods

50 recorded calls were analysed using two standardised coding systems: the RIAS and Verona-CoDES-C.

Results

Mean call length was 21 min (304 utterances) for nurse-outreach calls and 23 min (355 utterances) for helpline calls. Closed questioning, verbal attentiveness and giving information/counselling were the most common communication behaviours identified. Emotional cues were most commonly responded to through non-explicit back-channelling, exploration of content or provision of reassurance or advice.

Conclusions

This study confirmed the need to address the manner in which questions are framed to maximise patient disclosure. Responding to patent emotional cues was highlighted as an area for future training focus.

Practice implications

Communication skills training that addresses each of these tasks is likely to improve the effectiveness of telephone-based delivery of supportive care.     

Decision preparation, satisfaction and regret in a multi-center sample of men with newly diagnosed localized prostate cancer

Objective

To describe relationships between use of the Personal Patient Profile-Prostate (P3P) decision support system and patient characteristics, and perceived preparation for decision making (PrepDM), satisfaction and decisional regret in the context of prostate cancer treatment choice.

Methods

494 men with localized prostate cancer (LPC) were randomized to receive the P3P intervention or usual care and completed pre-treatment, 1-month and 6-month outcome measures. Multivariable linear regression models were fit for each outcome.

Results

Physician consult visits prior to enrollment, race/ethnicity, and use of clinic-provided books were significant predictors of perceived PrepDM at 1 month. Prior Internet use and PrepDM significantly predicted 6-month decision satisfaction. Decisional regret was significantly predicted by demographics, anxiety, PrepDM score, and EPIC bowel domain score at 6 months. Use of P3P did not predict any outcome.

Conclusion

While the P3P intervention did not significantly affect the outcomes, pre-enrollment information and preparation were strong predictors of the 1- and 6-month outcomes. Decision regret was significantly influenced by personal characteristics and post-treatment symptoms/side effects.

Practice implications

Information received and used between biopsy and the treatment options consult visit is likely to make a difference in decision satisfaction.     

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

Objective

In 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.

Methods

Meta-analysis of 25 articles representing 10 distinct data sets.

Results

Both patient-centered- and instrumental behavior are significantly, positively associated with satisfaction, with patient-centered communication having a relatively stronger association.

Conclusion

There is an evidence base for the efficacy of patient-centered care.

Practice implications

Cancer specialists need to train to improve their patient-centered communication.     

Patients’ evaluation of quality of care in general practice: What are the cultural and linguistic barriers?

Objective

Increased migration implies increased contacts for physicians with patients from diverse cultural backgrounds who have different expectations about healthcare. How satisfied are immigrant patients, and how do they perceive the quality of care? This study investigated which patient characteristics (such as cultural views and language proficiency) are related to patients’ satisfaction and perceived quality of care.

Methods

Patients (n = 663) from 38 general practices in Rotterdam (The Netherlands) were interviewed. General satisfaction with the general practitioner (GP) was measured by a report mark. Perceived quality of care was measured using the ‘Quote-mi’ scale (quality of care through the patient's eyes—for migrants), which contains an ethnic-specific subscale and a communication process subscale. Using multilevel regression techniques, the relation between patient characteristics (ethnicity, age, education, Dutch language proficiency, cultural views) and satisfaction and perceived quality of care was analysed.

Results

In general, patients seemed fairly satisfied. Non-Western patients perceived less quality of care and were less satisfied than Dutch-born patients. The older the patients and the more modern cultural views they had, the more satisfied they were about the GP in general, as well as about the communication process. However, non-Western patients holding more modern views were the most critical regarding the ethnic-specific quality items. The poorer patients’ Dutch language proficiency, the more negative they were about the communication process.

Conclusion

It is concluded that next to communication aspects, especially when the patient's proficiency in Dutch is poor, physician awareness about the patient's cultural views is very important during the consultation. This holds especially true when the immigrant patient seems to be more or less acculturated.

Practice implications

Medical students and physicians should be trained to become aware of the relevance of patients’ different cultural backgrounds. It is also recommended to offer facilities to bridge the language barrier, by making use of interpreters or cultural mediators.     

Educational benefits of Internet and computer-based programmes for prostate cancer patients: A systematic review

Objective

This study aims to review systematically the available literature on Internet and computer-based patient education programmes, assess the quality of these studies and analyze the benefit of these programmes for prostate cancer patients.

Methods

Complete databases were searched. Studies were included if they concerned patient education of prostate cancer patients, were qualitative or quantitative and examined Internet or interactive CD-ROM use.

Results

Eighteen studies met the inclusion criteria. The majority of the studies reported a significant increase in the knowledge of the disease, satisfaction with treatment options and support for men. The benefit of the programmes was that the patients felt more empowered and obtained a heightened sense of control over their disease.

Conclusion

The Internet or computer-based programmes had a positive impact on prostate cancer patient education. Most papers reported that the programmes were beneficial, but few presented data from studies with rigorous research methodologies to support these claims.

Practice implications

Internet and computer-based programmes can be useful tools in prostate cancer patient education. In order to improve the benefits of the programmes, more Internet and computer-based programmes need to be developed and studied.     

Patients’ experiences with navigation for cancer care

Objective

We examined how navigation, defined as the assessment and alleviation of barriers to adequate health care, influences patients’ perspectives on the quality of their cancer care.

Methods

We conducted post-study patient interviews from a randomized controlled trial (usual care vs. patient navigation services) from cancer diagnosis through treatment completion. Patients were recruited from 11 primary care, hospital and community oncology practices in New York. We interviewed patients about their expectations and experience of patient navigation or, for non-navigated patients, other sources of assistance.

Results

Thirty-five patients newly diagnosed with breast or colorectal cancer. Valued aspects of navigation included emotional support, assistance with information needs and problem-solving, and logistical coordination of cancer care. Unmet cancer care needs expressed by patients randomized to usual care consisted of lack of assistance or support with childcare, household responsibilities, coordination of care, and emotional support.

Conclusion

Cancer patients value navigation. Instrumental benefits were the most important expectations for navigation from navigated and non-navigated patients. Navigated patients received emotional support and assistance with information needs, problem-solving, and logistical aspects of cancer care coordination.

Practice implications

Navigation services may help improve cancer care outcomes important to patients by addressing fragmented, confusing, uncoordinated, or inefficient care.     

Patient compliance with telephone triage recommendations: a meta-analytic review

Objective

To systematically investigate the extent to which patients comply with triage advice from telenurses and to identify factors that potentially influence compliance.

Methods

Findings from 13 studies identified through interdisciplinary research databases (1990–2010) were meta-analyzed. Separate pooled analyses compared patients’ compliance rates for emergency services and office care (13 outcomes), emergency services and self care (13 outcomes), and self care and office care (12 outcomes).

Results

Overall patient compliance was 62%, but varied by intensity of care recommended with low compliance rates for advice to see a general practitioner. Reasons for noncompliance include patients reporting to have heard a different disposition, patients’ intentions and health beliefs.

Conclusion

Patient compliance to triage recommendations was influenced by the interactive role of patient perceptions and the quality of provider communication, both of which were mediated by access to health services. Further research is needed to clarify whether noncompliance is attributable to poor communication by the nurse or patient misinterpretation.

Practice implications

We highlight the need for communication-skills training in a telephone-consultation context that is patient centered, and specifically addresses building active listening and active advising skills and advantages to structuring the call.     

Communicating shared decision-making: Cancer patient perspectives

Objective

To contribute to the evolving dialogue on optimizing cancer care communication through systematic analyzes of patients’ perspectives.

Methods

Using constant comparative analysis, inductively derived thematic patterns of communication preferences for shared decision-making were drawn from individual interviews with 60 cancer patients.

Results

Thematic patterns in how patients understand barriers and facilitators to communication within shared decision-making illuminate the basis for distinctive patient preferences and needs. Prevailing cancer communication considerations included focusing attention on the tone and setting of the consultation environment, the attitudinal climate within the consult, the specific approach to handling numerical/statistical information, and the critical messaging around hope. The patient accounts surfaced complex dynamics whereby the experiences of living with cancer permeated interpretations and enactment of the shared decision-making that is emerging as a dominant ideal of cancer care.

Conclusion

In our efforts to move beyond traditional paternalism, shared decision-making has been widely advocated as best practice in cancer communication. However, patient experiential evidence suggests the necessity of a careful balance between standardized approaches and respect for diversities.

Practice implications

Shared decision-making as a practice standard must be balanced against individual patient preferences.     

The impact of patient and physician computer mediated communication skill training on reported communication and patient satisfaction

Objective

The objective was to evaluate parallel patient and physician computer-mediated communication skill training on participants’ report of skill use and patient satisfaction.

Methods

Separate patient and clinician web-tools comprised of over 500, 10-s video clips demonstrating patient-centered skills in various ways. Four clinician members of the American Academy of Family Physicians National Research Network participated by enrolling 194 patients into a randomized patient trial and 29 physicians into a non-randomized clinician trial of respective interventions. All participants completed baseline and follow-up self-report measures of visit communication and satisfaction.

Results

Intervention patients reported using more skills than controls in five of six skill areas, including identification of problems/concerns, information exchange, treatment adherence, shared decision-making and interpersonal rapport (all p < .05); post intervention, physicians reported using more skills in the same 5 areas (all p < .01). Intervention group patients reported higher levels of satisfaction than controls in five of six domains (all p < .05).

Conclusion

Communication skill training delivered in a computer mediated format had a positive and parallel impact on both patient and clinician reported use of patient-centered communication and in patient satisfaction.

Practice Implications

Computer-mediated interventions are cost and time effective thereby increasing patient and clinician willingness to undertake training.     

“Attention on the flight deck”: What ambulatory care providers can learn from pilots about complex coordinated actions

Objective

Technical and interpersonal challenges of using electronic health records (EHRs) in ambulatory care persist. We use cockpit communication as an example of highly coordinated complex activity during flight and compare it with providers’ communication when computers are used in the exam room.

Methods

Maximum variation sampling was used to identify two videotapes from a parent study of primary care physicians’ exam room computer demonstrating the greatest variation. We then produced and analyzed visualizations of the time providers spent looking at the computer and looking at the patient.

Results

Unlike the cockpit which is engineered to optimize joint attention on complex coordinated activities, we found polar extremes in the use of joint focus of attention to manage the medical encounter.

Conclusion

We conclude that there is a great deal of room for improving the balance of interpersonal and technical attention that occurs in routine ambulatory visits in which computers are present in the exam room.

Practice implications

Using well-known aviation practices can help primary care providers become more aware of the opportunities and challenges for enhancing the physician patient relationship in an era of exam room computing.     

Patient–provider communication and low-income adults: Age,race, literacy,and optimism predict communication satisfaction

Objective

To assess whether literacy, numeracy, and optimism are related to low-income adults’ satisfaction with their healthcare provider's communication skills.

Methods

Low-income adults (N = 131) were recruited from seven counties in Indiana through University extension programs. To achieve research triangulation, participants were surveyed and interviewed about their communication satisfaction with health providers.

Results

Survey data revealed that four variables significantly predicted satisfaction: age, race, literacy, and optimism. Low-income adults in the current study were more critical of their healthcare provider's communication skills if they were younger, White, functionally literate, and pessimistic. Follow-up interviews confirmed this pattern and suggested it was a byproduct of patient activism.

Conclusion

In low-income populations, communication satisfaction may be lower for groups that are traditionally active in doctor–patient interactions (e.g., younger patients, patients with higher literacy skills).

Practice implications

Healthcare providers should be aware that older, non-White, optimistic, and literacy deficient patients report greater communication satisfaction than their younger, White, pessimistic, and functionally literate peers. Both groups may be coping with their situation, the former by withdrawing and the latter by actively pushing for a higher standard of care. Healthcare providers should continue to seek out ways to facilitate dialogue with these underserved groups.     

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.