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1: J Altern Complement Med. 2005;11 Suppl 1:S51-6.
Communication about symptoms in primary care: impact on patient outcomes.
Jackson JL.
Department of Medicine, Uniformed Services University of the Health Sciences,
Bethesda, MD 20814, USA. jejackson@usuhs.mil
BACKGROUND AND PURPOSE: Good communication is an integral part of a healing
relationship. Our study's purpose was to explore the relationship between
patient-doctor communication about physical symptoms and patient outcomes
METHODS: Five hundred (500) consecutive adults presenting with physical symptoms
were surveyed. Previsit surveys assessed for patient symptom characteristics,
illness worry, stress, expectations, functional status (MOS SF-6), and mental
disorders (PRIME-MD). Immediately postvisit, patients were asked about their
satisfaction (Rand-9), the presence of unmet expectations, and what the
clinicians did for them; clinicians were asked what they did for the patients
and also completed a 10-item measure of how difficult the encounter was from
their perspective (DDPRQ). At 2 weeks, patient surveys assessed symptom outcome,
functional status (MOS SF6), and satisfaction. RESULTS: There was a high degree
of agreement between clinician and patient reports about concrete actions during
the encounter, such as prescription writing, diagnostic test ordering, or
providing referrals. However, there was little agreement about whether
clinicians discussed the symptom's diagnosis (k = 0.18) or prognosis (k = 0.27).
Encounters in which patients' reported receiving such information were
associated with greater satisfaction (Diagnosis: 2.1, 95% CI: 1.5-3.1;
Prognosis: 2.0, 95% CI: 1.4-2.9), fewer unmet expectations (Diagnosis: 0.41, 95%
CI: 0.24-0.71; Prognosis: 0.75, 95% CI: 0.52-0.98), less postvisit worry that
their symptom( s) could be serious (Diagnosis: 0.41, 95% CI: 0.29-0.64;
Prognosis: 0.53, 95% CI: 0.36-0.79), and better 2-week symptom outcomes
(Diagnosis: 1.7, 95% CI: 1.1-2.5; Prognosis: 1.9, 95% CI: 1.3-3.0). CONCLUSIONS:
Patients and clinicians disagreed about whether or not communication about
symptom diagnosis and prognosis occurred during their encounter. Patient reports
of receiving such information were associated with greater satisfaction, less
worry, fewer unmet expectations, and better 2-week symptom outcomes.
PMID: 16332187 [PubMed - in process]
2: J Affect Disord. 2005 Jan;84(1):43-51.
Communicative skills of general practitioners augment the effectiveness of
guideline-based depression treatment.
van Os TW, van den Brink RH, Tiemens BG, Jenner JA, van der Meer K, Ormel J.
Department of Psychiatry and Graduate School of Behavioral and Cognitive
Neuroscience's, University of Groningen, The Netherlands.
T.W.D.P.van.Os@acggn.azg.nl
BACKGROUND: Although good physician communication is associated with positive
patient outcomes, it does not figure in current depression treatment guidelines.
We examined the effect of depression treatment, communicative skills and their
interaction on patient outcomes for depression in primary care. METHODS: In a
cohort of 348 patients with ICD-10 depression in primary care, patient outcomes
were studied over 3- and 12-month follow-ups. The association of these outcomes
with both depression-specific process of care variables and a nonspecific
variable-communicative skillfulness of GP-was examined. Patient outcomes
consisted of change from baseline in symptomatology, disability, activity
limitation days, and duration of the depressive episode. RESULTS: In accordance
with treatment guidelines, some main effects of depression treatment were found,
in particular on symptomatology, but these remained small (effect size<0.50). A
moderate effect was found for treatment with a sedative, which proved to be
related to worse patient outcomes at 12 months. An accurate GP diagnosis of
depression and adequate antidepressant treatment were associated with better
patient outcomes, but only when provided by GPs with good communicative skills.
In contrast to the main effects, these interactions were seen on disability and
activity limitation days, not on symptomatology. LIMITATIONS: The study is
observational and does not permit firm conclusions about causal relationships.
Communicative skillfulness of the GP was assessed by patient report only.
CONCLUSION: Neither depression-specific interventions nor good GP communication
skills seem to be sufficient for optimal patient improvement. Only the
combination of treatments according to guidelines and good communication skills
results in an effective antidepressive treatment.
PMID: 15620384 [PubMed - indexed for MEDLINE]
3: Am J Psychiatry. 2004 Oct;161(10):1892-901.
Treatment outcome and physician-patient communication in primary care patients
with chronic, recurrent depression.
Schwenk TL, Evans DL, Laden SK, Lewis L.
Department of Family Medicine, L2003, Box 0239, Ann Arbor, MI 48109, USA.
tschwenk@umich.edu.
OBJECTIVE: The authors' goal was to assess the adequacy of control, quality of
life, and treatment experiences of patients with chronic, recurrent depression
being treated by primary care physicians. METHOD: The sample comprised 1,001
patients 18 years old or older who had chronic, recurring depression and were
currently being treated with a single antidepressant prescribed by a primary
care physician. These patients had responded positively to questions regarding
the presence of clinical depression and prescription of a single antidepressant
by a primary care physician during a telephone survey conducted in two stages
separated by 18 to 24 months. The 1,001 patients participated in a structured,
20-minute, anonymous interview conducted by trained personnel. RESULTS: Most
patients had recurrent depression (median=5 episodes), and most had taken their
current antidepressant for more than 1 year. The mean age at onset of depression
was 33.8 years, and the mean age at time of diagnosis was 38.0 years, with
treatment following a mean of 2 years later. Most patients were satisfied with
the care they received from their primary care physician, but many also reported
incomplete symptom resolution and substantial side effects from medications that
were not discussed with or by their primary care physician. A majority of
patients reported that treatment decisions were made in conjunction with their
physician, a method that was preferred by three-quarters of the group. Although
752 patients reported that they had mild or moderate depression, 729 were
satisfied with their life and 600 said they were in good or excellent health.
CONCLUSIONS: Despite being mostly satisfied with the care received from their
primary care physician, patients with chronic, recurring depression had
substantial levels of continuing dysfunction, distress, unrelieved symptoms, and
medication side effects, which suggests several possible physician-centered,
patient-centered, or system-centered barriers to treatment to full function and
wellness.
PMID: 15465988 [PubMed - indexed for MEDLINE]
4: J Womens Health. 1998 Oct;7(8):1041-8.
Factors influencing outcome in consultations for chronic pelvic pain.
Selfe SA, Matthews Z, Stones RW.
University Department of Obstetrics and Gynaecology, Princess Anne Hospital,
Southampton, U.K.
We aimed to document the demographic and clinical characteristics of women
referred by primary care physicians for investigation of chronic pelvic pain to
a university hospital gynecology outpatient clinic and to test the hypothesis
that specific patient features and the quality of doctor/patient communication
at the initial consultation would influence pain outcomes. A clinical
questionnaire, visual analog scales for pain, and instruments for hostility and
the experience of the consultation were administered at the initial clinic
attendance to 105 consecutive women. Follow-up pain scores were obtained 6
months later from 98 women. The mean hostility score was highly significantly
elevated compared with normative data (p < 0.001). In a logistic regression
model, a favorable patient rating of the initial consultation was associated
with complete recovery at follow-up and interacted significantly with whether or
not exercise was impaired (p < 0.005). For those in whom symptoms persisted,
significant factors found by multiple regression models to predict continuing
pain levels were the initial level of pain, the number of functions of daily
life impaired, endometriosis, and the doctor who carried out the initial
consultation. Patient hostility scores and the doctor's level of experience or
gender were not significantly associated with continuing pain. This study
highlights the importance of good communication as a basis for successful
treatment of a group of hostile patients and indicates the influence in
individual doctors of subtle attitudinal and personality factors that modify
patients' experience of the medical consultation.
PMID: 9812301 [PubMed - indexed for MEDLINE]
5: Am J Med. 1998 Sep;105(3):222-9.
Outcomes, preferences for resuscitation, and physician-patient communication
among patients with metastatic colorectal cancer. SUPPORT Investigators. Study
to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.
Haidet P, Hamel MB, Davis RB, Wenger N, Reding D, Kussin PS, Connors AF Jr, Lynn
J, Weeks JC, Phillips RS.
Division of General Medicine and Primary Care, Beth Israel Deaconess Medical
Center, Boston, Massachusetts 02215, USA.
PURPOSE: To describe characteristics, outcomes, and decision making in patients
with colorectal cancer metastatic to the liver, and to examine the relationship
of doctor-patient communication with patient understanding of prognosis and
physician understanding of patients' treatment preferences. PATIENTS AND
METHODS: The Study to Understand Prognoses and Preferences for Outcomes and
Risks of Treatments (SUPPORT) was a prospective cohort study conducted at five
teaching hospitals in the United States between 1989 and 1994. Participants in
this study were hospitalized patients 18 years of age or older with known liver
metastases who had been diagnosed with colorectal cancer at least 1 month
earlier. Data were collected by patient interview and chart review at study
entry; patients were interviewed again at 2 and 6 months. Data collected by
physician interview included estimates of survival and impressions of patients'
preferences for cardiopulmonary resuscitation (CPR). Patients and physicians
were also asked about discussions about prognosis and resuscitation preferences.
RESULTS: We studied 520 patients with metastatic colorectal cancer (median age
64, 56% male, 80% white, 2-month survival 78%, 6-month survival 56%). Quality of
life (62% "good" to "excellent") and functional status (median number of
disabilities = 0) were high at study entry and remained so among interviewed
survivors at 2 and 6 months. Of 339 patients with available information, 212
(63%) of 339 wanted CPR in the event of a cardiopulmonary arrest. Factors
independently associated with preference for resuscitation included younger age,
better quality of life, absence of lung metastases, and greater patient estimate
of 2-month prognosis. Of the patients who preferred not to receive CPR, less
than half had a do-not-resuscitate note or order written. Patients'
self-assessed prognoses were less accurate than those of their physicians.
Physicians incorrectly identified patient CPR preferences in 30% of cases.
Neither patient prognostication nor physician understanding of preferences were
significantly better when discussions were reported between doctors and
patients. CONCLUSIONS: A majority of patients with colorectal cancer have
preferences regarding end of life care. The substantial misunderstanding between
patients and their physicians about prognosis and treatment preferences appears
not to be improved by direct communication. Future research focused on enhancing
the effectiveness of communication between patients and physicians about end of
life issues is needed.
PMID: 9753025 [PubMed - indexed for MEDLINE]
6: Med J Aust. 1998 Apr 20;168(8):386-9.
Comment in:
Med J Aust. 1999 Feb 1;170(3):144.
Women's satisfaction with general practice consultations.
Young AF, Byles JE, Dobson AJ.
Research Institute for Gender and Health, University of Newcastle, NSW.
stafy@cc.newcastle.edu.au
OBJECTIVE: To determine women's satisfaction with general practice services.
DESIGN: Cross-sectional postal questionnaire conducted during April to September
1996 (part of the baseline survey of the Australian Longitudinal Study on
Women's Health). PARTICIPANTS: Women aged 18-22 (n = 14,739), 45-49 (n = 14,013)
and 70-74 (n = 12,941) years, randomly selected from the Medicare database, with
oversampling of women from rural and remote areas. MAIN OUTCOME MEASURES:
Frequency of use of general practice services; satisfaction with the most recent
visit to a general practitioner (GP); prevalence of selected symptoms;
preference for a female doctor. RESULTS: The most recent visit to a GP was rated
overall as good, very good or excellent by more than 80% of women, with
increasing levels of satisfaction with increasing age of the women. However,
satisfaction was lower for waiting room time and cost of the visit. A third of
the young and middle-aged women living in rural and remote areas were
dissatisfied with the cost of the visit. Young women were more likely to prefer
a female doctor, and many were dissatisfied with their GP's skills at explaining
their problem and giving them a chance to give an opinion and ask questions. The
most prevalent symptoms for all women included headaches and tiredness, and may
were not satisfied with the health services available to help them deal with
these symptoms. CONCLUSIONS: Australian women have high levels of satisfaction
with GP consultations. However, more effective strategies may be needed to
improve communication with younger women, and there is an unmet need for
services to help all women deal with some common symptoms. Dissatisfaction with
cost of services and women's preference for female doctors have implications for
future health policy.
PMID: 9594948 [PubMed - indexed for MEDLINE]
7: Soc Sci Med. 1995 Apr;40(7):903-18.
Doctor-patient communication: a review of the literature.
Ong LM, de Haes JC, Hoos AM, Lammes FB.
Department of Medical Psychology, Academic Medical Hospital, Amsterdam, The
Netherlands.
Communication can be seen as the main ingredient in medical care. In reviewing
doctor-patient communication, the following topics are addressed: (1) different
purposes of medical communication; (2) analysis of doctor-patient communication;
(3) specific communicative behaviors; (4) the influence of communicative
behaviors on patient outcomes; and (5) concluding remarks. Three different
purposes of communication are identified, namely: (a) creating a good
inter-personal relationship; (b) exchanging information; and (c) making
treatment-related decisions. Communication during medical encounters can be
analyzed by using different interaction analysis systems (IAS). These systems
differ with regard to their clinical relevance, observational strategy,
reliability/validity and channels of communicative behavior. Several
communicative behaviors that occur in consultations are discussed: instrumental
(cure oriented) vs affective (care oriented) behavior, verbal vs non-verbal
behavior, privacy behavior, high vs low controlling behavior, and medical vs
everyday language vocabularies. Consequences of specific physician behaviors on
certain patient outcomes, namely: satisfaction, compliance/adherence to
treatment, recall and understanding of information, and health
status/psychiatric morbidity are described. Finally, a framework relating
background, process and outcome variables is presented.
Publication Types:
Review
PMID: 7792630 [PubMed - indexed for MEDLINE]
8: Geburtshilfe Frauenheilkd. 1989 May;49(5):472-6.
[Communication, compliance and perinatal risks of Turkish females in Tyrol]
[Article in German]
Brezinka C, Huter O, Busch G, Unus S.
Univ.-Klinik fur Frauenheilkunde Innsbruck.
Migrant workers from Turkey and their families make up 1% of the population of
the Tyrol province in the west of Austria. They are the largest group of aliens.
152 Turkish women who were seen at our obstetrics department were investigated.
Records of 121 women who had given birth to infants in the years 1984-86 were
compared. 31 pregnant women were interviewed in their native language. More than
80% of all women studied went for routine check-ups four times or more during
pregnancy. A number of conditions that would otherwise remain undetected are
being diagnosed at routine pregnancy checks: tuberculosis, diabetes, genetic
disease. Although patient compliance is good in this group, communication
problems often put a successful outcome of the pregnancy at risk. Many women,
who have been living in Austria for many years, are still unable to speak and
understand German. Unqualified interpreters (husbands, children, relatives,
hospital cleaning staff that is composed largely of Turks) often create problems
by making up things the doctor would like to hear. The rate of cesarean sections
is 11% in this group. Perinatal infant mortality rate is much higher than in the
native Austrian population. The strict hygienic rules of Islam, the support and
nurture supplied by the tightly-knit family structure of Turkish emigrants and a
basically confident and trusting attitude towards doctors and nurses, if these
can make themselves understood, should be recognised as positive factors and
should be used to reduce perinatal risks in pregnant Turkish women.
PMID: 2737437 [PubMed - indexed for MEDLINE] |
