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PubMed1996

Facing future challenges in general practice: a clinical method with computer support.

This paper proposes a clinical method for general practice which is patient-centred and which ensures that the doctor's agenda is supported to secure 'best practice'. It encompasses self-learning for GPs which is patient-focused and describes the encouragement and support of patient self-care. The method attempts to be pragmatic and usable within GPs' available time. The method, however, is not solely focused on the GP; it encompasses the primary health care team and the patient. It uses clinical information systems to assist in the management of the patient care plan, to supply information to the GP and patient, in order to aid shared decision making and to quality assure clinical activity. It goes further by extending the care process to handle 'virtual' encounters in which the clinical information systems play a central role.

Education, Medical, Continuing↗
PubMed2004

Antibiotics for acute respiratory tract symptoms: patients' expectations, GPs' management and patient satisfaction.

BACKGROUND: GPs often assume that prescribing antibiotics increases patient satisfaction. OBJECTIVE: The purpose of this study was to determine the associations between receiving antibiotics and information/reassurance on the one hand and patients' satisfaction on the other in patients with acute respiratory tract symptoms, and to assess whether this relationship is influenced by patients' expectations. METHODS: Questionnaires were distributed among patients presenting with acute respiratory tract symptoms in 51 general practices (122 GPs) in the region of Utrecht, The Netherlands. Outcome measures were patients' expectations, GPs' management regarding antibiotic prescribing and information/reassurance, and patient satisfaction. RESULTS: Information/reassurance was expected by 90% of the respondents (916/1014); 97% of those actually received it (888/916). Fifty percent expected antibiotics (467/926), while 73% of them received antibiotics (343/467). Receiving information/reassurance was more strongly associated with satisfaction than an antibiotic prescription [adjusted odds ratio (OR) 10.6; 95% confidence interval (CI) 5.6-20.1, and adjusted OR 2.2; 95% CI 1.3-3.8, respectively]. Patients' expectations towards antibiotics modified these associations; in patients not expecting antibiotics, receiving information/reassurance was the only independent determinant of satisfaction (adjusted OR 21.6; 95% CI 7.4-62.7) and in patients who expected antibiotics, actually receiving antibiotics and receiving information/reassurance were equally important determinants of satisfaction (adjusted OR 3.8; 95% CI 1.9-7.5, and adjusted OR 4.7; 95% CI 1.9-11.9, respectively). CONCLUSION: GPs should first explore patients' expectations about antibiotic treatment before giving information about the self-limitedness of respiratory tract symptoms and (in)effectiveness of antibiotics in order to enhance shared decision making and rationalize antibiotic prescribing.

Adolescent↗
PubMed2001

The longitudinal primary care clerkship at Harvard Medical School.

The primary care clerkship (PCC) at Harvard Medical School was established in 1997. The goals are to provide students with longitudinal experiences with patients and to include modern themes in the curriculum: managing illness and clinical relationships over time; finding the best available answers to clinical questions; preventing illness and promoting health; dealing with clinical uncertainty; getting the best outcomes with available resources; working in a health care team; and sharing decision making with patients. The PCC, a required course in the clinical years, meets one afternoon a week for nine months. Students spend three afternoons per month in primary care practices, where they see three to five patients per session and follow at least one patient ("longitudinal patient") over time. Classroom sessions, in both large- and small-group formats, promote a common educational philosophy and experience, and reinforce habits of problem-based learning established in the preclinical years. The students rated 74% of their preceptors excellent, especially praising their ability to facilitate and support good interpersonal relationships with patients, their ability to encourage students' independent evaluation of patients (as opposed to shadowing), and their enthusiasm for teaching. Students saw their longitudinal patients a mean of 4.8 times; 83% saw their patients at least three times. The PCC complements the curriculum of block clerkships in hospitals, and because the two are offered concurrently, students are required to come to terms with two substantially different cultures within medicine. Other medical schools are beginning to develop longitudinal clerkships to ensure that students have essential educational experiences that are difficult to achieve in block, hospital-based clerkships.

Attitude of Health Personnel↗
PubMed2002

An advanced communication skills course for fourth-year, post-clerkship students.

OBJECTIVE: A novel five-module advanced communication skills course entitled "Doctor-Patient Relationships" was planned and implemented in 2000-01 at the University of British Columbia (UBC). The course was part of the final four-month component of the new MD undergraduate program: Effective Skills for Medical Practice. The goals of the communication skills course were to (1) address problems experienced by the students so far; (2) address deficiencies in achieving the UBC exit competencies; (3) help the students pass the Medical Council of Canada examinations, in particular objectives related to the Considerations of the Legal, Ethical, and Organizational aspects of the practice of medicine (CLEO); and (4) help students prepare for their roles beyond undergraduate medicine (residency, independent practice). DESCRIPTION: The course was developed by an interdisciplinary team (family practice, pathology, pediatrics, psychiatry, surgery) with input from students. The broad strengths and weaknesses of their communication skills training were identified by seven third-year medical students who kept logs over the course of their clinical clerkships to document their learning of communication skills. Analysis of these logs plus feedback meetings with the students revealed attitudinal and skills issues that needed to be addressed in the new course. The goals and principles of the course were in part agreed upon by focus groups with students, attended by faculty observers, to ensure their relevance to students. The first module "Beyond the Mask: Surviving and Thriving in Residency Training" is designed to focus students' attention on the personal relevance of developing excellence in communication skills in preparation for residency training. It includes a video of residents talking about their experiences of communication problems to trigger reflection and discussion. In the remaining four modules the students are required to put communication skills together with their medical knowledge. Each module includes pre-readings, video demonstrations (in sessions 4 and 5), practice with standardized patients (total of 14 scenarios) and structured feedback from SPs, students, and tutor. The themes of the sessions are "Dealing with Emotionally Challenging Patient Situations (informing about bad news), "Compliance and Patient Information," "Informed Consent and Shared Decision Making," and "Difficult Physician-Patient Encounters." Each module lasts two hours. The course was implemented for 120 students, facilitated by 14 tutors (seven to eight students per group). DISCUSSION: Student involvement in many different ways provided an important reality check and made us think about how to present the new course so that it was relevant and interesting to students. Attention to student input was a major contributor to the good evaluations given the course. Students rated the course highly: the relevance of the weekly themes was rated 4.21 on a five-point scale; the effectiveness of the SP interviews, 4.10; the effectiveness of the group discussion and feedback, 4.18; and overall course effectiveness in enhancing communication skills, 3.91. The tutors also rated the course highly, and the students rated the tutors highly. Minor changes will be made to the course next year based on the specific suggestions for improvement, which were identified.

British Columbia↗
PubMed1998

The patient's role in rheumatology care.

This article reviews narrative and empiric studies in rheumatology and related literature to explicate the patient's role in rheumatology care. In contrast to early conceptualizations, such as Parsons' sick role that emphasized compliance, current literature describes chronic disease patients as active participants in their care, rather than passive recipients of care. Active patients roles include participant in shared decision making, self-manager, and help and information seeker. All of these roles are colored by the individual's need to preserve a personally defined acceptable lifestyle. Suggestions for strategies that physicians and health professionals can use to engage and support these essential patient roles are also reviewed.

Decision Making↗
PubMedDate not supplied

Effectiveness of an intervention to improve parent-professional collaboration in neonatal intensive care.

OBJECTIVE: This study tested the effect of an intervention to strengthen parent-professional collaboration by increasing the accuracy of parents' understanding of medically relevant information and providing parent-professional meetings to plan infants' care. METHODS: A tri-ethnic sample of mothers of 154 very-low-birth-weight infants participated, with parents of 77 infants in a control group and parents of 77 infants in an intervention group. Comprehension of infant medical condition and satisfaction with collaboration in treatment decisions in the 2 groups were measured 3 times during the first 28 days after admission using 9 collaboration scales. Intervention effects were analyzed with ANOVA and ANCOVA. RESULTS AND CONCLUSIONS: Statistically significant change was found in 6 of 9 scales used to measure collaboration and accuracy of parents' understanding. The intervention group had fewer unrealistic concerns (P = .018), and less uncertainty about infant medical conditions (P = .003); less decision conflict (P < or = .001), more satisfaction with the process by which medical decisions were made (P = .012) and with the amount of decision input they had (P = .058), and reported more shared decision making with professionals (P = .010). There were no statistically significant differences between the groups in satisfaction with infants' care, satisfaction with relationships with physicians and nurses, and satisfaction with the decisions made for their infants' treatment. Infant birth weight and gestational age and maternal demographic characteristics were found to influence collaboration results. The intervention was especially effective in improving understanding and collaboration in low-income, young, minority mothers.

Adolescent↗
PubMed2001

Measuring and predicting surgeons' practice styles for breast cancer treatment in older women.

BACKGROUND: Few measures exist to assess physicians' practice style, and there are few data on physicians' practice styles and patterns of care. OBJECTIVES: To use clinical vignettes to measure surgeons' "propensity" for local treatments for early-stage breast cancer and to describe factors associated with propensity. RESEARCH DESIGN AND SUBJECTS: A cross-sectional mailed survey with telephone follow-up of a random sample of 1,000 surgeons treating Medicare beneficiaries in fee-for-service settings. MEASURES: Outcome measures include treatment propensity, self-reported practice, and actual treatment received by the surgeons' patients. RESULTS: Propensities were significantly associated with actual treatment, controlling for covariates. Area Medicare fees were the strongest predictor of propensity, followed by region, attitudes, volume, and gender. For instance, after other factors were considered, surgeons practicing in areas with the highest breast-conserving surgery (BCS) fees were 8.61 (95% CI 2.26-32.73) times more likely to have a BCS propensity than surgeons in areas with the lowest fees. Surgeons with the strongest beliefs in patient participation in treatment decisions were nearly 6 times (95% CI 1.67-20.84) more likely to have a BCS propensity than surgeons with the lowest such beliefs, controlling for covariates. Male surgeons were also independently more likely to have a mastectomy propensity than female surgeons. CONCLUSIONS: Surgeons' propensities explain some of the observed variations in breast cancer treatment patterns among older women. Standardized scenarios provide a practical method to measure practice style and could be used to evaluate physician contributions to shared decision making, practice patterns, costs and outcomes, and adherence to guidelines.

Adult↗
PubMed2006

Toward interventions to improve end-of-life care in the pediatric intensive care unit.

Although children account for only about 3% of all deaths that occur in the United States each year, these patients and their families have needs that are uniquely different from those of adult patients. To date, however, no research on interventions to improve end-of-life care in the pediatric intensive care unit (PICU) has been performed. This review seeks to facilitate and inform future interventional studies by summarizing existing descriptive data about end-of-life care in this setting. These data are organized around six domains that have been identified as critical to high-quality, family-centered care: 1) support of the family unit; 2) communication with the child and family about treatment goals and plans; 3) ethics and shared decision making; 4) relief of pain and other symptoms; 5) continuity of care; and 6) grief and bereavement support. These data are integrated and used to develop evidence-based suggestions for a variety of interventions that could be implemented and then evaluated for their potential contribution to improving the care of children dying in the PICU.

Bereavement↗
PubMed2006

Interdisciplinary model for palliative care in the trauma and surgical intensive care unit: Robert Wood Johnson Foundation Demonstration Project for Improving Palliative Care in the Intensive Care Unit.

Integrating palliative care into the surgical and trauma intensive care unit is challenging. The nature of surgical illness, practice patterns of surgeons and critical care nurses, and the culture of the intensive care unit all suggest that familiar models of palliative care do not apply in this setting. We describe a novel interdisciplinary model of palliative care in the surgical intensive care unit, which addresses communication, shared decision making, and pain and symptom management for all critically ill patients, regardless of prognosis. This communication-based model integrates new processes of care into existing surgical critical care practice so that palliative care can be provided in parallel with surgical care.

Decision Making↗
PubMed2006

Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: challenges and opportunities for moving forward.

Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.

Cooperative Behavior↗
PubMed2006

Development of a practical tool for assessing the severity of acute otitis media.

BACKGROUND: Watchful waiting management of nonsevere acute otitis media (AOM) can reduce the use of antibiotics, but it requires a reliable means of assessing clinical severity. OBJECTIVE: We present the development of a pocket AOM card with which the clinician can rapidly assess total AOM severity. DESIGN/METHODS: The components of the pocket card consisted of a faces scale, to assess parent perception of severity, and a standard set of tympanic membrane photographs, with which the pediatrician can grade the severity of tympanic membrane inflammation. The components of the pocket card were tested for validity, reliability and responsiveness with the use of data from parents, pediatricians and pediatric otolaryngologists. STATISTICS: Instruments were assessed for concurrent correlation, sequence validity and reliability against previously published questionnaires with the use of Spearman correlation. Responsiveness was calculated with the use of enrollment, day 12 and day 30 data from a randomized clinical trial. RESULTS: The components of the pocket AOM card demonstrated excellent sequence validity, concurrent correlation and reliability (r = 0.58-0.99). Total AOM card severity, consisting of the sum of the 2 scales, demonstrated better responsiveness to change than any of the scales taken individually. CONCLUSIONS: The AOM card combines a parent assessment of symptoms and the clinician assessment of the tympanic membrane to provide an assessment of total AOM severity that can be used to facilitate shared decision making between parent and clinician. The combined score of the AOM card was more responsive to change than any of the instruments used alone. The AOM card provides a useful tool for teaching and research.

Acute Disease↗
PubMed2006

Legal and ethical issues relating to use of complementary therapies in pediatric hematology/oncology.

Pediatricians increasingly are asked to advise pediatric patients and their families concerning integration into conventional care (including hematology and oncology) of complementary and alternative medical (CAM) therapies such as chiropractic, massage therapy, and herbal medicine. Inclusion of CAM therapies in pediatric oncology and hematology--as in any medical subspecialty--is not itself "unethical," clinically inadvisable, or legally risky; the danger comes from over-reliance on one or more CAM therapies (particularly those with evidence of danger and/or paltry evidence of success) to the exclusion of conventional care that is curative and imminently necessary. Pediatricians can help address potential malpractice liability issues by evaluating the level of clinical risk, engaging the patient in shared decision making and documenting this in the medical record, continuing to monitor conventionally, and being prepared to intervene conventionally when medically required.

Child↗
PubMed2001

Involving patients in research: setting up a service users' advisory group.

Looks at some of the issues raised by patients' involvment in the research process. Uses the example of a service users' advisory group established as part of a diabetes service evaluation in the north of England. Key conclusions were: a precise role for the group should be specified at the outset; genuine user involvement is needed; wide and accurate representation of all relevant groups in society is essential; and, researchers must approach users with open minds with a view to shared decision making rather than control.

Asia, Southeastern↗
PubMed2004

Assessment of medical communication skills by computer: assessment method and student experiences.

BACKGROUND: A computer-assisted assessment (CAA) program for communication skills designated ACT was developed using the objective structured video examination (OSVE) format. This method features assessment of cognitive scripts underlying communication behaviour, a broad range of communication problems covered in 1 assessment, highly standardised assessment and rating procedures, and large group assessments without complex organisation. SETTING: The Academic Medical Centre (AMC) at the University of Amsterdam, the Netherlands. Aims To describe the development of the AMC Communication Test (ACT); to describe our experiences with the examination and rating procedures; to present test score descriptives, and to present the students' opinions of ACT. DESIGN: The ACT presents films on history taking, breaking bad news and shared decision making. Each film is accompanied by 3 types of short essay questions derived from our assessment model: "knows", "knows why/when" and "knows how". Evaluation questions about ACT were integrated into the assessment. Participants A total of 210 third year medical undergraduates were assessed. This study reports on the 110 (53%) students who completed all evaluation questions. RESULTS: Marking 210 examinations took about 17 days. The test score matched a normal distribution and showed a good level of discrimination of the students. About 75% passed the examination. Some support for the validity of our assessment model was found in the students' differential performance on the 3 types of questions. The ACT was well received. Student evaluations confirmed our efforts to develop realistic films that related well to the communication training programme. CONCLUSIONS: The ACT is a useful assessment method which complements interpersonal assessment methods for the evaluation of the medical communication skills of undergraduates.

Attitude of Health Personnel↗
PubMed2004

The future of general internal medicine. Report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine.

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep-ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.

Career Choice↗
PubMed2005

The doctor will see you shortly. The ethical significance of time for the patient-physician relationship.

Many physicians and health care leaders express concern about the amount of time available for clinical practice. While debates rage on about how much time is truly available, the perception that time is inadequate is now pervasive. This perception has ethical significance, because it may cause clinicians to forego activities and behaviors that promote important aspects of the patient-physician relationship, to shortcut shared decision making, and to fall short of obligations to act as patient advocates. Furthermore, perceived time constraints can hinder the just distribution of physician time. Although creating more time in the clinical encounter would certainly address these ethical concerns, specific strategies-many of which do not take significantly more time-can effectively change the perception that time is inadequate. These approaches are critical for clinicians and health systems to maintain their ethical commitments and simultaneously deal with the realities of time.

Attitude of Health Personnel↗
PubMed2006

When do older adults turn to the internet for health information? Findings from the Wisconsin Longitudinal Study.

BACKGROUND: Understanding how and when patients use nonphysician sources of health information is important to facilitate shared decision making within provider outpatient visits. However, little is known about which older adults seek health information on the internet or when. OBJECTIVE: To determine how patient characteristics are related to seeking health information online and to the timing of these searches in relation to doctor visits. PARTICIPANTS: Six thousand two hundred and seventy-nine respondents (aged 63 to 66 years) who completed the 2004 round of phone and mail surveys (70% response) as part of the Wisconsin Longitudinal Study Graduate Sample. MEASUREMENTS: Self-reported use of the internet to search for health information and timing of use. RESULTS: One-third of respondents had searched online for information about their own health or health care. Half of these searched for health information unrelated to their last doctor visit, while 1/3 searched after a visit, and 1/6 searched before. Among respondents with internet access at home or work, years of education (odds ratio [OR]=1.09, confidence interval [CI]=1.06 to 1.13) and openness-to-experience (OR=1.26, CI=1.16 to 1.36) were positively associated with searching online for health information irrespective of timing in relation to doctor visits. Compared with those who had never sought health information online, sicker individuals (especially those with cancer, OR=1.51, CI=1.14 to 1.99) were more likely to seek information online after a doctor visit. Attitudinal and personality factors were related to seeking health information online before or unrelated to a visit. CONCLUSIONS: There are important differences in the timing of online health information searches by psychological and health characteristics among older adults with internet access.

Aged↗