A.M. van Dulmen

Do patients with irritable bowel syndrome in primary care really differ from outpatients with irritable bowel syndrome

Background—Little is known about the comparability of outpatients with irritable bowel syndrome (IBS) and patients with IBS in primary care with regard to severity of complaints, perceived limitations, other aspects of the complaints, and sex differences. Aims—To compare outpatients with IBS with primary care patients with IBS. Patients—One hundred and nine patients with IBS were recruited from general practices in Amsterdam and 86 patients with IBS were recruited from the outpatient clinic of the Department of Internal Medicine of the University Hospital in Nijmegen. Methods—Each patient completed a questionnaire on demographic variables, abdominal complaints, related complaints, and attributed causes of their abdominal complaints. The scores of the two groups were compared by univariate and multivariate analysis. Results—The outpatient group contained significantly more men, reported more severe abdominal pain, more frequent complaints, more interference with daily activities, and a higher degree of avoidance of activities (p<0.01) than the primary care group. When each sex was analysed separately, these differences remained for female (p<0.01) but not for male patients. Outpatients were more likely to attribute their complaints to somatic causes (p<0.01), whereas primary care patients were more likely to attribute their complaints to stress (p<0.01) or their agitated way of life (p<0.05). Multivariate analysis showed that a high severity score, a large number of additional complaints, and a low score on the stress attribution were important determinants for being in the outpatient group. Conclusions—Female outpatients consider their complaints to be more serious and interfering than do patients with IBS in primary care. Male outpatients were comparable to primary care patients with IBS. More research needs to be done into sex specific differences in IBS and into the factors that influence the decision to refer a patient with IBS.

Health promoting effects of the physician–patient encounter

The efficacy of a medical treatment partly depends on the interpersonal context in which an intervention takes place. By identifying what factors in the medical encounter engender effect beyond that of the therapeutic intervention, treatment outcome is likely to increase. This study gives an overview of the most important literature examining the relationship between physiological outcome measures and factors pertaining to the medical health care visit. Research findings suggest that the stressfulness of the medical encounter impacts on a patients health negatively. Yet, this negative experience can be transformed into a positive one when physicians use empathic and patient-centred communication styles and assist patients in altering incorrect ideas about their complaints.

Survival and psychosocial adjustment to stoma surgery and nonstoma bowel resection: a 4-year follow-up.

A prospective 4-year follow-up study was conducted to compare the psychosocial adjustment process and survival rate of 59 stoma patients with 64 bowel-resected nonstoma patients. Adjustment was assessed at 4 months. 1 year, and 4 years after surgery by the Psychosocial Adjustment to Illness Scale, a self-report questionnaire (PAIS-SR). Analyses of covariance demonstrated that both subgroups experienced the same level of psychosocial problems 4 years after surgery. Interestingly, patients with poor early adjustment scores (4 months after surgery) were at significantly higher risk of dropping out because of death and terminal status during the follow-up period (1 and 4 years postoperatively). The presence of a stoma did not influence the risk rate for dropping out. These results demonstrate the need for prolonged psychosocial guidance of outpatients who have been surgically treated for colorectal cancer or inflammatory bowel disease.

Gender differences in gynecologist communication

ABSTRACT The intimate nature of gynecological health problems requires the physicians specific attention. On the basis of previous findings in primary care, female gynecologists are expected to communicate more affectively than men. This study addressed gender differences in gynecologist communication behavior by comparing videotapes of real-life outpatient encounters with female (N = 107) and male (N = 196) gynecologists by means of bivariate and multilevel analysis. Only a few gender differences were found: female gynecologists performed longer physical examinations, showed more global attentiveness, and asked fewer medical questions. Either the duration of the medical education or the type of statistical analysis may account for this lack of gender differences.

Communication at an online infertility expert forum: provider responses to patients’ emotional and informational cues

Abstract Online patient-provider communication has become increasingly popular in fertility care. However, it is not known to what extent patients express cues or concerns and how providers respond. In this study, we investigated cues and responses that occur in online patient-provider communication at an infertility-specific expert forum. We extracted 106 threads from the multidisciplinary expert forum of two Dutch IVF clinics. We performed the following analyses: (1) thematic analysis of patients’ questions; and (2) rating patients’ emotional and informational cues and subsequent professionals’ responses using an adaptation of the validated Medical Interview Aural Rating Scale. Frequencies of themes, frequencies of cues and responses, and sequences (what cue is followed by what response) were extracted. Sixty-five infertile patients and 19 providers participated. The most common themes included medication and lifestyle. Patients gave more informational than emotional cues (106 versus 64). Responses to informational cues were mostly adequate (61%). The most common response to emotional cues was empathic acknowledgment (72%). Results indicate that an online expert forum could have a positive effect on patient outcomes, which should guide future research. Offering infertile patients an expert forum to communicate with providers can be a promising supplement to usual care in both providing information and addressing patients’ concerns.

Communication in health care

Introduction approach which has exercised considerable influence Although communication in health care is as old as came from the communication sciences. Dividing comHippocrates, it has only recently received attention in its munication into senders, receivers, media, and messages, own right. That is not to say that great doctors such as this discipline formulated the requirements to be put on Hippocrates, Maimonides, Boerhaave or Virchow did not the message in particular. The influence of this approach mention the doctor-patient relationship. On the contrary, was especially felt in the field of patient instruction, 9 they stressed that it was of the utmost importance. In health promotion, and patient education. Watzlawick’s fact, in the days before bacteriological and virological thorough analysis of interaction between people made knowledge, trust, confidence and the power of persuasion clear that messages are not simply messages, but can were a doctors most effective tools. But it is only in the carry different layers of sometimes contradictory meanlast half century that doctor-patient communication has ing. In addition, senders and receivers do not have fixed become an object of attention in its own right. The roles, but constantly take different points of view.A final conference on Communication in Health Care, with the group of theoretical approaches to be mentioned here abstracts presented in this volume, represents the state of came from information theory and has had its influence 10 the art in this subject in 1998. In this editorial we give a on medical decision making .These theoretical apretrospective account of the preceding issues in this proaches, formulated between 1940 and 1970, provide ongoing story. the foundations for the purposes of communication in 11 health care as distinguished by Ong and colleagues : Theoretical foundations creating a good personal relationship, exchanging inSeveral theoretical perspectives fostered the early studies formation, and making treatment decisions. of doctor-patient communication. From a sociological perspective, the concept of ‘power’ was a central issue. 1 The ‘medical model‘ elaborated by Parsons and Vocational and postgraduate training 2 Freidson defines a hierarchical relationship between Training and research into patient-provider interactions doctor and patient. This relationship was criticized by seem to have developed more or less independently of 3 4 many, including Thomas Szasz , Ivan Illich and followeach other. For centuries, communication skills were ers of the Frankfurter Schule, to name just a few of the taught In medical education implicitly. The clinical 5 most well-known. In a special way, ethnomethodology method as taught at universities, mostly in a classical 6 and conversation analysis elaborated sociological remaster-disciple relationship with its roots in the middle search on communication at a micro-level through paying ages, paid little explicit attention to communicative skills. attention to linguistic aspects. ‘Power,’ however, remains Students learned to take a good anamnesis, following a a significant theme within this tradition.Psychoanalysis hypothetico-deductive route to come to a proper diagand psychotherapy offered a different point of view. nosis. ‘Good bed-side manners’ were considered to be Concepts like therapeutic transference and counter-transimportant, but more of an art than a skill. In fact, 7 ference inspired Balint in his work with small groups of communication was learned by imitation of the master, general practitioners. His aim was to make doctors aware not as a discipline of its own. In 1924 the first textbook 12 of the complex interaction between them and their on medical interviewing was published . It must have patients, often built up over a life-time partnership. Carl taken another forty years to put the medical interview on 8 Rogers and his ideas of a therapeutic relationship based the curriculum, at least in the Netherlands. The content of on unconditional positive regard required attention for the curriculum was derived from clinical expertise and such concepts as empathy and interest and focused on the focused on good case history taking skills and models for importance of non-verbal behaviour.Another theoretical special kinds of interactions, like ‘breaking bad news’.

Self-Management Support Program for Patients With Cardiovascular Diseases: User-Centered Development of the Tailored, Web-Based Program Vascular View

Background In addition to medical intervention and counseling, patients with cardiovascular disease (CVD) need to manage their disease and its consequences by themselves in daily life. Objective The aim of this paper is to describe the development of “Vascular View,” a comprehensive, multi-component, tailored, Web-based, self-management support program for patients with CVD, and how this program will be tested in an early randomized controlled trial (RCT). Methods The Vascular View program was systematically developed in collaboration with an expert group of 6 patients, and separately with a group of 6 health professionals (medical, nursing, and allied health care professionals), according to the following steps of the intervention mapping (IM) framework: (1) conducting a needs assessment; (2) creating matrices of change objectives; (3) selecting theory-based intervention methods and practical applications; (4) organizing methods and applications into an intervention program; (5) planning the adaption, implementation, and sustainability of the program, and (6) generating an evaluation plan. Results The needs assessment (Step 1) identified 9 general health problems and 8 determinants (knowledge, awareness, attitude, self-efficacy, subjective norm, intention, risk perception, and habits) of self-managing CVD. By defining performance and change objectives (Step 2), 6 topics were distinguished and incorporated into the courses included in Vascular View (Steps 3 and 4): (1) Coping With CVD and its Consequences; (2) Setting Boundaries in Daily Life; (3) Lifestyle (general and tobacco and harmful alcohol use); (4) Healthy Nutrition; (5) Being Physically Active in a Healthy Way; and (6) Interaction With Health Professionals. These courses were based on behavioral change techniques (BCTs) (eg, self-monitoring of behavior, modeling, re-evaluation of outcomes), which were incorporated in the courses through general written information: quotes from and videos of patients with CVD as role models and personalized feedback, diaries, and exercises. The adoption and implementation plan (Step 5) was set up in collaboration with the members of the two expert groups and consisted of a written and digital instruction manual, a flyer, bimonthly newsletters, and reminders by email and telephone to (re-)visit the program. The potential effectiveness of Vascular View will be evaluated (Step 6) in an early RCT to gain insight into relevant outcome variables and related effect sizes, and a process evaluation to identify intervention fidelity, potential working mechanisms, user statistics, and/or satisfaction. Conclusion A comprehensive, multi-component, tailored, Web-based, self-management support program and an early RCT were developed in order to empower patients to self-manage their CVD. Trial Registration Nederlands Trial Register NTR5412; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5412 (Archived by WebCite at http://www.webcitation.org/6jeUFVj40)

How do medical specialists value their own intercultural communication behaviour? A reflective practice study

BackgroundIntercultural communication behaviour of doctors with patients requires specific intercultural communication skills, which do not seem structurally implemented in medical education. It is unclear what motivates doctors to apply intercultural communication skills. We investigated how purposefully medical specialists think they practise intercultural communication and how they reflect on their own communication behaviour.MethodsUsing reflective practice, 17 medical specialists independently watched two fragments of videotapes of their own outpatient consultations: one with a native patient and one with a non-native patient. They were asked to reflect on their own communication and on challenges they experience in intercultural communication. The interviews were open coded and analysed using thematic network analysis.ResultsThe participants experienced only little differences in their communication with native and non-native patients. They mainly mentioned generic communication skills, such as listening and checking if the patient understood. Many participants experienced their communication with non-native patients positively. The participants mentioned critical incidences of intercultural communication: language barriers, cultural differences, the presence of an interpreter, the role of the family and the atmosphere.ConclusionDespite extensive experience in intercultural communication, the participants of this study noticed hardly any differences between their own communication behaviour with native and non-native patients. This could mean that they are unaware that consultations with non-native patients might cause them to communicate differently than with native patients. The reason for this could be that medical specialists lack the skills to reflect on the process of the communication. The participants focused on their generic communication skills rather than on specific intercultural communication skills, which could either indicate their lack of awareness, or demonstrate that practicing generic communication is more important than applying specific intercultural communication. They mentioned well-known critical incidences of ICC: language barriers, cultural differences, the presence of an interpreter, the role of the family and the atmosphere. Nevertheless, they showed a remarkably enthusiastic attitude overall was noteworthy.A strategy to make doctors more aware of their intercultural communication behaviour could be a combination of experiential learning and ICC training, for example a module with reflective practice.