Annette H. Blankenstein

Perceived barriers and facilitators for general practitioner-patient communication in palliative care: A systematic review

While effective general practitioner (GP)–patient communication is required for the provision of good palliative care, barriers and facilitators for this communication are largely unknown. We aimed to identify barriers and facilitators for GP–patient communication in palliative care. In a systematic review seven computerized databases were searched to find empirical studies on GP–patient communication in palliative care. Fifteen qualitative studies and seven quantitative questionnaire studies were included. The main perceived barriers were GPs’ lack of availability, and patients’ and GPs’ ambivalence to discuss ‘bad prognosis’. Main perceived facilitators were GPs being available, initiating discussion about several end-of-life issues and anticipating various scenarios. Lack of availability and failure to discuss former mistakes appear to be blind spots of GPs. GPs should be more forthcoming to initiate discussions with palliative care patients about prognosis and end-of-life issues. Empirical studies are needed to investigate the effectiveness of the perceived barriers and facilitators.

Randomised controlled trial of disclosure of emotionally important events in somatisation in primary care.

Abstract Objective: To test whether a disclosure intervention improves subjective health and reduces medical consumption and sick leave in somatising patients in general practice. Design: Non-blind randomised controlled trial. Setting: 10 general practices in the Netherlands. Participants: 161 patients who frequently attended general practice with somatising symptoms. Intervention: Patients in the intervention group were visited two to three times and invited to disclose emotionally important events in their life. Control patients received normal care from their general practitioners. Main outcome measures: Use of medical services (drugs and healthcare visits), subjective health, and sick leave assessed by self completion questionnaires after 6, 12, and 24 months. Results: Of the 161 patients, 137 completed the trial (85%). Both groups were comparable at baseline. The intervention had no effect on the main outcome measures at any point. Intervention patients made one more visit to health care (95% confidence interval −4 to 6); the use of medicines did not change in both groups (−1 to 1); subjective health improved 3.6 points more in the control group (−11.2 to 4.3); and disclosure patients were on sick leave one more week (−1 to 3). Patients often had a depression or anxiety disorder for which they were not receiving adequate care. Conclusion: Although the intervention was well received by patients and doctors, disclosure had no effect on the health of somatising patients in general practice. What is already known on this topic Up to 5% of patients in general practice attend frequently with somatising symptoms Emotional expression techniques have been shown to have favourable effects on subjective health, visits to the doctor, and symptoms in healthy people What this study adds A disclosure intervention does not improve somatisation in primary care About 45% of patients had an anxiety or depressive disorder, which was often unrecognised

Encounters between medical specialists and patients with medically unexplained physical symptoms; influences of communication on patient outcomes and use of health care: a literature overview.

Medically unexplained physical symptoms (MUPS) burden patients and health services due to large quantities of consultations and medical interventions. The aim of this study is to determine which elements of communication in non-psychiatric specialist MUPS care influence health outcomes. Systematic search in PubMed, PsycINFO and Embase. Data extraction comprising study design, patient characteristics, number of patients, communication strategies, outcome measures and results. Elements of doctor-patient communication were framed according to symptoms, health anxiety, satisfaction, daily functioning and use of health care. Eight included studies. Two studies described the effect of communication on patient outcome in physical symptoms, three studies on health anxiety and patient satisfaction and one study on daily functioning. Two studies contained research on use of health care. Qualitative synthesis of findings was conducted. Communication matters in non-psychiatric MUPS specialist care. Perceiving patients’ expectations correctly enables specialists to influence patients’ cognitions, to reduce patients’ anxiety and improve patients’ satisfaction. Patients report less symptoms and health anxiety when symptoms are properly explained. Positive interaction and feedback reduces use of health care and improves coping. Development of communication skills focused on MUPS patients should be part of postgraduate education for medical specialists.

Does patient feedback improve the consultation skills of general practice trainees? A controlled trial

Medical Education 2010: 44 : 156–164

Clinical variables associated with recovery in patients with chronic tension-type headache after treatment with manual therapy

Summary Prognostic models could be useful in clinical settings to improve prediction of outcome for participants with chronic tension type headache after manual therapy treatment. Abstract The aims of this study were to describe the course of chronic tension‐type headache (CTTH) in participants receiving manual therapy (MT), and to develop a prognostic model for predicting recovery in participants receiving MT. Outcomes in 145 adults with CTTH who received MT as participants in a previously published randomised clinical trial (n = 41) or in a prospective cohort study (n = 104) were evaluated. Assessments were made at baseline and at 8 and 26 weeks of follow‐up. Recovery was defined as a 50% reduction in headache days in combination with a score of ‘much improved’ or ‘very much improved’ for global perceived improvement. Potential prognostic factors were analyzed by univariable and multivariable regression analysis. After 8 weeks 78% of the participants reported recovery after MT, and after 26 weeks the frequency of recovered participants was 73%. Prognostic factors related to recovery were co‐existing migraine, absence of multiple‐site pain, greater cervical range of motion and higher headache intensity. In participants classified as being likely to be recovered, the posterior probability for recovery at 8 weeks was 92%, whereas for those being classified at low probability of recovery this posterior probability was 61%. It is concluded that the course of CTTH is favourable in primary care patients receiving MT. The prognostic models provide additional information to improve prediction of outcome.

Reliability of consultation skills assessments using standardised versus real patients.

Medical Education 2011; 45: 578–584

Minimal clinically important change on the Headache Impact Test-6 questionnaire in patients with chronic tension-type headache

Objective: To determine the minimal clinically important change (MCIC) in Headache Impact Test-6 (HIT-6) score in patients with chronic tension-type headache (CTTH). Methods: The HIT-6 was administered at baseline and at 8 weeks follow-up in a cohort of 186 participants with CTTH who received manual therapy or usual care by their general practitioner. An anchor-based method was used to determine the MCIC, with the external criterion (anchor) being based on general perceived improvement (‘much improved or very much improved’ on a 7-point Likert scale) in combination with 50% reduction in headache days. Using receiver operating characteristic (ROC) curve analysis we defined an optimal cut-off score discriminating between improved and not improved participants. Results: The optimal cut-off point for the MCIC for the HIT-6 was −8 points, on a total scale range of 42 points. Conclusion: A clinically relevant improvement in patients with CTTH is reflected by a decrease of at least 8 points on the HIT-6.

Development and feasibility of a patient feedback programme to improve consultation skills in general practice training.

OBJECTIVE To develop an attractive and effective patient feedback training programme for general practice trainees (GPTs). METHODS First, an exploratory study was conducted in which patients and GPTs were interviewed after they had worked with patient feedback. This contributed to the development of the patient feedback training programme. Subsequently, in a feasibility study, first-year GPTs asked patients to give feedback on their consultation skills by completing a questionnaire. The outcomes of group discussions with the GPTs and the results of the evaluation forms filled in by the GPTs were analysed. RESULTS Forty-eight GPTs collected 878 questionnaires. GPTs and patients alike expected patient feedback to be a major tool for acquiring consultation skills. The GPTs encountered several obstacles in the organisation of this programme in their practice. They reported that the learning effects were more limited than they had expected because patients gave positively biased answers and because not all consultations provided an appropriate source of patient feedback. CONCLUSION The new patient feedback programme on consultation skills is feasible for patients and GPTs. PRACTICE IMPLICATIONS To optimise the educational potential and benefits of patient feedback, GPTs should ask for feedback from patients after challenging consultations, and should stimulate patients to be critical in their answers.

Sick-listed employees with severe medically unexplained physical symptoms: burden or routine for the occupational health physician? A cross sectional study

BackgroundThe two primary objectives of this study were to the assess consultation load of occupational health physicians (OHPs), and their difficulties and needs with regard to their sickness certification tasks in sick-listed employees with severe medical unexplained physical symptoms (MUPS). Third objective was to determine which disease-, patient-, doctor- and practice-related factors are associated with the difficulties and needs of the OHPs.MethodsIn this cross-sectional study, 43 participating OHPs from 5 group practices assessed 489 sick-listed employees with and without severe MUPS. The OHPs filled in a questionnaire about difficulties concerning sickness certification tasks, consultation time, their needs with regard to consultation with or referral to a psychiatrist or psychologist, and communication with GPs. The OHPs also completed a questionnaire about their personal characteristics.ResultsOHPs only experienced task difficulties in employees with severe MUPS in relation to their communication with the treating physician. This only occured in cases in which the OHP attributed the physical symptoms to somatoform causes. If they attributed the physical symptoms to mental causes, the OHPs reported a need to consultate a psychiatrist about the diagnosis and treatment.ConclusionsOHPs experience few difficulties with their sickness certification tasks and consultation load concerning employees with severe MUPS. However, they encounter problems if the diagnostic uncertainties of the treating physician interfere with the return to work process. OHPs have a need for psychiatric expertise whenever they are uncertain about the psychiatric causes of a delayed return to work process. We recommend further training programs for OHPs. They should also have more opportunity for consultation and referral to a psychiatrist, and their communication with treating physicians should be improved.

Effectiveness of the palliative care 'Availability, Current issues and Anticipation' (ACA) communication training programme for general practitioners on patient outcomes: A controlled trial

Background: Although communicating effectively with patients receiving palliative care can be difficult, it may contribute to maintaining or enhancing patients’ quality of life. Little is known about the effect of training general practitioners in palliative care–specific communication. We hypothesized that palliative care patients of general practitioners exposed to the ‘Availability, Current issues and Anticipation’ communication training programme would report better outcomes than patients of control general practitioners. Aim: To evaluate the effectiveness of the Availability, Current issues and Anticipation training programme for general practitioners on patient-reported outcomes. Design: In a controlled trial, general practitioners followed the Availability, Current issues and Anticipation programme or were part of the control group. Patients receiving palliative care of participating general practitioners completed the Palliative Care Outcome Scale, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative, the Rest & Peace Scale, the Patient Satisfaction Questionnaire–III and the Availability, Current issues and Anticipation Scale, at baseline and 12 months follow-up. We analysed differences between groups using linear mixed models. Trial registration: ISRCTN56722368. Setting/participants: General practitioners who attended a 2-year Palliative Care Training Course in the Netherlands. Results: Questionnaire data were available for 145 patients (89 in intervention and 56 in control group). We found no significant differences over time between the intervention and control groups in any of the five outcome measures. Ceiling effects were observed for the Rest & Peace Scale, Patient Satisfaction Questionnaire–III and Availability, Current issues and Anticipation Scale. Conclusion: General practitioner participation in the Availability, Current issues and Anticipation training programme did not have a measurable effect on any of the outcomes investigated. Patients reported high levels of satisfaction with general practitioner care, regardless of group assignment. Future research might focus on general practitioners without special interest in palliative care.