Dennis H. Novack

Doctor-patient communication: the Toronto consensus statement.

This report was compiled on behalf of the staff at the Northern General Hospital, Sheffield, the staff at the Royal Hallamshire Hospital, Sheffield, and the many people who helped at the scene. The efforts of hundreds of professionals and volunteers were vital and greatly appreciated. We thank Neil Appleyard, David Edbrooke, David Dawson, Stuart Yates, Ian Winston, John Duncan, G A Baker, Charlie Cooper, Kath Sherry, Tim Shaw, and A Moss for access to the neuropsychological reports on some of the survivors.

The Impact of the Changing Health Care Environment on the Health and Well-Being of Faculty at Four Medical Schools

Purpose Increased pressure for clinical and research productivity and decreased control over the work environment have been reported to have adverse impacts on academic faculty in limited studies. The authors examined whether work-related stressors in academic medicine negatively affected the physical and mental health, as well as life and job satisfaction, of academic medical school faculty. Method A 136-item self-administered anonymous questionnaire modified from a small 1984 study was distributed to 3,519 academic faculty at four U.S. medical schools following institutional review board approval at each school. Validated scales measuring depression, anxiety, work strain, and job and life satisfaction; a checklist of common physical and mental health symptoms; and questions about the impact of institutional financial stability, colleague attrition, and other work-related perceptions were used. Responses were analyzed by sex, academic rank, age, marital status, faculty discipline, and medical school. Results Responses were received from 1,951 full-time academic physicians and basic science faculty, a 54.3% response rate. Twenty percent of faculty, almost equal by sex, had significant levels of depressive symptoms, with higher levels in younger faculty. Perception of financial instability was associated with greater levels of work strain, depression, and anxiety. Significant numbers of faculty acknowledged that work-related strain negatively affected their mental health and job satisfaction, but not life satisfaction or physical health. Specialties were differentially affected. Conclusions High levels of depression, anxiety, and job dissatisfaction—especially in younger faculty—raise concerns about the well-being of academic faculty and its impact on trainees and patient care. Increased awareness of these stressors should guide faculty support and development programs to ensure productive, stable faculty.

MedEthEx Online: A Computer-Based Learning Program in Medical Ethics and Communication Skills

Background: Bioethics education often focuses on lectures and discussions to set a foundation for ethical decision making. Our goal was to bridge the gap between classroom learning and bedside competence through computer-assisted instruction. This article assesses the efficacy of MedEthEx Online, a computer-based learning program as part of a required Bioethics course. Description: Of 173 American medical students, 89 in Section 1 attended 8 bioethics lectures and 8 small-group discussions. Eighty-four in Section 2 had a similar course, although two group discussions were replaced with computerized learning. We compared (a) final exam scores, (b) topic-specific question scores, (c) performance with standardized patients, (d) self-assessments, and (e) course evaluations. Evaluation: Exam scores were comparable, although computerized-learning students scored higher in specific exam areas, felt somewhat more clinically prepared, and rated the course slightly better. Standardized patient interactions differed, although they were comparable overall. Conclusion: MedEthEx Online is a viable option for fostering effective communication and problem resolution skills.

Communication Skills for Preventive Interventions.

Effective communication relevant to preventive services and practices has at its basis the physicians skills in not only basic history taking and data collection but also relationship building, facilitation, negotiation, and partnership. These skills, fundamental to doctor-patient communication, are now routinely and systematically taught in many U.S. medical schools. This article defines and examines a communication model for enhancing the provision and adoption of preventive practices in the primary care setting and discusses teaching that model in the medical school context. Within the office visit, broad areas for communication tasks important to providing preventive services are defined as: (1) the medical interview and preventive counseling; (2) working with patients to change unhealthy behaviors, promote healthy behaviors, and enhance adherence; and (3) communication related to office procedures for screening and prevention. Within each of these areas, communication and counseling skills and approaches are defined, and examples of associated prevention activities are provided. Methods for integrating communication skills for prevention into the medical school curriculum are discussed, and examples at Dartmouth, Brown, and MCP Hahnemann medical schools are presented.

A comprehensive support system for reducing house staff distress

The stresses of postgraduate medical training may lead to depression, impaired patient care, and a poor professional attitude. The goal of the Rhode Island Hospital House Staff Support System is to reduce stress among residents by providing them with a forum for their views and by offering counseling to those who need it. The authors report that the program has been well received during its first three years, and they offer guidelines for implementing similar support programs at other institutions.

Teaching Medical Interviewing: The Lipkin Model

This chapter describes the evolution of a unique faculty development course and innovative educational model designed by Mack Lipkin, Jr. for teachers of medical interviewing. His approach integrates principles of learner-centered (or self-directed) learning with core human values, such as unconditional positive regard for others and attention to affect. We first describe some experiences that led Lipkin to the development of the course model. We then discuss the educational context and principles of the course and detail its structure, process, and problems. We end with some short examples of other applications of this approach in medical education.

eLearning to enhance physician patient communication: A pilot test of “doc.com” and “WebEncounter” in teaching bad news delivery

Background: Physician-patient communication skills help determine the nature and quality of diagnostic information elicited from patients, the quality of the physicians counseling, and the patients adherence to treatment. In spite of their importance, surveys have demonstrated a wide variability and deficiencies in the teaching of these skills. Aim: Describe two specific methodologies for teaching physician-patient communication skills developed at our institution and pilot test them for effectiveness. Methods: Between 2004 and 2009 we developed “doc.com,” a series of 41 media-rich online modules on all aspects of healthcare communication jointly with the American Academy on Communication in Healthcare. Starting in 2006, we expanded our pre-existing experience with the videoconferencing system “WebOSCE” into the online application “WebEncounter.” This new methodology combines practice of communication skills on standardized patients with structured assessment and constructive feedback. We had three randomized groups: controls who did only the assessment parts of a WebOSCE on two occasions, a doc.com group who had doc.com in between the assessment occasions, and a combined group that had both doc.com and a WebEncounter between assessments. Results/Conclusion: We found significant improvement in skills as components were added, and the training program was well received.

Physicians' experiences with patients who transgress boundaries.

AbstractBACKGROUND: Boundary violations have been discussed in the literature, but most studies report on physician transgressions of boundaries or sexual transgressions by patients. We studied the incidence of all types of boundary transgressions by patients and physicians’ responses to these transgressions. METHODS: We surveyed 1,000 members of the Society of General Internal Medicine (SGIM) for the number of patient transgressions of boundaries which had occurred in the previous year. Categories were created by the investigators based on the literature. Physicians picked the most important transgression, and then were asked about their response to the transgression and its effect on the patient-physician relationship. Attitudinal questions addressed the likelihood of discharging patients who transgressed boundaries. The impact of demographic variables on the incidence of transgressions was analyzed using analysis of variance. RESULTS: Three hundred thirty (37.5%) randomly selected SGIM members responded to the survey. Almost three quarters of the respondents had patients who used their first name, while 43% encountered verbal abuse, 39% had patients who asked personal questions, 31% had patients who were overly affectionate, and 27% encountered patients who attempted to socialize. All other transgressions, including physical abuse and attempts at sexual contact, were uncommon. Only gender affected the incidence of transgressions; female physicians encountered more personal questions (P=.001), inappropriate affection (P < .005), and sexually explicit language (P < .05) than male physicians and responded more negatively to boundary transgressions. Respondents dealt with transgressions by discussion with the patient or colleagues or by ignoring the incident, but such transgressions generally had a negative impact on the relationship. Most physicians would discharge patients who engaged in physical abuse or attempts at sexual contact, but were more tolerant of verbal abuse and overly affectionate patients. CONCLUSIONS: Boundary transgressions by patients is common, but usually involves more minor infractions. Female physicians are more likely to encounter certain types of transgressions. The incidence and outcomes of such transgressions are important in assisting physicians to deal effectively with this issue.

Anxiety and depression among medical and surgical patients nearing hospital discharge

Ninety-eight medical and surgical inpatients were interviewed 24–72 hours prior to discharge. Thirty-five (36%) had clinical levels of anxiety and depression as defined by the SCL-90-R, a self-report symptom inventory. Compared with patients with normal SCL-90-R subtest scores, anxious and depressed patients more often had the following characteristics: older age, black race, lower socioeconomic class, a recent previous hospitalization, and impaired functional status prior to admission. Three to four weeks after discharge, 25 of the 35 anxious and depressed patients were again interviewed. Thirteen remained anxious and depressed, while 11 patients had returned to normative distress levels. Older, black, poor inpatients with a recent prior hospitalization and impaired functional status are at high risk for clinical anxiety and depression. Half of those with anxiety and depression may remain anxious and depressed after discharge. Intervention should be considered for these patients.

Refocusing on history-taking skills during internal medicine training.

Recognizing that skilled history-taking is in danger of becoming a lost art, the American Board of Internal Medicine calls attention to the urgent need for internal medicine residency programs to ensure that these skills are taught and assessed. Although the Boards certification examination contains standardized items that test the physicians ability to use information from a patients medical history, the written examination cannot assess the physicians ability to elicit that history. The Board believes that history-taking skills will become even more crucial as health care delivery changes, requiring more cost efficiency without sacrificing quality. By highlighting the skills of effective history-taking and strategies for assessment, the Board offers specific recommendations for its promotion as a key element of quality patient care.