Edward Krupat

Patient Participation in Medical Consultations: Why Some Patients are More Involved Than Others

Background:Patients vary in their willingness and ability to actively participate in medical consultations. Because more active patient participation contributes to improved health outcomes and quality of care, it is important to understand factors affecting the way patients communicate with healthcare providers. Objectives:The objectives of this study were to examine the extent to which patient participation in medical interactions is influenced by 1) the patients personal characteristics (age, gender, education, ethnicity); 2) the physicians communication style (eg, use of partnership-building and supportive talk); and 3) the clinical setting (eg, the health condition, medical specialty). Research Design and Subjects:The authors conducted a post hoc cross-sectional analysis of 279 physician–patient interactions from 3 clinical sites: 1) primary care patients in Sacramento, California, 2) patients with systemic lupus erythematosus (SLE) from the San Francisco Bay area, and 3) patients with lung cancer from a VA hospital in Texas. Main Outcome Measures:The outcome measures included the degree to which patients asked questions, were assertive, and expressed concerns and the degree to which physicians used partnership-building and supportive talk (praise, reassurance, empathy) in their consultations. Results:The majority of active participation behaviors were patient-initiated (84%) rather than prompted by physician partnership-building or supportive talk. Patients who were more active participants received more facilitative communication from physicians, were more educated, and were more likely to be white than of another ethnicity. Women more willingly expressed negative feelings and concerns. There was considerable variability in patient participation across the 3 clinical settings. Female physicians were more likely to use supportive talk than males, and physicians generally used less supportive talk with nonwhite compared with white patients. Conclusions:Patient participation in medical encounters depends on a complex interplay of personal, physician, and contextual factors. Although more educated and white patients tended to be more active participants than their counterparts, the strongest predictors of patient participation were situation-specific, namely the clinical setting and the physicians communicative style. Physicians could more effectively facilitate patient involvement by more frequently using partnership-building and supportive communication. Future research should investigate how the nuances of individual clinical settings (eg, the health condition, time allotted for the visit) impose constraints or opportunities for more effective patient involvement in care.

The practice orientations of physicians and patients: the effect of doctor–patient congruence on satisfaction

This study investigated the extent to which the individual orientations of physicians and patients and the congruence between them are associated with patient satisfaction. A survey was mailed to 400 physicians and 1020 of their patients. All respondents filled out the Patient-Practitioner Orientation Scale, which measures the roles that doctors and patients believe each should play in the course of their interaction. Patients also rated their satisfaction with their doctors. Among patients, we found that females and those who were younger, more educated, and healthier were significantly more patient-centered. However, none of these variables were significantly related to satisfaction. Among physicians, females were more patient-centered, and years in practice was related to satisfaction and orientation in a non-linear fashion. The congruence data indicated that patients were highly satisfied when their physicians either had a matching orientation or were more patient-centered. However, patients whose doctors were not as patient-centered were significantly less satisfied.

Unmet Expectations for Care and the Patient-physician Relationship

AbstractOBJECTIVE: To profile patients likely to have unmet expectations for care, examine the effects of such expectations, and investigate how physicians’ responses to patients’ requests affect the development of unfulfilled expectations. DESIGN: Patient and physician questionnaires were administered before and after outpatient visits. A follow-up telephone survey was administered 2 weeks post visit. SETTING: The offices of 45 family practice, internal medicine, and cardiology physicians. PATIENTS: Nine hundred nine adults reporting a health problem or concern. MEASUREMENTS AND MAIN RESULTS: Before their visits, patients rated their general health and trust in the index physician. After the visit, patients reported upon 8 types of unmet expectations and any request they made. Two weeks thereafter, patients rated their visit satisfaction, improvement, and intention to adhere to the physician’s advice. They also reported any postvisit health system contacts. Overall, 11.6% of patients reported ≥1 unmet expectation. Visits in which a patient held an unmet expectation were rated by physicians as less satisfying and more effortful. At follow-up, patients who perceived an unmet expectation for care also reported less satisfaction with their visits, less improvement, and weaker intentions to adhere. Patients with an unmet expectation related to clinical resource allocation had more postvisit health system contacts. Unmet expectations were typically reported by a patient whose request for a resource was not fulfilled. CONCLUSIONS: Unmet expectations adversely affect patients and physicians alike. Physicians’ nonfulfillment of patients’ requests plays a significant role in patients’ beliefs that their physicians did not meet their expectations for care.

Beliefs about control in the physician-patient relationship: Effect on communication in medical encounters

OBJECTIVES: Effective communication is a critical component of quality health care, and to improve it we must understand its dynamics. This investigation examined the extent to which physicians’ and patients’ preferences for control in their relationship (e.g., shared control vs doctor control) were related to their communications styles and adaptations (i.e., how they responded to the communication of the other participant).DESIGN: Stratified case-controlled study.PATIENTS/PARTICIPANTS: Twenty family medicine and internal medicine physicians and 135 patients.MEASUREMENTS: Based on scores from the Patient-Practitioner Orientation Scale, 10 patient-centered physicians (5 male, 5 female) and 10 doctor-centered physicians (5 male, 5 female) each interacted with 5 to 8 patients, roughly half of whom preferred shared control and the other half of whom were oriented toward doctor control. Audiotapes of 135 consultations were coded for behaviors indicative of physician partnership buidling and active patient participation.MAIN RESULTS: Patients who preferred shared control were more active participants (i.e., expressed more opinions, concerns, and questions) than were patients oriented toward doctor control. Physicians’ beliefs about control were not related to their use of partnership building. However, physicians did use more partnership building with male patients. Not only were active patient participation and physician partnership building mutually predictive of each other, but also approximately 14% of patient participation was prompted by physician partnership building and 33% of physician partnership building was in response to active patient participation.CONCLUSIONS: Communication in medical encounters is influenced by the physician’s and patient’s beliefs about control in their relationship as well as by one another’s behavior. The relationship between physicians’ partnership building and active patient participation is one of mutual influence such that increases in one often lead to increases in the other.

Educational Outcomes of the Harvard Medical School-Cambridge Integrated Clerkship: A Way Forward for Medical Education

Purpose The authors report data from the Harvard Medical School–Cambridge Integrated Clerkship (CIC), a model of medical education in which students’ entire third year consists of a longitudinal, integrated curriculum. The authors compare the knowledge, skills, and attitudes of students completing the CIC with those of students completing traditional third-year clerkships. Method The authors compared 27 students completing the first three years of the CIC (2004–2007) with 45 students completing clerkships at other Harvard teaching hospitals during the same period. At baseline, no significant between-group differences existed (Medical College Admission Test and Step 1 scores, second-year objective structured clinical examination [OSCE] performance, attitudes toward patient-centered care, and plans for future practice) in any year. The authors compared students’ National Board of Medical Examiners Subject and Step 2 Clinical Knowledge scores, OSCE performance, perceptions of the learning environment, and attitudes toward patient-centeredness. Results CIC students performed as well as or better than their traditionally trained peers on measures of content knowledge and clinical skills. CIC students expressed higher satisfaction with the learning environment, more confidence in dealing with numerous domains of patient care, and a stronger sense of patient-centeredness. Conclusions CIC students are at least as well as and in several ways better prepared than their peers. CIC students also demonstrate richer perspectives on the course of illness, more insight into social determinants of illness and recovery, and increased commitment to patients. These data suggest that longitudinal integrated clerkships offer students important intellectual, professional, and personal benefits.

Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools.

Purpose Vital, productive faculty are critical to academic medicine, yet studies indicate high dissatisfaction and attrition. The authors sought to identify key personal and cultural factors associated with intentions to leave one’s institution and/or academic medicine. Method From 2007 through early 2009, the authors surveyed a stratified random sample of 4,578 full-time faculty from 26 representative U.S. medical schools. The survey asked about advancement, engagement, relationships, diversity and equity, leadership, institutional values and practices, and work–life integration. A two-level, multinomial logit model was used to predict leaving intentions. Results A total of 2,381 faculty responded (52%); 1,994 provided complete data for analysis. Of these, 1,062 (53%) were female and 475 (24%) were underrepresented minorities in medicine. Faculty valued their work, but 273 (14%) had seriously considered leaving their own institution during the prior year and 421 (21%) had considered leaving academic medicine altogether because of dissatisfaction; an additional 109 (5%) cited personal/family issues and 49 (2%) retirement as reasons to leave. Negative perceptions of the culture—unrelatedness, feeling moral distress at work, and lack of engagement—were associated with leaving for dissatisfaction. Other significant predictors were perceptions of values incongruence, low institutional support, and low self-efficacy. Institutional characteristics and personal variables (e.g., gender) were not predictive. Conclusions Findings suggest that academic medicine does not support relatedness and a moral culture for many faculty. If these issues are not addressed, academic health centers may find themselves with dissatisfied faculty looking to go elsewhere.

Musculoskeletal medicine: an assessment of the attitudes and knowledge of medical students at Harvard Medical School.

Purpose To assess medical students’ knowledge and clinical confidence in musculoskeletal medicine as well as their attitudes toward the education they receive in this specialty. Method A cross-sectional survey of students in all four years of Harvard Medical School was conducted during the 2005–2006 academic year. Participants were asked to fill out a 30-question survey and a nationally validated basic competency exam in musculoskeletal medicine. Results The response rate was 74% (449/608). Medical students rated musculoskeletal education to be of major importance (3.8/5) but rated the amount of curriculum time spent on musculoskeletal medicine as poor (2.1/5). Third-year students felt a low to adequate level of confidence in performing a musculoskeletal physical examination (2.7/5) and failed to demonstrate cognitive mastery in musculoskeletal medicine (passing rate on competency exam: 7%), whereas fourth-year students reported a similar level of confidence (2.7/5) and exhibited a higher passing rate (26%). Increasing exposure to the subject by taking clinical electives resulted in greater clinical confidence and enhanced performance on the exam (P < .001). Students’ feedback suggested that musculoskeletal education can be better integrated into the preclinical curriculum, more time should be spent in the field, and more focus should be placed on common clinical conditions. Conclusions These findings, which are consistent with those from other schools, suggest that medical students do not feel adequately prepared in musculoskeletal medicine and lack both clinical confidence and cognitive mastery in the field. Implementing a four-year integrated musculoskeletal curriculum is one way that medical schools can address this concern.

Request fulfillment in office practice: antecedents and relationship to outcomes.

Background: Patients communicate their desires and expectations largely by making requests. However, the antecedents and consequences of request fulfillment have received limited attention. Objective: To describe patient and physician characteristics associated with request fulfillment and to understand the consequences of request fulfillment and nonfulfillment on visit evaluations by patients and physicians, self-reported health care use, and health outcomes. Design: Data were gathered from patient and physician surveys administered at several points before and after problem-driven outpatient visits. Setting: The study was carried out in the office practices of 45 family practice, internal medicine, and cardiology physicians working either in a large multispecialty group practice or in a group-model health maintenance organization. Patients: Data were collected at the index visit from 909 patients (cooperation rate, 68%; net response rate, 32%). A telephone follow-up survey was administered to 887 (98%) of these patients 2 weeks after the visit. Measurements: Before the visit, patients provided ratings of their health concerns, physical functioning, role limitations, general health perceptions, and trust in the index physician. After the visit, patients reported on any request that they made, physician responses to these requests, and their satisfaction with care. At the 2-week follow-up evaluation, patients again reported on satisfaction, health concerns, health status, and self-reported postvisit health care use. Results: Patients reported making at least one request in 84% of encounters; requests for medical information, examination, and tests or procedures were most common. Four-fifths of patients who made at least one request reported complete fulfillment of all requests. Perceived request fulfillment was significantly lower among patients with relatively low pr-visit trust in the treating physician. Higher request fulfillment was predictive of more positive patient evaluations of care. Visits in which requests could not be completely fulfilled were rated by physicians as more demanding and less satisfying. Request fulfillment was also positively associated with fewer health concerns and greater symptom improvement at follow up. Nonfulfillment of patient requests did not predict postvisit health care use. Conclusions: Request fulfillment affects patient and physician satisfaction and perceptions of health outcomes. New approaches that efficiently recognize and respond to patient requests are needed.

Effectiveness of a short course in clinical communication skills for hospital doctors: results of a crossover randomized controlled trial (ISRCTN22153332).

OBJECTIVE To test the hypothesis that a 20-h communication skills course based on the Four Habits model can improve doctor-patient communication among hospital employed doctors across specialties. METHODS Crossover randomized controlled trial in a 500-bed hospital with interventions at different time points in the two arms. Assessments were video-based and blinded. Intervention consisted of 20 h of communication training, containing alternating plenary with theory/debriefs and practical group sessions with role-plays tailored to each doctor. RESULTS Of 103 doctors asked to participate, 72 were included, 62 received the intervention, 51 were included in the main analysis, and another six were included in the intention-to-treat analysis. We found an increase in the Four Habits Coding Scheme of 7.5 points (p = 0.01, 95% confidence interval 1.6-13.3), fairly evenly distributed on subgroups. Baseline score (SD) was 60.3 (9.9). Global patient satisfaction did not change, neither did average encounter duration. CONCLUSION Utilizing an outpatient-clinic training model developed in the US, we demonstrated that a 20-h course could be generalized across medical and national cultures, indicating improvement of communication skills among hospital doctors. PRACTICE IMPLICATIONS The Four Habits model is suitable for communication-training courses in hospital settings. Doctors across specialties can attend the same course.

Live Lecture Versus Video-Recorded Lecture: Are Students Voting With Their Feet?

Purpose In light of educators’ concerns that lecture attendance in medical school has declined, the authors sought to assess students’ perceptions, evaluations, and motivations concerning live lectures compared with accelerated, video-recorded lectures viewed online. Method The authors performed a cross-sectional survey study of all first- and second-year students at Harvard Medical School. Respondents answered questions regarding their lecture attendance; use of class and personal time; use of accelerated, video-recorded lectures; and reasons for viewing video-recorded and live lectures. Other questions asked students to compare how well live and video-recorded lectures satisfied learning goals. Results Of the 353 students who received questionnaires, 204 (58%) returned responses. Collectively, students indicated watching 57.2% of lectures live, 29.4% recorded, and 3.8% using both methods. All students have watched recorded lectures, and most (88.5%) have used video-accelerating technologies. When using accelerated, video-recorded lecture as opposed to attending lecture, students felt they were more likely to increase their speed of knowledge acquisition (79.3% of students), look up additional information (67.7%), stay focused (64.8%), and learn more (63.7%). Conclusions Live attendance remains the predominant method for viewing lectures. However, students find accelerated, video-recorded lectures equally or more valuable. Although educators may be uncomfortable with the fundamental change in the learning process represented by video-recorded lecture use, students’ responses indicate that their decisions to attend lectures or view recorded lectures are motivated primarily by a desire to satisfy their professional goals. A challenge remains for educators to incorporate technologies students find useful while creating an interactive learning culture.