Gregory Makoul

How does communication heal? Pathways linking clinician–patient communication to health outcomes

OBJECTIVE Although prior research indicates that features of clinician-patient communication can predict health outcomes weeks and months after the consultation, the mechanisms accounting for these findings are poorly understood. While talk itself can be therapeutic (e.g., lessening the patients anxiety, providing comfort), more often clinician-patient communication influences health outcomes via a more indirect route. Proximal outcomes of the interaction include patient understanding, trust, and clinician-patient agreement. These affect intermediate outcomes (e.g., increased adherence, better self-care skills) which, in turn, affect health and well-being. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions. CONCLUSION Future research should hypothesize pathways connecting communication to health outcomes and select measures specific to that pathway. PRACTICE IMPLICATIONS Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual understanding, adherence, social support, self-efficacy) associated with improved health.

Essential elements of communication in medical encounters: the Kalamazoo consensus statement.

In May 1999, 21 leaders and representatives from major medical education and professional organizations attended an invitational conference jointly sponsored by the Bayer Institute for Health Care Communication and the Fetzer Institute. The participants focused on delineating a coherent set of essential elements in physician—patient communication to: (1) facilitate the development, implementation, and evaluation of communication-oriented curricula in medical education and (2) inform the development of specific standards in this domain. Since the group included architects and representatives of five currently used models of doctor—patient communication, participants agreed that the goals might best be achieved through review and synthesis of the models. Presentations about the five models encompassed their research base, overarching views of the medical encounter, and current applications. All attendees participated in discussion of the models and common elements. Written proceedings generated during the conference were posted on an electronic listserv for review and comment by the entire group. A three-person writing committee synthesized suggestions, resolved questions, and posted a succession of drafts on a listserv. The current document was circulated to the entire group for final approval before it was submitted for publication. The group identified seven essential sets of communication tasks: (1) build the doctor—patient relationship; (2) open the discussion; (3) gather information; (4) understand the patients perspective; (5) share information; (6) reach agreement on problems and plans; and (7) provide closure. These broadly supported elements provide a useful framework for communication-oriented curricula and standards.

The SEGUE Framework for teaching and assessing communication skills.

This article examines uses and characteristics of the SEGUE Framework, a research-based checklist of medical communication tasks. A recent survey of US and Canadian medical schools indicates that the SEGUE Framework is the most widely used structure for communication skills teaching and assessment in North America. Student and faculty response to the SEGUE Framework as a teaching tool has been positive. Data drawn from clinical skills assessments with standardized patients provide evidence of concurrent and construct validity. Analysis of visits between general internists and their patients reinforces validity of the SEGUE Framework in an actual practice setting. Interrater reliability is high when standardized patients are recording student performance immediately after a live encounter, and when coders are evaluating videotaped or audiotaped encounters; intrarater reliability is strong as well. The SEGUE Framework has a high degree of acceptability, can be used reliably, has evidence of validity, and is applicable to a variety of contexts. Studies of predictive validity are needed.

The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters

OBJECTIVE To assess physician-patient communication patterns associated with use of an electronic medical record (EMR) system in an outpatient setting and provide an empirical foundation for larger studies. DESIGN An exploratory, observational study involving analysis of videotaped physician-patient encounters, questionnaires, and medical-record reviews. SETTING General internal medicine practice at an academic medical center. PARTICIPANTS Three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean, 34 for each physician). MAIN OUTCOME MEASURES Content analysis of whether physicians accomplished communication tasks during encounters; qualitative analysis of how EMR physicians used the EMR and how control physicians used the paper chart. RESULTS Compared with the control physicians, EMR physicians adopted a more active role in clarifying information, encouraging questions, and ensuring completeness at the end of a visit. A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patients agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patients life). Physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The relatively fixed position of the computer limited the extent to which EMR physicians could physically orient themselves toward the patient. Although there was no statistically significant difference between the EMR and control physicians in terms of mean time across all visits, a difference did emerge for initial visits: Initial visits with EMR physicians took an average of 37.5 percent longer than those with control physicians. SUMMARY An EMR system may enhance the ability of physicians to complete information-intensive tasks but can make it more difficult to focus attention on other aspects of patient communication. Further study involving a controlled, pre-/post-intervention design is justified.

The Use of Electronic Medical Records

OBJECTIVE To assess physician-patient communication patterns associated with use of an electronic medical record (EMR) system in an outpatient setting and provide an empirical foundation for larger studies. DESIGN An exploratory, observational study involving analysis of videotaped physician-patient encounters, questionnaires, and medical-record reviews. SETTING General internal medicine practice at an academic medical center. PARTICIPANTS Three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean, 34 for each physician). MAIN OUTCOME MEASURES Content analysis of whether physicians accomplished communication tasks during encounters; qualitative analysis of how EMR physicians used the EMR and how control physicians used the paper chart. RESULTS Compared with the control physicians, EMR physicians adopted a more active role in clarifying information, encouraging questions, and ensuring completeness at the end of a visit. A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patients agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patients life). Physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The relatively fixed position of the computer limited the extent to which EMR physicians could physically orient themselves toward the patient. Although there was no statistically significant difference between the EMR and control physicians in terms of mean time across all visits, a difference did emerge for initial visits: Initial visits with EMR physicians took an average of 37.5 percent longer than those with control physicians. SUMMARY An EMR system may enhance the ability of physicians to complete information-intensive tasks but can make it more difficult to focus attention on other aspects of patient communication. Further study involving a controlled, pre-/post-intervention design is justified.

Examining Empathy in Medical Encounters: An Observational Study Using the Empathic Communication Coding System

Educators, researchers, clinicians, and patients often advocate empathy in the physician–patient relationship. However, little research has systematically examined how patients present opportunities for physicians to communicate empathically and how physicians respond to such opportunities. The Empathic Communication Coding System was used to investigate empathic opportunity–response sequences during initial visits in a general internal medicine clinic. This study focuses on 100 visits during which patients created at least 1 explicit empathic opportunity. Overall, patients presented 249 empathic opportunities in these 100 visits; physicians most often responded by acknowledging, pursuing, or confirming the patients statement. The mean length of empathic opportunity–response sequences was 25.8 sec; sequences tended to be longer in duration when the physician used a more empathic response. Positively valenced empathic opportunities generated a more empathic response than did negatively valenced empathic opportunities. However, there was no relation between the emotional intensity of empathic opportunities and the level of empathy in subsequent physician responses. Further research should examine patient preferences and outcomes associated with varying levels of empathic responses.

The relationship between health literacy and knowledge improvement after a multimedia type 2 diabetes education program

OBJECTIVE Multimedia diabetes education programs (MDEP) have the potential to improve communication and education of those with low health literacy. We examined the effect of a MDEP targeted to patients with low literacy on knowledge and assessed the association between literacy and knowledge improvement. METHODS We showed the MDEP to 190 patients recruited from clinics at a federally qualified health center and an academic health center. We measured diabetes knowledge before and after viewing the MDEP. RESULTS Seventy-nine percent of patients had adequate literacy, 13% marginal, and 8% inadequate literacy. Patients across all literacy levels had significant increases in knowledge scores after viewing the MDEP (p-value<0.001). Patients with inadequate literacy learned significantly less after the MDEP (adjusted beta-coefficient=-2.3, SE=0.70) compared to those with adequate literacy. CONCLUSIONS A MDEP designed for those with low literacy significantly increased diabetes knowledge across literacy levels. However, the MDEP did not overcome the learning gap between patients with low and high literacy. PRACTICE IMPLICATIONS A literacy appropriate MDEP may be an effective way to teach patients about diabetes. Combining the MDEP with other education methods may improve comprehension and learning among those with low literacy. Research is needed to identify which characteristics of low-literate patients influence the ability to learn health information. Identifying these factors and incorporating solutions into a diabetes education intervention may help bridge the learning gap related to literacy status.

Ixodes dammini: Evidence for Salivary Prostacyclin Secretion

Pilocarpine-induced saliva of adult Ixodes dammini ticks contained abundant amounts (523 +/- 140 ng/ml, mean +/- SE, n = 14) of 6-keto-PGF1 alpha, the stable degradation product of prostacyclin. This prostaglandin was identified by radioimmunoassay and reversed-phase chromatography. This activity may help tick feeding by preventing host hemostatic reactions, by increasing host blood flow at the tick feeding site, and by preventing leukocyte degranulation.

Comparative analysis of print and multimedia health materials: A review of the literature

OBJECTIVE Evaluate the evidence regarding the relative effectiveness of multimedia and print as modes of dissemination for patient education materials; examine whether development of these materials addressed health literacy. METHODS A structured literature review utilizing Medline, PsycInfo, and the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), supplemented by reference mining. RESULTS Of 738 studies screened, 30 effectively compared multimedia and print materials. Studies offered 56 opportunities for assessing the effect of medium on various outcomes (e.g., knowledge). In 30 instances (54%), no difference was noted between multimedia and print in terms of patient outcomes. Multimedia led to better outcomes vs. print in 21 (38%) comparisons vs. 5 (9%) instances for print. Regarding material development, 12 studies (40%) assessed readability and 5 (17%) involved patients in tool development. CONCLUSIONS Multimedia appears to be a promising medium for patient education; however, the majority of studies found that print and multimedia performed equally well in practice. Few studies involved patients in material development, and less than half assessed the readability of materials. PRACTICE IMPLICATIONS Future research should focus on comparing message-equivalent tools and assessing their effect on behavioral outcomes. Material development should include explicit attention to readability and patient input.

Physician-patient communication about colorectal cancer screening.

BackgroundDespite the documented benefits of colorectal cancer screening, patient participation rates remain low. Physician recommendation has been identified as a significant predictor of screening completion.ObjectiveThe aim of this study is to investigate how primary care physicians perceive colorectal cancer screening communication tasks, as well as to explore the form and content of actual screening discussions.DesignThe research design includes a mailed physician survey and a separate observational study in a sample of videotaped medical encounters.Participants and Data SourcesThe participants were 270 primary care physicians who completed a mailed questionnaire (57.9% response rate) and 18 physician–patient encounters that included discussions of colorectal cancer screening.MeasurementThe questionnaire focused on perceived importance and accomplishment of communication tasks relevant to colorectal cancer screening. Two of the authors reviewed transcripts of videotaped physician encounters to determine whether the same communication tasks assessed in the survey were accomplished. Interrater reliability was high across all of the mutually exclusive coding categories (Kappa > .90).ResultsPhysicians rated colonoscopy as the most important screening option to discuss; self-reports indicate that colonoscopy (84.8%) is more frequently mentioned than fecal occult blood test (FOBT; 49.4%), flexible sigmoidoscopy (34.1%), or computed tomography (CT) imaging (18.1%). Explaining benefits and risks, describing test procedure and frequency, eliciting patient preferences, and making a plan for screening were all viewed as very important. Self-reported accomplishment of these communication tasks was considerably higher than that observed in our separate videotape sample.ConclusionMost physicians recognize and espouse the importance of recommending colorectal cancer screening to eligible patients. However, findings from both the physician survey and observational study suggest that physicians tend to overestimate the extent of discussions about screening. Interventions may be warranted to improve clinical practice.