Helen Riess

The Influence of the Patient-Clinician Relationship on Healthcare Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective To determine whether the patient-clinician relationship has a beneficial effect on either objective or validated subjective healthcare outcomes. Design Systematic review and meta-analysis. Data Sources Electronic databases EMBASE and MEDLINE and the reference sections of previous reviews. Eligibility Criteria for Selecting Studies Included studies were randomized controlled trials (RCTs) in adult patients in which the patient-clinician relationship was systematically manipulated and healthcare outcomes were either objective (e.g., blood pressure) or validated subjective measures (e.g., pain scores). Studies were excluded if the encounter was a routine physical, or a mental health or substance abuse visit; if the outcome was an intermediate outcome such as patient satisfaction or adherence to treatment; if the patient-clinician relationship was manipulated solely by intervening with patients; or if the duration of the clinical encounter was unequal across conditions. Results Thirteen RCTs met eligibility criteria. Observed effect sizes for the individual studies ranged from d = −.23 to .66. Using a random-effects model, the estimate of the overall effect size was small (d = .11), but statistically significant (p = .02). Conclusions This systematic review and meta-analysis of RCTs suggests that the patient-clinician relationship has a small, but statistically significant effect on healthcare outcomes. Given that relatively few RCTs met our eligibility criteria, and that the majority of these trials were not specifically designed to test the effect of the patient-clinician relationship on healthcare outcomes, we conclude with a call for more research on this important topic.

Patient and Practitioner Influences on the Placebo Effect in Irritable Bowel Syndrome

Objective: To determine whether placebo responses can be explained by characteristics of the patient, the practitioner, or their interpersonal interaction. Methods: We performed an analysis of videotape and psychometric data from a clinical trial of patients with irritable bowel syndrome who were treated with placebo acupuncture in either a warm empathic interaction (Augmented, n = 96), a neutral interaction (Limited, n = 97), or a waitlist control (Waitlist, n = 96). We examined the relationships between the placebo response and a) patient personality and demographics; b) treating practitioner; and c) the patient-practitioner interaction as captured on videotape and rated by the Psychotherapy Process Q-Set. Results: Patient extraversion, agreeableness, openness to experience, and female gender were associated with placebo response, but these effects held only in the augmented group. Regression analyses controlling for all other independent variables suggest that only extraversion is an independent predictor of placebo response. There were significant differences between practitioners in outcomes; this effect was twice as large as the effect attributable to treatment group assignment. Videotape analysis indicated that the augmented group fostered a treatment relationship similar to a prototype of an ideal healthcare interaction. Conclusions: Personality and gender influenced the placebo response, but only in the warm, empathic, augmented group. This suggests that, to the degree a placebo effect is evoked by the patient-practitioner relationship, personality characteristics of the patient will be associated with the placebo response. In addition, practitioners differed markedly in effectiveness, despite standardized interactions. We propose that the quality of the patient-practitioner interaction accounts for the significant difference between the groups in placebo response. IBS = irritable bowel syndrome; FFI = Five Factor Inventory; PQS = Psychotherapy Process Q-Set; M-PQS = Modified Psychotherapy Process Q-Set.

Interdisciplinary management of EGFR-inhibitor-induced skin reactions: a German expert opinion

BACKGROUND Anti-epidermal growth factor receptor treatment strategies, i.e. monoclonal antibodies such as cetuximab and panitumumab, or epidermal growth factor receptor (EGFR) small molecule tyrosine kinase inhibitors, such as erlotinib and gefitinib, have expanded the treatment options for different tumor types. Dermatologic toxic effects are the most common side-effects of EGFR inhibitor therapy. They can profoundly affect the patients quality of life. PURPOSE The aim of this study was to provide interdisciplinary expert recommendations on how to treat patients with skin reactions undergoing anti-EGFR treatment. MATERIAL AND METHODS An expert panel from Germany with expertise in medical oncology, dermatology or clinical pharmacology was convened to develop expert recommendations based on published peer-reviewed literature. RESULTS The expert recommendations for the state-of-the-art treatment of skin reactions induced by EGFR inhibitor therapy include recommendations for diagnostics and grading as well as grade-specific and stage-adapted treatment approaches and preventive measures. It was concluded that EGFR-inhibitor-related dermatologic reactions should always be treated combining basic care of the skin and a specific therapy adapted to stage and grade of skin reaction. For grade 2 and above, specific treatment recommendations for early- and later-stage skin reactions induced by EGFR-inhibitor therapy were proposed. CONCLUSION This paper presents a German national expert opinion for the treatment of skin reactions in patients receiving EGFR inhibitor therapy.

Empathy in Medicine—A Neurobiological Perspective

Correction Contact me if this article is corrected. Citations Contact me when this article is cited. Topic collections Contact me when new articles are published in these topic areas. Care, Other Patient-Physician Communication; Psychosocial Issues; Quality of Care; Quality of Functional Imaging; Neurology, Other; Pain; Patient-Physician Relationship/ Care; Aging/ Geriatrics; Medical Practice; Medical Education; Neurology; Neuroimaging;

A phase 3 randomized, double-blind, placebo-controlled trial of ganitumab or placebo in combination with gemcitabine as first-line therapy for metastatic adenocarcinoma of the pancreas: the GAMMA trial

BACKGROUND This double-blind, phase 3 study assessed the efficacy and safety of ganitumab combined with gemcitabine as first-line treatment of metastatic pancreatic cancer. PATIENTS AND METHODS Patients with previously untreated metastatic pancreatic adenocarcinoma were randomly assigned 2 : 2 : 1 to receive intravenous gemcitabine 1000 mg/m(2) (days 1, 8, and 15 of each 28-day cycle) plus placebo, ganitumab 12 mg/kg, or ganitumab 20 mg/kg (days 1 and 15 of each cycle). The primary end point was overall survival (OS). Secondary end points included progression-free survival (PFS), safety, and efficacy by levels of circulating biomarkers. RESULTS Overall, 322 patients were randomly assigned to placebo, 318 to ganitumab 12 mg/kg, and 160 to ganitumab 20 mg/kg. The study was stopped based on results from a preplanned futility analysis; the final results are reported. Median OS was 7.2 months [95% confidence interval (CI), 6.3-8.2] in the placebo arm, 7.0 months (95% CI, 6.2-8.5) in the ganitumab 12-mg/kg arm [hazard ratio (HR), 1.00; 95% CI, 0.82-1.21; P = 0.494], and 7.1 months (95% CI, 6.4-8.5) in the ganitumab 20-mg/kg arm (HR, 0.97; 95% CI, 0.76-1.23; P = 0.397). Median PFS was 3.7, 3.6 (HR, 1.00; 95% CI, 0.84-1.20; P = 0.520), and 3.7 months (HR, 0.97; 95% CI, 0.77-1.22; P = 0.403), respectively. No unexpected toxicity was observed with ganitumab plus gemcitabine. The circulating biomarkers assessed [insulin-like growth factor-1 (IGF-1), IGF-binding protein-2, and -3] were not associated with a treatment effect on OS or PFS by ganitumab. CONCLUSION Ganitumab combined with gemcitabine had manageable toxicity but did not improve OS, compared with gemcitabine alone in unselected patients with metastatic pancreatic cancer. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT01231347.

E.M.P.A.T.H.Y.: A Tool to Enhance Nonverbal Communication Between Clinicians and Their Patients

There is a gap in the medical education literature on teaching nonverbal detection and expression of empathy. Many articles do not address nonverbal interactions, instead focusing on “what to say” rather than “how to be.” This focus on verbal communication overlooks the essential role nonverbal signals play in the communication of emotions, which has significant effects on patient satisfaction, health outcomes, and malpractice claims. This gap is addressed with a novel teaching tool for assessing nonverbal behavior using the acronym E.M.P.A.T.H.Y.—E: eye contact; M: muscles of facial expression; P: posture; A: affect; T: tone of voice; H: hearing the whole patient; Y: your response. This acronym was the cornerstone of a randomized controlled trial of empathy training at Massachusetts General Hospital, 2010–2012. Used as an easy-to-remember checklist, the acronym orients medical professionals to key aspects of perceiving and responding to nonverbal emotional cues. An urgent need exists to teach nonverbal aspects of communication as medical practices must be reoriented to the increasing cultural diversity represented by patients presenting for care. Where language proficiency may be limited, nonverbal communication becomes more crucial for understanding patients’ communications. Furthermore, even in the absence of cultural differences, many patients are reluctant to disagree with their clinicians, and subtle nonverbal cues may be the critical entry point for discussions leading to shared medical decisions. A detailed description of the E.M.P.A.T.H.Y. acronym and a brief summary of the literature that supports each component of the teaching tool are provided.

Physician Burnout: Coaching a Way Out

ABSTRACTTwenty-five to sixty percent of physicians report burnout across all specialties. Changes in the healthcare environment have created marked and growing external pressures. In addition, physicians are predisposed to burnout due to internal traits such as compulsiveness, guilt, and self-denial, and a medical culture that emphasizes perfectionism, denial of personal vulnerability, and delayed gratification. Professional coaching, long utilized in the business world, provides a results-oriented and stigma-free method to address burnout, primarily by increasing one’s internal locus of control. Coaching enhances self-awareness, drawing on individual strengths, questioning self-defeating thoughts and beliefs, examining new perspectives, and aligning personal values with professional duties. Coaching utilizes established techniques to increase one’s sense of accomplishment, purpose, and engagement, all critical in ameliorating burnout. Coaching presumes that the client already possesses strengths and skills to handle life’s challenges, but is not accessing them maximally. Although an evidence base is not yet established, the theoretical basis of coaching’s efficacy derives from the fields of positive psychology, mindfulness, and self-determination theory. Using a case example, this article demonstrates the potential of professional coaching to address physician burnout.

Improving Empathy and Relational Skills in Otolaryngology Residents A Pilot Study

Physician empathy and relational skills are critical factors predicting quality of care, patient safety, patient satisfaction, and decreasing malpractice claims. Studies indicate that physician empathy declines throughout medical training, yet little is published about methods to enhance empathy, especially in surgical residency training. The Accreditation Council for Graduate Medical Education requires competencies in 6 areas, including interpersonal skills and communication. To address this important problem, the first author developed an innovative empathy-relational skills training protocol focusing on the underlying neurobiological mechanisms of empathy and the interpersonal processes that positively affect the patient-doctor relationship. The authors tested the effectiveness of this protocol in a pilot study with 11 otolaryngology residents. Results showed that a brief series of 3 empathy training sessions can significantly improve physicians’ knowledge of the neurobiology and physiology of empathy, as well as their self-reported capacity to empathize with patients. A trend toward increased patient satisfaction was observed.

Biomarkers in the Psychotherapeutic Relationship: The Role of Physiology, Neurobiology, and Biological Correlates of E.M.P.A.T.H.Y.

&NA; Emerging biomarker research could powerfully influence the practice of psychotherapy, a standard treatment that is as strongly rooted in brain plasticity as are psychopharmacologic interventions. Psychotherapy is associated with measurable changes in central and peripheral neurophysiology. These markers could be harnessed to aid informed, personalized recommendations for specific psychosocial treatments, to guide a course of treatment, and to predict treatment outcomes, in lieu of relying on costly, trial‐and‐error approaches. Psychotherapy and empathy research also demonstrate that the patient‐doctor relationship has important neurophysiological correlates that can be salient to treatment outcomes, as illustrated in a case example. These correlates include autonomic nervous system arousal manifested by heart rate, respiration rate, muscle tension, and galvanic skin resistance; electroencephalography; and brain‐imaging markers. While additional biomarker research is unfolding, there are specific neurobiologically based clinical and subclinical observations, organized by using the E.M.P.A.T.H.Y. mnemonic, that may guide and enhance psychotherapy. Empathic attunement to patients is equally relevant for psychopharmacologic interventions and psychotherapy, and for all patient‐doctor relationships.

Teaching the Teachers: A Model Course for Psychodynamic Psychotherapy Supervisors

ObjectiveThere are no standard training programs for teaching psychotherapy supervisors effective, ethical, and legal aspects of supervision. This article describes an eight session training course containing essential information for supervisors.MethodsThe literature on psychotherapy supervision was reviewed and an evening seminar series was offered to veteran supervisor. The seminars were then translated into a course for faculty supervisors and trainees interested in becoming supervisors.ResultsParticipants completed a postcourse surveyand ranked as high the quality and content of the course and course satisfaction on Likert scales. Participants felt well prepared and reported increased confidence in going forward in their supervisory roles.ConclusionWhile current Residency Review Committee guidelines do not define standards for competency in psychotherapy supervision, the authors suggest that a course containing these principles of psychodynamic psychotherapy supervision be a prerequisite for those supervising residents. New and veteran supervisors reported learning essential aspects of supervision unknown before their course enrollment.