Lesley Gray

How well do medical students rate and communicate clinical empathy

Background: This article presents findings from a prospective, longitudinal cohort educational study investigating empathy communication in clinical consultations. It reports on changes in students’ self-report empathy during medical undergraduate training, investigates how well peers can assess student competence in motivational interviewing/brief interventions (MI/BI) skills and explores the relationship between students’ self-report empathy and peer- or tutor-assessments of competence. Methods: 72 medical students completed the Jefferson Scale of Physician Empathy at three time points: at the beginning of their fifth year medical training (Time 1), after a specific MI/BI training session during their fifth year medical training (Time 2) and 1 year later during a revision session in year 6. Competence in BI/MI consultation was assessed using the validated tool Behaviour Change Counselling Index. Results: A significant decline in medical students’ empathy scores was observed from year 5 to year 6, consistent with international findings. Peer assessments and tutor ratings of competence in MI/BI skills performance were moderately correlated, but peer assessments were negatively correlated with medical students’ self-rated empathy. Senior medical students who self-rated as more empathic received lower competence evaluations of MI/BI skills from their peers. Interventions to further investigate teaching and learning of empathy are discussed.

Nurse-patient communication in primary care diabetes management: an exploratory study

BackgroundDiabetes is a major health issue for individuals and for health services. There is a considerable literature on the management of diabetes and also on communication in primary care consultations. However, few studies combine these two topics and specifically in relation to nurse communication. This paper describes the nature of nurse-patient communication in diabetes management.MethodsThirty-five primary health care consultations involving 18 patients and 10 nurses were video-recorded as part of a larger multi-site study tracking health care interactions between health professionals and patients who were newly diagnosed with Type 2 diabetes. Patients and nurses were interviewed separately at the end of the 6-month study period and asked to describe their experience of managing diabetes. The analysis used ethnography and interaction analysis.In addition to analysis of the recorded consultations and interviews, the number of consultations for each patient and total time spent with nurses and other health professionals were quantified and compared.ResultsThis study showed that initial consultations with nurses often incorporated completion of extensive checklists, physical examination, referral to other health professionals and distribution of written material, and were typically longer than consultations with other health professionals. The consultations were driven more by the nurses’ clinical agenda than by what the patient already knew or wanted to know. Interactional analysis showed that protocols and checklists both help and hinder the communication process. This contradictory outcome was also evident at a health systems level: although organisational targets may have been met, the patient did not always feel that their priorities were attended to. Both nurses and patients reported a sense of being overwhelmed arising from the sheer volume of information exchanged along with a mismatch in expectations.ConclusionsConscientious nursing work was evident but at times misdirected in terms of optimal use of time. The misalignment of patient expectations and clinical protocols highlights a common dilemma in clinical practice and raises questions about the best ways to balance the needs of individuals with the needs of a health system. Video- recording can be a powerful tool for reflection and peer review.

An interprofessional community education project as a socially accountable assessment.

Abstract As part of a clinically based rotational undergraduate interprofessional programme, an assessment was devised which was construed as being socially accountable. An interprofessional programme, with cohorts of students from six different health professions, was evaluated in a number of ways. Students completed pre and post questionnaires about many aspects of the programme and also participated in focus groups. The social accountability of the key assignment emerged as important for both students and the community agencies that provided the clinical experience for students. Students implicitly and explicitly reported that their awareness of the need for health professionals to be socially accountable was heightened as a result of the assignment task. This article indicates that with creativity and perseverance an assessment can be devised that is relevant both to the student and the community, and is a powerful learning exercise for all involved.

“Basically you wait for an ‘in’’’: community pharmacist views on their role in weight management in New Zealand

INTRODUCTION Obesity is now widely regarded as the main contributor to poor health globally, overtaking tobacco as the leading potentially modifiable risk to health. Community pharmacists are delivering an increasing number of extended services and are potentially well placed to contribute to obesity management strategies. No studies to date have investigated the views of community pharmacists in New Zealand about their role in weight management. AIM To explore the views of community pharmacists in one region of New Zealand about their role in weight management, including the perceived barriers and facilitators to their involvement. METHODS Qualitative, face-to-face, semi-structured interviews were undertaken with 11 community pharmacists from the Greater Wellington region. Interviews were transcribed verbatim and analysed thematically using an inductive approach. RESULTS Four key themes were identified from data analysis. These were: (i) perceptions of obesity; (ii) perceptions of weight management treatment options; (iii) the unique position of the community pharmacist; and (iv) barriers to involvement. The main barriers described included: (i) a lack of time and remuneration; (ii) the absence of an appropriate space within the pharmacy to discuss weight-related matters; (iii) and a lack of awareness of who to contact for specialist support. DISCUSSION Community pharmacists in Greater Wellington believe that they have a distinct role in their local community and can contribute to a multidisciplinary approach to reduce levels of obesity. Further work is required to determine the most appropriate role for community pharmacy in weight management and the training needs for pharmacy staff to optimally fulfil this role.

A taboo topic? How General Practitioners talk about overweight and obesity in New Zealand

INTRODUCTION Obesity is overtaking tobacco smoking in New Zealand as the leading potentially modifiable risk to health. International obesity guidelines recommend that health professionals opportunistically encourage weight management with their patients. However, research shows consistently low rates of weight management discussion, suggesting that health professionals may not be realising their full potential to address obesity. AIM To identify communication strategies used by General Practitioners (GPs) to open the topic of weight and weight management in routine consultations. METHODS A secondary analysis was conducted of 36 video-recorded consultations in general practices, selected for relevance from a database of 205 consultations. Content and interactional analysis was conducted in the context of the entire consultation. RESULTS The topic of weight was initiated more often by GPs than patients and was raised mostly once or twice in a consultation and occasionally as many as six times. GPs employed opportunistic strategies twice as often as they used structured strategies. DISCUSSION This study of naturally occurring consultations confirmed GPs do engage in opportunistic discussions about weight. However, such discussions are challenging and interactionally delicate. Highlighting the clinical relevance of weight appears to be effective. The high frequency of patient contact with GPs provides opportunity to reach and work with people at risk of chronic conditions associated with excess weight. Further research is required to identify suitable training and brief intervention tools for use in routine consultations that may be beneficial for both GPs and patients.

A Longitudinal Study of Interactions Between Health Professionals and People With Newly Diagnosed Diabetes

PURPOSE We undertook a study to observe in detail the primary care interactions and communications of patients with newly diagnosed diabetes over time. In addition, we sought to identify key points in the process where miscommunication might occur. METHODS All health interactions of 32 patients with newly diagnosed type 2 diabetes were recorded and tracked as they moved through the New Zealand health care system for a period of approximately 6 months. Data included video recordings of patient interactions with the health professionals involved in their care (eg, general practitioners, nurses, dietitians). We analyzed data with ethnography and interaction analysis. RESULTS Challenges to effective communication in diabetes care were identified. Although clinicians showed high levels of technical knowledge and general communication skill, initial consultations were often driven by biomedical explanations out of context from patient experience. There was a perception of time pressure, but considerable time was spent with patients by health professionals repeating information that may not be relevant to patient need. Health professionals had little knowledge of what disciplines other than their own do and how their contributions to patient care may differ. CONCLUSIONS Despite current high skill levels of primary care professionals, opportunities exist to increase the effectiveness of communication and consultation in diabetes care. The various health professionals involved in patient care should agree on the length and focus of each consultation.

Morbid Obesity in Disasters: Bringing the “Conspicuously Invisible” into Focus

It is a frightening reality for some people to be caught up in the midst of a disaster, alone and vulnerable due to their relative size, shape or weight. A literature search failed to find any empirical reports of data specific to body mass index (BMI) in disaster situations. A handful of largely anecdotal reports described situations in which people categorised as morbidly obese were negatively impacted in disasters because of their size and/or weight. While a small number of toolkits and training resources were found, there remains a paucity of research in relation to obesity and emergency planning or disaster risk reduction. This is somewhat surprising, considering the concern about increasing levels of obesity globally. Research is urgently needed to prioritise and address the specific considerations of people with morbid obesity and how communities plan, prepare, respond, and recover from disasters and public health emergencies.

Longitudinal impact of interprofessional education on attitudes, skills and career trajectories: a protocol for a quasi­experimental study in New Zealand

Introduction Interprofessional practice is recognised as an important element of safe and effective healthcare. However, few studies exist that evaluate how preregistration education contributes to interprofessional competencies, and how these competencies develop throughout the early years of a health professional’s career. This quasiexperimental study will gather longitudinal data during students’ last year of preregistration training and their first 3 years of professional practice to evaluate the ongoing development of interprofessional competencies and the influence that preregistration education including an explicit interprofessional education (IPE) programme may have on these. Methods and analysis Participants are students and graduates from the disciplines of dentistry, dietetics, medicine, nursing, occupational therapy, oral health, pharmacy and physiotherapy recruited before their final year of study. A subset of these students attended a 5-week IPE immersion programme during their final year of training. All data will be collected via five written or electronic surveys completed at 12-month intervals. Each survey will contain the Attitudes Towards Health Care Teams Scale and the Team Skills Scale, as well as quantitative and free-text items to explore vocational satisfaction, career trajectories and influences on these. Students who attend the IPE programme will complete additional free-text items to explore the effects of this programme on their careers. Quantitative analysis will compare scores at each time point, adjusted for baseline scores, for graduates who did and did not participate in the IPE programme. Associations between satisfaction data and discipline, professional setting, location and IPE participation will also be examined. Template analysis will explore free-text themes related to influences on career choices including participation in preregistration IPE. Ethics and dissemination This study has received approval from the University of Otago Ethics Committee (D13/019). Results will be disseminated through peer-reviewed publications, conferences and stakeholder reports. Findings will inform future IPE developments and health workforce planning.

Social Determinants of Health, Disaster Vulnerability, Severe and Morbid Obesity in Adults: Triple Jeopardy?

Severe and morbid obesity are associated with highly elevated risks of adverse health outcomes and the prevalence of severe obesity is increasing globally. To date, disaster literature has not considered severe and morbid obesity as a specific vulnerability, despite reports of people being left behind during disasters because of their body size, shape or weight. The complex causes of obesity are associated with the social determinants of health and one’s potential vulnerability to disasters. The absence of appropriate considerations may lead to people being exposed to disproportionate and potentially avoidable risk. The intersection of the social determinants of health, disaster vulnerability, severe and morbid obesity is explored. Previously identified vulnerable groups are also represented in severe and morbid obesity data. This poses the prospect for ‘triple jeopardy’ compounding the social determinants of health, disaster vulnerability and considerations with and for people with morbid obesity. When working to reduce disaster risk for vulnerable groups, the author proposes specific consideration is required to ensure ‘all-of-society engagement and partnership’ in an inclusive, accessible and non-discriminatory manner, to ensure no one is left behind.