Marijana Braš

The Role of Communication

According to modern concepts, medical knowledge, communication skills, physical examination, and problem solving are four essential components of clinical competence of a physician. Communication and relationship have been demonstrated to have an impact on patients’ experience of care, to improve patients’ adherence to treatment regimens, clinical outcomes and quality, patient safety, teamwork, cultural sensitivity, and to reduce medical malpractice risk. Inter-professional communication between the various healthcare practitioners is another important aspect in the treatment of patients. Medicine is becoming a shared effort not only between the various healthcare practitioners involved in treatment but also the patients themselves. All parties involved would benefit from proper collaboration and communication. Appropriate communication is a cornerstone of modern medicine, where understanding and context-driven interview lead the way in improved patient experience. The medical interview is a complex process of taking information for the purpose of diagnosis, and it is an extremely important factor in establishing a relationship between doctors and patients. Integrated patient-centered and physician-centered interview builds a relationship, opens the discussion, gathers information, understands the patient’s perspective, shares information, reaches agreement, and provides closure. All these are essential elements of the medical interview. The person-centered medical interview is an important bridge between personalized and person-centered medicine. It is necessary to develop, evaluate, and implement training programs aimed at enhancing person-centerd communication and care.

Quality of life in Croatian Homeland war (1991- 1995) veterans who suffer from post-traumatic stress disorder and chronic pain

BackgroundThe aim of this study was to investigate the quality of life in Croatian homeland war veterans who suffer from post-traumatic stress disorder and chronic low back pain (LBP).MethodsA total of 369 participants were included, classified in four study groups: those with post-traumatic stress disorder (PTSD; N = 59), those with both PTSD and lower back pain (PTSD+LBP; N = 80), those with isolated LBP (N = 95) and controls (N = 135). WHOQOL-BREF survey was used in the estimation of quality of life. The data were analysed using statistical methods and hierarchical clustering.ResultsThe results indicated a general pattern of lowering quality of life in participants with both psychological (PTSD) and physical (LBP) burden. The average overall quality of life was 2.82 ± 1.14 for the PTSD+LBP group, 3.29 ± 1.28 for the PTSD group, 4.04 ± 1.25 for the LBP group and 4.48 ± 0.80 for the controls (notably, all the pair-wise comparisons were significantly different at the level of P < 0.001, except for the pair LBP-controls, which was insignificant). This result indicated that quality of life was reduced for 9.9% in patients with LBP, 26.6% in patients with PTSD and 37.1% in PTSD+LBP, suggesting strong synergistic effect of PTSD and LBP. The analysis also identified several clusters of participants with different pattern of quality of life related outcomes, reflecting the complex nature of this indicator.ConclusionsThe results of this study reiterate strong impact of PTSD on quality of life, which is additionally reduced if the patient also suffers from LBP. PTSD remains a substantial problem in Croatia, nearly two decades after the beginning of the 1991-1996 Homeland war.

Person-centered pain management - science and art.

We are witnessing an unprecedented development of the medical science, which promises to revolutionize health care and improve patients’ health outcomes. However, the core of the medical profession has always been and will be the relationship between the doctor and the patient, and communication is the most widely used clinical skill in medical practice. When we talk about different forms of communication in medicine, we must never forget the importance of communication through art. Although one of the simplest, art is the most effective way to approach the patient and produce the effect that no other means of communication can achieve. Person-centered pain management takes into account psychological, physical, social, and spiritual aspects of health and disease. Art should be used as a therapeutic technique for people who suffer from pain, as well as a means of raising public awareness of this problem. Art can also be one of the best forms of educating medical professionals and others involved in treatment and decision-making on pain.

Person-centered medical interview

Abstract We are witnessing an unprecedented development of medical science and personalized medicine. However, technological superiority must not make us lose sight of the physical, psychological, social, and spiritual totality of the patient. The core of the medical profession has always been and will be the relationship between the health professional and the person seeking assistance. However, the traditional relationship between the physician and the patient has changed and is greatly impacted by huge social, philosophical, economic, and scientific developments. It is important to develop and promote the culture of health instead of the culture of illness through a patient-doctor collaborative partnership, as well as partnership among professionals. Person-centered medical interview is an important bridge between personalized and person-centered medicine.

Is experimentally induced pain associated with socioeconomic status? Do poor people hurt more?

Background The association of pain and socioeconomic status is widely reported, yet much less clearly understood. The aim of this study was to investigate the association of experimentally induced pain threshold and tolerance with socioeconomic status. Material/Methods The study sample consisted of 319 adult subjects from the population of the island of Vis, Croatia, which was previously shown to have a high level of social homogeneity. A manual dolorimeter was used to measure mechanical pressure pain threshold (least stimulus intensity) and pain tolerance (maximum tolerance stimulus intensity) on both hands. Pain tolerance interval was defined as the difference between pain tolerance and threshold. Years of schooling and material status were used as socioeconomic estimates. Results Both of the socioeconomic estimates were significantly correlated with pain threshold, tolerance, and tolerance interval (P<0.001). The mixed modeling analysis, controlled for the effects of age, gender, and 4 psychological variables, indicated that education was not a significant predictor in any of the 3 models. However, lower material status was significantly associated with lower pain tolerance (P=0.038) and narrower pain tolerance interval (P=0.032), but not with pain threshold (P=0.506). The overall percentages of explained variance were lower in the tolerance interval model (20.2%) than in pain tolerance (23.1%) and threshold (33.1%), suggesting the increasing share of other confounding variables in pain tolerance and even more so in tolerance interval model. Conclusions These results suggest a significant association between experimentally induced pain tolerance and tolerance interval with material status, suggesting that poor people indeed do hurt more.

The founding of the Centre for Palliative Medicine, Medical Ethics and Communication Skills: a new step toward the development of patient-oriented medicine in Croatia.

One of the main conceptual changes in the 20th century medicine is the inclusion of social dimension. The “golden era” of Parson’s medical model (1), which uses the “active-passive” dichotomy to describe the positions and expectations of physicians and patients, is over. Physicians’ supremacy has slowly and systematically been challenged by the emergence of third party stakeholders, development of new media sources, strengthening of the civil society, and democratization of information, which all have contributed to the development of the patients’ active role in the healing processes (2). The rise of medical consumerism has stimulated the medical authorities to react with a new ideological policy: the patient-oriented medicine, insisting on the partnership in the diagnostic and therapeutic processes, and viewing the patient as a person with biological, psychological, social, and spiritual needs (2).

Person-Centered Psychiatric Education

Person-centered psychiatric care requires person-centered psychiatric education (PCPE), as one is undeniably the mirror of the other. In parallel to the person-centered care it promotes, PCPE holds the person as the core substance of the learning process. PCPE aims for the learner to develop the knowledge and skills required for person-centered psychiatric care. The distinctive feature of PCPE, however, is its focus on the development of the attitudes necessary for such an approach to care. The present chapter describes some key elements and strategies of PCPE for medical students, psychiatrist trainees, and trained psychiatrists. In every case, PCPE is presented as an interactional process, dialogical in nature, and transformative in essence.

Communication skills in medicine: where do we come from and where are we going?

The physician-patient relationship has changed throughout history, as the role of physician has been transformed. Modern physicians need to be educated on how to use highly specialized knowledge when approaching the patient as a unique and whole person living in a given psychological, social, and material context. This relationship evolved from a paternalistic model to a cooperative-deliberative one, representing a meeting between two “experts:” the physician as the medical expert and the patient as the expert on himself. According to this model, communication between patients and physicians must be based on common understanding in a caring and dynamic relationship that also involves the patient’s family. Nevertheless, this new approach is not free from difficulties, because physicians have to learn to adapt to its demands. This situation has led to a new concept known as the “empowered patient” (1). Effective physician-patient communication is a central clinical function in building a therapeutic relationship. Therefore, in recent decades great attention has been paid to the quality of communication in medicine. However, the educational background and characteristics of communication skills teaching are a less studied field. Anglo-Saxon countries are pioneers in integrating this subject into undergraduate and postgraduate medical education. Less is known about other countries, especially Spanish-speaking and Central and Eastern European countries (2-4). The only way the future physicians (today’s students) can develop effective communication with their patients is to integrate this teaching at the university level. Therefore, it was necessary to analyze how teaching of communication skills in medical schools has evolved. This essay provides a brief historical analysis of the integration of this teaching in the pioneering countries. We also focus our attention to Spain and Croatia, where our teams come from. It can be said that these reflections are the result of teamwork and collaboration between Croatia and Spain.

Neuroticism and pain catastrophizing aggravate response to pain in healthy adults: an experimental study

Background The aim of this study was to investigate the association between neuroticism, pain catastrophizing, and experimentally induced pain threshold and pain tolerance in a healthy adult sample from two regions of the country of Croatia: the island of Korcula and city of Split. Methods A total of 1,322 participants were enrolled from the Island of Korcula (n = 824) and the city of Split (n = 498). Participants completed a self-reported personality measure Eysenck Personality Questionnaire (EPQ) and pain catastrophizing questionnaire Pain Catastrophizing Scale (PCS), followed by a mechanical pain pressure threshold and tolerance test. We have explored the mediating role of catastrophizing in the relationship between neuroticism and pain intensity. Results The results showed that pain catastrophizing partially mediated the relationship between neuroticism and pain intensity, suggesting the importance of pain catastrophizing in increasing vulnerability to pain. The results also indicated gender-related differences, marked by the higher pain threshold and tolerance in men. Conclusions This study adds to the understanding of the complex interplay between personality and pain, by providing a better understanding of such mechanisms in healthy adults.

Person-Centered Palliative Care

Palliative care is by definition the approach of having the person at the center of the intervention (patient-centered care) in the advanced and terminal phases of physical illness. It is important in palliative care to integrate the scientific method with psychological insights and infuse this end-of-life experience with transcendental/existential awareness and the search for meaning and purpose. Interpersonal, psychological, and spiritual needs, as well as psychiatric disorders (e.g., depression, stress-related disorders, delirium) and psychosocial conditions (e.g., demoralization, distress and existential pain) need to be addressed by multidisciplinary, person-centered palliative care teams. Therefore, a dignity conserving approach should be part of care of patients in the advanced stage of illness. A series of psychosocial interventions have recently been developed as helpful approaches to be applied in palliative care, including supportive-expressive therapy, meaning-centered psychotherapy, managing cancer, and living meaningfully therapy, and dignity therapy. These interventions, integrated with psychopharmacology when needed, are interventions to heighten the patients’ sense of dignity, to increase their sense of purpose and meaning, to lessen their sense of suffering and to decrease demoralization, anxiety, and depression at the end-of-life. Also, communication skills training and psychosocially oriented intervention for palliative care health professionals have demonstrated to reduce burnout, increase job satisfaction, and, in turn, improve the quality of patient care.