Neda Ratanawongsa

What patients say about their doctors online: a qualitative content analysis.

ABSTRACTBACKGROUNDDoctor rating websites are a burgeoning trend, yet little is known about their content.OBJECTIVETo explore the content of Internet reviews about primary care physicians.DESIGNQualitative content analysis of 712 online reviews from two rating websites. We purposively sampled reviews of 445 primary care doctors (internists and family practitioners) from four geographically dispersed U.S. urban locations. We report the major themes, and because this is a large sample, the frequencies of domains within our coding scheme.RESULTSMost reviews (63%) were positive, recommending the physician. We found a major distinction between global reviews, “Dr. B is a great doctor.” vs. specific descriptions which included interpersonal manner, “She always listens to what I have to say and answers all my questions.”; technical competence “No matter who she has recommended re: MD specialists, this MD has done everything right.”; and/or systems issues such as appointment and telephone access. Among specific reviews, interpersonal manner “Dr. A is so compassionate.” and technical competence “He is knowledgeable, will research your case before giving you advice.” comments tended to be more positive (69% and 80%, respectively), whereas systems-issues comments “Staff is so-so, less professional than should be…” were more mixed (60% positive, 40% negative).CONCLUSIONSThe majority of Internet reviews of primary care physicians are positive in nature. Our findings reaffirm that the care encounter extends beyond the patient–physician dyad; staff, access, and convenience all affect patient’s reviews of physicians. In addition, negative interpersonal reviews underscore the importance of well-perceived bedside manner for a successful patient–physician interaction.

A Multicenter Study of Physician Mindfulness and Health Care Quality

PURPOSE Mindfulness (ie, purposeful and nonjudgmental attentiveness to one’s own experience, thoughts, and feelings) is associated with physician well-being. We sought to assess whether clinician self-rated mindfulness is associated with the quality of patient care. METHODS We conducted an observational study of 45 clinicians (34 physicians, 8 nurse practitioners, and 3 physician assistants) caring for patients infected with the human immunodeficiency virus (HIV) who completed the Mindful Attention Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites across the United States. We measured patient-clinician communication quality with audio-recorded encounters coded using the Roter Interaction Analysis System (RIAS) and patient ratings of care. RESULTS In adjusted analyses comparing clinicians with highest and lowest tertile mindfulness scores, patient visits with high-mindfulness clinicians were more likely to be characterized by a patient-centered pattern of communication (adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58–10.86), in which both patients and clinicians engaged in more rapport building and discussion of psychosocial issues. Clinicians with high-mindfulness scores also displayed more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46–1.9). Patients were more likely to give high ratings on clinician communication (adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17–1.86) and to report high overall satisfaction (APR = 1.45; 95 CI, 1.15–1.84) with high-mindfulness clinicians. There was no association between clinician mindfulness and the amount of conversation about biomedical issues. CONCLUSIONS Clinicians rating themselves as more mindful engage in more patient-centered communication and have more satisfied patients. Interventions should determine whether improving clinician mindfulness can also improve patient health outcomes.

Third-year medical students' experiences with dying patients during the internal medicine clerkship: a qualitative study of the informal curriculum.

Purpose To explore third-year medical students’ experiences with death and dying patients during the first internal medicine clerkship. Method In August 2002, through purposeful sampling, the authors targeted for open-ended interviews 32 third-year medical students at the University of California, San Francisco in the first core internal medicine clerkship. Interviews averaged 45 minutes in length and were audiotaped, transcribed, and analyzed using a grounded theory approach. Results Twenty-eight (87.5%) students participated in interviews. All students encountered death or dying patients, and most cared directly for at least one dying patient. Students’ relationships with patients were characterized by attachment, empathy, and advocacy. Students valued preparation by preclinical end-of-life (EOL) courses, but assigned greater value to patient care experiences guided by teams that acknowledged deaths, role-modeled EOL care, and respected students’ participation in patient care. Clerkship experiences in EOL care affected students’ developing professional identities by affording opportunities to manage strong emotions, understand the challenges of transitioning to residency, and gain a sense of self-efficacy as future physicians providing EOL care. Conclusions Third-year medical students’ experiences with dying patients affect their skills and attitudes in EOL care, as well as the emergence of their professional identities. The behaviors and attitudes modeled by residents and attendings during the clerkships can strongly influence students’ perceptions of and self-efficacy in EOL care. Further research and interventions into how residents and attendings model responses to death in the clinical clerkship may suggest strategies not only for EOL training, but also for mentoring professional development.

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

BACKGROUND: The Accreditation Council for Graduate Medical Education duty hour requirements may affect residents’ understanding and practice of professionalism.OBJECTIVE: We explored residents’ perceptions about the current teaching and practice of professionalism in residency and the impact of duty hour requirements.DESIGN: Anonymous cross-sectional survey.PARTICIPANTS: Internal medicine, neurology, and family practice residents at 3 teaching hospitals (n=312).MEASUREMENTS: Using Likert scales and open-ended questions, the questionnaire explored the following: residents’ attitudes about the principles of professionalism, the current and their preferred methods for teaching professionalism, barriers or promoters of professionalism, and how implementation of duty hours has affected professionalism.RESULTS: One hundred and sixty-nine residents (54%) responded. Residents rated most principles of professionalism as highly important to daily practice (91.4%, 95% confidence interval [CI] 90.0 to 92.7) and training (84.7%, 95% CI 83.0 to 86.4), but fewer rated them as highly easy to incorporate into daily practice (62.1%, 95% CI 59.9 to 64.3), particularly conflicts of interest (35.3%, 95% CI 28.0 to 42.7) and self-awareness (32.0%, 95% CI 24.9 to 39.1). Role-modeling was the teaching method most residents preferred. Barriers to practicing profession-alism included time constraints, workload, and difficulties interacting with challenging patients. Promoters included role-modeling by faculty and colleagues and a culture of professionalism. Regarding duty hour limits, residents perceived less time to communicate with patients, continuity of care, and accountability toward their colleagues, but felt that limits improved professionalism by promoting resident well-being and teamwork.CONCLUSIONS: Residents perceive challenges to incorporating professionalism into their daily practice. The duty hour implementation offers new challenges and opportunities for negotiating the principles of professionalism.

The Association of Provider Communication with Trust among Adults with Sickle Cell Disease

BackgroundAdults with sickle cell disease often report poor interpersonal healthcare experiences, including poor communication with providers. However, the effect of these experiences on patient trust is unknown.ObjectiveTo determine the association between patient ratings of the previous quality of provider communication and current trust in the medical profession among adults with sickle cell disease.Research designCross-sectional survey.ParticipantsA total of 95 adults with sickle cell disease.MeasurementsThe four-item Provider Communication Subscale from the Consumer Assessment of Healthcare Plans and Systems Survey; The five-item Wake Forest Trust in the Medical Profession Scale.Main resultsBetter ratings of previous provider communication were significantly associated with higher levels of trust toward the medical profession. A 10% increase in provider communication rating was associated with a 3.76% increase in trust scores (p < 0.001, 95% CI [1.76%, 5.76%]), adjusting for patient-level demographic, clinical, and attitudinal characteristics.ConclusionsPoorer patient ratings of provider communication are associated with lower trust toward the medical profession among adults with sickle cell disease. Future research should examine the impact of low trust in the medical profession on clinical outcomes in this population of patients.

The reported validity and reliability of methods for evaluating continuing medical education: A systematic review

Purpose To appraise the reported validity and reliability of evaluation methods used in high-quality trials of continuing medical education (CME). Method The authors conducted a systematic review (1981 to February 2006) by hand-searching key journals and searching electronic databases. Eligible articles studied CME effectiveness using randomized controlled trials or historic/concurrent comparison designs, were conducted in the United States or Canada, were written in English, and involved at least 15 physicians. Sequential double review was conducted for data abstraction, using a traditional approach to validity and reliability. Results Of 136 eligible articles, 47 (34.6%) reported the validity or reliability of at least one evaluation method, for a total of 62 methods; 31 methods were drawn from previous sources. The most common targeted outcome was practice behavior (21 methods). Validity was reported for 31 evaluation methods, including content (16), concurrent criterion (8), predictive criterion (1), and construct (5) validity. Reliability was reported for 44 evaluation methods, including internal consistency (20), interrater (16), intrarater (2), equivalence (4), and test–retest (5) reliability. When reported, statistical tests yielded modest evidence of validity and reliability. Translated to the contemporary classification approach, our data indicate that reporting about internal structure validity exceeded reporting about other categories of validity evidence. Conclusions The evidence for CME effectiveness is limited by weaknesses in the reported validity and reliability of evaluation methods. Educators should devote more attention to the development and reporting of high-quality CME evaluation methods and to emerging guidelines for establishing the validity of CME evaluation methods.

Health care provider attitudes toward patients with acute vaso-occlusive crisis due to sickle cell disease: Development of a scale §

OBJECTIVE Patients with sickle cell disease (SCD) often perceive negative provider attitudes, which may affect the quality of patient-provider communication and care during vaso-occlusive crises (VOCs). This study investigated the validity and reliability of a scale to measure provider attitudes toward patients with acute VOC. METHODS Using a cohort of adults with VOC (September 2006 to June 2007), we administered a 10-item provider questionnaire within 72 h of patient encounters. After factor analysis, we created a 7-item Positive Provider Attitudes toward Sickle Cell Patients Scale (PASS); higher scores indicate more positive attitudes. We assessed internal consistency and evidence of construct validity, exploring bivariate relationships between provider or patient characteristics and the PASS score using multilevel modeling. RESULTS We collected 121 surveys from 84 health care providers for 47 patients. Patients averaged 30.3 years in age, and 60% were women. Among providers, 79% were nurses, and 70% worked in inpatient settings. PASS scores averaged 24.1 (S.D. 6.7), ranged 7-35, and had high internal consistency (Cronbachs alpha=0.91). As hypothesized, inpatient vs. emergency department providers (Delta=4.65, p<0.001) and nurses vs. other providers (Delta=0.95, p<0.001) had higher PASS scores. Higher patient educational attainment (Delta per year=2.74, p<0.001) and employment (Delta=5.62, p=0.001) were associated with higher PASS scores. More frequent hospitalizations (Delta per episode=-0.52, p<0.001) and prior disputes with staff (Delta=-7.53, p=0.002) were associated with lower PASS scores. CONCLUSION Our findings provide preliminary evidence for the reliability and construct validity of the PASS score in measuring provider attitudes toward patients with VOC. PRACTICE IMPLICATIONS Future studies should examine the validity of PASS in other cohorts of patients with SCD and their providers. With further evidence, PASS may prove useful for investigating the impact of provider attitudes on the quality of communication and care provided to these patients.

Getting under the skin of clinical inertia in insulin initiation: the Translating Research Into Action for Diabetes (TRIAD) Insulin Starts Project.

Purpose The purpose of this cross-sectional study is to explore primary care providers’ (PCPs) perceptions about barriers to initiating insulin among patients. Studies suggest that many patients with poorly controlled type 2 diabetes do not receive insulin initiation by PCPs. Methods As part of the Translating Research Into Action for Diabetes study, the authors conducted structured interviews in health systems in Indiana, New Jersey, and California, asking PCPs about the importance of insulin initiation and factors affecting this decision. The authors calculated proportions choosing each multiple-choice response option and listed the most frequently offered open-ended response categories. Results Among 83 PCPs, 45% were women; 60% were white; and they averaged 13.4 years in practice. Four-fifths of PCPs endorsed guideline-concordant glycemic targets, but 54% individualized targets based on patient age, life expectancy, medical comorbidities, self-management capacity, and willingness. Most (64%) reported that many patients were resistant to new oral or insulin therapies due to fears about the therapy and what it meant about their disease progression. Two-thirds (64%) cited patient resistance as a barrier to insulin initiation, and 43% cited problems with patient self-management, including cognitive or mental health issues, dexterity, or ability to adhere. Eighty percent felt that patient nonadherence would dissuade them from initiating insulin at least some of the time. Conclusions PCPs perceived that patient resistance and poor self- management skills were significant barriers to initiating insulin. Future studies should investigate whether systems-level interventions to improve patient-provider communication about insulin and enhance providers’ perceptions of patient self-management capacity can increase guideline-concordant, patient-centered insulin initiation.

A Video-Intervention to Improve Clinician Attitudes Toward Patients with Sickle Cell Disease: The Results of a Randomized Experiment

ABSTRACTBACKGROUNDClinician attitudes toward patients are associated with variability in the quality of health care. Attitudes are typically considered difficult to change, and few interventions have attempted to do so. Negative attitudes toward adults with sickle cell disease have been identified as an important barrier to the receipt of appropriate pain management for this patient population.OBJECTIVETo test the effect of a video-intervention designed to improve clinician attitudes toward adults with sickle cell disease.INTERVENTIONSAn 8-minute video depicting a clinician expert and patients discussing challenges in seeking treatment for sickle cell pain.DESIGN AND PARTICIPANTSA randomized post-test only control group design was used to assess the impact of the intervention on the attitudes of 276 nurses and housestaff working at a large, urban, academic medical center.MAIN MEASURESAttitudes toward adult sickle cell patients assessed using 5- and 6-point Likert-scale items. Exploratory factor analysis was used to identify underlying attitudinal domains and develop scales. Examples of the negative and positive attitudes assessed include clinician estimates of the percentage of SCD patients that exaggerate pain (negative) or make clinicians glad they went into medicine (positive).KEY RESULTSCompared to the control group, the intervention group exhibited decreased negative attitudes (Difference in means = -8.9, 95%CI [-14.2, -3.6]; Cohen’s d = 0.41), decreased endorsement of certain patient behaviors as “concern-raising” (Difference in means = -7.8, 95%CI [-13.1, -2.5]; Cohen’s d = 0.36), and increased positive attitudes toward sickle cell patients (Difference in means = 6.6, 95% CI [0.6, 12.6]; Cohen’s d = 0.27).CONCLUSIONSOur results suggest that the attitudes of clinicians toward sickle cell patients may be improved through a short and relatively easy to implement intervention. Whether the attitudinal differences associated with our intervention are sustainable or are linked to clinical outcomes remains to be seen.

Hospital self‐discharge among adults with sickle‐cell disease (SCD): Associations with trust and interpersonal experiences with care

BACKGROUND Patient self-discharge from hospitals has been associated with a number of negative clinical outcomes. Research suggests that low patient trust and poor quality interpersonal experiences with care may be associated with hospital self-discharge. Although adults with sickle-cell disease (SCD) often report poorer quality healthcare experiences, research examining hospital self-discharge and its associations with both patient trust and quality of healthcare experiences is lacking for this patient population. OBJECTIVE To examine the association of interpersonal experiences with care and trust in the medical profession with hospital self-discharge history among patients with SCD. DESIGN Cross-sectional study. SETTING A large, urban academic medical center. PATIENTS Adults (age 18+ years) with SCD seeking outpatient or inpatient care. MEASUREMENTS We compared patient characteristics, patient perceptions of the quality of interpersonal experiences with care, and levels of trust between patients with and without a history of hospital self-discharge. RESULTS Adjusted analyses indicated that having a history of hospital self-discharge was associated with more negative interpersonal experiences and lower levels of trust. CONCLUSIONS Hospital self-discharge may be an important indicator of the quality of care received by adults with SCD. Further research is needed to better understand this phenomenon so that effective interventions can be designed to prevent its occurrence.