Ronald D. Adelman

Caregiver Burden: A Clinical Review

IMPORTANCE Caregiver burden may result from providing care for patients with chronic illness. It can occur in any of the 43.5 million individuals providing support to midlife and older adults. Caregiver burden is frequently overlooked by clinicians. OBJECTIVES To outline the epidemiology of caregiver burden; to provide strategies to diagnose, assess, and intervene for caregiver burden in clinical practice; and to evaluate evidence on interventions intended to avert or mitigate caregiver burden and related caregiver distress. EVIDENCE Cohort studies examining the relation between demographic and social risk factors and adverse outcomes of caregiver burden were reviewed. Review of recent meta-analyses to summarize the effectiveness of caregiver burden interventions were identified by searching Ovid MEDLINE, AgeLine, and the Cochrane Library. RESULTS Risk factors for caregiver burden include female sex, low educational attainment, residence with the care recipient, higher number of hours spent caregiving, depression, social isolation, financial stress, and lack of choice in being a caregiver. Practical assessment strategies for caregiver burden exist to evaluate caregivers, their care recipients, and the care recipients overall caregiving needs. A variety of psychosocial and pharmacological interventions have shown mild to modest efficacy in mitigating caregiver burden and associated manifestations of caregiver distress in high-quality meta-analyses. Psychosocial interventions include support groups or psychoeducational interventions for caregivers of dementia patients (effect size, 0.09-0.23). Pharmacologic interventions include use of anticholinergics or antipsychotic medications for dementia or dementia-related behaviors in the care recipient (effect size, 0.18-0.27). Many studies showed improvements in caregiver burden-associated symptoms (eg, mood, coping, self-efficacy) even when caregiver burden itself was minimally improved. CONCLUSIONS AND RELEVANCE Physicians have a responsibility to recognize caregiver burden. Caregiver assessment and intervention should be tailored to the individual circumstances and contexts in which caregiver burden occurs.

Completing an Advance Directive in the Primary Care Setting: What Do We Need for Success?

OBJECTIVES: To systematically review studies designed to increase advance directive completion in the primary care setting and employ meta‐analytic techniques to quantify their effects.

Older patient satisfaction with communication during an initial medical encounter

There has been extensive research on the factors associated with patient satisfaction with communication during medical encounters, however, little attention has been paid to satisfaction among subgroups of patients, including the elderly. It is inappropriate to assume that all patients have the same physician-patient relationship needs, and thus, they will all be satisfied with the same communication approaches during medical visits. In this study, we examine the interactional correlates of older patient satisfaction with an initial visit with a general internist. A multidisciplinary team composed of social scientists and physicians used the Multi-dimensional Interaction Analysis system to code audiotapes. Patients and physicians completed post-visit satisfaction questionnaires. Older patient satisfaction was positively correlated with the following variables: physician questioning and supportiveness on patient-raised topics; patient information-giving on patient-raised topics; the length of the visit; the physicians use of questions worded in the negative; shared laughter between the physician and the patient; and physician satisfaction. These findings suggest that older patients prefer encounters in which: (1) there is physician supportiveness and shared laughter; (2) they are questioned about and given an opportunity to provide information on their own agenda items; and (3) physicians provide some structure for the first meeting through their use of questions worded in the negative. The authors caution that although this sample of older patients appears to be satisfied with a communication style usually considered characteristic of the traditional model of the physician-patient relationship (i.e. a warm interpersonal style and physician-generated structure for the visit), older patients in other settings and future cohorts of elderly patients may prefer other communication approaches. It is also suggested that aspects of communication which provide satisfaction to patients in first visits may be different than aspects of communication associated with patient satisfaction in follow-up visits.

The Effects of the Presence of a Third Person on the Physician‐Older Patient Medical Interview

Objective: To compare communication in triadic (three‐person) and dyadic (two‐person) older patient medical interviews and to determine the influence of the presence of a third person on the physician‐older patient relationship.

COMMUNICATION BETWEEN OLDER PATIENTS AND THEIR PHYSICIANS

This article provides an overview of communication between older patients and their physicians. The authors discuss distinctive features of geriatric medical visits and empirical investigations of communication between physicians and older patients in real life clinical encounters highlighting the content, interactional processes, and outcomes of care. They also discuss strategies for improving communication between physicians and older patients using new and innovative technologies. The authors conclude that healing in its broadest sense can occur only through a humanistic approach to geriatric care.

Issues in Physician—Elderly Patient Interaction

The basis of an effective and satisfactory physician–patient relationship is found in the communication which occurs between these two individuals. By studying the interaction, we can learn much about the identities of the physician and patient, and how they view each other and the world. The interactional dynamics between physician and patient are unique. For example, even in initial medical encounters which involve the meeting of two strangers, patients and physicians deal with concerns as diverse as life and death as well as other intimate or personal issues. Researchers of physician–patient interaction seek to discover how communication evolves and how that communication reveals the multiple levels of meaning in the medical encounter.

Physicians' Attitudes Towards Copy and Pasting in Electronic Note Writing

BACKGROUNDThe ability to copy and paste text within computerized physician documentation facilitates electronic note writing, but may affect the quality of physician notes and patient care. Little is known about physicians’ collective experience with the copy and paste function (CPF).OBJECTIVESTo determine physicians’ CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use.DESIGNCross-sectional survey.PARTICIPANTSResident and faculty physicians within two affiliated academic medical centers currently using a computerized documentation system.MEASUREMENTSResponses on a self-administered survey.RESULTSA total of 315 (70%) of 451 eligible physicians responded to the survey. Of the 253 (80%) physicians who wrote inpatient notes electronically, 226 (90%) used CPF, and 177 (70%) used it almost always or most of the time when writing daily progress notes. While noting that inconsistencies (71%) and outdated information (71%) were more common in notes containing copy and pasted text, few physicians felt that CPF had a negative impact on patient documentation (19%) or led to mistakes in patient care (24%). The majority of physicians (80%) wanted to continue to use CPF.CONCLUSIONSAlthough recognizing deficits in notes written using CPF, the majority of physicians used CPF to write notes and did not perceive an overall negative impact on physician documentation or patient care. Further studies of the effects of electronic note writing on the quality and safety of patient care are required.

Multi-dimensional interaction analysis: A collaborative approach to the study of medical discourse

This paper reviews the conceptual frameworks of several research approaches to the study of medical interactions. Two methods are discussed: process analysis and microanalysis. Adapted from Robert Baless study of the behavior of small groups, process analysis sorts and tallies such interviewing processes as questioning and informing, achieving analysis of large numbers of interviews at the expense of attention to the content or context of the interview. When used in medical interaction research, process analysis seeks correlation between processes documented in the interview and outcomes of the interview. The methods of conversation analysts and discourse analysts, microanalyses subject medical conversations to close linguistic study and contextualization. This review focuses on the underlying assumptions, generalizability of findings, and the types of subjective judgment applied by the methods. It then describes the Multi-Dimensional Interaction Analysis (MDIA) system, a linguistic analytic instrument that combines features of process analysis and microanalysis to capture content, process, and context of medical conversations. The MDIAs validity and reliability are reported and implications for future research are outlined.

Introduction to the Older Patient: A “First Exposure” to Geriatrics for Medical Students

In 2003, Weill Cornell Medical College developed a 4‐hour module to introduce the geriatric patient within the required first‐year doctoring course. The educational intervention highlights the importance of communication between older patients and physicians, the utility of an enhanced social history and functional assessment, and the pitfalls of ageism in the medical setting. The module incorporates film, the performing arts, and small‐group exposure to a community‐residing older person.

Reflections of medical students on visiting chronically ill older patients in the home.

The expanding number of Americans living with chronic illness necessitates educating future physicians about chronic illness care. Weill Cornell Medical Colleges Chronic Illness Care in the Home Setting Program (CIC‐HSP), a mandatory part of the primary care clerkship, exposes medical students to persons with chronic illness via a half day of house calls with a geriatrics team. The investigators sought to qualitatively assess the effect of the CIC‐HSP on medical students and recent medical graduates. Fifty‐two prospective participants were approached, and 50 (96%) with varying training levels and time since completing the program were interviewed.