Sean Meldrum

Patient trust: Is it related to patient-centered behavior of primary care physicians?

Background:Patients’ trust in their health care providers may affect their satisfaction and health outcomes. Despite the potential importance of trust, there are few studies of its correlates using objective measures of physician behavior during encounters with patients. Methods:We assessed physician behavior and length of visit using audio tapes of encounters of 2 unannounced standardized patients (SPs) with 100 community-based primary care physicians participating in a large managed care organization. Physician behavior was assessed via 3 components of the Measure of Patient-Centered Communication (MPCC) scale. The Primary Care Assessment Survey (PCAS) trust subscale was administered to 50 patients from each physicians practice and to SPs. We used multilevel modeling to examine the associations between physicians’ Patient-Centered Communication during the SP visits and ratings of trust by both patients and SPs. Results:Component 1 of the MPCC, which explored the patients experience of the disease and illness, was independently associated with patients rating of trust in their physician. A 1 SD increase in this score was associated with 0.08 SD increase in trust (95% confidence interval 0.02–0.14). Each additional minute spent in SP visits was also independently associated with 0.01 SD increase in patient trust. (95% confidence interval 0.0001–0.02). Component 1 and visit length were also positively associated with SP trust ratings. Conclusions:Physician verbal behavior during an SP encounter is associated with trust reported by SPs and patients. Research is needed to determine whether interventions designed to enhance physicians’ exploration patients’ experiences of disease and illness improves trust.

Patient-Centered Communication and Diagnostic Testing

PURPOSE Although patient-centered communication is associated with improved health and patient trust, information about the impact of patient-centered communication on health care costs is limited. We studied the relationship between patient-centered communication and diagnostic testing expenditures. METHODS We undertook an observational cross-sectional study using covert standardized patient visits to study physician interaction style and its relationship to diagnostic testing costs. Participants were 100 primary care physicians in the Rochester, NY, area participating in a large managed care organization (MCO). Audio recordings of 2 standardized patient encounters for each physician were rated using the Measure of Patient-Centered Communication (MPCC). Standardized diagnostic testing and other expenditures, adjusted for patient demographics and case-mix, were derived from the MCO claims database. Analyses were adjusted for demographics and standardized patient detection. RESULTS Compared with other physicians, those who had MPCC scores in the lowest tercile had greater standardized diagnostic testing expenditures (11.0% higher, 95% confidence interval [CI], 4.5%–17.8%) and greater total standardized expenditures (3.5% higher, 95% CI, 1.0%–6.1%). Whereas lower MPCC scores were associated with shorter visits, adjustment for visit length and standardized patient detection did not affect the relationship with expenditures. Total (testing, ambulatory and hospital care) expenditures were also greater for physicians who had lower MPCC scores, an effect primarily associated with the effect on testing expenditures. CONCLUSIONS Patient-centered communication is associated with fewer diagnostic testing expenditures but also with increased visit length. Because costs and visit length may affect physicians’ and health systems’ willingness to endorse and practice a patient-centered approach, these results should be confirmed in future randomized trials.

Low-dose mifepristone for uterine leiomyomata.

OBJECTIVE To compare the effect of 5 and 10 mg of mifepristone on uterine leiomyoma size and symptoms, and to measure side effects. METHODS Forty premenopausal women with large, symptomatic leiomyomata were randomized to receive either 5 or 10 mg of mifepristone daily for 6 months in an open-label study. Uterine volume was measured at bimonthly intervals by sonography. Serum concentrations of hemoglobin levels, follicle-stimulating hormone, and liver enzymes were obtained, and endometrial samples, symptoms, and menstrual bleeding were also assessed. RESULTS Nineteen of 20 subjects taking 5 mg and all 20 subjects taking 10 mg completed all 6 months of the study. Mean uterine volume shrank by 48% (P < .001) in the 5-mg group and 49% (P < .001) in the 10-mg group, a nonsignificant difference. Leiomyoma-related symptoms were comparably reduced in both groups. Amenorrhea occurred in 60–65% of both groups. Hemoglobin levels increased by 2.5 g/dL in anemic subjects. The incidence of hot flashes increased significantly over baseline in the 10-mg group but not in the 5-mg group. Simple endometrial hyperplasia occurred in 28% of all subjects, with no difference between groups. No atypical hyperplasia was noted. CONCLUSION Mifepristone in doses of 5 mg or 10 mg results in comparable leiomyoma regression, improvement in symptoms, and few side effects. Further study is needed to assess the long-term safety and efficacy of low-dose mifepristone.

Effect of mifepristone for symptomatic leiomyomata on quality of life and uterine size: a randomized controlled trial.

OBJECTIVE: To assess the effect of low-dose mifepristone on quality of life, pain, bleeding, and uterine size among women with symptomatic leiomyomata. METHODS: Forty-two women with symptomatic uterine leiomyomata and uterine volume of 160 mL or more were randomized to mifepristone, 5 mg daily, or placebo for 26 weeks. Quality of life (Uterine Fibroid Symptoms Quality of Life Questionnaire and Medical Outcomes Study 36-Item Short Form survey) and uterine and leiomyoma size (ultrasonography) were assessed at baseline, and at 1 month, 3 months, and 6 months of treatment. Bleeding (daily logs and pictorial charts) and pain (McGill Pain Questionnaire) were assessed monthly. Endometrial pathology was assessed at baseline and 6 months. RESULTS: Forty-two women were randomized; 37 women completed all 6 months. Women randomized to mifepristone showed an improvement in leiomyoma-specific quality of life. Forty-one percent became amenorrheic, rates of anemia improved, and adjusted uterine size was reduced by 47%. Compared with the placebo group, improvements in these outcomes in the treatment group were significantly greater (P<.05 to .001). There were no significant differences in adverse effects between the groups. No endometrial hyperplasia was noted in any participant. CONCLUSION: Low-dose mifepristone improves leiomyoma-specific quality of life and reduces leiomyoma size among women with symptomatic leio-myomata. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov www.clinicaltrials.gov NCT00133705 LEVEL OF EVIDENCE: I

Could this Be Something Serious? Reassurance, Uncertainty, and Empathy in Response to Patients' Expressions of Worry

BACKGROUNDPrevious work suggests that exploration and validation of patients’ concerns is associated with greater patient trust, lower health care costs, improved counseling, and more guideline-concordant care.OBJECTIVETo describe physicians’ responses to patients’ worries, how their responses varied according to clinical context (straightforward versus medically unexplained symptoms [MUS]) and associations between their responses and patients’ ratings of interpersonal aspects of care.DESIGNMultimethod study. For each physician, we surveyed 50 current patients and covertly audiorecorded 2 unannounced standardized patient (SP) visits. SPs expressed worry about “something serious” in 2 scenarios: straightforward gastroesophageal reflux or poorly characterized chest pain with MUS.PARTICIPANTSOne hundred primary care physicians and 4,746 patients.MEASUREMENTSPatient surveys measuring interpersonal aspects of care (trust, physician knowledge of the patient, satisfaction, and patient activation). Qualitative coding of 189 transcripts followed by descriptive, multivariate, and lag-sequential analyses.RESULTSPhysicians offered a mean of 3.1 responses to each of 613 SP prompts. Biomedical inquiry and explanations, action, nonspecific acknowledgment, and reassurance were common, whereas empathy, expressions of uncertainty, and exploration of psychosocial factors and emotions were uncommon. Empathy expressed during SP visits was associated with higher patient ratings of interpersonal aspects of care. After adjusting for demographics and comorbidities, the association was only statistically significant for the MUS role. Empathy was most likely to occur if expressed at the beginning of the conversational sequence.CONCLUSIONSEmpathy is associated with higher patient ratings of interpersonal care, especially when expressed in situations involving ambiguity. Empathy should be expressed early after patient expressions of worry.

Peer assessment of professional competence.

Background  Current assessment formats for medical students reliably test core knowledge and basic skills. Methods for assessing other important domains of competence, such as interpersonal skills, humanism and teamwork skills, are less well developed. This study describes the development, implementation and results of peer assessment as a measure of professional competence of medical students to be used for formative purposes.

Physicians' responses to patients' medically unexplained symptoms.

Objective: To understand how physicians communicate may contribute to the mistrust and poor clinical outcomes observed in patients who present with medically unexplained symptoms (MUS). Methods: After providing informed consent, 100 primary care physicians in greater Rochester, New York, were visited by two unannounced covert standardized patients (actors, or SPs) portraying two chest pain roles: classic symptoms of gastroesophageal reflux disease (GERD) with nausea and insomnia (the GERD role) and poorly characterized chest pain with fatigue and dizziness (the MUS role). The visits were surreptitiously audiorecorded and analyzed using the Measure of Patient-Centered Communication (MPCC), which scores physicians on their exploration of the patients’ experience of illness (component 1) and psychosocial context (component 2), and their attempts to find common ground on diagnosis and treatment (component 3). Results: In multivariate analyses, MUS visits yielded significantly lower scores on MPCC component 1 (p = .01). Subanalysis of component 1 scores showed that patients’ symptoms were not explored as fully and that validation was less likely to be used in response to patient concerns in the MUS than in the GERD visits. Component 2 and component 3 were unchanged. Conclusion: Physicians’ inquiry into and validation of symptoms in patients with MUS was less common compared with more medically straightforward patient presentations. Further research should study the relationship between communication variables and poor clinical outcomes, misunderstandings, mutual distrust, and inappropriate healthcare utilization in this population, and test interventions to address this problem. GERD = gastrointestinal reflux disease; MPCC = Measure of Patient-Centered Communication; MUS = medically unexplained symptoms; PCC = patient-centered communication.

Low-planned suicides in China

BACKGROUND Acts of suicide differ widely in the amount of planning preceding the act. Correlates of completed suicide in China identified in a previous investigation were re-examined to identify those that may be especially relevant to low-planned (impulsive) and high-planned suicidal behavior. The association of planning and method in completed suicide was also assessed. METHOD A psychological autopsy study of 505 suicide decedents aged > or = 18 years sampled to be representative of suicides in China was conducted. Multinomial regression analyses compared three levels of suicide planning (low, intermediate, high). RESULTS Women and younger individuals were more likely to carry out low-planned and intermediate-planned than high-planned acts of suicide. Greater acute stress distinguished low-planned from high-planned suicides. Ingestion of pesticides stored in the home was a more commonly employed method in low-planned than high-planned suicides. CONCLUSIONS Low-planned suicides are more common in women, in younger individuals, and among those who are experiencing acute stress. Prevention strategies targeted at restricting access to pesticides may preferentially lower the rate of low-planned suicides.

Comprehensive Assessment of Professional Competence: The Rochester Experiment

Background: A required 2-week comprehensive assessment (CA) for 2nd-year medical students that integrates basic science, clinical skills, information management, and professionalism was implemented. Description: The CA links standardized patients (SPs) with computer-based exercises, a teamwork exercise, and peer assessments; and culminates in student-generated learning plans. Evaluation: Scores assigned by SPs showed acceptable interrater reliability. Factor analyses defined meaningful subscales of the peer assessment and communication rating scales. Ratings of communication skills were correlated with information gathering, patient counseling, and peer assessments; these, in turn, were strongly correlated with the written exercises. Students found the CA fair, with some variability in opinion of the peer and written exercises. Useful learning plans and positive curricular changes were undertaken in response to the CA results. Conclusion: A CA that integrates multiple domains of professional competence is feasible, useful to students, and fosters reflection and change. Preliminary data suggest that this format is reliable and valid.

Predictors of Low-Intent and High-Intent Suicide Attempts in Rural China

OBJECTIVES Acts of suicide are heterogeneous with respect to level of intent. Data on correlates of intent are overwhelmingly from Western samples. We sought to identify correlates of low-intent and high-intent suicide attempts in China. METHODS We compared 277 adult case patients who presented to the emergency department in a rural hospital because of attempted suicide to 277 community control individuals, pair-matched for age, gender, and location of residence. Attempted suicides were stratified into 3 levels of suicide intent: low, intermediate, and high. Paired logistic regression analyses were used to analyze the data. RESULTS High-intent acts of suicide were associated with major depression, chronic stress, and a relative or associate who had a history of suicidal behavior. These correlates were not associated with low-intent acts of suicide. CONCLUSIONS High-intent acts of suicide in China are the culmination of longstanding difficulties or symptoms including depression, chronic stress, and previous exposure to suicidal behavior. Prevention of high-intent acts of suicide should include a focus on these domains.