Susan Eggly

Parents' perspectives on physician-parent communication near the time of a child's death in the pediatric intensive care unit

Objective: Communicating bad news about a child’s illness is a difficult task commonly faced by intensive care physicians. Greater understanding of parents’ scope of experiences with bad news during their child’s hospitalization will help physicians communicate more effectively. Our objective is to describe parents’ perceptions of their conversations with physicians regarding their child’s terminal illness and death in the pediatric intensive care unit (PICU). Design: A secondary analysis of a qualitative interview study. Setting: Six children’s hospitals in the National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Participants: Fifty-six parents of 48 children who died in the PICU 3–12 months before the study. Interventions: Parents participated in audio recorded semistructured telephone interviews. Interviews were analyzed using established qualitative methods. Measurements and Main Results: Of the 56 parents interviewed, 40 (71%) wanted to provide feedback on the way information about their child’s terminal illness and death was communicated by PICU physicians. The most common communication issue identified by parents was the physicians’ availability and attentiveness to their informational needs. Other communication issues included honesty and comprehensiveness of information, affect with which information was provided, withholding of information, provision of false hope, complexity of vocabulary, pace of providing information, contradictory information, and physicians’ body language. Conclusions: The way bad news is discussed by physicians is extremely important to most parents. Parents want physicians to be accessible and to provide honest and complete information with a caring affect, using lay language, and at a pace in accordance with their ability to comprehend. Withholding prognostic information from parents often leads to false hopes and feelings of anger, betrayal, and distrust. Future research is needed to investigate whether the way bad news is discussed influences psychological adjustment and family functioning among bereaved parents.

Communicating Professional Identity in Medical Socialization: Considering the Ideological Discourse of Morning Report

In this study, the authors investigate how medical ideology and physician professional identity are socially constructed during morning report, a formal teaching conference considered to be a cornerstone of medical education. Analysis of transcripts from 20 meetings reveals physician identity is developed through ideological discourse that produces and reproduces systems of domination that privilege scientific medicine and marginalize humanistic approaches. Findings indicate how, in a socialization context uniquely focused on discourse, communication functions to construct a professional identity grounded in the principles of the biomedical model. Although medical residents deviate from traditional ideology by articulating the voice of the lifeworld, faculty physicians counter these moves by asserting the voice of medicine. The authors draw conclusions regarding identity formation and the socialization practices of medical education.

Discussing Bad News in the Outpatient Oncology Clinic: Rethinking Current Communication Guidelines

Aware that his pancreatic cancer had metastasized to his liver, Mr B and his adult son and daughter traveled several hundred miles to see an oncologist at a regional comprehensive cancer center. As the oncologist explained the treatment options, Mr B and his family occasionally interrupted with questions, statements, or expressions of emotion. During the interaction, Mr B and his family learned that surgery was not a treatment option, as they had hoped. They also learned that Mr B was not eligible for any clinical trials. The only available option was chemotherapy, but it carried the potential for severe adverse effects, had less than a 10% chance of shrinking the tumor, and had no chance of “melting the tumor away.” In response to one of the son’s questions, the oncologist said that complementary or alternative medicines were not available at this center. As part of his response to the daughter’s question about the urgency of a treatment decision, the oncologist mentioned that the cancer had been in Mr B’s body for a number of years. Mr B and both of his children asked several questions about this piece of information, indicating their surprise and dismay. Mr B shook his head and exclaimed, “And I go to the doctor all the time!” As the discussion concluded, the oncologist provided details about how chemotherapy might be delivered and repeated that there was no urgency to the decision.

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.

Differences in Patient–Provider Communication for Hispanic Compared to Non-Hispanic White Patients in HIV Care

BackgroundHispanic Americans with HIV/AIDS experience lower quality care and worse outcomes than non-Hispanic whites. While deficits in patient–provider communication may contribute to these disparities, no studies to date have used audio recordings to examine the communication patterns of Hispanic vs. non-Hispanic white patients with their health care providers.ObjectiveTo explore differences in patient–provider communication for English-speaking, HIV-infected Hispanic and non-Hispanic white patients.DesignCross-sectional analysis.SettingTwo HIV care sites in the United States (New York and Portland) participating in the Enhancing Communication and HIV Outcomes (ECHO) study.SubjectsNineteen HIV providers and 113 of their patients.MeasurementsPatient interviews, provider questionnaires, and audio-recorded, routine, patient–provider encounters coded with the Roter Interaction Analysis System (RIAS).ResultsProviders were mostly non-Hispanic white (68%) and female (63%). Patients were Hispanic (51%), and non-Hispanic white (49%); 20% were female. Visits with Hispanic patients were less patient-centered (0.75 vs. 0.90, p = 0.009), with less psychosocial talk (80 vs. 118 statements, p < 0.001). This pattern was consistent among Hispanics who spoke English very well and those with less English proficiency. There was no association between patient race/ethnicity and visit length, patients’ or providers’ emotional tone, or the total number of patient or provider statements categorized as socioemotional, question-asking, information-giving, or patient activating. Hispanic patients gave higher ratings than whites (AOR 3.05 Hispanic vs. white highest rating of providers’ interpersonal style, 95% CI 1.20-7.74).ConclusionIn this exploratory study, we found less psychosocial talk in patient–provider encounters with Hispanic compared to white patients. The fact that Hispanic patients rated their visits more positively than whites raises the possibility that these differences in patient–provider interactions may reflect differences in patient preferences and communication style rather than “deficits” in communication. If these findings are replicated in future studies, efforts should be undertaken to understand the reasons underlying them and their impact on the quality and equity of care.

Patient–Provider Communication Differs for Black Compared to White HIV-Infected Patients

Poor patient–provider interactions may play a role in explaining racial disparities in the quality and outcomes of HIV care in the United States. We analyzed 354 patient–provider encounters coded with the Roter Interaction Analysis System across four HIV care sites in the United States to explore possible racial differences in patient–provider communication. Providers were more verbally dominant in conversations with black as compared to white patients. This was largely due to black patients’ talking less than white patients. There was no association between race and other measures of communication. Black and white patients rated their providers’ communication similarly. Efforts to more effectively engage patients in the medical dialogue may lead to improved patient–provider relationships, self-management, and outcomes among black people living with HIV/AIDS.

Physician-Patient Co-Construction of Illness Narratives in the Medical Interview

Researchers and medical educators in the area of physician-patient communication encourage physicians to elicit patient narratives during medical encounters to facilitate data collection, rapport building, and patient satisfaction. These scholars, however, provide little information about the nature of the narrative, especially in the context of the medical interview. This article reviews the multidisciplinary literature on narrative and reports the results of a narrative analysis of 21 physician-patient interviews. A set of criteria for defining narrative is derived from the literature and applied to these interviews, demonstrating the limitations of previous conceptions of narrative and suggesting an expanded definition. This expansion emphasizes the notion that narratives are co-constructed through the interaction of both participants in the conversation in which they occur. Application of the expanded definition to the same interviews reveals 3 new narrative forms: narratives that emerge through the co-constructed chronology of key events, the co-constructed repetition and elaboration of key events, and the coconstructed interpretation of the meaning of key events.

Patient Perspective on Watchful Waiting/Active Surveillance for Localized Prostate Cancer

Objective: To describe prostate cancer treatment decision making, focusing on knowledge and attitudes toward observation, known as watchful waiting (WW) or active surveillance (AS), and reasons for not choosing WW/AS. Methods: Semistructured in-person interviews were conducted with 21 men (14 black; 7 white) with recently diagnosed localized prostate cancer. Results: All cancers were detected by prostate-specific antigen screening; 14 men had low-risk disease. Nineteen chose surgery or radiation treatment. The majority wanted to “get rid of” or “cure” the cancer by undergoing aggressive therapy, even with awareness of the potential for significant side effects. Most men seemed unaware of the uncertainty/controversies that aggressive treatment may not cure their cancer or improve their survival. Limited knowledge about WW/AS was common, and few remembered WW/AS being presented as a viable option. Rather, many men perceived it as “doing nothing.” Some men, who initially were inclined toward WW/AS, yielded to pressure from family, physicians, or both to choose aggressive treatment. Lack of physician support was a significant barrier to WW/AS. Conclusions: The observational strategy (WW/AS) was not viewed as a reasonable approach, even for those with low-risk cancer. The desire for aggressive therapy may reflect the complex psychology associated with receiving a diagnosis of cancer and the limited supportive counseling received. Further efforts to better understand and educate patients and physicians may help men make informed and appropriate treatment decisions to maximize quality of life without compromising survival.

Family-Centered Care in the Pediatric Intensive Care Unit

Patient-centered and family-centered care (PFCC) has been endorsed by many professional health care organizations. Although variably defined, PFCC is an approach to care that is respectful of and responsive to the preferences, needs, and values of individual patients and their families. Research regarding PFCC in the pediatric intensive care unit has focused on 4 areas including (1) family visitation; (2) family-centered rounding; (3) family presence during invasive procedures and cardiopulmonary resuscitation; and (4) family conferences. Although challenges to successful implementation exist, the growing body of evidence suggests that PFCC is beneficial to patients, families, and staff.

Studying the process of clinical communication: issues of context, concepts, and research directions.

Much cancer-related health communication research has involved studies of the effects of media campaigns and strategies on secondary prevention. Cancer diagnosis rates, however, continue to affect millions of people. The need exists for communication studies to address the quality of the clinical interaction, the point of actual care delivery in addressing diagnosis, treatment, and survivorship. Using examples from a 6-year communication and behavioral oncology research program established at the Karmanos Cancer Institute (KCI) in Detroit, Michigan, we describe selected empirical issues; models, particularly the “convergence model” (adapted from Rogers & Kincaid, 1981); and associated constructs that are relevant and promising foundations for building future research in cancer clinical settings. Two examples from our empirical research program are described.