Wendy Levinson

Not All Patients Want to Participate in Decision Making: A National Study of Public Preferences

AbstractBACKGROUND: The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation. OBJECTIVES: 1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people’s preferences for participation in decision making. DESIGN AND PARTICIPANTS: A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N=2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences. MAIN RESULTS: Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined. CONCLUSION: This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.

Grounded Theory, Mixed Methods, and Action Research

These commonly used methods are appropriate for particular research questions and contexts

The heart of darkness: the impact of perceived mistakes on physicians.

Objectives:To describe how physicians think and feel about their perceived mistakes, to examine how physicians’ prior beliefs and manners of coping with mistakes may influence their emotional responses, and to promote further discussion in the medical community about this sensitive issue.Design:Audiotaped, in-depth interviews with physicians in which each physician discussed a previous mistake and its impact on his or her lift. Transcripts of the interviews were analyzed qualitatively and the data organized into five topic areas: the nature of the mistake, the physician’s beliefs about the mistake, the emotions experienced in the aftermath of the mistake, the physician’s way of coping with the mistake, and changes in the physician’s practice as a result of the mistake.Participants and setting:Eleven general internists and medical subspecialists practicing at a community, university-affiliated hospital in Oregon.Results:Themes emerging from analysis of the interviews were the ubiquity of mistakes in clinical practice; the infrequency of self-disclosure about mistakes to colleagues, family, and friends; the lack of support among colleagues; the degree of emotional impact on the physician, so that some mistakes were remembered in great detail even after several years; and the influence of the physician’s professional locus of control on subsequent emotions.Conclusions:The perception of having made a mistake creates significant emotional distress for practicing physicians. The severity of this distress may be influenced by factors such as prior beliefs and perfectionism. The extent to which physicians share this distress with colleagues may be influenced by the degree of competitiveness engendered by medical training. Open discussion of mistakes should be more prominent in medical training and practice, and there should be continued research on this topic.

Developing Physician Communication Skills For Patient-Centered Care

Growing enthusiasm about patient-centered medical homes, fueled by the Patient Protection and Affordable Care Acts emphasis on improved primary care, has intensified interest in how to deliver patient-centered care. Essential to the delivery of such care are patient-centered communication skills. These skills have a positive impact on patient satisfaction, treatment adherence, and self-management. They can be effectively taught at all levels of medical education and to practicing physicians. Yet most physicians receive limited training in communication skills. Policy makers and stakeholders can leverage training grants, payment incentives, certification requirements, and other mechanisms to develop and reward effective patient-centered communication.

An introduction to reading and appraising qualitative research

This article explores the difference between qualitative and quantitative research and the need for doctors to be able to interpret and appraise qualitative research

Impact of Interpreter Services on Delivery of Health Care to Limited–English‐proficient Patients

OBJECTIVE: To determine whether professional interpreter services increase the delivery of health care to limited-English-proficient patients.DESIGN: Two-year retrospective cohort study during which professional interpreter services for Portuguese and Spanish-speaking patients were instituted between years one and two. Preventive and clinical service information was extracted from computerized medical records.SETTING: A large HMO in New England.PARTICIPANTS: A total of 4,380 adults continuously enrolled in a staff model health maintenance organization for the two years of the study, who either used the comprehensive interpreter services (interpreter service group [ISG]; N=327) or were randomly selected into a 10% comparison group of all other eligible adults (comparison group [CG]; N=4,053).MEASUREMENTS AND MAIN RESULTS: The measures were change in receipt of clinical services and preventive service use. Clinical service use and receipt of preventive services increased in both groups from year one to year two. Clinical service use increased significantly in the ISG compared to the CG for office visits (1.80 vs 0.70; P<.01), prescriptions written (1.76 vs 0.53; P<.01), and prescriptions filled (2.33 vs 0.86; P<.01). Rectal examinations increased significantly more in the ISG compared to the CG (0.26 vs 0.02; P=.05) and disparities in rates of fecal occult blood testing, rectal exams, and flu immunization between Portuguese and Spanish-speaking patients and a comparison group were significantly reduced after the implementation of professional interpreter services.CONCLUSION: Professional interpreter services can increase delivery of health care to limited-English-speaking patients.

Women in academic medicine: combining career and family

We conducted a national survey to explore how women in academic medicine balance career and family responsibilities. A questionnaire was mailed to all women 50 years of age and under who held full-time appointments in departments of medicine (n = 862), as listed in the faculty roster of the Association of American Medical Colleges. The survey included questions about childbearing and child rearing, attitudes about personal and professional issues, and role models. Of the 694 questionnaires that were delivered, over 80 percent were completed (n = 558). The mean age of the respondents was 38.1 years, and 63 percent had children. The 350 mothers had a mean of 1.9 children; only 3 had 4 or more children. Approximately half the respondents with children had their first child after completing medical training (mean age, 30.6 years), and they were absent from work for a median of 6 weeks post partum; 72 percent took no time off before labor and delivery, and 83 percent were back at work within 12 weeks. The majority were satisfied with their decision to have children and with their careers, despite the fact that 78 percent believed that their career progress had been slowed or markedly slowed by their having had children. We conclude that it is possible for women to combine motherhood with a fulfilling career in academic medicine, but it is difficult, and most such women believe that motherhood slows the progress of their careers.

‘Choosing Wisely’: a growing international campaign

Much attention has been paid to the inappropriate underuse of tests and treatments but until recently little attention has focused on the overuse that does not add value for patients and may even cause harm. Choosing Wisely is a campaign to engage physicians and patients in conversations about unnecessary tests, treatments and procedures. The campaign began in the United States in 2012, in Canada in 2014 and now many countries around the world are adapting the campaign and implementing it. This article describes the present status of Choosing Wisely programs in 12 countries. It articulates key elements, a set of five principles, and describes the challenges countries face in the early phases of Choosing Wisely. These countries plan to continue collaboration including developing metrics to measure overuse.

A Behavioral and Systems View of Professionalism

Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the US health care system, but without it, the health care enterprise is lost. Formal statements defining professionalism have been abstract and principle based, without a clear description of what professional behaviors look like in practice. This article proposes a behavioral and systems view of professionalism that provides a practical approach for physicians and the organizations in which they work. A more behaviorally oriented definition makes the pursuit of professionalism in daily practice more accessible and attainable. Professionalism needs to evolve from being conceptualized as an innate character trait or virtue to sophisticated competencies that can and must be taught and refined over a lifetime of practice. Furthermore, professional behaviors are profoundly influenced by the organizational and environmental context of contemporary medical practice, and these external forces need to be harnessed to support--not inhibit--professionalism in practice. This perspective on professionalism provides an opportunity to improve the delivery of health care through education and system-level reform.

«Oh, by the way...»: the closing moments of the medical visit

AbstractObjective: To define and describe the communication between physicians and patients in the closing phase of the medical visit. To identify types of communication throughout the visit that are associated with the introduction of a new problem during the closing moments of the visit or with longer closures. Design: Audiotaping of office visits. Tapes were analyzed using a modified Roter Interactional Analysis System (RIAS). The coders’ definition of closure was compared with the opinion of communication experts. Setting: Outpatient offices of practicing physicians. Participants: Eighty-eight patients visiting 20 primary care physicians participated. Physicians were selected by a letter from the Oregon Board of Medical Examiners. The mean number of years from graduation was 16 (range 3–47). One physician per site participated. Measurements: Frequencies of physician and patient communication behaviors and global affect scores were calculated and correlations were drawn using t-test and chi-square analyses. Results: The physicians initiated the closing in 86% of the visits. The physicians clarified the plan of care in 75% of the visits and asked whether the patients had more questions in 25% of the cases. The patients introduced new problems not previously discussed in 21% of the closures. New problems in closure were associated with less information exchanged previously by physicians and patients about therapy (t=−3.28, p=0.002; t=−2.26, p=0.03), fewer orientation statements by physicians (t=1.86, p=0.001), and higher patient affect scores (t=0.252, p=0.016). Long closures (>2 minutes) correlated with physicians’ asking open-ended questions (0.2438; p=0.019), laughing (0.3002; p=0.005), showing responsiveness to patients (03996; p<0.001), being self-disclosing (03948; p < 0.001), and engaging in psychosocial discussion with patients (0.2410; p=0.020). Conclusion: This study is the first description of how physicians and patients communicate during the closing of office visits. Notably, the patients raised new problems at the end of the visit in 21% of the cases. The findings suggest ways physicians might improve communication in the closing phase of the medical interview. Orienting patients in the flow of the visit, assessing patient beliefs, checking for understanding, and addressing emotions and psychosocial issues early on may decrease the number of new problems in the final moments of the visit.