Patients' health as a predictor of physician and patient behavior in medical visits. A synthesis of four studies

OBJECTIVES: Although some patient characteristics are known to be related to physician and patient communication in medical encounters, very little is known about the impact of patients' health status on communication processes. The authors assess relations of patients' physical and emotional health status to verbal and nonverbal communication between physicians and patients in four original studies, and combine results across the four studies using meta-analytic procedures. METHODS: In four original studies of routine outpatient visits (consisting of more than 250 physicians and more than 1,300 patients), health status was measured and audiotape or videotape records were coded for verbal content and nonverbal cues indicating task-related behavior and affective reactions on the part of both the physician and the patient. Both physical and mental health data were obtained, using physicians and/or patients as sources; in two studies, physicians' satisfaction with the visit also was measured. All available background characteristics for both physicians and patients were controlled via partial correlations. The meta-analytic procedures used were the unweighted and weighted (by sample size) average partial correlations, the combined P across studies (Stouffer method), and the test of effect size heterogeneity. RESULTS: Physicians showed signs of negative response to sicker or more emotionally distressed patients, both in their behavior and in their ratings of satisfaction with the visit. Sicker patients also behaved more negatively than healthier patients. However, physicians also engaged in a variety of positive and professionally appropriate behaviors with the sicker or more distressed patients. This mixed pattern of responses is discussed in terms of alternative frameworks: the physician's goals, reciprocation of affect, and ambivalence on the part of the physician. CONCLUSIONS: The patient's health status appears to influence physician-patient communication. In clinical practice, increased attention by physicians to their own and their patients' behavior may enhance diagnosis and prevent misunderstandings.     

Verbal response mode correlates of experiencing.

This study, one in a series seeking indices of good psychotherapy process in the client's verbal behavior, compared specific verbal response mode (VRM) indices with the more global Experiencing (EXP) Scale, a measure reported to correlate with positive psychotherapy outcome. W. B. Stiles's (1978, 1979) VRM taxonomy was used to code the 90 transcribed interview segments published in the EXP manual. As predicted, the strongest VRM correlate of EXP level was the percentage of utterances that were Disclosure in form (1st person; "I") and intent (revealing subjective experience). Results suggest that good process may be measurable on an utterance-by-utterance basis. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is "involuntary childlessness" within the realm of family medicine responsibility of the general practitioner?

The aim of the study was to assess whether or not management of infertility is within the domain of the general practitioner in his capacity as a family physician. All accredited family physicians in the wider area of Goettingen were invited to take part in our survey. A total of 57 doctors (84%) participated. In personal interviews the family physicians were encouraged to frankly discuss the following main topics: the frequency of infertility in their own practice as well as their care for and attitudes towards infertile patients. Many family physicians interviewed were reluctant to address involuntary childlessness and underestimated its frequency. According to their patients' needs and demands, however, family doctors--above all in rural practices--have been participating in the screening and counseling of, and providing emotional support for, involuntarily childless patients. A qualitative analysis of the interview data revealed that many family physicians regarded infertility as the patients' private matter and placed it within the domain of specialists. About one-third of the physicians expressed negative attitudes towards infertile patients. Moreover, assisted reproduction techniques were sometimes rejected as "unnatural" methods. If a family-oriented approach should be amplified in family practice by offering supportive counseling for infertile patients, continuing medical education will have to take these attitudes into account.     

Verbal processes on psychological radio call-in programs: Comparisons with other help-intended interactions.

We describe the verbal process of program hosts and callers during call-in psychology interviews; we measured the similarity of these interactions with other help-intended interactions, and we assessed the compatibility of hosts' verbal behavior with prescribed ethical guidelines. Radio interviews with 30 callers were recorded from each of 6 programs broadcast in major American cities. Hosts' and callers' verbal response modes (VRMs) were coded and compared with the VRMs used in psychotherapy, university settings, and medical interviews. Hosts' VRMs most resembled those of rational-emotive therapists and those of physicians in the conclusion segment of medical interviews. Callers' VRMs most resembled those of clients in cognitive-behavioral therapy. The results call into question the viability of the distinctions made in current ethical guidelines governing psychologists' behavior on such programs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A therapeutic approach to schizophrenics of extreme pathology: An operant-interpersonal method.

Chronic withdrawn schizophrenics were exposed to operant conditioning procedures. Involved were gradually increasingly complex psychomotor tasks involving minimal verbal interpersonal communication. Ultimately, the patient performed a relatively complex assignment with a partner (interpersonal behavior). Improvement in clinical behavior (as assessed by tests, interview, and ward observations) was compared under the operant-interpersonal conditions and under verbal therapy, recreational therapy, and control (no specific therapy) conditions. Significant improvement was noted under the operant-interpersonal conditions as compared to the others, those patients with better premorbid adjustment (reactive schizophrenia) faring best. Some uncommunicative patients became worse with verbal therapy, but in the 15-week period, only 1 patient improved enough under experimental conditions to be transferred to an open ward. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Integration of chicken cytogenetic and genetic maps: 18 new polymorphic markers isolated from BAC and PAC clones

OBJECTIVE: Informed consent, as practiced in Australian chiropractic practice, was explored by means of a collective case study. DESIGN: Twenty-one chiropractic practices were visited and 25 chiropractor-patient units explored. Purposive sampling of practitioners was undertaken using a maximum variation strategy. Convenience sampling of patients was performed within each participating practice. Data was gathered from each chiropractor-patient unit, consisting of one practitioner and usually five patients, by means of practitioner interview, patient questionnaire and interview and, in certain cases, practice observation. Thematic analysis of the interviews were correlated with information derived from the patient questionnaires and validated by selective practice observation. Data was compared within and across chiropractor-patient units. RESULTS: Consent for chiropractic care was usually implied. Chiropractors in this study seldom obtained formal verbal, and never written, informed consent. New chiropractic patients were nonetheless informed about the procedures that the chiropractor intended to perform, and their acquiescence was taken as consent. Participants seldom discussed the potentially serious consequences of chiropractic adjustment but did actively attempt to identify and avoid exposing at-risk patients. Patients were often counseled about potential muscle soreness after the chiropractic adjustment. The behavior of chiropractors in this study was consistent with their patients' expectations. CONCLUSION: This study suggests that chiropractic behavior in Australian clinical practice meets the moral, but not all of the legal, requirements for informed consent.     

Intake interviewing with suicidal patients: A systematic approach.

Assessment and management of suicidal patients is one of the most challenging and stressful tasks associated with the practice of psychology. This article provides information on how to conduct suicide assessment interviews and initial patient management within the context of an intake interview. A brief review of professional training issues and suicide risk factors precedes discussion of suicide assessment interviewing procedures. Strategies for evaluating depression, suicide ideation, suicide plan, self-control, and suicide intent are presented. General guidelines for initial management of and clinical decision making with suicidal patients are reviewed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interactional structure of the supervision interview.

Five supervisors audiotaped Sessions 3, 6, and 9 of their supervision interviews with each of their assigned trainees (N?=?19). A 20-min segment of each of the resulting interviews was coded by trained raters using an adapted version of A. Blumberg's (1970) system for analyzing supervisor–teacher interaction. A quadratic assignment paradigm was used to determine whether the probability that particular behaviors would be emitted by either the supervisor or the trainee, given the behavior emitted previously by the other member of the dyad, was greater or less than the unconditional probability of these particular behaviors being emitted. Results indicate that certain repetitive patterns of verbal behavior occurred in the supervisory interview and that a sequential analysis can effectively describe these interactions. The verbal coding scheme used appeared conceptually relevant to the supervision process. (22 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients' anxiety as a function of expectation and degree of initial interview ambiguity.

Each of 9 psychiatric residents administered 5 structured and 5 unstructured initial interviews to patients of an adult outpatient clinic. Patients' expectations about psychotherapy were obtained before the interviews. As predicted, when patients experienced interviews compatible with their expectations, they tended to rate their anxiety significantly lower than did patients experiencing interviews incompatible with their expectations. The kind of interview alone did not make a significant difference. Residents rated those interviews incompatible with the patients' expectations as most difficult. The implications for psychotherapy of these and related findings are discussed. (18 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Warfarin for atrial fibrillation. The patient's perspective

OBJECTIVE: To determine the minimal clinically important difference (MCID) of warfarin therapy for the treatment of nonvalvular atrial fibrillation from the perspective of patients using 2 different elicitation methods. DESIGN: All patients completed 2 face-to-face interviews, which were 2 weeks apart. For each interview, they were randomized to receive 1 of 2 elicitation methods: ping-ponging or starting at the known efficacy. SETTING: The practices of 2 university-affiliated family medicine centers (8 physicians each), 14 community-based family physicians, and 2 cardiologists. PATIENTS: Sixty-four patients with nonvalvular atrial fibrillation who were initiated with warfarin therapy at least 3 months before the study. INTERVENTION: During each interview, the patients' MCIDs were determined by using (1) a pictorial flip chart to describe atrial fibrillation; the consequences of a minor stroke, a major stroke, and a major bleeding episode; the chance of stroke if not taking warfarin; the chance of a major bleeding episode if taking warfarin; examples of the inconvenience, minor side effects, and costs of warfarin therapy; and then (2) 1 of the 2 elicitation methods to determine their MCIDs (the smallest reduction in stroke risk at which the patients were willing to take warfarin). Patients' knowledge of their stroke risk, acceptability of the interview process, and factors determining their preferences were also assessed. MAIN RESULTS: Given a baseline risk of having a stroke in the next 2 years, if not taking warfarin, of 10 of 100, the mean MCID was 2.01 of 100 (95% confidence interval, 1.60-2.42). Fifty-two percent of the patients would take warfarin for an absolute decrease in stroke risk of 1% over 2 years. Before eliciting their MCIDs, patients showed poor knowledge of their stroke risk, which improved afterward. The interview process was well accepted by the patients. The MCID using the ping-ponging elicitation method was 1.015 of 100 smaller compared with use of the starting at the known efficacy method (P = .01). CONCLUSIONS: We were able to determine the MCID of warfarin therapy for the prevention of stroke from the perspective of patients with nonvalvular atrial fibrillation. Their MCIDs were much smaller than those that have been implied by some experts and clinicians. The interview process, using the flip chart approach, appeared to improve the patients' knowledge of their disease and its consequences and treatment. The method used to elicit the patients' MCIDs can have a clinically important effect on patient responses. The method used in our study can be generalized to other conditions and, thus, could be helpful in 3 ways: (1) from a clinical decision-making perspective, it could facilitate patient-physician communication; (2) it could clarify the patient perspective when interpreting the results of previously completed trials; and (3) it could be used to derive more clinically relevant sample sizes for randomized treatment trials.     

The story of suffering. On the traces of narrative medicine

In recognising the importance of narratives of illness we conducted a study on the ability of a specific method to elicit the patient's story. A Five Minute Speech Sample (FMSS) interview was applied to 92 patients with a recent diagnosis of breast cancer. According to Mishler, a complete narrative has six elements: abstract, orientation, complicating action, evaluation, result and coda, with complicating action and evaluation as the essential parts. Of the 92 patients, 50 gave a narrative during the FMSS. One of the narratives is referred in detail. The article advocates giving renewed attention to patients' stories, because they bring the doctor closer to the patients' point of view. This is particularly important when dealing with chronic illness and crises.     

Verbal fluency deficits in Parkinson's disease.

Administered verbal (category naming, letter fluency) and nonverbal (category drawing, design fluency) tasks to patients with Parkinson's disease (PD). PD patients were significantly impaired only in their category naming for a semantic target like fruit. The hypothesis that compromised lexical retrieval contributed to PD patients' impaired category naming by examining free recall and recognition on a supraspan learning task was tested. PD patients were significantly impaired in free recall but not recognition. Category naming fluency correlated with free recall but not recognition on the supraspan learning task. It is argued that the verbal fluency deficit in PD is due to a lexical retrieval impairment and that the difference between category naming and letter fluency is due to the nature of the prompts for lexical retrieval that patients can derive from these tasks. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical insights into pragmatic theory: frontal lobe deficits and sarcasm

The validity of psycholinguistic theories of sarcasm was explored by examining subjects with mainly frontal lobe (FL) damage and concomitant concreteness of thought. The majority of FL subjects could interpret consistent verbal exchanges but not literally contradictory (sarcastic) verbal exchanges which implied that the literal meaning of a sarcastic comment needs to be rejected in order for the inference to be detected. Subsidiary analyses confirmed that failure on sarcasm tasks was associated with poor conceptual skills. Ability to process attitude was not associated with success at recognizing sarcasm. This suggested that attitude is not pivotal to the detection of sarcastic inference.     

Pancreas carcinoid with extensive liver metastasis--simultaneous excision

BACKGROUND: While patients' needs for adequate preoperative information are generally recognized, data evaluating the effectiveness of the consultation before laparoscopic cholecystectomy have not been published until today. This prospective study was performed to investigate the success of preoperative information. METHODS: A combination of oral and written information was given to all patients in two interviews. Information concentrated on indications for surgery, operative procedures, and risks. Patients were asked to answer questionnaires 5 days after the operation. RESULTS: From January 1996 to January 1997, 200 patients were interviewed. Ninety-seven percent indicated to wish detailed information. Eighty-four percent indicated a high level of satisfaction with the presented information. While the levels of knowledge concerning indications for surgery and procedures were satisfactory in 85 and 51% respectively, only 30% were able to name at least one risk factor of laparoscopic cholecystectomy. CONCLUSION: This study demonstrated that patients' evaluation of their surgical knowledge and the process by which it was communicated to them did not correspond to their ability to recall this information after surgery.     

Effects of behavioral (reinforcement) and advice-giving counseling on information-seeking behavior.

Conducted a 2 * 3 factorial nested design study in which 4 counselors provided reinforcement or persuasive advice-giving to increase information seeking by 20 high and 20 low self-esteem undergraduates. A nonactive control group of 10 Ss was included. The 2 experimental groups were scheduled for 2 counseling interviews 1 wk. apart. A 3rd structured interview was scheduled 2 wk. later so all Ss could report their information-seeking behavior outside the interviews. Results demonstrate that behavioral reinforcement counseling is superior to advice-giving on 4 criterion measures: (a) counselees exhibited significantly higher frequency of verbal information-seeking behavior in the interview; (b) they engaged more in eventual information-seeking activities outside the interview (frequency and variety); (c) verbal and "eventual" information-seeking behaviors were significantly and positively correlated (generalization effect); and (d) student-counselor talk ratio was significantly higher. (44 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Differences in treatment of ischemic heart disease at a public and a voluntary hospital: sources and consequences

A study of hospital patients with ischemic heart disease reports that patients in a public hospital received fewer needed diagnostic tests, surgeries, and follow-up visits for their conditions than their private hospital counterparts. Factors in the hospitals' organizational environments and the patients' social backgrounds were observed to have an impact on content of treatment and to affect patient as well as provider perspectives on the quality of care. To facilitate the analysis, data were collected from four sources: direct observation of the care of each patient on rounds and at the bedside; interviews with physicians concerning the rationale for their decisions; a process-oriented chart audit assessing the appropriateness of care; and an extensive home interview with each patient three months following hospital discharge to establish further use of health services, health status, and satisfaction with care.