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Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'IV: perspectives on practice--lenses of appreciation', authors address the following themes: 'Relational connections in the doctor-patient partnership', 'Feminism and family medicine', 'Positive family medicine', 'Mindful practice', 'The new, old ethics of family medicine', 'Public health, prevention and populations', 'Information mastery in family medicine' and 'Clinical courage.' May readers nurture their curiosity through these essays. [ABSTRACT FROM AUTHOR]

Policy PointsThe meaning of health in health care remains poorly defined, defaulting to a narrow, biomedical disease model. A national dialogue could create a consensus regarding a holistic and humanized definition of health that promotes health care transformation and health equity.Key steps for operationalizing a holistic meaning of health in health care include national leadership by federal agencies, intersectoral collaborations that include diverse communities, organizational and cultural change in medical education, and implementation of high‐quality primary care.The 2023 report by the National Academies of Sciences, Engineering, and Medicine on achieving whole health offers recommendations for action. [ABSTRACT FROM AUTHOR]

Background: Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized. Objective: Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others. Methods: Systematic searches were conducted in five major electronic databases—MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)—to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings. Results: The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism. Conclusions: Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity. [ABSTRACT FROM AUTHOR]

Introduction: Mindfulness-based interventions for health professionals have been linked to improvements in burnout, well-being, empathy, communication, patient-centered care, and patient safety, but the optimal formats and intensity of training have been difficult to determine because of the paucity of studies and the heterogeneity of programs. A 4-days residential "Mindful Practice" workshop for physicians and medical educators featuring contemplative practices, personal narratives, and appreciative dialogs about challenging experiences may hold promise in improving participants' well-being while also improving compassionate care, job satisfaction, work engagement, and teamwork. Methods: We collected baseline and 2-month follow-up data during four workshops conducted in 2018 to 2019 at conference centers in the United States and Europe. Primary outcomes were burnout, work-related distress, job satisfaction, work engagement, patient-centered compassionate care, and teamwork. Results: Eighty-five of 120 participants (71%) completed both surveys (mean age was 49.3 and 68.2% female). There were improvements (P <.01) in two of three burnout components (emotional exhaustion and depersonalization), work-related distress, job satisfaction, patient-centered compassionate care, work engagement and meaning, teamwork, well-being, positive emotion, mindfulness, somatic symptoms, and spirituality. Effect sizes (standardized mean difference of change) ranged from 0.25 to 0.61. With Bonferroni adjustments (P <.0031), teamwork, general well-being, and mindfulness became nonsignificant. Discussion: An intensive, multiday, mindfulness-based workshop for physicians had clinically significant positive effects on clinician well-being, quality of interpersonal care and work satisfaction, and meaning and engagement, all important indicators of improved health and sustainability of the health care workforce. Future iterations of the program should increase the focus on teamwork. [ABSTRACT FROM AUTHOR]

Background: Caregiver perceived autonomy support by the oncologist is important for caregiver well‐being and may be affected by the patient's survival. We determined the association of caregiver‐oncologist discordance in patient's life expectancy estimates with perceived autonomy support over time and whether the association differed by patient survival status. Materials and Methods: We used data from a geriatric assessment cluster‐randomized trial (URCC 13070) that recruited patients aged at least 70 years with incurable cancer considering or receiving treatment, their caregivers, and their oncologists. At baseline, caregivers and oncologists were asked to estimate patient's life expectancy (0–6 months, 7–12 months, 1–2 years, 2–5 years, and >5 years; any difference in response was considered discordant). At 4–6 weeks, 3 months, and 6 months, caregivers completed the Health Care Climate Questionnaire (HCCQ), which measured perceived autonomy support by the oncologist. Generalized estimating equation modeling was conducted to assess the association of baseline caregiver‐oncologist discordance with longitudinal HCCQ scores, stratified by patient 6‐month survival status. Results: Discordant life expectancy estimates were present in 72.0% of dyads. In multivariate analyses, caregiver‐oncologist discordance in patient's life expectancy estimates was associated with higher caregiver HCCQ scores. In stratified analysis, caregiver‐oncologist discordance was associated with lower caregiver HCCQ scores (β = −3.46; 95% CI, −4.64 to −2.29) among patients who died within 6 months but with higher caregiver HCCQ scores (β = 1.33; 95% CI, 0.63–2.04) among patients who survived beyond 6 months. Conclusion: Interventions aimed at mitigating discordance need to consider its association with caregiver perceived autonomy support and patient's survival in order to better inform caregiver expectations. Implications for Practice: Among patients who died within the first 6 months, caregivers who estimated a different length of life for the patient compared with oncologists were more likely to report lower support from the oncologist, whereas the opposite relationship was seen within patients who survived beyond the first 6 months. When designing interventions to improve caregiver understanding of the patient's prognosis, its relationship with caregiver‐perceived support and patient's survival needs to be considered. Prognostic discordance refers to a discrepancy in estimates of prognosis by two individuals. This article evaluates the association between caregiver‐oncologist prognostic discordance regarding a patient's life expectancy estimates and caregiver perceived autonomy support. [ABSTRACT FROM AUTHOR]

Rationale: Implicit racial bias affects many human interactions including patient-physician encounters. Its impact, however, varies between studies. We assessed the effects of physician implicit, racial bias on their management of cancer-related pain using a randomized field experiment. Methods: We conducted an analysis of a randomized field experiment between 2012 and 2016 with 96 primary care physicians and oncologists using unannounced, Black and White standardized patients (SPs)who reported uncontrolled bone pain from metastatic lung cancer. We assessed implicit bias using a pain-adaptation of the race Implicit Association Test. We assessed clinical care by reviewing medical records and prescriptions, and we assessed communication from coded transcripts and covert audiotapes of the unannounced standardized patient office visits. We assessed effects of interactions of physicians' implicit bias and SP race with clinical care and communication outcomes. We conducted a slopes analysis to examine the nature of significant interactions. Results: As hypothesized, physicians with greater implicit bias provided lower quality care to Black SPs, including fewer renewals for an indicated opioid prescription and less patient-centered pain communication, but similar routine pain assessment. In contrast to our other hypotheses, physician implicit bias did not interact with SP race for prognostic communication or verbal dominance. Analysis of the slopes for the cross-over interactions showed that greater physician bias was manifested by more frequent opioid prescribing and greater discussion of pain for White SPs and slightly less frequent prescribing and pain talk for Black SPs with the opposite effect among physicians with lower implicit bias. Findings are limited by use of an unvalidated, pain-adapted IAT. Conclusion: Using SP methodology, physicians' implicit bias was associated with clinically meaningful, racial differences in management of uncontrolled pain related to metastatic lung cancer. There is favorable treatment of White or Black SPs, depending on the level of implicit bias. [ABSTRACT FROM AUTHOR]

Background: Although many older patients with end-stage renal disease and limited prognoses prefer conservative management (CM), it is not widely offered in the United States. Moreover, there is a dearth of US-based literature reporting clinical experience with shared decision making regarding CM of advanced chronic kidney disease (CKD).Methods: We describe the clinical experience of 13 patients who opted for CM at the University of Rochester Medical Center's CKD clinic during 2016-2017. Main outcomes include: (1) reason for choosing CM, (2) completion of advance directives, (3) location of death, and (4) utilization of hospice service. Patients' reasons for choosing CM were categorized into 4 broad categories based on a review of their electronic medical records. A retrospective chart review conducted by 2 reviewers determined the status of advance care planning, hospice referral, and place of death.Results: The mean age of these patients was 81.8 years (SD 7.3). Their reasons for choosing CM included: poor prognoses; a wish to maintain their quality of life; their desire for a dignified life closure; and the intention to protect family members from having to see them suffer, based on their own memory of having witnessed a relative on dialysis previously. A total of 8 patients died: all received hospice services, 6 died at home, one at a nursing home, and one at a hospital. Advance care planning was completed in 100% of the cases. Symptoms were managed in collaboration with primary care physicians.Conclusion: Patients' decisions to choose CM were influenced by their values and previous experience with dialysis, in addition to comorbidities and limited prognoses. Promoting the choice of CM in the United States will require training of clinicians in primary palliative care competencies, including communication and decision-making skills, as well as basic symptom management proficiencies. [ABSTRACT FROM AUTHOR]

An editorial is presented on epidemic of distress and burnout in the oncology workforce and recommending the actions for preventing and reducing burnout, mitigating the downstream effects, and enhancing well-being. Topics include raising the specter of threat to the lives, livelihoods, and identities of clinicians on the front lines; and involved pay cuts and delayed incentive payments while increasing demands on clinicians.

Introduction: Moral distress is a negative affective response to a situation in which one is compelled to act in a way that conflicts with one's values. Little is known about the workplace scenarios that elicit moral distress in nephrology fellows. Methods: We sent a moral distress survey to 148 nephrology fellowship directors with a request to forward it to their fellows. Using a 5-point (0–4) scale, fellows rated both the frequency (never to very frequently) and severity (not at all disturbing to very disturbing) of commonly encountered workplace scenarios. Ratings of ≥3 were used to define "frequent" and "moderate-to-severe" moral distress. Results: The survey was forwarded by 64 fellowship directors to 386 fellows, 142 of whom (37%) responded. Their mean age was 33 ± 3.6 years and 43% were female. The scenarios that most commonly elicited moderate to severe moral distress were initiating dialysis in situations that the fellow considered futile (77%), continuing dialysis in a hopelessly ill patient (81%) and carrying a high patient census (75%), and observing other providers giving overly optimistic descriptions of the benefits of dialysis (64%). Approximately 27% had considered quitting fellowship during training, including 9% at the time of survey completion. Conclusion: A substantial majority of nephrology trainees experienced moral distress of moderate to severe intensity, mainly related to the futile treatment of hopelessly ill patients. Efforts to reduce moral distress in trainees are required. [ABSTRACT FROM AUTHOR]

Background: Caregivers of adults with cancer often report a different understanding of the patient's prognosis than the oncologist. We examine the associations of caregiver–oncologist prognostic concordance with caregiver depressive symptoms, distress, and quality of life (QoL). We also explore whether these relationships differed by caregiver environment mastery, an individual's sense of control, and effectiveness in managing life situations. Materials and Methods: We used data from a national geriatric assessment cluster‐randomized trial (URCC 13070) that recruited patients aged 70 years and older with incurable cancer considering any line of cancer treatment at community oncology practices, their caregivers, and their oncologists. At enrollment, caregivers and oncologists estimated the patient's prognosis (0–6 months, 7–12 months, 1–2 years, 2–5 years, and >5 years; identical responses were concordant). Caregivers completed the Ryff's environmental mastery at enrollment. At 4–6 weeks, caregivers completed the Patient Health Questionnaire‐2 (depressive symptoms), distress thermometer, and 12‐Item Short‐Form Health Survey (quality of life [QoL]). We used generalized estimating equations in models adjusted for covariates. We then assessed the moderation effect of caregiver mastery. Results: Of 411 caregiver–oncologist dyads (mean age = 66.5 years), 369 provided responses and 28% were concordant. Prognostic concordance was associated with greater caregiver depressive symptoms (β = 0.30; p =.04) but not distress or QoL. A significant moderation effect for caregiver depressive symptoms was found between concordance and mastery (p =.01). Specifically, among caregivers with low mastery (below median), concordance was associated with greater depressive symptoms (β = 0.68; p =.003). Conclusions: Caregiver–oncologist prognostic concordance was associated with caregiver depressive symptoms. We found a novel moderating effect of caregiver mastery on the relationship between concordance and caregiver depressive symptoms. Implications for Practice: Caregiver–oncologist prognostic concordance is associated with greater caregiver depressive symptoms, particularly in those with low caregiver mastery. When discussing prognosis with caregivers, physicians should be aware that prognostic understanding may affect caregiver psychological health and should assess their depressive symptoms. In addition, while promoting accurate prognostic understanding, physicians should also identify strengths and build resilience among caregivers. Patients and caregivers need an accurate understanding of prognosis to help them make informed treatment decisions and to prepare for the future. This article examines the association of caregiver–oncologist concordance in their estimates of patient length of life with caregiver depressive symptoms, distress, and quality of life. [ABSTRACT FROM AUTHOR]

Background: Disagreements between patients and caregivers about treatment benefits, care decisions, and patients' health are associated with increased patient depression as well as increased caregiver anxiety, distress, depression, and burden. Understanding the factors associated with disagreement may inform interventions to improve the aforementioned outcomes. Methods: For this analysis, baseline data were obtained from a cluster‐randomized geriatric assessment trial that recruited patients aged ≥70 years who had incurable cancer from community oncology practices (University of Rochester Cancer Center 13070; Supriya G. Mohile, principal investigator). Patient and caregiver dyads were asked to estimate the patient's prognosis. Response options were 0 to 6 months, 7 to 12 months, 1 to 2 years, 2 to 5 years, and >5 years. The dependent variable was categorized as exact agreement (reference), patient‐reported longer estimate, or caregiver‐reported longer estimate. The authors used generalized estimating equations with multinomial distribution to examine the factors associated with patient‐caregiver prognostic estimates. Independent variables were selected using the purposeful selection method. Results: Among 354 dyads (89% of screened patients were enrolled), 26% and 22% of patients and caregivers, respectively, reported a longer estimate. Compared with dyads that were in agreement, patients were more likely to report a longer estimate when they screened positive for polypharmacy (β = 0.81; P =.001), and caregivers reported greater distress (β = 0.12; P =.03). Compared with dyads that were in agreement, caregivers were more likely to report a longer estimate when patients screened positive for polypharmacy (β = 0.82; P =.005) and had lower perceived self‐efficacy in interacting with physicians (β = −0.10; P =.008). Conclusions: Several patient and caregiver factors were associated with patient‐caregiver disagreement about prognostic estimates. Future studies should examine the effects of prognostic disagreement on patient and caregiver outcomes. Nearly one‐half (48%) of older patients and caregivers disagree with each other about the patient's prognosis; specifically, 26% of patients and 22% of caregivers report a longer estimate of the patient's prognosis. Caregiver distress, patient communication self‐efficacy, polypharmacy, and oncologist sex are associated with patient‐caregiver agreement about prognostic estimates. [ABSTRACT FROM AUTHOR]

Purpose: The quality of the relationship between oncologists and cancer patients has been associated with caregiver bereavement outcomes, but no studies have examined whether the perceived quality of the relationship between cancer caregivers and oncologists is associated with caregiver experiences of end-of-life care or psychological adjustment after the patient's death.Methods: We conducted secondary analyses of data collected in the Values and Options in Cancer Care (VOICE) study, a randomized controlled trial of an intervention that improved communication between oncologists and patients/caregivers (n = 204 dyads). At study entry, we assessed caregivers' experiences with the oncologist using four items from the Human Connection Scale. Following patients' deaths, we assessed bereaved caregivers' experiences with end-of-life cancer care (Quality of Death; Peace, Equanimity, and Acceptance in the Cancer Experience [PEACE]; Caregiver Evaluation of the Quality of End-of-Life Care [CEQUEL]; and modified Decision Regret scales) and psychological adjustment (Prolonged Grief Disorder-13 and Purpose in Life scales). We conducted multivariable regressions examining prospective associations between caregiver experiences with the oncologist at study entry and outcome variables.Results: Data were collected from 105 caregivers of patients who died during the course of the study. Positive experience with the oncologist was prospectively associated with better experiences of end-of-life care, as reflected in better quality of death (estimate = 0.33, SE = 0.14, p = 0.02), PEACE (estimate = 0.11, SE = 0.05, p = 0.04), and decisional regret (estimate = - 0.16, SE = 0.06, p = 0.01). Caregivers' experience with the oncologist was not significantly associated with indicators of psychological adjustment.Conclusion: Caregivers' early experiences with oncologists may affect their experiences of the patient's end-of-life care. [ABSTRACT FROM AUTHOR]

Objectives: The well‐being of doctors is at risk, as evidenced by high burnout rates amongst doctors around the world. Alarmingly, burned‐out doctors are more likely to exhibit low levels of professionalism and provide suboptimal patient care. Research suggests that burnout and the well‐being of doctors can be improved by mindfulness‐based interventions (MBIs). Furthermore, MBIs may improve doctors' performance (eg in empathy). However, there are no published systematic reviews that clarify the effects of MBIs on doctor well‐being or performance to inform future research and professional development programmes. We therefore systematically reviewed and narratively synthesised findings on the impacts of MBIs on doctors' well‐being and performance. Methods: We searched PubMed and PsycINFO from inception to 9 May 2018 and independently reviewed studies investigating the effects of MBIs on doctor well‐being or performance. We systematically extracted data and assessed study quality according to the Medical Education Research Study Quality Instrument (MERSQI), and narratively reported study findings. Results: We retrieved a total of 934 articles, of which 24 studies met our criteria; these included randomised, (un)controlled or qualitative studies of average quality. Effects varied across MBIs with different training contents or formats: MBIs including essential mindfulness training elements, or employing group‐based training, mostly showed positive effects on the well‐being or performance of doctors across different educational and hospital settings. Doctors perceived both benefits (enhanced self‐ and other‐understanding) and challenges (time limitations and feasibility) associated with MBIs. Findings were subject to the methodological limitations of studies (eg the use of self‐selected participants, lack of placebo interventions, use of self‐reported outcomes). Conclusions: This review indicates that doctors can perceive positive impacts of MBIs on their well‐being and performance. However, the evidence was subject to methodological limitations and does not yet support the standardisation of MBIs in professional development programmes. Rather, health care organisations could consider including group‐based MBIs as voluntary modules for doctors with specific well‐being needs or ambitions regarding professional development. Mindfulness is often promoted as a means to facilitate well‐being and performance. This review offers guidance regarding the essential interventional elements that determine perceptions of impact. [ABSTRACT FROM AUTHOR]

Background: Disagreements between patients and caregivers about treatment benefits, care decisions, and patients' health are associated with increased patient depression as well as increased caregiver anxiety, distress, depression, and burden. Understanding the factors associated with disagreement may inform interventions to improve the aforementioned outcomes.Methods: For this analysis, baseline data were obtained from a cluster-randomized geriatric assessment trial that recruited patients aged ≥70 years who had incurable cancer from community oncology practices (University of Rochester Cancer Center 13070; Supriya G. Mohile, principal investigator). Patient and caregiver dyads were asked to estimate the patient's prognosis. Response options were 0 to 6 months, 7 to 12 months, 1 to 2 years, 2 to 5 years, and >5 years. The dependent variable was categorized as exact agreement (reference), patient-reported longer estimate, or caregiver-reported longer estimate. The authors used generalized estimating equations with multinomial distribution to examine the factors associated with patient-caregiver prognostic estimates. Independent variables were selected using the purposeful selection method.Results: Among 354 dyads (89% of screened patients were enrolled), 26% and 22% of patients and caregivers, respectively, reported a longer estimate. Compared with dyads that were in agreement, patients were more likely to report a longer estimate when they screened positive for polypharmacy (β = 0.81; P = .001), and caregivers reported greater distress (β = 0.12; P = .03). Compared with dyads that were in agreement, caregivers were more likely to report a longer estimate when patients screened positive for polypharmacy (β = 0.82; P = .005) and had lower perceived self-efficacy in interacting with physicians (β = -0.10; P = .008).Conclusions: Several patient and caregiver factors were associated with patient-caregiver disagreement about prognostic estimates. Future studies should examine the effects of prognostic disagreement on patient and caregiver outcomes. [ABSTRACT FROM AUTHOR]

Background: Care teams are increasingly expected to attend to the needs of patient's personal caregivers (e.g., family members). Improving communication among oncologists, patients with advanced cancer, and their personal caregivers might enhance caregivers' experiences of end-of-life (EoL) cancer care and bereavement outcomes. Objective: To explore the effects of the Values and Options in Cancer Care intervention on caregivers' experiences of EoL care and bereavement outcomes. Design: We developed a brief behavioral intervention to improve communication among oncologists, patients with advanced cancer, and their personal caregivers. The intervention was designed to help patients/caregivers ask questions, express concerns, and help oncologists respond effectively. We randomly assigned oncologists (and their patients/caregivers) to the intervention or usual care. Setting/Subjects: Medical oncologists in NY and CA; patients/personal caregivers with advanced cancer. Measurements: Two months after the patient's death, caregivers completed three instruments assessing their experiences of EoL care. Seven months after the patient's death, caregivers completed the Prolonged Grief Disorder-13 (PG-13; primary prespecified outcome), the Purpose-in-Life scale, and scales assessing mental health function, depression, and anxiety. Results: The intervention did not significantly improve caregivers' scores on the PG-13 (p = 0.21), mental health function, depression, or anxiety, but it did improve purpose-in-life scores (p = 0.018). Cohen's d (95% confidence interval) for all three experiences of EoL care outcomes were promising, ranging from 0.22 (−0.19 to 0.63) to 0.39 (−0.07 to 0.86) although none was statistically significant. Conclusion: Preliminary findings show promise that scalable interventions in cancer care settings may improve caregiver experiences with cancer care and some bereavement outcomes. [ABSTRACT FROM AUTHOR]

Background: Patients with advanced, incurable cancer who understand their illness is incurable are more likely to prefer hospice care at the end of life compared with patients who believe their illness is curable. To the authors' knowledge, it is unclear whether patient-caregiver agreement regarding perceived prognosis is associated with hospice enrollment.Methods: The current study examined the prospective relationship between patient-caregiver agreement concerning perceived prognosis and hospice enrollment in the last 30 days of life. Data were collected during a cluster randomized controlled trial examining a communication intervention for oncologists and patients with advanced cancer and their caregivers. At the time of study entry, patients and caregivers (141 dyads) were categorized as endorsing a "good" prognosis if they: 1) reported a >50% chance of surviving ≥2 years; or if they 2) predicted that the patient's quality of life 3 months into the future would be ≥7 on an 11-point scale.Results: Approximately one-fifth of dyads agreed on a poor prognosis whereas approximately one-half disagreed regarding prognosis. In approximately one-third of dyads, patients and caregivers both believed the patient's future quality of life would be good (34%) and that the patient would live for ≥2 years (30%). Patients in these dyads were less likely to enroll in hospice compared with patients in dyads who disagreed and those who agreed on a shorter life expectancy and poor future quality of life.Conclusions: Dyadic understanding of patients' projected life expectancy and future quality of life appears to be predictive of care received at the end of life. Improving rates of hospice enrollment may be best achieved with dyadic interventions. [ABSTRACT FROM AUTHOR]

Background: In caring for patients with advanced cancer, accurate estimation of survival is important for clinical decision making. The purpose of this study was to assess the accuracy of 2-year survival probabilities estimated by oncologists, patients, and caregivers and to identify demographic and clinical factors associated with prognostic accuracy.Methods: This was a secondary observational analysis of data obtained from a cluster randomized controlled trial. Participants included 38 oncologists, 263 patients with advanced nonhematologic cancer, and 193 of their caregivers from clinics in Sacramento and Western New York. Discrimination within each group (oncologists, patients, caregivers) was evaluated using the C statistic, whereas calibration was assessed by comparing observed to predicted 2-year mortality using the chi-square statistic.Results: The median survival from study entry was 18 months, and 41.8% of patients survived for 2 years. C statistics for oncologists, patients, and caregivers were 0.81 (95% CI, 0.76-0.86), 0.62 (95% CI, 0.55-0.68), and 0.72 (95% CI, 0.65-0.78), respectively; oncologists' predictions were better than the predictions of both patients (P = .001) and caregivers (P = .03). Oncologists also had superior calibration: their predictions of 2-year survival were similar to actual survival (P = .17), whereas patients' (P = .0001) and caregivers' (P = .003) predictions diverged significantly from actual survival. Although most oncologists' predictions were classified as realistic (62.0%), approximately one-half of patients' and caregivers' predictions (50.0% and 46.0%, respectively) were unduly optimistic. Among patients, nonwhite race and higher levels of social well-being predicted undue optimism (P < .05).Conclusions: Compared with oncologists, patients and caregivers displayed inferior prognostic discrimination, and their predictions were poorly calibrated, primarily because of overoptimism. [ABSTRACT FROM AUTHOR]

Background: Older patients with advanced cancer who are 100% certain they will be cured pose unique challenges for clinical decision making, but to the authors' knowledge, the prevalence and correlates of absolute certainty about curability (ACC) are unknown.Methods: Cross-sectional data were collected in a geriatric assessment trial. ACC was assessed by asking patients, "What do you believe are the chances that your cancer will go away and never come back with treatment?" Response options were 100% (coded as ACC), >50%, 50/50, <50%, 0%, and uncertain. The willingness to bear adversity in exchange for longevity was assessed by asking patients to consider trade-offs between survival and 2 clinical outcomes that varied in abstractness: 1) maintaining quality of life (QOL; an abstract outcome); and 2) specific treatment-related toxicities (eg, nausea/vomiting, worsening memory). Logistic regression was used to assess the independent associations between willingness to bear adversity and ACC.Results: Of the 524 patients aged 70 to 96 years, approximately 5.3% reported that there was a 100% chance that their cancer would be cured (ACC). ACC was not found to be significantly associated with willingness to bear treatment-related toxicities, but was more common among patients who were willing to trade QOL for survival (adjusted odds ratio, 4.08; 95% CI, 1.17-14.26).Conclusions: Patients who were more willing to bear adversity in the form of an abstract state, namely decreased QOL, were more likely to demonstrate ACC. Although conversations regarding prognosis should be conducted with all patients, those who are willing to trade QOL for survival may especially benefit from conversations that focus on values and emotions. [ABSTRACT FROM AUTHOR]

Purpose: It is unclear whether life-expectancy estimates of patients with advanced cancer and their caregivers are associated with patient existential, social, or emotional quality of life (QOL) or caregiver emotional QOL. Methods: Patients with advanced cancer and their caregivers (n = 162 dyads) reported estimates of the chance the patient would live for 2 years or more from 0% (most pessimistic) to 100% (most optimistic). They also completed self-report measures of QOL. Results: Adjusting for sociodemographic confounds and multiple comparisons, more pessimistic caregiver and patient life-expectancy estimates were associated with worse caregiver emotional QOL and worse patient existential QOL. Discrepancies between patient and caregiver estimates were not associated with patient or caregiver QOL. Conclusions: Pessimistic life-expectancy estimates are associated with worse existential QOL in patients and worse emotional QOL in caregivers. Prospective research to establish causal relationships is needed, and interventions to address the relationship between beliefs about life expectancy and existential and emotional QOL should be considered. Providing these interventions to patients and caregivers receiving information on life expectancy may mitigate the negative impact of life-expectancy information on patient existential quality of life. [ABSTRACT FROM AUTHOR]

Background: Patient gender and race, and physician–patient communication are associated with clinical outcomes. Aim: To understand the role of these factors in the diagnosis of colorectal cancer (CRC) during primary care visits as measured by appropriate outcome. Materials and Methods: Caucasian and African American unannounced standardized patients (USPs) of both genders presented to 207 primary care physicians (PCPs) from community and academic practices in Ohio and Virginia as new patients with CRC symptoms. PCPs were blinded to the diagnosis. Physician subjects consented to audiotaping the encounter. Medical records were obtained. Communication elements were coded by trained observers and appropriate visit outcomes were coded from the medical record and audiofiles, defined as (1) recommendation for colonoscopy/sigmoidoscopy/fecal occult blood test (FOBT) or (2) referral to gastroenterologist. Results: A total of 141 of 367 USP visits (38%) resulted in appropriate clinical outcomes. Patient race was not associated with outcome, but being a male USP was (χ2 = 4.12, p = 0.04). Relational communication was represented as a latent variable with seven indicators (alpha = 0.84) and was independently associated with outcome (beta = 0.15; p = 0.025). After controlling for clustered sampling, relational communication, and race, structural equational modeling indicated that female USPs were less likely to have an appropriate clinical visit outcome (beta = −0.13; p = 0.033). Conclusions: Using a novel and innovative methodology capturing PCP behaviors during real-time clinician–patient interaction, appropriate clinical outcome was independently associated with being male and PCP relational communication factors such as encouraging patient communication, being engaged and expressive in the physician–patient conversation, and appearing friendly and sincere. There are persistent biases in the delivery of health care to female patients and further research into targeted communication skills programs may be warranted. [ABSTRACT FROM AUTHOR]

Context: Completion of advance directives (ADs) enhances the likelihood of receiving goal-concordant treatments near the end of life. Previous research on community samples have shown that completion of ADs is less common in lower socioeconomic status demographic group; there is a paucity of such research in patients with cancer. Objectives: To study the effect of income and education on the completion of ADs. Hypothesis: Patients with cancer having lower incomes and education levels would be less likely to report completing ADs. Methods: We conducted cross-sectional analyses of data provided by patients (n = 265) enrolled in the Values and Options in Cancer Care clinical trial. Patients with advanced cancer reported whether they had (1) completed a living will or (2) designated a health-care proxy. Response options for both questions were yes (scored 1), no (scored 0), and unsure (scored 0). We studied the association of lower household income (≤US$20 000) and education level (never attended college) with AD scores. Results: Patients with lower annual incomes had lower AD scores (estimate −0.44; confidence intervals [CI]: −0.71 to −0.16, P = .001); the association between higher educational attainment (some college or more) and completion of ADs was not statistically significant (estimate 0.04, CI: −0.16 to 0.24, P = .70). Conclusion: Interventions to promote completion of ADs among lower income patients with serious illnesses are needed. [ABSTRACT FROM AUTHOR]

Background: Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer.Objective: To examine the effect of race on physicians' pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation.Design: Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles-a 62-year-old man with advanced lung cancer and uncontrolled pain-differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions.Participants: Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians' mean age was 52 years (SD = 27.17), 59% male, and 64% white.Main Measures: Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment.Key Results: SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81).Conclusions: Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain.Trial Registration: NCT01501006. [ABSTRACT FROM AUTHOR]

Objective: To identify predictors of participation of patients with advanced cancer in clinical encounters with oncologists and to assess the impact of patient and caregiver participation on perceptions of physician support.Methods: This is a secondary data analysis from the Values and Options in Cancer Care study, a cluster randomized clinical trial of a patient-centered communication intervention. Patients and caregivers completed pre-visit and post-visit health and communication measures. Audio recorded patient-caregiver (when present)-physician encounters were coded for active patient/caregiver participation behaviors (eg, question asking, expressing concern) and for physicians' facilitative communication (eg, partnership-building, support). Mixed linear regression models were used to identify patient, physician, and situational factors predicting patient and patient plus caregiver communication behaviors and post-visit outcomes.Results: Physician partnership building predicted greater expressions of concern and more assertive responses from patients and patient-caregiver pairs. Patients' perceptions of greater connectedness with their physician predicted fewer patient expressions of concern. Patient perceptions of physician respect for their autonomy were lower among patients accompanied by caregivers. Caregiver perceptions of physician respect for patient autonomy decreased with increasing patient age and varied by site.Conclusions: In advanced cancer care, patient and caregiver communication is affected by ecological factors within their consultations. Physicians can support greater patient participation in clinical encounters through facilitative communication such as partnership-building and supportive talk. The presence of a caregiver complicates this environment, but partnership building techniques may help promote patient and caregiver participation during these visits. [ABSTRACT FROM AUTHOR]

Background: Racial disparities exist in the care provided to advanced cancer patients. This article describes an investigation designed to advance the science of healthcare disparities by isolating the effects of patient race and patient activation on physician behavior using novel standardized patient (SP) methodology.Methods/design: The Social and Behavioral Influences (SBI) Study is a National Cancer Institute sponsored trial conducted in Western New York State, Northern/Central Indiana, and lower Michigan. The trial uses an incomplete randomized block design, randomizing physicians to see patients who are either black or white and who are "typical" or "activated" (e.g., ask questions, express opinions, ask for clarification, etc.). The study will enroll 91 physicians.Discussion: The SBI study addresses important gaps in our knowledge about racial disparities and methods to reduce them in patients with advanced cancer by using standardized patient methodology. This study is innovative in aims, design, and methodology and will point the way to interventions that can reduce racial disparities and discrimination and draw links between implicit attitudes and physician behaviors.Trial Registration: https://clinicaltrials.gov/ , #NCT01501006, November 30, 2011. [ABSTRACT FROM AUTHOR]

Background: Physical activity (PA) counselling is challenging in primary care. It is unknown whether clinician training on the 5As (Ask, Advise, Agree, Assist, Arrange) improves PA counselling skills.Objective: To evaluate the effect of a clinician training intervention on PA counselling for underserved adults using the 5As framework.Methods: Pragmatic pilot clinical trial was used in the study. Clinicians (n = 13) were randomly assigned to two groups. Each group received the intervention consisting of four 1-hour training sessions to teach the 5As for PA counselling. Patient-clinician visits (n = 325) were audio recorded at baseline, immediately post-intervention, and at 6 months. Outcomes were the frequency and quality of PA discussions using the 5As, assessed by blinded coders.Results: Patients' mean age was 44 years; 75% were African American. PA was discussed in 37% (n = 119) of visits overall and did not change from baseline to follow-up. When PA discussions occurred, the frequency of 5As increased from baseline to follow-up for Advise (51-54%), Agree (11-26%), and Assist (11-17%); however, none of the 5As had a statistically significant increase. For Agree, exploration of patient willingness to engage in PA increased from 23% at baseline to 50% at follow-up.Conclusion: A clinician-directed intervention to improve PA counselling increased the frequency of Advise, Agree and Assist, and the quality of Ask and Agree statements, though the absolute numbers were small and only Agree reached statistical significance. Future research is needed to understand the factors that affect the optimal uptake and approach to 5As counselling. [ABSTRACT FROM AUTHOR]

Objective: To test the feasibility and assess the uptake and acceptability of implementing a consumer questions programme, AskShareKnow, to encourage consumers to use the questions ‘1. What are my options; 2. What are the possible benefits and harms of those options; 3. How likely are each of those benefits and harms to happen to me?’ These three questions have previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement. Methods: This single‐arm intervention study invited participants attending a reproductive and sexual health‐care clinic to view a 4‐min video‐clip in the waiting room. Participants completed three questionnaires: (T1) prior to viewing the intervention; (T2) immediately after their consultation; and (T3) two weeks later. Results: A total of 121 (78%) participants viewed the video‐clip before their consultation. Eighty‐four (69%) participants asked one or more questions, and 35 (29%) participants asked all three questions. For those making a decision, 55 (87%) participants asked one or more questions, while 27 (43%) participants asked all three questions. Eighty‐seven (72%) participants recommended the questions. After two weeks, 47 (49%) of the participants recalled the questions. Conclusions: Enabling patients to view a short video‐clip before an appointment to improve information and involvement in health‐care consultations is feasible and led to a high uptake of question asking in consultations. Practice Implications: This AskShareKnow programme is a simple and feasible method of training patients to use a brief consumer‐targeted intervention that has previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement and use of evidence‐based questions. [ABSTRACT FROM AUTHOR]

Background: Compassion has been extolled as a virtue in the physician–patient relationship as a response to patient suffering. However, there are few studies that systematically document the behavioural features of physician compassion and the ways in which physicians communicate compassion to patients. Objective: To develop a taxonomy of compassionate behaviours and statements expressed by the physician that can be discerned by an outside observer. Design: Qualitative analysis of audio‐recorded office visits between oncologists and patients with advanced cancer. Setting and Participants: Oncologists (n = 23) and their patients with advanced cancer (n = 49) were recruited in the greater Rochester, New York, area. The physicians and patients were surveyed and had office visits audio recorded. Main Outcome Measures: Audio recordings were listened to for qualitative assessment of communication skills. Results: Our sensitizing framework was oriented around three elements of compassion: recognition of the patient's suffering, emotional resonance and movement towards addressing suffering. Statements of compassion included direct statements, paralinguistic expressions and performative comments. Compassion frequently unfolded over the course of a conversation rather than being a single discrete event. Additionally, non‐verbal linguistic elements (e.g. silence) were frequently employed to communicate emotional resonance. Discussion and Conclusions: This study is the first to systematically catalogue instances of compassionate communication in physician‐patient dialogues. Further refinement and validation of this preliminary taxonomy can guide future education and training interventions to facilitate compassion in physician–patient interactions. [ABSTRACT FROM AUTHOR]

Objective: Discussing end-of-life (EOL) care is challenging when death is not imminent, contributing to poor decision-making and EOL quality-of-life. A communication support program (CSP) targeting these issues may facilitate discussions. We aimed to qualitatively explore responses to a nurse-led CSP, incorporating a question prompt list (QPL—booklet of questions patients/caregivers can ask clinicians), promoting life expectancy and EOL-care discussions. Methods: Participants met a nurse-facilitator to explore an EOL-focussed QPL. Prognosis and advance care planning (ACP) QPL content was highlighted. Thirty-one transcribed meetings were analysed using thematic text analysis before reaching data saturation. Results: Thirty-one advanced cancer patients (life expectancy <12 months) and 11 family caregivers were recruited from six medical oncology clinics in Sydney, Australia. Intent to use the QPL related to information needs, involvement in care and readiness to discuss EOL issues. Many participants did not want life expectancy estimates, citing unreliable estimates, unknown treatment outcomes, or coping by not looking ahead. Most displayed interest in ACP, often motivated by a loved one's EOL experiences, clear treatment preferences, concerns about caregivers or recognition that ACP is valuable regardless of life expectancy. Timing emerged as a reason not to discuss EOL issues; many maintaining it was too early. Conclusion: Patients and caregivers appear ambivalent about acknowledging approaching death by discussing life expectancy but value ACP. Given heterogeneity in responses, individualised approaches are required to guide EOL discussion conduct and content. Further exploration of the role of prognostic discussion in ACP is warranted. [ABSTRACT FROM AUTHOR]

Introduction: Timely communication about life expectancy and end-of-life care is crucial for ensuring good patient quality-of-life at the end of life and a good quality of death. This article describes the protocol for a multisite randomised controlled trial of a nurse-led communication support programme to facilitate patients' and caregivers' efforts to communicate about these issues with their healthcare team. Methods and analysis: This NHMRC-sponsored trial is being conducted at medical oncology clinics located at/affiliated with major teaching hospitals in Sydney, Australia. Patients with advanced, incurable cancer and life expectancy of less than 12 months will participate together with their primary informal caregiver where possible. Guided by the self-determination theory of health-behaviour change, the communication support programme pairs a purpose-designed Question Prompt List (QPL--an evidence-based list of questions patients/caregivers can ask clinicians) with nurse-led exploration of QPL content, communication challenges, patient values and concerns and the value of early discussion of end-of-life issues. Oncologists are also cued to endorse patient and caregiver question asking and use of the QPL. Behavioural and self-report data will be collected from patients/caregivers approximately quarterly for up to 2.5 years or until patient death, after which patient medical records will be examined. Analyses will examine the impact of the intervention on patients' and caregivers' participation in medical consultations, their self-efficacy in medical encounters, quality-of-life, end-of-life care receipt and quality-of-death indicators. Ethics and dissemination: Approvals have been granted by the human ethics review committee of Royal Prince Alfred Hospital and governance officers at each participating site. Results will be reported in peer-reviewed publications and conference presentations. [ABSTRACT FROM AUTHOR]

Patient-centered care requires different approaches depending on the clinical situation. Motivational interviewing and shared decision making provide practical and well-described methods to accomplish patient-centered care in the context of situations where medical evidence supports specific behavior changes and the most appropriate action is dependent on the patient's preferences. Many clinical consultations may require elements of both approaches, however. This article describes these 2 approaches—one to address ambivalence to medically indicated behavior change and the other to support patients in making health care decisions in cases where there is more than one reasonable option—and discusses how clinicians can draw on these approaches alone and in combination to achieve patient-centered care across the range of health care problems. [ABSTRACT FROM AUTHOR]

George Engel's biopsychosocial vision was simultaneously scientific and humanistic. He passionately presented an approach to clinical care to correct the progressive distancing of clinical care and research from the lived experience of the patient. Yet, while science provides ever greater evidence for the linkages between subjectively-reported experience and health outcomes, trainees and practicing clinicians struggle to realize a biopsycho-social vision in a pragmatic way. These challenges are magnified by the mandate for greater patient autonomy and participation in care, increased access to information, and overlaps and omissions as multiple professionals try to address the whole person. Importantly, trainees and clinicians get stuck implementing the biopsychosocial model partly because they have not developed the capacity for resilience, self-awareness, and self-monitoring. These capacities must accompany efforts to help clinicians engage more deeply with their patients; otherwise, they risk emotional distress, empathic failure, premature closure, and withdrawal from effective connections with patients. This article will explore ways in which Engel's biopsychosocial vision can be realized through building the capacities of clinicians to become more self-aware and resilient, and engage in compassionate action. [ABSTRACT FROM AUTHOR]

Introduction Burnout is a very prevalent type of stress among health professionals. It affects their well-being, performance, and attitude toward patients. This study assessed the effectiveness of a training program for primary health care professionals designed to reduce burnout and mood disturbance, increase empathy, and develop mindfulness. Methods Pragmatic randomized controlled trial with pre- and postintervention measurements of 68 primary health care professionals (43 in the intervention and 25 in the control group) in Spain. The intervention consisted of presentations of clinically relevant topics, mindfulness-based coping strategies, mindfulness practice, yoga, and group discussions (8 sessions of 2.5 hours per week plus a 1-day session of 8 hours). Outcome measures included the Maslach Burnout Inventory, Profile of Mood States, Jefferson Scale of Physician Empathy, Baer's Five Facets Mindfulness Questionnaire, and a questionnaire on changes in personal habits and mindfulness practice. Measurements were performed at baseline and after 8 weeks. Results The intervention group improved in the 4 scales measured. The magnitude of the change was large in total mood disturbance (difference between groups -7.1; standardized effect-size [SES] 1.15) and mindfulness (difference between groups 11; SES 0.9) and moderate in the burnout (difference between groups -7; SES 0.74) and empathy scales (difference between groups 5.2; SES 0.71). No significant differences were found in the control group. Discussion Our study supports the use of mindfulness-based programs as part of continuing professional education to reduce and prevent burnout, promote positive attitudes among health professionals, strengthen patient-provider relationships, and enhance well-being. [ABSTRACT FROM AUTHOR]

Importance: Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment.Objective: To determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing.Design, Setting, and Participants: Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire-9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California.Interventions: DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control).Main Outcomes and Measures: Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted.Results: Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, -6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control, -0.2 (95% CI, -1.2 to 0.8); IMCP vs control,  0.9 (95% CI, -0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, -2.2 [90% CI, -8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, -3.3 [90% CI, -9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control,  0.9 [90% CI, -4.9 to 6.7], P = .23 for noninferiority; IMCP vs control,  0.3 [90% CI, -5.1 to 5.7], P = .16 for noninferiority).Conclusions and Relevance: A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded.Trial Registration: clinicaltrials.gov Identifier: NCT01144104. [ABSTRACT FROM AUTHOR]

IMPORTANCE Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment. OBJECTIVE TO determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing. DESIGN, SETTING. AND PARTICIPANTS Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire-9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California. INTERVENTIONS DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control). MAIN OUTCOMES AND MEASURES Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted. RESULTS Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, -6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control, -0.2 (95% CI, -1.2 to 0.8); IMCP vs control, 0.9 (95% CI, -0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, -2.2 [90% CI, -8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, -3.3 [90% CI, -9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control, 0.9 [90% CI, -4.9 to 6.7], P = .23 for noninferiority; IMCP vs control, 0.3 [90% CI, -5.1 to 5.7], P = .16 for noninferiority). CONCLUSIONS AND RELEVANCE A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-weel< follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01144104 [ABSTRACT FROM AUTHOR]

The article discusses the challenges involved in prognosis and end-of-life care. It states that misunderstanding one's prognosis add to bad decision making. An expert panel used a question prompt list to study this. Patients with advanced cancer and health professionals participated. Analysis identified themes including reinforcement of known benefits of question prompt list, appraisal of content and suggestions for further development, and contrast feedbacks in Australian and U. S. patients.

The article focuses on a study conducted to determine the association of self-rated mindfulness of a physician with patient care quality and how it can improve health outcomes. The study includes an analysis of audio-recorded patient-clinician communication using the Roter Interaction Analysis System (RIAS). The participants of the study were HIV-infected patients and their clinicians.

Background: Communication about prognosis and treatment choices is essential for informed decision making in advanced cancer. This article describes an investigation designed to facilitate communication and decision making among oncologists, patients with advanced cancer, and their caregivers. Methods/design: The Values and Options in Cancer Care (VOICE) Study is a National Cancer Institute sponsored randomized controlled trial conducted in the Rochester/Buffalo, NY and Sacramento, CA regions. A total of 40 oncologists, approximately 400 patients with advanced cancer, and their family/friend caregivers (one per patient, when available) are expected to enroll in the study. Drawing upon ecological theory, the intervention uses a two-pronged approach: oncologists complete a multifaceted tailored educational intervention involving standardized patient instructors (SPIs), and patients and caregivers complete a coaching intervention to facilitate prioritizing and discussing questions and concerns. Follow-up data will be collected approximately quarterly for up to three years. Discussion: The intervention is hypothesized to enhance patient-centered communication, quality of care, and patient outcomes. Analyses will examine the effects of the intervention on key elements of physician-patient-caregiver communication (primary outcomes), the physician-patient relationship, shared understanding of prognosis, patient well-being, and health service utilization (secondary outcomes). [ABSTRACT FROM AUTHOR]

Background: The present study protocol describes the trial design of a clinician training intervention to improve physical activity counseling in underserved primary care settings using the 5As. The 5As (Ask, Advise, Agree, Assist, Arrange) are a clinical tool recommended for health behavior counseling in primary care. Methods/Design: The study is a two-arm randomized pilot pragmatic trial to examine a primary care clinician communication intervention on use of the 5As in discussion of physical activity in audio-recorded office visits in an ethnically diverse, low-income patient population. The study setting consists of two federally qualified community health centers in Rochester, NY. Eligible clinicians (n=15) are recruited and randomized into two groups. Group 1 clinicians participate in the training intervention first; Group 2 clinicians receive the intervention six months later. The intervention and its outcomes are informed by self-determination theory and principles of patient-centered communication. Assessment of outcomes is blinded. The primary outcome will be the frequency and quality of 5As discussions as judged by evaluating 375 audio-recorded patient visits distributed over baseline and in the post-intervention period (immediately post and at six months). Secondary outcomes will be changes in patients' perceived competence to increase physical activity (Aim 2) and patients and clinicians beliefs regarding whether pertinent barriers to promoting exercise have been reduced. (Aim 3). Exploratory outcomes (Aim 4) are potential mediators of the intervention's effect and whether the intervention affects actual enrollment in the community program recommended for exercise. The analysis will use repeated measures (in the form of recorded office visits) from each clinician at each time point and aggregate measures of Groups 1 and 2 over time. Discussion: Results will help elucidate the role of 5As communication training for clinicians on counseling for physical activity counseling in primary care. Results will explore the effectiveness of the 5As model linked to community resources for physical activity promotion for underserved groups. [ABSTRACT FROM AUTHOR]

Background: Family and friends may help patients seek out and engage in depression care. However, patients' social networks can also undermine depression treatment and recovery. In an effort to improve depression care in primary care settings, we sought to identify, categorize, and alert primary care clinicians to depression-related messages that patients hear from friends and family that patients perceive as unhelpful or detrimental. Methods: We conducted 15 focus groups in 3 cities. Participants (n = 116) with a personal history or knowledge of depression responded to open-ended questions about depression, including self-perceived barriers to care-seeking. Focus group conversations were audio-recorded and analyzed using iterative qualitative analysis. Results: Four themes emerged related to negatively-received depression messages delivered by family and friends. Specifically, participants perceived these messages as making them feel labeled, judged, lectured to, and rejected by family and friends when discussing depression. Some participants also expressed their interpretation of their families' motivations for delivering the messages and described how hearing these messages affected depression care. Conclusions: The richness of our results reflects the complexity of communication within depression sufferers' social networks around this stigmatized issue. To leverage patients' social support networks effectively in depression care, primary care clinicians should be aware of both the potentially beneficial and detrimental aspects of social support. Specifically, clinicians should consider using open-ended queries into patients' experiences with discussing depression with family and friends as an initial step in the process. An open-ended approach may avoid future emotional trauma or stigmatization and assist patients in overcoming self-imposed barriers to depression discussion, symptom disclosure, treatment adherence and follow-up care. [ABSTRACT FROM AUTHOR]

In the context of serious illness, individuals usually rely on others to help them think and feel their way through difficult decisions. To help us to understand why, when, and how individuals involve trusted others in sharing information, deliberation, and decision making, we offer the concept of shared mind-ways in which new ideas and perspectives can emerge through the sharing of thoughts, feelings, perceptions, meanings, and intentions among 2 or more people. We consider how shared mind manifests in relationships and organizations in general, building on studies of collaborative cognition, attunement, and sensemaking. Then, we explore how shared mind might be promoted through communication, when appropriate, and the implications of shared mind for decision making and patient autonomy. Next, we consider a continuum of patient-centered approaches to patient-clinician interactions. At one end of the continuum, an interactional approach promotes knowing the patient as a person, tailoring information, constructing preferences, achieving consensus, and promoting relational autonomy. At the other end, a transactional approach focuses on knowledge about the patient, information-as-commodity, negotiation, consent, and individual autonomy. Finally, we propose that autonomy and decision making should consider not only the individual perspectives of patients, their families, and members of the health care team, but also the perspectives that emerge from the interactions among them. By drawing attention to shared mind, clinicians can observe in what ways they can promote it through bidirectional sharing of information and engaging in shared deliberation. [ABSTRACT FROM AUTHOR]

The article discusses the significance of shared mind in the decision making in clinical practice in the context of serious illness. It explores how shared mind, which involve sharing of information, thoughts, feelings, perceptions, meanings, and intentions, can be shared through communication and its implication for decision making and patient autonomy. Moreover, patient-centered approaches to patient-clinician interactions have been considered to promote relational autonomy.

The article presents a study which examines the reasons of individuals not to disclose depression to their primary care physician. The study conducted a follow-up telephone survey which asked about reasons for nondisclosure of depressive symptoms in 1,054 adults in California. Results reveal that concern that physician would recommend antidepressants is the most frequent reason for not disclosing depression in which an intervention should be developed to encourage patient to disclose symptoms.

Medical Education 2011:: 663-668 For doctors, curiosity is fundamental to understanding each patient's unique experience of illness, building respectful relationships with patients, deepening self-awareness, supporting clinical reasoning, avoiding premature closure and encouraging lifelong learning. Yet, curiosity has received limited attention in medical education and research, and studies from the fields of cognitive psychology and education suggest that common practices in medical education may inadvertently suppress curiosity. This study aimed to identify common barriers to and facilitators of curiosity and related habits of mind in the education of doctors. We conducted a theory-driven conceptual exploration and qualitative review of the literature. Curiosity is related to inquisitiveness, reflection and mindfulness. Instructional practices can suppress curiosity by confusing haste with efficiency, neglecting negative emotions, promoting overconfidence and using teaching approaches that encourage passive learning. Curiosity tends to flourish in educational environments that promote the student's responsibility for his or her own learning, multiple perspectives and mindful reflection on both the subject and the learning process. Specific educational strategies that can support curiosity in classroom and clinical settings include the mindful pacing of teaching, modelling effective management of emotions, confronting uncertainty and overconfidence, using inquiry-based learning, helping students see familiar situations as novel, simultaneously considering multiple perspectives, and maximising the value of small-group discussions. Instructor attributes that contribute to the development of student curiosity include patience, a habit of inquiry, emotional candour, intellectual humility, transparency and recognition of the benefits to be gained in learning from peers. Curiosity, inquisitiveness and related habits of mind can be supported in medical education through specific, evidence-based instructional approaches. Medical educators should balance the teaching of facts, techniques and protocols with approaches that help students cultivate and sustain curiosity and wonder in the context-rich, often ambiguous world of clinical medicine. [ABSTRACT FROM AUTHOR]