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Chronic infection with hepatitis C virus (HCV) results in an increased risk of cirrhosis and hepatocellular carcinoma (HCC). Only 15% of baby boomers (born 1945–1965) have ever been screened. We aimed to develop a multilevel intervention to increase HCV screening for baby boomers in a primary care setting. This study included two phases: intervention development (phase 1) and feasibility testing (phase 2). In phase 1, we partnered with a Community Advisory Board and a Provider Advisory Board to develop a multilevel intervention to increase HCV screening to be delivered to both providers and patients in primary care. Phase 2 assessed intervention feasibility, acceptability, and usability by conducting Concurrent Think Aloud (CTA) interviews and surveys using previously validated scales with patients (n = 8) and providers (n = 7). Phase 1 results: The patient-level intervention included a mailed reminder letter and CDC pamphlet and a 7-min in-clinic educational video. The provider-level intervention included a 30-min educational session and monthly performance feedback e-mails. Phase 2 results: Qualitatively, both the patient and provider-level intervention were feasible, acceptable, and usable by the target audiences. Quantitatively, on a 1–4 scale, the range of patient-level scores was 3.00–4.00 and provider level was 3.50–4.00 for feasibility, acceptability, and usability. This intervention could improve HCV screening among a high-risk population and therefore reduce HCV-related morbidity and mortality. This project developed a feasible, acceptable, and usable multilevel intervention aimed at increasing HCV screening in primary care.

Some colleges, departments, and study abroad offices have developed cultural development courses and study abroad opportunities designed to help improve students’ cultural awareness, knowledge, and skills. Some evidence suggests combining these approaches can be effective at helping students increase their Cultural Intelligence (CQ). This study examined the effects of a combined semester long, on-campus cultural development course followed by either a three- or six-week faculty-led study abroad program on student CQ. Students in both short-term programs increased in all four CQ domains (motivation, cognitive, metacognitive and behavior CQ) relative to a comparison group. No differences were found between the three- and six-week program for motivation, cognition, and behavior. However, there was a significant difference in metacognitive CQ between the two programs. Our study suggests participating in a semester-long cultural development course prior to a short-term study abroad increases undergraduate students’ motivation, cognitive, metacognitive, and behavior CQ.

Objectives To describe and deepen our understanding of patient-centeredness, empathy, and boundary management in challenging conversations. Previous studies show frequent physician self-disclosure, while empathy and boundary management are infrequent. Methods Three standardized patients (SPs) portrayed cancer patients consulting a new community-based physician, resulting in 39 audio-recorded SP visits to 19 family physicians and 20 medical oncologists. Transcripts underwent qualitative iterative thematic analysis, informed by grounded theory, followed by directed content analysis. We further defined the identified communicative categories with descriptive and correlational calculations. Results We identified patient-centered physician response categories--empathy, affirmation, and acknowledgement; and physician-centered categories—transparency, self-disclosure, and projection. Acknowledgement and affirmation responses were frequent and empathy rare. Physician transparency and self-disclosure were common. Useful and not useful self-disclosures were highly correlated; empathy, useful and not useful transparency, and projection were moderately correlated. Most physicians used self-disclosure but few of these were judged patient-centered. Conclusions Physicians expressing empathy and patient-centered transparency were also more likely to use projection and physician-centered transparency, thus engaging in communication “boundary turbulence.” Patients may benefit from physicians’ improved use of empathy and boundary management.

This study examined how physicians initiated and navigated conversations about smoking with patients with lung cancer. While there are numerous health benefits associated with smoking cessation in patients with advanced lung cancer, conversations about smoking cessation are infrequent and often lack tangible cessation support. We conducted a qualitative inductive content analysis on transcripts of conversations (n = 58) recorded during an initial appointment between a physician and a standardized patient (SP). SPs portrayed a 62-year-old male with lung cancer completing an initial visit with a new physician. Qualitative analysis focused on examining how physicians discussed smoking with a new patient. We found that a majority of physicians initiated conversations about smoking, often during the medical history charting process or during conversations about the lung cancer diagnosis. The content of conversations about smoking generally fits within six categories: assesses smoking status, builds smoking history profile, praises smoking cessation, connects smoking behaviors to diagnosis or treatment, provides empathy or understanding, and presents a negative bias about smoking. We found that while a majority of physicians asked patients about smoking, most physicians aimed for these conversations to be short, routine, and medically driven. Conversations about smoking were not tailored to meet the specific needs of patients with lung cancer, which might include additional provision of support for smoking cessation and recognition of smoking-related stigma.

This study used a quasi-experimental design to compare the effects of an intercultural development program on students' Cultural Intelligence (CQ) compared with students in a summer research program who did not receive the intervention. Social Learning Theory guided a 9-week student-centered cultural learning course focused on attention, retention, and reproduction of each CQ domain. After the course, students had opportunities to practice their CQ abilities while studying abroad. Pre-assessment CQ determined an individualized learning plan. Reflective journaling and cultural mentoring were used to maximize student CQ growth. Using multi-level modeling, we observed a statistically significant increase in three CQ domains compared to the comparison control group: cognitive (p

PURPOSE: Cancer screening uptake differs between groups in ways that cannot be explained by socioeconomic status alone. This study examined associations between material, psychosocial, and behavioral aspects of financial hardship and cancer screening behaviors. METHODS: Surveys were mailed to 7,979 people ages 18–75 who were seen in the statewide health system in Indiana. Participants reported SES, feelings about finances, and whether they had to forgo medical care due to cost. This was compared to uptake of mammogram, colonoscopy/sigmoidoscopy, and Pap testing in best-fit multivariable logistic regression analyses controlling for demographic and healthcare characteristics. RESULTS: 970 surveys were returned, the majority of respondents were female (54%), non-Hispanic White (75%), and over 50 years old (76%). 15% reported forgoing medical care due to cost; this barrier was higher among Black than White participants (24% vs. 13%; p=0.001). In a best fit regression model for colonoscopy/sigmoidoscopy, those who reported they had to forgo medical care due to cost had lower odds of screening (aOR=0.41; 95%CI=0.22–0.74). Forgoing medical care due to cost was not significantly associated with Pap testing in bivariate analyses. For mammogram, forgoing medical care due to cost was significant in bivariate analyses (OR=0.44; 95% CI=0.22–0.88), but was not significant in the multivariable model. CONCLUSION: Associations between financial hardship and cancer screening suggest the need to reduce barriers to cancer screening even among patients who have access to healthcare. Future research should explore barriers related to both healthcare and personal costs.

This study examined how physicians initiated and navigated conversations about smoking with patients with lung cancer. While there are numerous health benefits associated with smoking cessation in patients with advanced lung cancer, conversations about smoking cessation are infrequent and often lack tangible cessation support. We conducted a qualitative inductive content analysis on transcripts of conversations (n = 58) recorded during an initial appointment between a physician and a standardized patient (SP). SPs portrayed a 62-year-old male with lung cancer completing an initial visit with a new physician. Qualitative analysis focused on examining how physicians discussed smoking with a new patient. We found that a majority of physicians initiated conversations about smoking, often during the medical history charting process or during conversations about the lung cancer diagnosis. The content of conversations about smoking generally fits within six categories: assesses smoking status, builds smoking history profile, praises smoking cessation, connects smoking behaviors to diagnosis or treatment, provides empathy or understanding, and presents a negative bias about smoking. We found that while a majority of physicians asked patients about smoking, most physicians aimed for these conversations to be short, routine, and medically driven. Conversations about smoking were not tailored to meet the specific needs of patients with lung cancer, which might include additional provision of support for smoking cessation and recognition of smoking-related stigma.

Background: Emotional distress often causes patients with cancer and their family caregivers (FCGs) to avoid end-of-life discussions and advance care planning (ACP), which may undermine quality of life (QoL). Most ACP interventions fail to address emotional barriers that impede timely ACP. Aim: We assessed feasibility, acceptability, and preliminary effects of a mindfulness-based intervention to facilitate ACP for adults with advanced-stage cancer and their FCGs. Design: A single-arm pilot was conducted to assess the impact of a 6-week group mindfulness intervention on ACP behaviors (patients only), QoL, family communication, avoidant coping, distress, and other outcomes from baseline (T1) to post-intervention (T2) and 1 month later (T3). Participants: Eligible patients had advanced-stage solid malignancies, limited ACP engagement, and an FCG willing to participate. Thirteen dyads (N = 26 participants) enrolled at an academic cancer center in the United States. Results: Of eligible patients, 59.1% enrolled. Attendance (70.8% across 6 sessions) and retention (84.6% for patients; 92.3% for FCGs) through T3 were acceptable. Over 90% of completers reported high intervention satisfaction. From T1 to T3, patient engagement more than doubled in each of 3 ACP behaviors assessed. Patients reported large significant decreases in distress at T2 and T3. Family caregivers reported large significant improvements in QoL and family communication at T2 and T3. Both patients and FCGs reported notable reductions in sleep disturbance and avoidant coping at T3. Conclusions: The mindfulness intervention was feasible and acceptable and supported improvements in ACP and associated outcomes for patients and FCGs. A randomized trial of mindfulness training for ACP is warranted. The study is registered at ClinicalTrials.gov with identifier NCT02367508 ( https://clinicaltrials.gov/ct2/show/NCT02367508 ).

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.

BACKGROUND Partners of breast cancer survivors experience the effects of a spouse's cancer years after treatment. Partners of younger survivors (YPs) may experience greater problems than partners of older survivors (OPs), just as younger survivors experience greater problems than their older counterparts. OBJECTIVES The aims of this study were to (1) compare quality of life (QoL) in YPs and OPs and (2) determine contributing factors to each group's QoL. METHODS Cross-sectional data were collected from YPs (n = 227) and OPs (n = 281) through self-report. Multivariate analysis of variance was used to determine differences between YPs and OPs on QoL while controlling for covariates. Multiple regression analyses were conducted to determine what contributes to each group's QoL. RESULTS Partners of younger survivors reported better physical function (effect size [ES], -0.57), lower marital satisfaction (ES, 0.39), and lower overall QoL (ES, 0.43) than OPs. Predictors of QoL also differed between partner groups. For YPs, overall QoL was predicted by greater physical functioning, fewer depressive symptoms, higher marital satisfaction, higher parenting satisfaction, and more personal resources (R = 0.47, F5,195 = 35.05, P < .001). For OPs, overall QoL was predicted by fewer depressive symptoms, higher parenting satisfaction, higher spirituality, and greater social support from the breast cancer survivor spouse (R = 0.33, F4,244 = 29.80, P < .001). CONCLUSION Partners of older survivors reported greater QoL than YPs. Common factors contributing to QoL between YPs and OPs were fewer depressive symptoms and higher parenting satisfaction. IMPLICATIONS FOR PRACTICE Partners of breast cancer survivors may need support coping with their spouse/partner's cancer. Partners of younger survivors may require more support than OPs.

Objective To examine adolescent and young adults’ experiences of sexuality communication with physicians, and gain advice for improving interactions. Methods Semi-structured interviews were conducted with questions focusing on: puberty, romantic attractions, sexual orientation, dating, sexual behavior, clinical environment, and role of parents. Interviews were transcribed and analyzed using thematic analysis with both open and axial coding. Results Five themes emerged from interviews: 1) need for increased quantity of sexual communication, 2) issues of confidentiality/privacy, 3) comfort (physician discomfort, physical space), 4) inclusivity (language use, gender-fluid patients, office environment), 5) need for increased quality of sexual communication. Conclusions Sexual minority and majority adolescents and young adults indicate sexuality discussions with physicians are infrequent and need improvement. They indicate language use and clinical physical environment are important places where physicians can show inclusiveness and increase comfort. Practice implications Physicians should make an effort to include sexual communication at every visit. They should consider using indirect questions to assess sexual topics, provide other outlets for sexual health information, and ask parents to leave the exam room to improve confidentiality. Clinic staff should participate in Safe Zone trainings, and practices can promote inclusion with signs that indicate safe and accepting environments.

Objective: Determine illness perceptions associated most frequently with measures of type-2 diabetes mellitus (T2DM) maintenance. We measured illness perceptions using the Illness Perception Questionnaire (IPQ) and variants (IPQ-Revised and Brief IPQ) Design: Review of literature from publication of IPQ to September 2020. Searched for articles utilizing IPQ but no other models of illness perception and studying T2DM Main Outcome Measures: Glucose control (measured by HbA1c levels), adherence to medications, and adherence to diet, exercise, and other lifestyle recommendations Results: Symptom attribution and fear of consequences are frequently associated with worse T2DM management and sense of control of illness progression and positive emotional valence are frequently associated with better T2DM management. Other subscales have less frequent but generally positive associations with the exceptions of recurring thoughts about T2DM duration, which had a negative association with management, and understanding the causes of T2DM, which had no associations at all. Other reviews found similar associations and highlighted a need for more general T2DM education. Conclusion: Future T2DM management interventions should promote sense of control over illness progression and positive emotional valence and provide education regarding symptoms to expect. Interventions should also consider managing patient fear, which has many associations with worse management.

Objective Our objective is to examine the relationship of patient and provider characteristics and communication with chronic non-cancer pain and opioid management in primary care. Method We conducted an observational study using audio-recorded primary care appointments (up to 3/patient) and self-reported assessments of primary care providers (PCPs) and patients. We coded visit transcripts for 1) opioid and pain management talk and 2) mental health and opioid safety talk. Results Eight PCPs and 30 patients had complete data for 78 clinic visits. PCPs and patients engaged in more opioid and pain management talk when patients reported greater pain catastrophizing and PCPs reported higher psychosocial orientation. PCPs and patients engaged in talk about mental health and opioid safety when patients reported greater anxiety, higher working alliance with their PCP, and when PCPs reported higher burnout. PCPs’ negative attitudes about opioids were associated with fewer discussions about mental health and opioid safety. Conclusions Our results should facilitate design of interventions that improve communication and, ultimately, pain outcomes for patients. Practice Implications Clinicians can use our results to increase patient engagement in discussions about opioid use and pain management or mental health and safety discussions.

ObjectiveAdvance care planning (ACP) increases quality of life and satisfaction with care for those with cancer and their families, yet these important conversations often do not occur. Barriers include patients’ and families’ emotional responses to cancer, such as anxiety and sadness, which can lead to avoidance of discussing illness-related topics such as ACP. Interventions that address psychological barriers to ACP are needed. The purpose of this study was to explore the effects of a mindfulness intervention designed to cultivate patient and caregiver emotional and relational capacity to respond to the challenges of cancer with greater ease, potentially decreasing psychological barriers to ACP and enhancing ACP engagement.MethodThe Mindfully Optimizing Delivery of End-of-Life (MODEL) Care intervention provided 12 hours of experiential training to two cohorts of six to seven adults with advanced-stage cancer and their family caregivers (n = 13 dyads). Training included mindfulness practices, mindful communication skills development, and information about ACP. Patient and caregiver experiences of the MODEL Care program were assessed using semistructured interviews administered immediately postintervention and open-ended survey questions delivered immediately and at 4 weeks postintervention. Responses were analyzed using qualitative methods.ResultFour salient themes were identified. Patients and caregivers reported the intervention (1) enhanced adaptive coping practices, (2) lowered emotional reactivity, (3) strengthened relationships, and (4) improved communication, including communication about their disease.Significance of resultsThe MODEL Care intervention enhanced patient and caregiver capacity to respond to the emotional challenges that often accompany advanced cancer and decreased patient and caregiver psychological barriers to ACP.

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

The purpose of this article is to identify characteristics of Black barbershop clients and barbers in an urban Midwestern city participating in a health promotion program called Affecting Cancer Together (ACT) that are associated with client knowledge about prostate cancer. Statistical analyses examined client and barber characteristics for their potential association with client prostate cancer knowledge, while controlling for ACT variables. Study findings suggested clients who are married (β = 0.99; confidence interval [CI] = 0.38, 1.59; p < .01) and have higher levels of education (β = 0.34; CI = 0.01, 0.67; p = .04) may be more likely to know more about prostate cancer. Barbers with at least “some college” education may be more effective in increasing client knowledge (β = 0.85; CI = 0.05, 1.64; p = .04). Trained peer-helper programs may consider prioritizing limited educational resources for barbers with at least some college education and incorporating the social support of spouses for making informed decisions. Considering the potential of barbershop programs to reach Black men about a serious racially disproportionate health issue, ameliorating adoption, implementation, effectiveness, and sustainment are an important public health priority for underserved populations.

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. 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. 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. https://clinicaltrials.gov/ , #NCT01501006, November 30, 2011.

The purpose of this article is to identify characteristics of Black barbershop clients and barbers in an urban Midwestern city participating in a health promotion program called Affecting Cancer Together (ACT) that are associated with client knowledge about prostate cancer. Statistical analyses examined client and barber characteristics for their potential association with client prostate cancer knowledge, while controlling for ACT variables. Study findings suggested clients who are married (β = 0.99; confidence interval [CI] = 0.38, 1.59; p < .01) and have higher levels of education (β = 0.34; CI = 0.01, 0.67; p = .04) may be more likely to know more about prostate cancer. Barbers with at least “some college” education may be more effective in increasing client knowledge (β = 0.85; CI = 0.05, 1.64; p = .04). Trained peer-helper programs may consider prioritizing limited educational resources for barbers with at least some college education and incorporating the social support of spouses for making informed decisions. Considering the potential of barbershop programs to reach Black men about a serious racially disproportionate health issue, ameliorating adoption, implementation, effectiveness, and sustainment are an important public health priority for underserved populations.

This study examines student perceived gains from an undergraduate research experience (URE) program, using data from pre-, mid-, and postparticipation surveys. Results suggest that students experienced different gains at developmentally different stages of their UREs and reported gains in fewer areas at the end of the Summer segment than at end of the yearlong experience., The current study examines the trajectories of student perceived gains as a result of time spent in an undergraduate research experience (URE). Data for the study come from a survey administered at three points over a 1-yr period: before participation in the program, at the end of a Summer segment of research, and at the end of the year. Repeated-measures analysis of variance was used to examine the effect of time on perceived gains in student research skills, research confidence, and understanding of research processes. The results suggest that the students experienced different gains/benefits at developmentally different stages of their UREs. Participants reported gains in fewer areas at the end of the Summer segment compared with the end of the yearlong experience, thus supporting the notion that longer UREs offer students more benefit.

Teamwork is critical to providing excellent healthcare, and effective communication is essential for teamwork. Physicians often discuss patient referrals from other physicians, including referrals from outside their primary institution. Sharing conflicting information or negative judgments of other physicians to patients may be unprofessional. Poor teamwork within healthcare systems has been associated with patient mortality and lower staff well-being.This analysis explored how physicians talk to patients with advanced cancer about care rendered by other physicians.Standardized patients (SPs) portraying advanced lung cancer attended covertly recorded visits with consenting oncologists and family physicians.Twenty community-based oncologists and 19 family physicians had encounters with SPs.Physician comments about care by other physicians were extracted from transcriptions and analyzed qualitatively. These comments were categorized as Supportive or Critical. We also examined whether there were differences between physicians who provide supportive comments and those who provided critical comments.Fourteen of the 34 encounters (41 %) included in this analysis contained a total of 42 comments about the patient's previous care. Twelve of 42 comments (29 %) were coded as Supportive, twenty-eight (67 %) as Critical, and two (4 %) as Neutral. Supportive comments attributed positive qualities to another physician or their care. Critical comments included one specialty criticizing another and general lack of trust in physicians.This study described comments by physicians criticizing other physicians to patients. This behavior may affect patient satisfaction and quality of care. Healthcare system policies and training should discourage this behavior.

Importance Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported. Objective To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life. Design, setting, and participants Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers. Interventions Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training. Main outcomes and measures The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life. Results Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; P = .02). Differences in secondary outcomes were not statistically significant. Conclusions and relevance A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes. Trial registration clinicaltrials.gov Identifier: NCT01485627.

This study examines lesbian, gay, and bisexual patients' disclosure patterns of sexual orientation to health care providers. Using a semistructured interview format, researchers conducted interviews with 24 lesbian, gay, bisexual, and queer (LGBQ) adults about sexual orientation disclosure strategies. All interviews were transcribed and independently coded using thematic analysis. Results suggest that patient sexual orientation disclosure may be patient initiated and may occur to clarify or correct provider misinformation. Participants disclosed their orientation early in the medical visit during introductions, during small talk with the provider, and during the history-taking phase of the visit. Participants characterized sexual orientation disclosures as presented with minimal information, casually, and often indirectly. Practical and theoretical implications are discussed.

We conducted clustering analyses to verify whether common patterns can be identified from two distinct types of end-stage cancer prognosis discussion information, including patient-centered communication and shared decision making data. We applied hierarchical clustering on patient-centered communication measurement data and frequent itemset hierarchical clustering on coded shared decision-making interaction information. Our results suggested modest association between the two data sets in clustering assignments when measuring it with a normalized mutual information index. However, we could not find any noticeable overlap between the two assignments.

In adjusting to chronic illness, patients often negotiate new or altered daily routines within a dynamic family context. Yet, the responses of family members to the disease and its management are understudied. The authors investigated patients with Type 2 diabetes and their spouses (N = 55 couples) and examined the association of diet-related interactions (i.e., diet-related support, diet-related pressure, and frequency of sharing meals together) with each partner's adjustment to the illness context (i.e., diabetes distress). All spouses (100%) reported providing some type of diet-related support to their partners with diabetes in the past month, and many reported exerting pressure to improve their partners' diet choices (60%). In addition, many couples (64%) indicated that they frequently shared meals together in the past month. For spouses, their provision of diet-related pressure was associated (positively) with their diabetes distress. Frequently sharing meals was associated with less diabetes distress among patients, even after controlling for their glycemic control and diet adherence. Findings reveal that spouses of patients with diabetes are actively involved in illness management with their partners, and these activities are associated with their own diabetes distress and with that of their ill partners.

Cancer prevention is a broad field that crosses many disciplines; therefore, educational efforts to enhance cancer prevention research focused on interdisciplinary approaches to the field are greatly needed. In order to hasten progress in cancer prevention research, the Cancer Prevention Internship Program (CPIP) at Purdue University was designed to develop and test an interdisciplinary curriculum for undergraduate and graduate students. The hypothesis was that course curriculum specific to introducing interdisciplinary concepts in cancer prevention would increase student interest in and ability to pursue advanced educational opportunities (e.g., graduate school, medical school). Preliminary results from the evaluation of the first year which included ten undergraduate and five graduate students suggested that participation in CPIP is a positive professional development experience, leading to a significant increase in understanding of interdisciplinary research in cancer prevention. In its first year, the CPIP project has created a successful model for interdisciplinary education in cancer prevention research.

Married men and women ( N = 1,899 couples) reported readiness to eat a healthier diet, lose weight, and get more exercise (stage of change) and indicated whether they were confident to make these changes (self-efficacy). Husbands’ and wives’ reports of readiness to change each health behavior were positively associated. Furthermore, women who indicated readiness to eat a healthier diet and get more exercise (contemplation or preparation stages) were less likely to endorse confidence to change when their husbands were in a lower stage than they were relative to those whose husbands shared the same stage of change. Similarly, men who indicated readiness to lose weight were less likely to endorse being confident in their ability to lose weight when their wives were in a lower stage than they were relative to those who shared the same stage. Consideration of interpersonal factors in the behavior change process may enhance behavioral interventions that include married partners together rather than either individual alone.

29 Background: A critical domain of patient-provider communication is helping cancer patients understand their prognosis, as well as the efficacy of treatment options. In this qualitative study, we explored the ways oncology providers approached prognostic discussions during initial office visits with patients with metastatic lung cancer. Methods: Transcripts of initial visits between unannounced standardized patients portraying metastatic non-small cell lung cancer and their oncologists were recorded at multiple practice sites in community and academic settings, as part of a large NIH-funded study. Thematic analysis was conducted on a subset of these recorded visits from one study site. In this secondary analysis, three coders (one medical oncologist, one palliative care physician and one research assistant) reviewed transcripts independently to extract quotes related to prognosis, meeting regularly to review selected quotes and to decide on codes. This process repeated until saturation of themes was achieved (n = 15). Results: Discussions of prognosis were found in all 15 transcripts reviewed. Three main themes were identified: (1) Vagueness, in which best-case/worst-case scenarios were presented without an estimate of life expectancy; (2) Statistical Reliance, in which complex statistical data were presented to the patient; and (3) Emotional Support, in which the discussion was infused with emotional reassurance which was contextually appropriate. A fourth identified theme was (4) Minimizing of Supportive Care, as discussions of management options did not always elaborate on best supportive care. Conclusions: Our qualitative analysis of initial office visits among simulated patients with metastatic lung cancer revealed that providers often frame prognostic information in vague terms without a realistic estimate of life expectancy, sometimes give patients complex statistical data, and tend to accompany their discussions with emotional reassurance. Best supportive care is not always fully explained when management options are reviewed. More work is needed to determine optimal ways to convey prognostic and management information during clinic visits for patients with advanced cancer.

To examine physician communication associated with prognosis discussion with cancer patients.We conducted a study of physician-patient communication using trained actors. Thirty-nine physicians, including 19 oncologists and 20 family physicians participated in the study. Actors carried two hidden digital recorders to unannounced visits. We coded recordings for eliciting and validating patient concerns, attentive voice tone, and prognosis talk.Actor adherence to role averaged 92% and the suspected detection rate was 14%. In a multiple regression, eliciting and validating patient concerns (beta=.40, C.I.=0.11-0.68) attentiveness (beta=.32, C.I.=0.06-0.58) and being an oncologist vs. a family physician (beta=.33, C.I.=0.33-1.36) accounted for 46% of the variance in prognosis communication.Eliciting and validating patient concerns and attentiveness voice tone is associated with increased discussion of cancer patient prognosis as is physician specialty.Eliciting and validating patient concerns and attentive voice tone may be markers of physician willingness to discuss emotionally difficult topics. Educating physicians about mindful practice may increase their ability to collect important information and to attend to patient concerns.

The purpose of this study was to investigate the relationship between satisfaction with information about treatment-related and survivorship issues and mental health outcomes, including vitality, in long-term breast cancer survivors.Participants who had finished treatment for breast cancer at least 3 months before enrollment completed a survey instrument designed to evaluate satisfaction with diagnostic and treatment information and satisfaction with survivorship information. Mental health and vitality were measured using the Medical Outcomes Study SF-36, and distress was measured using the impact of events scale. Bivariate analyses and linear regression analyses were performed to investigate the relationships between satisfaction with information, mental health, vitality, and distress controlling for clinical and treatment variables.The survey was completed by 231 participants (response rate 83%). More respondents were highly satisfied with treatment information (87%) than with survivorship information (30%, p=0.0001). There was a strong positive relationship between satisfaction with information (both treatment and survivorship issues) and vitality, mental health, and a strong negative relationship with distress. In multivariate analyses, satisfaction with treatment information was independently associated with mental health (p0.01), and satisfaction with survivorship information was independently associated with vitality (p0.05).Among patients who have completed treatment for breast cancer, satisfaction with diagnosis and treatment information is greater than satisfaction with survivorship issues and satisfaction with information may play an important role in mental health outcomes.Given the relationship between satisfaction with information and vitality, interventions to improve informational support regarding survivorship issues are warranted.

Background. Physicians can help guide teenagers in their emerging sexuality; however, teens rarely inform physicians about their sexual activity. Methods. We audio-recorded annual visits between 365 teenagers and 49 physicians. Before the recorded visit, the teens were asked in a confidential telephone survey whether they had ever engaged in sexual intercourse. Recordings were coded for teenage disclosures about previous sexual intercourse. We measured agreement between telephone survey responses and annual visit disclosures, and examined factors associated with agreement between the two. Results. Fifty-six teenagers (15%) reported previous sexual intercourse in either the telephone survey or to their physician. Among those who reported sexual intercourse, 57% shared this information to both the telephone survey and their physician (κ = .72, confidence interval = 0.63-0.82). Conclusions. Although a slight majority of teenagers disclosed their sexual activity to both the telephone survey and their doctor, a significant number disclosed to just one source.

In the context of a traumatic event, such as a breast cancer diagnosis, talking with others about the event can facilitate emotional adjustment and meaning-finding. Among women with a history of breast cancer, open communication is likely to be of particular importance in the family setting, as the family is frequently a primary source of support. The goal of this cross-sectional survey study was to determine the association between open family communication about cancer and breast cancer survivors' mental health. Responses from 230 women at various stages post-treatment suggest that the majority of women are able to talk openly with their family about breast cancer. Multivariate regression analysis further indicates that open family communication is independently associated with better mental health outcomes. Given that many women live long after a breast cancer diagnosis, maintaining mental health functioning is an important long-term goal. Efforts to enhance productive communication between patients and their family members may help women cope with and overcome the challenges of breast cancer survivorship.

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

Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.

Objectives: To conduct a pilot study to examine physician patient interaction when elderly patients are accompanied during a medical visit. Methods: This was a study in which 30 patients were randomly assigned to be accompanied (13) or unaccompanied (17) during a regular medical visit to their physician. Visits were tape recorded, transcribed, and coded with the Measure of Patient-Centered Communication (MPCC) and with the Rochester Participatory Decision-Making Scale (RPAD). Results: We found no differences between the number of words spoken in accompanied versus unaccompanied visits, comparing patients alone with patients and companions combined. Physicians spoke longer without interruption in accompanied encounters (39.9 vs 78.6 words per speech turn). There were no differences in the level of MPCC or in the level of participatory decision making between the 2 types of visits. In accompanied visits, patients introduced most of the concerns and physicians discussed concerns with patients more than with companions. Conclusions: Previously reported differences in accompanied versus unaccompanied visits may reflect patients’ preferences for being accompanied, the role they wish their companion to play, and the patients’ health status. Being accompanied by a family member or friend does not result in less attention being paid to patients’ concerns.

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

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

Objective The authors asked whether social support and depression are independently associated with functional disability and examined the potential role of social support as a moderator in the depression–functional disability association. Methods Subjects were 305 patients age 60 years and over. Predictor variables were social support, depressive symptoms, and depression diagnosis. Dependent variables were the Instrumental Activities of Daily Living Scale, the Physical Self-Maintenance Scale, and the Physical Functioning subscale of the Medical Outcomes Study 36-Item Short-Form Health Survey. Authors used multiple-regression analyses. Results Depressive symptoms and all dimensions of social support were independently associated with functional disability: the specifics of these relationships varied among types of social support and functional disability. Depression diagnosis was not independently associated with any functional disability measure. Social support (more instrumental help, more perceived satisfaction) moderated some depression diagnosis–functional disability associations, and one depressive symptom–functional disability association. Conclusions The study hypotheses were partially confirmed. Different dimensions of social support have important and varied roles in the depression–functional disability dynamic. Future research is needed to further specify the complex relationships among depression, social support, and functional disability.

This study examined patients' preferences for involvement in treatment decision-making. This was a multisite survey study of 1014 patients diagnosed with a variety of cancers. Patients' treatment decisions, role preferences, and characteristics were assessed with a questionnaire administered at the time of their first visit with a medical or radiation oncologist. The data showed that 35.7% preferred passive roles, 43.7% preferred shared roles, and 20.3% preferred active roles in decision-making. Bivariate analyses indicated that patients with a college education or in professional or managerial occupations preferred more active roles in decisionmaking compared with other patients. Similarly, men with prostate cancer and women with breast cancer, compared with other patients, also preferred more involvement in decision-making. Age was not associated with decision-making role preferences. Avoidant and fatalistic coping were associated with a passive decision-making role. Multinomial logistic regression analysis found that patients in professional/managerial occupations preferred a shared role (odds ratio [OR], 1.6; CI, 1.2–2.4) or an active role (OR, 2.3; CI, 1.5–3.5) compared with patients in other occupations. Patients with prostate or breast cancer preferred shared (OR, 2.3; CI, 1.6–3.2) or active roles (OR, 1.8; CI, 1.2–2.8) compared with patients with other diagnoses. Patients who scored higher on the Mental Adjustment to Cancer fatalism scale were less likely to prefer shared (OR, 0.94; CI, 0.89–0.99) or active roles (OR, 0.90; CI, 0.84–0.96) compared with patients with a less fatalistic orientation. Decision-making role preferences were influenced by multiple factors. Most patients wanted a shared or active role in treatment decision-making. Our results suggest that some patients may require encouragement to take a shared or active role in decision-making.

Recovery from stroke is a challenging process for stroke survivors and their families. Assessing family conflict may be useful in guiding interventions to reduce caregiver distress. The purpose of this study was to assess preliminary reliability and validity data for a 15-item family caregiver conflict scale [FCCS] for stroke. Construct validity was assessed using subscales from the family assessment device: communication, problem solving, general family functioning, and a perceived criticism scale. Data were pooled from three studies of caregivers of stroke survivors (total N=93). Internal consistency for the FCCS was adequate (>0.70). Higher family conflict was related to more ineffective family communication, general family functioning, and higher perceived criticism (p > or =0.05). Nonspouse caregivers reported more family conflict than spouse caregivers. The FCCS appears to have adequate internal consistency and construct validity and may provide information about family conflicts around stroke recovery and direction for family-focused interventions.

Importance Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality. Objective To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents. Design, Setting, and Participants Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area. Main Outcomes and Measures Total time per visit during which sexuality issues were discussed. Results One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation. Conclusions and Relevance Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making. Trial Registration clinicaltrials.gov Identifier:NCT01040975

We explore the use of variable selection methods to deal with high correlations among predicative variables (e.g., physician’s voice tone and language certainty) for examining physician communication associated with prognosis discussion with cancer patients. Our main method is principal component analysis. The comparative results show its benefit in predicting patient satisfaction on the prognosis communication. This preliminary regression analysis is expected to offer insights into patient-centered communication strategy design, especially for cancer prognosis communication with end-stage patients.