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OBJECTIVES: Even though Electronic Medical Records (EMRs) are increasingly used in healthcare organizations there is surprisingly little theoretical work or educational programs in this field. This study is aimed at comparing two training programs for doctor-patient-computer communication (DPCC). METHODS: 36 Family Medicine Residents (FMRs) participated in this study. All FMRs went through twelve identical simulated encounters, six pre and six post training. The experiment group received simulation based training (SBT) while the control group received traditional lecture based training. RESULTS: Performance, attitude and sense of competence of all FMRs improved, but no difference was found between the experiment and control groups. FMRs from the experiment group evaluated the contribution of the training phase higher than control group, and showed higher satisfaction. CONCLUSION: We assume that the mere exposure to simulation served as a learning experience and enabled deliberate practice that was more powerful than training. Because DPCC is a new field, all participants in such studies, including instructors and raters, should receive basic training of DPCC skills. PRACTICE IMPLICATION: Simulation enhances DPCC skills. Future studies of this kind should control the exposure to simulation prior to the training phase. Training and assessment of clinical communication should include EMR related skills. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Even though Electronic Medical Records (EMRs) are increasingly used in healthcare organizations there is surprisingly little theoretical work or educational programs in this field. This study is aimed at comparing two training programs for doctor–patient–computer communication (DPCC). Methods: 36 Family Medicine Residents (FMRs) participated in this study. All FMRs went through twelve identical simulated encounters, six pre and six post training. The experiment group received simulation based training (SBT) while the control group received traditional lecture based training. Results: Performance, attitude and sense of competence of all FMRs improved, but no difference was found between the experiment and control groups. FMRs from the experiment group evaluated the contribution of the training phase higher than control group, and showed higher satisfaction. Conclusion: We assume that the mere exposure to simulation served as a learning experience and enabled deliberate practice that was more powerful than training. Because DPCC is a new field, all participants in such studies, including instructors and raters, should receive basic training of DPCC skills. Practice implication: Simulation enhances DPCC skills. Future studies of this kind should control the exposure to simulation prior to the training phase. Training and assessment of clinical communication should include EMR related skills. [Copyright &y& Elsevier]

Abstract: Objective: The study aim was the development of a method to further enhance the educational benefit of medical students’ reflective writing. The setting is a Doctoring course at the Warren Alpert Medical School of Brown University, which includes reflective writing assignments, termed “field notes”, combining students’ reflective writing with ongoing individualized feedback from small group faculty. Methods: Three-year (2005–2008) iterative process with three stages of immersion, analysis, and revision that resulted in the analysis framework. An interdisciplinary team composed of the four authors with backgrounds in narrative medicine, qualitative research, psychology, and medical education analyzed 12 first and second year students’ selected field notes in iterative cycles. In each cycle, consultations with small group faculty and content experts were conducted to further validate the emergent framework. Results: This process culminated in the creation of the Brown Educational Guide to Analysis of Narrative (BEGAN) framework, a guide for crafting feedback to students’ reflective writing, and the integration of the BEGAN framework into the faculty and student manuals for the Doctoring Course in 2008–2009. Conclusions: We propose the BEGAN framework as a useful innovative tool that can be incorporated in reflective writing curricula in the field of health professions education. It is tailored to support the educational impact of the course through additional scaffolding of student writing, and the robust process it delineates for crafting of faculty feedback. Providing systematic feedback to enhance reflective writing may represent the path forward in fostering professional development through reflection in health professions education. Practice implications: The BEGAN can be incorporated in reflective writing curricula in the field of health professions education. It is a springboard for the necessary next steps of development and research into the acquisition of reflective and narrative competence in the emerging professional. [Copyright &y& Elsevier]

Abstract: Objective: To describe a new tool designed to capture patients’ perception of their low back pain (LBP) episodes—the patient perception scale (PPS) and test its ability to predict episode outcomes. Methods: Thirty-two family physicians recruited 526 low back pain patients during an office visit. Physicians completed a short questionnaire at the index visit, which included both their assessments of patients’ patient perception scale (PPS-doc) and contact information. Patients were then interviewed by telephone within 2 weeks after the index visit, with follow-up telephone contacts at 2, 4, 8 and 12 months. The patient perception scale as reported by the physician (PPS-doc) and patient (PPS-pt), each constituent question, and different combinations were analyzed for their ability to predict patient outcomes. Results: Patients’ responses (PPS-pt) proved predictive for all outcome items. PPS-doc was much less predictive. Measures of patient centeredness did not perform well in this study. Conclusion: By using a short scale based on the patient''s perception of pain (PPS-pt), it is possible to predict adverse outcomes of a low back pain episode. The patient perception scale should be evaluated further and perhaps combined with other instruments for targeting care and chronicity prevention efforts in low back pain. Practice implications: The PPS-pt could potentially be used as part of the standard initial patient evaluation of new LBP patients, as a proxy for “yellow flags” (markers of psychosocial risk) where a positive score might be the equivalent to high-risk identification. The apparent advantage of this scale is its brevity and simplicity of administration. The separation, through this scale of pain episodes into simple and complex LBP might be a useful tool for helping direct resources and avoiding chronicity. [Copyright &y& Elsevier]

Abstract: Objective: Aggregation (i.e., meta-ethnography or meta-synthesis) of qualitative studies remains relatively rare and controversial. We have attempted this procedure within an investigation of patient priorities and evaluations of primary care in order to triangulate an instrument development process as well as explore associated dilemmas. Methods: The procedures included a literature search of qualitative research on patient priorities and evaluations and creation of a framework for quality assessment of retrieved papers. The tool for the evaluation of quality in qualitative studies was piloted, refined, and applied to the retrieved literature. The articles were equally distributed between two teams in random fashion, and inter-rater agreement calculated. Finally, we formulated and applied a strategy for aggregation of data from included papers that allowed comparison to a systematic review of quantitative studies on the topic. Results: Thirty-seven articles met inclusion criteria. Twenty-four of these articles were of sufficient quality to be included in the qualitative aggregation. Inter-rater agreement ranged from 0.22 to 0.77 and 0.38 to 0.60 for pair and assessor comparisons, respectively. The aggregation strategy enabled synthesis within sub-categories of the heterogeneous papers. Conclusions: We have devised a modestly reliable instrument to assess the quality of qualitative work. The procedure for quality assessment and aggregation appears to be both feasible and potentially useful, though both theoretical and practical problems underline the need for further refinement prior to widespread utilization of this approach. Practice implications: An instrument to assess the quality of qualitative work within the context of aggregation efforts is described. Calculating inter-rater reliability in this framework can support future quality assessments. A method of breaking a heterogeneous collection of included papers into sub-categories to enable aggregation of qualitative studies is applied and demonstrates its feasibility and potential usefulness. [Copyright &y& Elsevier]

Objective: To examine the impact of an integrative medicine (IM) course on self-perceived IM-related communication and research skills.Methods: A 3-day mandatory "hybrid" (online and in-person) IM course was held within COVID-19 restrictions for 161 pre-clerkship medical students, with workshops facilitated by mentor healthcare professionals (IM and non-IM) and student-directed tasks. Self-perceived levels of 6 IM-related skills were scored (from 1 to 5) for history-taking; communicating with patients with "alternative" health-beliefs; referral to IM consultations; assessing risks/benefits; and working with non-medical IM practitioners.Results: 137 students (85.1%) completed pre-/post-course questionnaires, with overall scores improving from pre-course (1.98 ± 0.92) to post-course (3.31 ± 0.63; p < 0.0001), for the entire group and student subgroups (with vs. without prior IM experience). Multivariate analysis found no association between age, gender, primary language or prior experience with IM and improvement in skill scores.Conclusions: The IM course increased self-perceived skill levels, reflecting the course curriculum and workshops. Further research needs to explore the application of these skills during clinical training.Practice Implications: Teaching medical students about IM in a course comprising communication and research skills was shown to be feasible and effective. The application of IM-related skills needs to be evaluated during the clinical clerkship. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: This study aims to highlight the differences in physicians’ scores on two communication assessment tools: the SEGUE and an EMR-specific communication skills checklist. The first tool ignores the presence of the EMR in the exam room and the second, though not formally validated, rather focuses on it. Methods: We use the Wilcoxon Signed Ranks Test to compare physicians’ scores on each of the tools during 16 simulated medical encounters that were rated by two different raters. Results: Results show a significant difference between physicians’ scores on each tool (z =−3.519, p <0.05 for the first rater, and z =−3.521, p <0.05 for the second rater), while scores on the EMR-specific communication skills checklist were significantly and consistently lower. Conclusion: These results imply that current communication assessment tools that do not incorporate items that are relevant for communication tasks during EMR use may produce inaccurate results. Practice implications: We therefore suggest that a new instrument, possibly an extension of existing ones, should be developed and empirically validated. [Copyright &y& Elsevier]

Objective: To examine perceptions of cancer patients from different cultural and ethnic groups regarding the quality of their care at the hospital–community interface. Methods: Cross-sectional study of cancer patients from a large tertiary center in Israel. Patients were surveyed on the quality of their primary-care and on their transition from the hospital. Regression analyses were used to examine differences among Hebrew-, Russian-, and Arabic-speaking patients in their assessment of six primary-care domains and of their care transition process. Results: 422 patients completed the survey. Russian speakers gave the lowest and Arabic speakers the highest ratings for all primary care domains. Arabic speakers also gave higher ratings for their care transition process than the other two groups. Minority patients’ primary-care physicians were significantly more likely than Hebrew speakers’ physicians to facilitate the hospital transition process by reviewing the discharge recommendations. Conclusions: Cancer patients from different ethnic groups differ in their primary-care experience and their perceptions of their hospital to community transition. Primary-care physicians serve as facilitators of care transitions by discussing discharge recommendations with their minority patients. Practice implications: Reviewing the discharge recommendations with the patient at the post-discharge primary-care visit is an important contributor to high quality transitional care. [Copyright &y& Elsevier]

Abstract: Objectives: Within the context of medical care there is no greater reflection of the information revolution than the electronic medical record (EMR). Current estimates suggest that EMR use by Israeli physicians is now so high as to represent an almost fully immersed environment. This study examines the relationships between the extent of electronic medical record use and physician–patient communication within the context of Israeli primary care. Methods: Based on videotapes of 3 Israeli primary care physicians and 30 of their patients, the extent of computer use was measured as number of seconds gazing at the computer screen and 3 levels of active keyboarding. Communication dynamics were analyzed through the application of a new Hebrew translation and adaptation of the Roter Interaction Analysis System (RIAS). Results: Physicians spent close to one-quarter of visit time gazing at the computer screen, and in some cases as much as 42%; heavy keyboarding throughout the visit was evident in 24% of studied visits. Screen gaze and levels of keyboarding were both positively correlated with length of visit (r =.51, p <.001 and F(2,27)=2.83, p <.08, respectively); however, keyboarding was inversely related to the amount of visit dialogue contributed by the physician (F(2,27)=4.22, p <.02) or the patient (F(2,27)=3.85, p <.05). Specific effects of screen gaze were inhibition of physician engagement in psychosocial question asking (r =−.39, p <.02) and emotional responsiveness (r =−.30, p <.10), while keyboarding increased biomedical exchange, including more questions about therapeutic regimen (F(2,27)=4.78, p <.02) and more patient education and counseling (F(2,27)=10.38, p <.001), as well as increased patient disclosure of medical information to the physician (F(2,27)=3.40, p <.05). A summary score reflecting overall patient-centered communication during the visit was negatively correlated with both screen gaze and keyboarding (r =−.33, p <.08 and F(2,27)=3.19, p <.06, respectively). Discussion: The computer has become a ‘party’ in the visit that demanded a significant portion of visit time. Gazing at the monitor was inversely related to physician engagement in psychosocial questioning and emotional responsiveness and to patient limited socio-emotional and psychosocial exchange during the visit. Keyboarding activity was inversely related to both physician and patient contribution to the medical dialogue. Patients may regard physicians’ engrossment in the tasks of computing as disinterested or disengaged. Increase in visit length associated with EMR use may be attributed to keyboarding and computer gazing. Conclusions: This study suggests that the way in which physicians use computers in the examination room can negatively affect patient-centered practice by diminishing dialogue, particularly in the psychosocial and emotional realm. Screen gaze appears particularly disruptive to psychosocial inquiry and emotional responsiveness, suggesting that visual attentiveness to the monitor rather than eye contact with the patient may inhibit sensitive or full patient disclosure. Practical implications: We believe that training can help physicians optimize interpersonal and educationally effective use of the EMR. This training can assist physicians in overcoming the interpersonal distancing, both verbally and non-verbally, with which computer use is associated. Collaborative reading of the EMR can contribute to improved quality of care, enhance the decision-making process, and empower patients to participate in their own care. [Copyright &y& Elsevier]

Abstract: Objective: We have previously described a breaking bad news (BBN) training program for primary care physicians [Ungar L, Alperin M, Amiel GE, Beharier Z, Reis S. Breaking bad news: structured training for family medicine residents. Patient Educ Couns 2002;48:63–68]. In this paper, we present the assessment of an educational intervention aimed at improving this important skill. Methods: The assessment tool was an eight station objective structured clinical examination (OSCE) utilizing standardized patients (SPs). Intervention and control groups of 17 general practitioners (GP) each were evaluated before and after an educational intervention, or a Balint group (control). Results: Intervention group GPs significantly increased their average grade on the post-test as compared to the pre-test (58.5, S.D. 12.7 versus 68.4, S.D. 9.2), effect size 0.94. Improvement in the control group was minimal (pre-test 57, S.D. 10.4 versus 58.1, S.D. 9.5 for the post-test), effect size 0.23. Reliability of the OSCE was α =0.81. Conclusion: The performance assessment used in this study proved to be a reliable and valid tool to assess the ability of physicians to break bad news. It provided evidence of the effectiveness of the intervention. Practice implications: BBN training can and should be evaluated by valid and reliable measures. SPs can serve as reliable evaluators of BBN training. [Copyright &y& Elsevier]

Previous research has shown that physicians experience incompetence and difficulty in dealing with patients’ feelings after they have broken bad news to them. During the past 10 years, we have implemented a longitudinal training program targeting these issues. The present article describes this training and discusses its contribution to doctors’ skills at approaching distressed patients. In order to cope with breaking bad news to patients and their families, physicians should be skilled at crisis intervention and communication techniques. They should also be aware of their personal attitudes and emotional reactions when breaking bad news. Each session encompassed these areas, as well as the most prominent issues arising when breaking bad news. In a 1–5 Likert scale, the course received an overall score of 4.47 (S.D. 0.51). Participants noted that they had gained relevant communication skills for future patient encounters. [Copyright &y& Elsevier]

Abstract: Objectives: Educators are integrating new technology into medical curriculum. The impact of newer technology on educational outcomes remains unclear. We aimed to determine if two pilot interventions, (1) introducing iPads into problem-based learning (PBL) sessions and (2) online tutoring would improve the educational experience of our learners. Methods: We voluntarily assigned 26 second-year medical students to iPad-based PBL sessions. Five students were assigned to Skype for exam remediation. We performed a mixed-method evaluation to determine efficacy. Results: Pilot 1: Seventeen students completed a survey following their use of an iPad during the second-year PBL curriculum. Students noted the iPad allows for researching information in real time, annotating lecture notes, and viewing sharper images. Data indicate that iPads have value in medical education and are a positive addition to the curriculum. Pilot 2: Students agreed that online tutoring is at least or more effective than in-person tutoring. Conclusions: In our pilot studies, students experienced that iPads and Skype are beneficial in medical education and can be successfully employed in areas such as PBL and remediation. Practice implications: Educators should continue to further examine innovative opportunities for introducing technology into medical education. [Copyright &y& Elsevier]