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To better understand what makes cost-of-care communication between oncologists and cancer patients more or less successful, we conducted in-depth interviews with 32 oncologists (22 male, 10 female) who were board-certified in medical, surgical, or radiation oncology. Through qualitative descriptive analysis by four coders, we found that oncologists used six broad strategies to discuss cost with patients: open discussion, avoidance, reassurance, warning, outsourcing, and educating. We also found that oncologists invoked certain meanings of cost conversations: cost conversations as holistic care, coercion, a matter of timing, risking patient suspicions, advocacy, unwanted distraction, transparency, bad news delivery, problem-solving, pointless, informed decision making, or irrelevant. These meanings appeared to be linked to oncologists enacting certain strategies (e.g., oncologists who invoked cost conversations as holistic care tended to enact open discussion, those who saw cost conversations as risky tended to use avoidance). Theoretically, our results suggest that the invoked meaning of a difficult conversation may be a key explanatory mechanism for differentiating high-quality from low-quality communication in cost conversations. Practically, our findings suggest that oncologists should consider how well the invoked meaning of the cost conversation is serving their own and their patients' goals. [ABSTRACT FROM AUTHOR]

One of the core principles of providing care in general practice is giving more to those who need it most. We investigate some of the complexities of this ambition in the context of cancer care for patients defined as socially disadvantaged by their general practitioner (GP). We do this by exploring how care is sought, how it is offered, and what expectations patients and GPs carry with them when receiving and providing cancer care in the Danish welfare state. We carried out semi-structured interviews with eight GPs and seven socially disadvantaged cancer patients living with different types and stages of cancer. The interviews focused on needs and challenges in cancer follow-up in general practice and were thematically coded. Drawing on theoretical concepts of morality and Nordic individualism, we point to how one of the main challenges in cancer care and follow-up is to figure out how the doctor-patient relationship should be established, practiced, and maintained. Both GPs and patients stressed the importance of the relationship, but how it should be practiced amidst social norms about being a patient, a citizen and how care-seeking should unfold seems less clear. In conclusion we argue that giving more to those who need it the most is a difficult and ill-defined task that is shaped by the cultural, social, and political expectations of both GPs and patients. [ABSTRACT FROM AUTHOR]

The post-COVID-19 pandemic era has placed new demands on physicians. One of these demands is the need to use targeted knowledge and soft communication skills, to address the psychosocial problems (e.g. vaccine hesitancy, fears) of individuals with Chronic Physical Illnesses (CPIs). Focusing on training physicians in targeted soft communication skills can help health care systems to address psychosocial-type problems. Yet, such training programs are rarely implemented, effectively. This study aimed to (a) understand physicians' implementation challenges when using soft communication skills during the COVID-19 pandemic; (b) identify beliefs, barriers, and facilitators that can influence physicians' behaviours to use soft communication skills; and (c) inform the content of the LeadinCare; a new digital training platform, designed to improve physicians' soft communication skills, by leveraging the TDF Theoretical Domain Framework (TDF). We conducted 14 in-depth semi-structured interviews with physicians in Greece, supporting non-COVID-19 cases with CPIs. We analyzed their data using inductive and deductive approaches. Physicians highlighted time, inability to see patients in person, absence of space for non-COVID-19 cases, and poor organizational procedures as barriers to using soft communication skills. Five TDF domains (beliefs) were identified as the most salient to inform the LeadinCare platform: (1) practical and well-organized knowledge; (2) skills that support patients and their relatives; (3) physicians' beliefs about capabilities to use the skills; (4) beliefs about consequences of using the skills (job satisfaction); and (5) the use of digital, interactive, and on-demand platforms (environmental context & resources). We mapped the domains in six narrative-based practices that informed the content of the LeadinCare. Physicians need skills that go beyond talking and towards cultivating resilience and flexibility. [ABSTRACT FROM AUTHOR]

In early 2020, when the first COVID-19 cases were confirmed in Switzerland, the federal government started implementing measures such as national stay-at-home recommendations and a strict limitation of health care services use. General practitioners (GPs) and their at-risk patients faced similar uncertainties and grappled with subsequent sensemaking of the unprecedented situation. Qualitative interviews with 24 GPs and 37 at-risk patients were conducted which were analyzed using thematic analysis. Weick's (1993) four sources of -resilience – improvisation, virtual role systems, attitudes of wisdom and respectful interaction – heuristically guide the exploration of on-the-ground experiences and informal ways GPs and their at-risk patients sought to ensure continuity of primary care. GPs used their metaphorical Swiss army knives of learned tools as well as existing knowledge and relationships to adapt to the extenuating circumstances. Through improvisation, GPs and patients found pragmatic solutions, such as using local farmer apple brandy as disinfectant or at-home treatments of clavicle fractures. Through virtual role systems, GPs and patients came to terms with new and shifting roles, such as "good soldier" and "at-risk patient" categorizations. Both parties adopted attitudes of wisdom by accepting that they could not know everything. They also diversified their sources of information through personal relationships, formal networks, and the internet. The GP-patient relationship grew in importance through respectful interaction, and intersubjective reflection helped make sense of shifting roles and ambiguous guidelines. The empirical analysis of this paper contributes to theoretical considerations of sensemaking, resilience, crisis settings and health systems. [ABSTRACT FROM AUTHOR]

In routine healthcare consultations, patients often use prefaces containing the word "thing", including "the thing is", "there's this thing" or "one more thing". Although "thing" is an all-encompassing term that is used in myriad ways, in this article we show that thing-prefaces perform a specific job. This study uses Conversation Analysis to analyze 90 video-recorded primary care consultations with 14 primary care physicians in the United States. Patients' thing-prefaces mark the upcoming talk as a disclosure of sensitive information that may reflect negatively on the patient, physician or service (e.g., medication nonadherence, refill was not sent to pharmacy). Patients pursue explicit resolution of these problems (e.g., personalized recommendation, lab work, referral) despite these problems being downplayed and treated as delicate. Because patients may "talk around" these sensitive issues, thing-prefaces can be an important cue for physicians that patients are seeking resolution for a sensitive healthcare problem. [ABSTRACT FROM AUTHOR]

Patient-physician communication is a crucial aspect of clinical diagnoses and treatments. However, there are barriers to effective empathic practices, including consciousness, busy working rhythms, and difficulties recognising patients' implicit emotional expressions. While previous research has attempted to support asynchronous medical conversations, this study has explored the use of emotion visualisation techniques for synchronous, face-to-face medical encounters. After interviewing doctors to understand user requirements, an emotion-visualisation prototype, EMVIS, was created. The prototype was evaluated in a study with 31 patients and 37 healthcare providers within different specialist groups using a contextualised Technology Acceptance Model (TAM) and follow-up interviews. The results indicated that patients and physicians were generally accepting of emotion visualisation for medical encounters. Patients were more interested in their physicians' attitudes and intentions, while physicians accepted the visualisation, but their requirements differed according to their skill levels and specialities. Hence, four supportive factors - emotional empathy, careful attention, human connection, and reflective conversation - elicited information on how EMVIS contributed to medical conversations. Five future opportunities for the emotion visualisation of medical conversations were discussed in respect of the human factors and potential requirements. These include communicating uncertainty, addressing user diversity, providing explanatory information, managing attention, and supporting negotiations. [ABSTRACT FROM AUTHOR]

To support primary care physicians (PCPs) and their patients with knee osteoarthritis (OA), we created a series of evidence-based whiteboard educational videos for patients with knee OA. In a previous study we piloted these videos with patients to understand their acceptability and impact. The purpose of this study was to explore PCPs' perspectives to understand the utility of novel patient education videos to support management. We conducted a qualitative descriptive study using semi-structured interviews of newly practicing and resident PCPs after watching a series of patient education videos. A thematic analysis approach was used combining both inductive and research question driven coding, category formation, and theme identification. Ten participants were included. Barriers to optimal management were identified including the challenge of patient adherence and access to non-operative treatments. PCPs indicated that the videos would support their management of patients with knee OA by (1) supporting credibility and building trust with their patient, (2) reinforcing patient understanding, and (3) enhancing their own management of patients. Future implementation of these resources with attention to barriers that may limit uptake is necessary and may optimize management of knee OA in primary care. The provision of patient educational materials may support patient buy-in regarding appropriate management, enhance patient understanding, and improve physicians' future practice. Viewing these videos could potentially improve physicians' future resource use, recommendation of non-operative treatments, and the quality of their total knee replacement referrals, which has benefits to both the patient and the healthcare system. Perceived barriers to implementing evidence-based recommendations may pose a challenge for patients and clinicians and should be considered to help facilitate the uptake of educational interventions. [ABSTRACT FROM AUTHOR]

Telehealth involves real-time communication (telephone or video-call) between patients and health providers. The COVID-19 pandemic propelled general practitioners to conduct most consultations remotely, seeing patients face-to-face only when required. Placement opportunities and experience for medical students were reduced. Initially online learning programmes replaced clinical attachments. Subsequently, clinical teachers supervised students to engage in remote consultations, either in clinics or from their homes. This study aimed to explore the experience of New Zealand general practitioners undertaking clinical teaching with medical students when telehealth consulting. Semi-structured interviews with general practitioners who had taught medical students whilst consulting remotely. General inductive thematic analysis of transcribed interviews. Six female and four male participants aged 40 to over 65 years. Participants often focused on general practicalities of telehealth consultations and effects on the patient-doctor relationship, and needed direction to consider remote consultations with students, which added to the interactions. Four themes were identified: changes needed in teaching delivery format; direct comparison with face-to-face; challenges and advantages to remote teaching, each with subthemes. Clinicians needed to determine practical logistics and develop skills for both remote consulting and teaching. New format and structures of consultations needed planning. Differences from face-to-face teaching included scene-setting for the consultation and supervision factors. Telehealth teaching conferred new opportunities for learning but also challenges (e.g. consent, cues, uncertainty). Remote consultations are likely to remain a significant mode for doctor-patient interactions. Preliminary guidelines for teaching and learning using telehealth need to be developed and embedded into medical programmes and then evaluated. [ABSTRACT FROM AUTHOR]

Background: A review and meta- analysis of empathic communication and patients' expectations of interventions has shown that if positive messages are delivered there is a small but measurable reduction of pain and anxiety and some improvements in physical outcomes. Aim: To identify elements of health messages that may have a positive impact on patient health outcomes to guide effective nurse-patient- communication. Methods: Data were extracted from each study in a qualitative analysis of a systematic review investigating the health effects of positive messages, and analysed following the principles of thematic analysis. Findings: Central to effective positive messages were good communication skills. Five key features were identified. Discussion: The non-treatment care categories such as cognitive care and emotional care can significantly influence health outcomes across a range of interactions. Conclusion: Strategies to facilitate positivity can be incorporated into nursing education programs designed to improve patient outcomes. [ABSTRACT FROM AUTHOR]

The experiences of African, Caribbean and Black (ACB) Canadians are seldom explored in the Canadian context. Family physicians act as a gateway to the rest of the healthcare system and are necessary to provide proper patient care. However, Canada's history with colonialism may impact the socio-cultural context in which patients receive care. 41 participants from Waterloo Region, Ontario, were engaged in eight focus groups to discuss their experiences in the healthcare system. Data were analysed following thematic analysis. Style of care, racism and discrimination and a lack of cultural competence hindered access. oor Inadequate cultural competence was attributed to western and biomedical approaches, poor understanding of patients' context, physicians failing to address specific health concerns, and racism and discrimination. Participants highlighted that the two facilitators to care were having an ACB family physician and fostering positive relationships with physicians. Participants predominantly expressed dissatisfaction in physicians' approaches to care, which were compounded by experiences of racism and discrimination. Findings demonstrate how ACB patients are marginalized and excluded from the healthcare syste Iimplications for better access to care included utilizing community healthcare centres, increasing physicians' capacity around culturally inclusive care, and increasing access to ACB physicians. [ABSTRACT FROM AUTHOR]

PhenomenonMedical learners are more likely than practicing physicians to experience negative emotions toward some patients whom they find challenging, and medical students experience such emotions related to their identity as learners. Little is known about experiences of residents, who are further along in their physician identity formation and have greater autonomy and competence. We explored and characterized how residents understand their experiences of the phenomenon of feeling negative emotions toward patients in relation to their identities as residents. Approach: In 2018, 305 final-year obstetrics and gynecology residents were invited to participate in interviews, which we conducted until reaching theoretical sufficiency. In semi-structured interviews conducted by phone, we probed interactions when residents felt negative emotions toward patients, including reasons for their feelings related to their professional identities, strategies, and curricular desires. The authors coded data and identified patterns using thematic analysis. Findings: Nineteen residents were interviewed by phone. Residents experienced negative emotions toward patients because of challenges to their identities as: physicians – wanting respect and specific unexpected patient behaviors; learners – desiring complete autonomy and experiencing challenges with attending physicians; teachers – wanting to be a role model and protect junior learners; and workers – trying to complete tasks. Among the strategies used to manage feelings toward patients, they struggled with "venting", or complaining about patients, which was not always helpful and residents recognized as perceived negatively by students. They desired curricular support for these interactions such as debriefs and other supported reflection, faculty modeling, and communication skills training. Insights: Like medical students and physicians in practice, residents experience negative emotions toward patients, often because of and made more difficult by their identities as physicians, learners, teachers, and workers. Educators should support residents' reflections about these interactions, model compassionate behavior when feeling challenged by patients, and address unhealthy coping strategies. [ABSTRACT FROM AUTHOR]

To study the feasibility of a structured conversation tool (ICIT) in Norwegian general practice. A structured conversation tool with elements from Cognitive Behavioral Therapy (CBT) was developed for use at the encounter in general practice to increase patient's self-coping ability and the GPs management and sick leave assessment in patients with MUPS. Eight GPs received training and used the ICIT on 49 patients with MUPS. The physicians were gathered into two focus groups. The interviews were recorded on tape, transcribed, and analyzed with systematic text condensation. The aim of our study was to examine any benefit and the feasibility of the ICIT in general practice. The physicians found the ICIT helpful to sort out, clarify and concretize the patients' issues. They felt less fatigued as patients took on a greater responsibility for their own recovery and reported a greater satisfaction and better management with the patients. A salutogenic approach gave the physicians greater insight into their patients' lives and their issues, opening for new treatment options and aiding in recovery. By focusing on the patient's potential capabilities despite their medical condition, some physicians experienced that patients on sick leave returned to work quicker. The GPs in this study reported that the ICIT was helpful in consultations with patients due to unspecific medical conditions and facilitated a sense of competence for the physician. GPs need communication skill training for integrated treatment and sick leave assessment for patients with Medically Unexplained Physical Symptoms (MUPS). •The GPs experienced that the structured conversation tool was beneficial in structuring, clarifying, and substantiating the patient's problems. •The GPs experienced a greater insight into their patients and their issues, opening new treatment options and aiding in recovery. •The GPs experienced patients' quicker recovery and returns to work by starting immediate treatment using the conversation tool. [ABSTRACT FROM AUTHOR]

The aim of the study was to identify general practitioners' (GPs) strategies to avoid unnecessary diagnostic imaging when encountering patients with such expectations and to explore how patients experience these strategies. We conducted a qualitative study that combined observations of consultations and interviews with GPs and patients. A total of 24 patients visiting nine different GPs in two Norwegian urban areas were included in the study. Of these, 12 consultations were considered suitable for studying GP strategies and were therefore selected for a more thorough analysis. GPs' communication strategies to avoid unnecessary medical imaging and patients' experiences with such strategies. Five categories of strategies were identified: (1) wait and see – or suggest an alternative; (2) the art of rejection; (3) seek support from a professional authority; (4) partnership and shared decision-making and (5) reassurance, normalisation and recognition. The GPs often used multiple strategies. Factors related to a long-term doctor–patient relationship seemed to influence both communication and how both parties experienced the decision. Three important factors were evident: the patient trusted the doctor, the doctor knew the patient's medical history and the doctor knew the patient as a person. The patients seemed to be generally satisfied with the outcomes of the consultations. GPs largely combine different strategies when meeting patients' expectations of diagnostic imaging that are not strictly medically indicated. Continuity of the doctor–patient relationship with good personal knowledge and trust between doctor and patient appeared crucial for patients to accept the doctors' decisions. GPs usually combine a broad range of strategies to avoid unnecessary medical imaging The patients appeared generally satisfied regardless of the strategy the strategy used by the GPs and even where their referral request were rejected Factors related to a long-term doctor–patient relationship appeared decisive [ABSTRACT FROM AUTHOR]

This study aimed to explore and compare the perceptions of patients and primary healthcare professionals regarding the management of chronic low back pain. Qualitative study using 26 semi-structured individual interviews, and one discussion group, carried out in primary care in Lleida, Spain. Patients and primary healthcare professionals both had assumptions pertaining to: (1) the diagnosis and meaning of chronic low back pain, (2) expectations regarding treatment for pain reduction, and (3) communication between primary healthcare professionals and patients with chronic low back pain. Results suggest a mutual dissatisfaction with the diagnosis of chronic low back pain and a lack of understanding between primary healthcare professionals and patients. Some contradictions between them were also noted: the patients wanted quick solutions to reduce their pain, but the primary healthcare professionals required an accurate etiology to prescribe treatment, and the patients did not always follow the primary healthcare professionals' recommendations. Diagnosing and treating chronic low back pain is compromised due to differing expectations and the communication barriers that exist between healthcare professionals and their patients. Primary healthcare professionals should be aware of the power of their explanations and recommendations to patients. Primary healthcare professionals should negotiate treatments with patients and adapt them to their individual needs, according to a Patient-Centered approach and the biopsychosocial model of pain. Primary healthcare professionals should explain to patients the underlying mechanisms and multifactorial nature of chronic low back pain. Primary healthcare professional-patient communication needs to be improved to help patients to better understand their chronic condition. The healthcare professionals in Spain should be more trained into the (bio)psychosocial model of long-term pain, stop searching for non-evident pathologies and change their biomedical beliefs. [ABSTRACT FROM AUTHOR]

Resident physicians experience high degrees of burnout. Medical educators are tasked with implementing burnout interventions, however they possess an incomplete understanding of residents' lived experiences with this phenomenon. Attempts to understand burnout using quantitative methods may insufficiently capture the complexities of resident burnout and limit our ability to implement meaningful specialty-specific interventions. Qualitative studies examining how residents conceptualize burnout have been briefly examined in other specialties, however the specific stressors that characterize emergency medicine training may lead residents to experience burnout differently. This study used qualitative methodology to explore emergency medicine trainees' perceptions of the complex phenomenon of burnout during their residency training years. Approach: In order to evaluate a novel wellness intervention at their emergency medicine residency program, the authors conducted four semi-structured focus groups with residents and recent alumni from May 2018 to August 2018. After the focus groups concluded, the authors noted that they lacked an insightful understanding of their residents' own experiences with physician burnout. Thus, they performed a secondary analysis of data initially gathered for the curricular evaluation. They followed a reflexive thematic analysis approach, analyzing all focus group transcripts in an iterative manner, discussing and refining codes, and developing thematic categories. Findings: Residents described individual-level manifestations of burnout in their day-to-day lives, a calloused view of patient suffering in the clinical environment, and a fatalistic view toward burnout during their training. They experienced a pervasive negativity, emotional fragility, and neglect of self that bled into their social environments. Clinically, burnout contributed to the erosion of the therapeutic physician-patient relationship. Residents perceived burnout as an inevitable and necessary element of their residency training years. Insights: Residents' lived experiences with burnout include nonclinical manifestations that challenge existing frameworks suggesting that burnout is restricted to the work domain. Burnout interventions in emergency medicine training programs may be more effective if educators inculcate habitual practices of self-monitoring in trainees and explicitly set resident expectations of patient acuity in the clinical environment. Supplemental data for this article is available online at . [ABSTRACT FROM AUTHOR]

Despite the importance of cost-of-care conversations between physicians and patients, such discussions are not well understood. We used multiple goals theory to examine the specific goals that are salient in these discussions and how physicians pursue these goals. We used qualitative descriptive coding to analyze the verbatim transcripts from in-depth interviews with 36 primary care physicians. Our analysis identified a number of goals that are commonly salient in cost conversations, including task goals (reducing the cost of care, making treatment decisions, and promoting patient adherence), identity goals (reinforcing their professional identity as a "good doctor," acting as a steward of medical resources, being an advocate for patients, and preventing patient embarrassment), and relational goals (strengthening the physician–patient relationship and mitigating damage to the physician–patient relationship). In addition, participants articulated a number of ways in which these goals compete with each other, making cost conversations challenging. We found that physicians use a common repertoire of rhetorical strategies to manage these goals, including directly addressing cost, avoiding discussion of cost, and falsely reassuring patients about cost concerns. Our analysis revealed that the meaning of the cost conversation explains the connection between physicians' goals and strategies. Specifically, we found that physicians invoke polysemic meanings of cost conversations to achieve their multiple goals using seemingly contradictory strategies. The results of our analysis have implications for building theory and improving practice. [ABSTRACT FROM AUTHOR]

To understand the perceptions and attitudes of general practitioners (GPs) regarding children with an Autism Spectrum Disorder (ASD). Phenomenological qualitative study. Three focus groups, clinical settings. French GPs. 22 GPs took part in the study divided among three focus groups. They were volunteers to participate. Data were transcribed verbatim and analysed using a grounded theory data analysis, completed with a semiopragmatic analysis. Representing autism as a strange disorder in the doctor–patient relationship, GPs perceive a loss of sensory contact with the child with ASD that prevents the usual professional relationship between doctor and patient. They disengage themselves from monitoring the subject, concentrating on supporting the family. According to them, their role was to refer the patient to a specialist in the case of clinical intuition, but they have several reasons to give themselves time, all the more so because once the diagnosis is made, they lose sight of the patient and their place in the care pathway. GPs expressed the need to acquire skills and strategies to communicate with the autistic child to recover their role and values. GPs are disconcerted by the idea of communicating with children with ASD, as it takes them out of their usual professional benchmarks. They need communication tools that enable them to regain their role and relational value of the patient-centred approach. Beyond this, the question of the 'ethics of care' of the patient with a joint attention disorder is raised. GPs are disconcerted with the idea of communicating with children with ASD. GPs need communication tools that enable them to regain their role and relational value of the patient-centred approach. The question of the 'ethics of care' of the patient with a joint attention disorder is raised. [ABSTRACT FROM AUTHOR]

To explore how pictorial information on subclinical atherosclerosis affects GPs' perception of patient cardiovascular disease (CVD) risk, their communication with patients, and GPs' attitude to the treatment of CVD risk factors. Fifteen individual interviews were conducted between March 2014 and December 2016, with GPs who had received pictorial information regarding their patients' subclinical atherosclerosis. The pictorial information was also received by the patients together with written information regarding atherosclerosis and CVD risk prior to the appointment with their GP. The interviews were recorded, transcribed and analyzed using qualitative content analysis. Three categories were identified in the analysis. Increased knowledge makes a difference: When patients had more in-depth knowledge regarding atherosclerosis, the consultation became more patient-centered and moved towards shared decision making. This is real, not just a number: GPs described their risk assessment and the patient's risk perception as more accurate with pictorial information about subclinical atherosclerosis. How to deal with the result – A passive to active approach: Some GPs acted promptly on the pictorial information while others took no action. Pictorial information regarding patients' subclinical atherosclerosis affected GPs' assessment of CVD risk. The communication shifted towards shared decision-making although the GPs' attitude to the result and treatment of CVD risk factors varied. Informing patients about examination results, both in writing and pictures, prior to a consultation can facilitate shared decision making and enhance preventive measures. . Providing pictorial information about carotid ultrasound results and information regarding atherosclerosis to GPs and patients affects primary prevention: •Informing patients about examination results prior to a consultation can be useful in clinical practice to enhance preventive measures •GPs experienced that increased patient knowledge resulted in a more patient-centered consultation and improved shared decision-making •GPs described their risk assessment and patients' risk perception as more accurate with pictorial information about subclinical atherosclerosis [ABSTRACT FROM AUTHOR]

To explore GPs' perspectives on and daily experiences with the relational potential of email consultations. Qualitative study with data from participant observation and semi-structured interviews General practice setting in Denmark Practice personnel from four clinics were observed and 16 GPs (seven women and nine men, between 35 and 70 years of age) interviewed. Field notes and interview data were analysed using an inductive thematic analysis approach. Main themes and subthemes reporting GPs' perspectives on and experiences with the relational potential of email consultations. The analyses showed that due to perceived interpretational shortcomings, the GPs generally experienced email consultation as unsuitable for communication about relational, socio-emotional and sensitive matters. In doctor–patient relationships founded on mutual knowledge and trust, the email consultation was however used as a supportive communication channel, as a way for the patient to express emotions and affect and for the GP to proactively show interest and compassion towards the patient. Email consultations were highly context-variant. Within continuing relationships and in conjunction with face-to-face consultations, email consultation was used for supportive communication holding the potential for maintaining, strengthening and/or dissolving the GP-patient relationship. Therefore, email consultation is not simply an information-delivery tool but also holds more explicit relational potentials. Overall, the GPs perceived email consultation as unsuitable for non-medical, relationship-oriented purposes. Nonetheless, the GPs experienced that email consultations oftentimes comprised communication about relational and socio-emotional issues. Knowledge of the patient was a vital factor for the GP's comfort in and acceptability of relational functions of email consultation. Email consultation is not simply an information-delivery tool as it holds the potential for maintaining, strengthening and/or dissolving the GP-patient relationship. [ABSTRACT FROM AUTHOR]

Background: Good physician-patient communication is an important aspect of patient-centered care and contributes to positive health outcomes, however, there is a lack of standard European Union (EU) communication training policies for physicians. This study explores the barriers to good communication for both physicians and patients across four EU countries as part of the EU-funded project, Health Communication Training for Health Professionals – H-COM. Method: Focus groups were conducted with 31 patients and 38 physicians from Germany, Greece, Spain, and Cyprus. Two separate discussion guides were constructed for each target group around three themes: perceptions of, barriers to, and needs for health communication. Thematic analysis was used. Results: Commonalities and differences between countries and target groups were identified, with participants discussing attitudinal, emotional, educational, and systemic barriers to good communication. Participants indicated a significant gap in health communication knowledge, skills, and training for physicians, with regional differences. Conclusion: The results imply that there is a need for EU-wide communication training for physicians that would be best addressed by common themes and tailoring to specific regional differences. The results also imply that effective training should encompass a blend of theory and practical methods, and should be delivered via an e-learning platform for maximum accessibility. Training programs that adhere to these suggestions can begin to address the gaps in patient-centered care in the EU. [ABSTRACT FROM AUTHOR]

Quality of Life (QoL) may be a factor in physicians' decisions on treatment of persons with Profound Intellectual and Multiple Disabilities (PIMD). We explored the perception of physicians on the QoL of persons with PIMD. We conducted semi-structured interviews with seven experienced physicians treating persons with PIMD, thematically analysed them and identified clusters of related elements of QoL. Emotional, physical and relational clusters of elements were found. Physicians named mainly emotional elements to describe good QoL, physical elements to describe poor QoL and they emphasised the role of relational context on QoL. In addition, they mentioned a balance between good and poor elements as good QoL. Physical decline, bad prognosis and increasing problems in the relational context influenced QoL in a negative way. The influence of the relational context on both good and poor QoL needs more investigation because of its consequences for ethical decision-making. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this review was to identify, appraise and synthesise qualitative research that explores the experience of the disclosure of a dementia diagnosis from the perspectives of clinicians, patients and carers. Method: A systematic search of four databases, grey literature and reference lists identified 13 studies, which met the required criteria to be included in the review. All were appraised using a quality appraisal tool. Data were extracted and synthesised using a meta-ethnographic approach. Results: Five key themes were developed from an interpretation of the results: the clinician's approach; how to tell people the diagnosis is dementia; the importance of the clinician offering hope; level of understanding; and who should attend the disclosure meeting. The process can be improved through a compassionate clinician offering hope, answers to patient and carer questions, and written and/or visual information to support understanding of the diagnosis. These features could be included in guidance to clinicians. There was a large amount of variance in the quality of the studies. Future qualitative research could focus on clinician compassion, giving hope, the management of dynamics within sessions, supporting information and follow-up sessions. Conclusion: Clinical practice can be informed by a body of literature but there is much work to be done to develop evidence-based detailed guidance for improving the dementia diagnosis experience for all parties, and supporting clinicians to manage inherent tensions in this process. Further research is required on this topic to addresses the shortcomings highlighted in this review. [ABSTRACT FROM AUTHOR]

Objective: This qualitative study sought to identify and describe patients' variant perceptions of disease severity after receiving a type 2 diabetes (T2DM) or prediabetes (preDM) diagnosis. Design: Researchers interviewed 29 patients from two US medical centers to ascertain perceptions of severity. We used the constant comparative method from a grounded theory approach to identify themes from patients' perspectives that inform their disease severity. This approach was used to help translate research to practice and ultimately identify intervention strategies informed by authentic experiences of preDM and T2DM patients. Results: Perceptions of disease severity fell into two groups: high and low severity. Patients diagnosed with T2DM and preDM emerged in both groups and were comparative in terms of sample size, gender, and ethnic diversity. Several factors contributed to patients' beliefs, including what they were told about the disease, observations from experiences within their own social network, and information from formal diabetes classes and their own research. The two perspectives diverged when patients described how their belief was informed by three thematic properties or personal factors: (i) fears; (ii) clinician communication; and (iii) social comparisons. Conclusions: Beliefs about severity are influenced by patients' fears, interactions with clinicians, and experiences within their social networks. These findings show that when interacting with patients with T2DM or preDM, clinicians should elicit patient perceptions of disease severity so they may then tailor the discussion to address these perceptions and help patients grasp the severity of these conditions. [ABSTRACT FROM AUTHOR]

Phenomenon: Patients have access to a wide variety of sources of information about their health in their day-to-day contexts. This can sometimes result in discordance between a physician's perception of a patient's health issue and a patient's perception of their health issue. Even after the physician has negotiated an understanding and treatment plan with a patient, subsequent interactions outside the physician-patient encounter may modify the patient's understanding of their health issue. A patient's reinterpretation of his or her health issue can then result in nonadherence of the treatment plan or even alternative treatment plans that the physician perceives as being unsatisfactory. Current models of physician-patient communication do not prepare physicians to manage this phenomenon. Approach: Using an ethnographic and a social network analysis research design, participants' patterns of social interaction around health information were investigated over a yearlong period (2012-2013) in a small rural community in Western Canada. Data included (a) individual interviews, (b) focus group interviews, and (c) field notes. Data were analyzed in a three-stage process: (a) item analysis, (b) pattern analysis, and (c) structural analysis. Findings: The findings highlight how physicians are only one nodal point in patients' broad, multilayered networks of communication. Interactions around health topics were not isolated events but rather occurred in various patterns of social interactions that were longitudinal and iterative. Meaning making around health topics was constructed, shared, elaborated, reconstructed, and interpreted in participants' social networks, as information was distributed through a complex temporal system of interpersonal ties. Insights: Issues concerning physician communication have been a long-standing conversation in the field of medical education. Many competency frameworks have attempted to encompass this core competency in their elaboration of the physician communicator. However, most representations and discussions in the field tend to depict physician communicators as experts who translate their knowledge to patients in a simplified way, in a single moment in time. This study suggests that educational initiatives in physician-patient communication would benefit from contextualizing physicians as part of patients' resource-rich, temporally extended, iterative process of meaning making. This alternative framing has the potential to support physicians' continuing engagement with patients as a meaningful and responsive node in patients' meaning-making networks. [ABSTRACT FROM AUTHOR]

The ANRS-IPERGAY trial consisted in providing sexual activity-based antiretroviral prophylaxis for HIV prevention (PrEP) with a package of prevention tools (counselling, condoms, HIV and sexually transmitted infections’ screening) to highly exposed HIV-negative men who have sex with men (MSM). Few data exist concerning the patient-physician relationship in the particular context of PrEP, where physicians discuss sexual behaviours with MSM who are not classic patients, in that consultation is for prevention purposes, not for illness. This study took place during the open-label extension of ANRS-IPERGAY trial when all participants received PrEP. In this qualitative study, we examined how physicians perceived their relationship with participants in the ANRS-IPERGAY trial. Of all 30 physicians involved in the trial who were contacted by email to participate in an interview about their opinions and perceptions of ANRS-IPERGAY 18 volunteered to participate in the current sub-study. We performed a vertical analysis for each interview to identify the extract in each physician’s discourse concerning their relationship with MSM participants, and conducted a horizontal analysis to construct the thematic tree and subsequently investigate differences and similitudes between themes. An analysis of all physicians’ discourses showed that the participant-physician relationship during the trial could be described through 4 themes: (i) personal experience of the relationship, (ii) trust and non-judgement, (iii) positive relational climate and (iv) influence of physician’s characteristics (age, gender, etc.) on relationship. We found that the particular context of PrEP led some physicians to adopt a patient-as-partner approach during consultations rather than a paternalist or hierarchical approach. Indeed, the close follow-up provided by the trial and the active role of patients in their own prevention care trajectory, are more compatible with the patient-as-partner approach. The prescription of PrEP may lead to an evolution in patient-physician relationships and may even modify the professional identity of physicians. [ABSTRACT FROM AUTHOR]

The purpose of this study was to explore the experience of decision making in the care of children with palliative care needs in Jordan, from the perspective of their mothers. This study employed a collective qualitative case study approach. Data were collected in 3 pediatric wards in a Jordanian hospital. The study used 2 data collection methods: participant observation (197 observational hours) and 56 semi-structured interviews with 24 mothers, 12 physicians and 20 nurses. The findings show how Jordanian mothers seek to transfer the role of decision making to physicians, as they perceive themselves to be unable to make decisions about critical issues related to the treatment of their children. Mothers had a widespread apprehension of “future guilt,” especially when they feared that any decisions they might make could have an adverse impact on their children. Contrary to the predominant pattern, some mothers took a proactive approach towards decision making about their children’s treatment. These mothers requested detailed information from primary physicians and sought different sources of knowledge such as second opinions, reading online resources, or talking to other parents who had a child with similar circumstances. The study concludes that mothers prefer to involve physicians in decisions about their children’s healthcare and treatment to eliminate their fear of probable future guilt; this modifies any tendency to autonomously decide for their children. These findings are underpinned by the Jordanian culture in which doctors’ opinions are highly regarded. [ABSTRACT FROM PUBLISHER]

There is limited information about doctors’ communication behaviors and their salient beliefs with regard to bad news disclosure in Greece. In this qualitative study we investigated the self-reported practices of doctors on breaking bad news, their perceptions about the factors affecting the delivery of such news, and their beliefs about the most appropriate disclosure manner. A focus group discussion and individual interviews were conducted. Twenty-five resident and specialist doctors from primary health care and hospital settings participated. We analyzed the collected data with content analysis techniques. Participants were found to acknowledge the importance of appropriate and effective delivery of bad news; however, none of them reported the implementation of empirically informed communication practices. They described communication patterns mainly formed by their work experience and often guided by the patient’s family requests. Doctor, patient, and family characteristics and organizational features and resources were reported to affect the delivery of bad news. Participants perceived the most appropriate disclosure manner as an individualized approach to each patient’s unique needs. They suggested an interdisciplinary, collaborative management of the delivery process and the establishment of formal supportive services. These findings may provide useful information for the development of tailored, empirically informed curriculum interventions and educational programs in order to address several barriers to communication. Sociocultural characteristics that influence the disclosure practice, as well as physicians’ perceptions that are consistent with the optimal information delivery, should be taken into account. System-level strategies that focus on the development of patient-centered communication also need to be prioritized. [ABSTRACT FROM PUBLISHER]

Objective:The objective of this study is to identify points of agreement and disagreements among general practitioners (GPs) in Denmark concerning how the existential dimension is understood, and when and how it is integrated in the GP–patient encounter. Design:A qualitative methodology with semi-structured focus group interviews was employed. Setting:General practice setting in Denmark. Subjects:Thirty-one GPs from two Danish regions between 38 and 68 years of age participated in seven focus group interviews. Results:Although understood to involve broad life conditions such as present and future being and identity, connectedness to a society and to other people, the existential dimension was primarily reported integrated in connection with life-threatening diseases and death. Furthermore, integration of the existential dimension was characterized as unsystematic and intuitive. Communication about religious or spiritual questions was mostly avoided by GPs due to shyness and perceived lack of expertise. GPs also reported infrequent referrals of patients to chaplains. Conclusion:GPs integrate issues related to the existential dimension in implicit and non-standardized ways and are hindered by cultural barriers. As a way to enhance a practice culture in which GPs pay more explicit attention to the patients’ multidimensional concerns, opportunities for professional development could be offered (courses or seminars) that focus on mutual sharing of existential reflections, ideas and communication competencies. Key pointsAlthough integration of the existential dimension is recommended for patient care in general practice, little is known about GPs’ understanding and integration of this dimension in the GP–patient encounter.The existential dimension is understood to involve broad and universal life conditions having no explicit reference to spiritual or religious aspects.The integration of the existential dimension is delimited to patient cases where life-threatening diseases, life crises and unexplainable patient symptoms occur. Integration of the existential dimension happens in unsystematic and intuitive ways.Cultural barriers such as shyness and lack of existential self-awareness seem to hinder GPs in communicating about issues related to the existential dimension. Educational initiatives might be needed in order to lessen barriers and enhance a more natural integration of communication about existential issues. [ABSTRACT FROM PUBLISHER]

Aims: To investigate the perspectives and experiences of service providers regarding provision of take-home naloxone to people who use opioids in Victoria, Australia. Methods: Content analysis of qualitative semi-structured interviews with 15 service providers who are either involved with take-home naloxone programs or whose work brings them in contact with people who use opioids. Findings: Statements about take-home naloxone were universally positive. Both direct and indirect benefits of take-home naloxone were described. Alongside potential reductions in opioid overdose-related harms, service providers highlighted the empowering effects of providing people who use opioids with take-home naloxone. No significant risks were described. Service providers supported the expansion of naloxone availability, but also identified several intertwined barriers to doing so. Key among these were costs, current regulations and scheduling, availability of prescribers and stigma related to illicit and injecting drug use. Conclusions: Expanding the availability of naloxone is a key component of strategies to reduce harms associated with opioid overdose. Our article provides Australian evidence of the successful operational implementation of peer-to-peer THN delivery within a range of drug primary health services and needle syringe programs. Further research is required to better understand the implications of and impediments to scale-up of this potentially life-saving public health intervention. [ABSTRACT FROM AUTHOR]

Based on data obtained from in-depth, qualitative interviews conducted with 30 older Canadian women, this article examines older women’s experiences with, and views of, physicians. The research participants report a very high level of satisfaction with the patient–physician relationship; however, they also report physician shortcomings. Findings indicate that participants’ satisfaction with the patient–physician relationship was influenced by “stories about other doctors,” rationalizations and justifications, and a high level of patient assertiveness. [ABSTRACT FROM PUBLISHER]

Background Stroke is the leading cause of death in Indonesia and correspondingly the prevalence of stroke risk factors is high. Improved risk factor screening along with education and counseling for patients on the behavior changes that they need to make to reduce their stroke risk have the potential to lessen stroke burden. Methods Focus groups were conducted with physicians working in community health centers (puskesmas) in Indonesia to explore physicians' practices with regard to stroke risk screening and patient education to reduce stroke risk. Results Physicians perceive that patients commonly have misconceptions about their stroke risk factors, indicating a need for patient education. Screening and education practices vary considerably among Indonesian primary care physicians, suggesting a need for physicians to improve their patient education and counseling practices. Physicians reported lack of time during appointments, as well as their perceptions of patients' reluctance to modify their behaviors and patients' low level of education as barriers to patient education for stroke prevention. Conclusion Physicians reported knowledge, attitudinal, and health care system barriers that need to be addressed as part of interventions aimed at improving stroke screening and patient education and counseling in this setting. [ABSTRACT FROM AUTHOR]

Objective. To explore the views and experiences of general practitioners (GPs) in relation to recognition, recording, and treatment of mental health problems of undocumented migrants (UMs), and to gain insight in the reasons for underregistration of mental health problems in the electronic medical records. Design. Qualitative study design with semi-structured interviews using a topic guide. Subjects and setting. Sixteen GPs in the Netherlands with clinical expertise in the care of UMs. Results. GPs recognized many mental health problems in UMs. Barriers that prevented them from recording these problems and from delivering appropriate care were their low consultation rates, physical presentation of mental health problems, high number of other problems, the UM's lack of trust towards health care professionals, and cultural differences in health beliefs and language barriers. Referrals to mental health care organizations were often seen as problematic by GPs. To overcome these barriers, GPs provided personalized care as far as possible, referred to other primary care professionals such as social workers or mental health care nurses in their practice, and were a little less restrictive in prescribing psychotropics than guidelines recommended. Conclusions. GPs experienced a variety of barriers in engaging with UMs when identifying or suspecting mental health problems. This explains why there is a gap between the high recognition of mental health problems and the low recording of these problems in general practice files. It is recommended that GPs address mental health problems more actively, strive for continuity of care in order to gain trust of the UMs, and look for opportunities to provide mental care that is accessible and acceptable for UMs. [ABSTRACT FROM AUTHOR]

Although scientific evidence concerning harms and benefits of direct-to-consumer advertising (DTCA) is constantly growing, there is a paucity of published research focusing on gaining a better understanding of the perceptions and experiences of involved parties. This gap in the literature becomes even more salient when it comes to the indirect target audiences of DTCA, such as healthcare providers. This study explores American physician perceptions of prescription drug advertising, while elucidating the perceived impact of DTCA in a US context. Our results suggest that 15 years after the introduction of DTCA, physician concerns about its impact on the doctor-patient relationship persist. Negative effects of DTCA include patient acquiring a false sense of autonomy; requests for unnecessary or more expensive drugs; exaggerated perception of advertised drugs' side effects; as well as additional workload and time commitment. Nevertheless, DTCA is also viewed as a stimulus for 'opening communication opportunities' with the patient. Results of this study can be used to inform the dialogue not only in the United States, but also in other countries where efforts are being made to reduce restrictions on DTCA. [ABSTRACT FROM AUTHOR]

General practitioners are often exhorted to routinely counsel patients who smoke about quitting in light of current evidence-based medicine (EBM) guidelines suggesting that such brief interventions provide an easy and effective way of increasing quit rates. Drawing on semi-structured interviews conducted with 25 smokers and 10 general practitioners (GPs) in British Columbia, Canada, this article explores smokers’ and GPs’ perspectives on smoking cessation interventions in primary care settings. Study findings indicate that both patients and GPs believe smoking is best broached when it is patient-initiated or raised in the context of smoking-related health issues, and there was a broader consensus that the role of doctors is to provide education and information rather than coercing smokers to quit. However, smokers wanted further recognition of the difficulties of quitting smoking and many questioned the competence of GPs to deal with addiction-related issues. Similar barriers to smoking cessation were raised by smokers and GPs – primarily inadequate time and resources. Based on these findings, we argue that the assumption that primary care consultations provide an important venue for encouraging smokers to quit deserves reconsideration based on the complexity of this issue, the circumstances in which most GPs practice, and the danger of alienating smokers. Questions are raised about whether current EBM guidelines are an adequate tool for guiding individual clinical interactions between GPs and smokers. [ABSTRACT FROM PUBLISHER]

One of the oldest goals of the medical profession is to benefit, and do no harm to, the patient. The role of the physician was once a paternal one, with total physician control, and little value given to patient knowledge of their own illness experiences. With changing patient expectations and medical education reform, patient-centeredness has emerged as a dominant ideal in doctor-patient communication. Patient autonomy is increasingly valued. In this changing time of increased patient involvement in medical decision making, how do physicians describe their professional roles/identities? Self-described professional identity is often quite reflective of professional beliefs and practice. The present study offers a qualitative perspective on self-perceived physician professional roles from primary care physicians of three age groups, in their 50s, 40s, and 30s. Younger physicians in the sample expect patients to have the most autonomy and most control over their decision making, while older physicians still expect to have the most control. It is possible that these age-based patterns of physician professional identity reflect an increasingly autonomous patient role and a decreasing role for physician beneficence. Implications and practical applications of these results for the medical interview will be discussed. [ABSTRACT FROM AUTHOR]

Background: Research on registered psychologists' knowledge of and attitudes toward Animal-Assisted Therapy (AAT) is virtually nonexistent. Aim: To explore Australian psychologists' knowledge of and attitudes toward AAT. Materials and Methods: This paper presents a thematic analysis of qualitative data collected from 9 psychologists speaking about AAT during individual interviews. Results: The first research question explored psychologists' knowledge of AAT and identified 3 key themes: AAT use across the client lifespan in various health settings; training is inadequate; and efficacy studies are lacking. The second question exploring psychologists' attitudes towards AAT identified further themes: AAT enhances therapeutic relationships; AAT used purposefully or incidentally is effective; and there are barriers to AAT implementation. Conclusion: Whilst AAT is deemed to be a useful intervention by some psychologists, its evidence base and training in such interventions are lacking. [ABSTRACT FROM AUTHOR]

It is well known that clients occasionally threaten or assault their therapists. No studies to date have attempted to systematically measure client aggression by transgender patients towards clinicians. One of the major questions of this study was to determine if clients with gender dysphoria have greater levels of aggression towards therapists than non-gender dysphoric clients. One hundred and fourteen professional therapists who are members of the Harry Benjamin International Gender Dysphoria Association responded to a questionnaire that addressed aggression by both transgender and non-transgender clients. Transgender clients were shown to commit significantly less acts of aggression than did non-transgendered clients (p = 0.0094). Within the relatively small subgroup of transgender clients that did commit acts of aggression, male-to-female transgender clients were significantly more likely to do so than female-to-male clients (p = 0.002). While the transgendered client undergoes significant suffering in violating inviolable gender boundaries, this suffering, in general, does not translate into acting out behaviors directed towards their therapists. [ABSTRACT FROM AUTHOR]

Background: Performance-based financing (PBF) was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010. PBF is a reform approach to improve the quality, quantity, and equity of health services and aims at achieving universal health coverage. It focuses on how to best motivate health practitioners. Objective: To elicit physicians’ and nurses’ experiences and views on how PBF influenced and helped them in healthcare delivery. Methods: A qualitative cross-sectional study was carried out among frontline health workers such as physicians and nurses. The data was gathered through individual face-to-face, in-depth, semi-structured interviews with 6 physicians and 30 nurses from February to March 2011 in three hospitals in Gitega Province. A simple framework approach and thematic analysis using a combination of manual technique and MAXQDA software guided the analysis of the interview data. Results: Overall, the interviewees felt that the PBF scheme had provided positive motivation to improve the quality of care, mainly in the structures and process of care. The utilization of health services and the relationship between health practitioners and patients also improved. The salary top-ups were recognized as the most significant impetus to increase effort in improving the quality of care. The small and sometimes delayed financial incentives paid to physicians and nurses were criticized. The findings of this study also indicate that the positive interaction between performance-based incentive schemes and other health policies is crucial in achieving comprehensive improvement in healthcare delivery. Conclusions: PBF has the potential to motivate medical staff to improve healthcare provision. The views of medical staff and the context of the area of implementation have to be taken into consideration when designing and implementing PBF schemes. [ABSTRACT FROM PUBLISHER]