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Objective To explore socioeconomic status (SES) differences in patterns of doctor-patient communication within head and neck cancer clinics and why such differences exist. Methods Thirty-six head and neck cancer review appointments with five Physicians were observed and audio-taped, along with follow-up interviews involving 32 patients. Data were analysed using Thematic Analysis, and compared by patient SES (education, occupation and Indices of Multiple Deprivation). Results Three main themes were identified: (a) Physicians used more humour and small talk in their consultations with high SES patients; (b) Low SES patients were more passive in their participation, engaged in less agenda setting and information-seeking, and framed their clinical experience differently; (c) Low SES patients had different preferences for involvement, defining involvement differently to high SES patients and were seen to take a more stoical approach. Conclusion Low SES patients take a more passive role in medical consultations, engage in less relational talk and are less likely to raise concerns, but were satisfied with this. Physicians may adapt their communication behaviour in response to low SES patients' expectations and preferences. Practice implications A question prompt list may help low SES patients to raise concerns during their consultations. This may reduce inequalities in communication and health.

Background:\ud Mental health care has lagged behind other health-care domains in developing and applying shared decision making (SDM) for treatment decisions. This is despite compatibilities with ideals of modern mental health care such as self-management and recovery-oriented practice, and growing policy-level interest. Psychiatric medication is a mainstay of mental health treatment, but there are known problems with prescribing practices, and service users report feeling uninvolved in medication decisions and concerned about adverse effects. SDM has potential to produce better tailoring of psychiatric medication to individuals' needs.\ud Objectives:\ud This conceptual review argues that several aspects of mental health care that differ from other health-care contexts (e.g. forms of coercion, questions about service users' insight and disempowerment) may impact on processes and possibilities for SDM. It is therefore problematic to uncritically import models of SDM developed in other health-care contexts. We argue that decision making for psychiatric medication is better understood in a broader way that moves beyond the micro-social focus of a medical consultation. Contextualizing specific medication-related consultations within longer term relationships, and broader service systems enables recognition of the multiple processes, actors and agendas that shape how psychiatric medication is prescribed, managed and used, and which may facilitate or impede SDM.\ud Conclusion:\ud A broad conceptualization of decision making for psychiatric medication that moves beyond the micro-social can account for why SDM in this domain remains a rarity. It has both conceptual and practical utility for evaluating research evidence, identifying future research priorities and highlighting fruitful ways of developing and implementing SDM in mental health care.

Scand J Caring Sci; 2013; 27; 70–76 Doctor–patient communication and cancer patients’ choice of alternative therapies as supplement or alternative to conventional care Cancer patients’ use of complementary and alternative medicine (CAM) is widespread, despite the fact that clinical studies validating the efficacy of CAM remain sparse in the Nordic countries. The purpose of this study was to explore possible connections between cancer patients’ communication experiences with doctors and the decision to use CAM as either supplement or alternative to conventional treatment (CT). The Regional Committee for Medical and Health Research Ethics and the Norwegian Data Inspectorate approved the study. From a group of 52 cancer patients with self-reported positive experiences from use of CAM, 13 were selected for qualitative interviews. Six used CAM as supplement, and seven as alternative to CT, periodically or permanently. Communication experiences with 46 doctors were described. The analysis revealed three connections between doctor–patient communication and patients’ treatment decisions: (i) negative communication experiences because of the use of CAM; (ii) negative communication experiences resulted in the decision to use CAM, and in some cases to decline CT; and (iii) positive communication experiences led to the decision to use CAM as supplement, not alternative to CT. The patients, including the decliners of CT, wanted to discuss treatment decisions in well-functioning interpersonal processes with supportive doctors. In doctors’ practices and education of doctors, a greater awareness of potential positive and negative outcomes of doctor–patient communication that concern CAM issues could be of importance. More research is needed to safeguard CAM users’ treatment decisions and their relationship to conventional health care.

Objective To study how physicians feel about patients’ efforts to be engaged in shared decision making (SDM). Study setting and design Survey of physicians from distinctly different medical disciplines (238 psychiatrists and 169 vascular surgeons). Participants were requested to judge which patient behaviours they find helpful and which behaviours detrimental for SDM. Results Psychiatrists and surgeons had rather positive attitudes about active patient behaviours. However, there were quite a few patient behaviours (e.g. searching the Internet, being assertive towards the doctor) which provoked ambivalent or negative attitudes. Discussion and conclusions Physicians are generally quite open towards active patient behaviour in the consultation. They, however, do consider it as less helpful and become more annoyed if patients insist on their preferences and doubt their doctors’ recommendations. Physicians must realize that SDM implies giving up decisional power and try to be more flexible in their interactions with patients.

Objective: To explore cancer patients' and caregivers' decisions regarding whether to discuss cancer-related information they found on the Internet with their doctors. Methods: 238 participants (cancer patients and caregivers) from three online cancer communities responded to a survey about their experiences finding information on the Internet about their cancer and their reasons for discussing or not discussing that information with their doctors. The reasons were coded into mutually exclusive categories. Results: Participants most frequently reported discussing information in order to be proactive in improving their health. Other reasons included appealing to the doctor as expert, wanting to become more educated, meeting a psychological or coping need, and checking up on or testing the doctor. Of the participants, caregivers were more likely than patients to cite checking up on or testing the doctor as a reason for discussing Internet information. Sixty-two percent of participants reported sometimes or never talking about Internet information that they thought was important with their doctors. Across all participants, the most frequently reported reasons for not talking about Internet information were attributions about the information and systems-related reasons. Participants who reported information attribution as a reason for not discussing it with their doctors had higher overall comfort levels with these types of discussions. Conclusions: Many factors influence cancer patients' and caregivers' decisions about discussing Internet information with their doctors. The coherence of the reasons across the communities in this study and in other studies suggests that this typology of reasons is both thorough and valid. Copyright © 2009 John Wiley & Sons, Ltd.

Rationale, aims and objectives The aim of this qualitative study was to examine patients’ experiences of being diagnosed with multiple sclerosis (MS), the information that they were given at this time, subsequent treatment and its impact on their lives. Method Data were collected through semi-structured interviews with 24 people with MS. The use of interviews allowed participants’ experiences to be explored in depth. Participants were recruited by the MS Society through membership details and through a press release in a local newspaper. Telephone interviews lasted between 30 and 60 minutes, were tape-recorded and transcribed verbatim. Data were analysed using thematic content analysis. Results The majority of participants were female (n = 17), with ages ranging from 35 to 72 years. Disease duration ranged from 1 to 37 years. Many participants’ diagnosed before and after 2000 had experienced long delays in diagnosis. At the point of diagnosis, participants had to make sense of and understand their diagnosis often with insufficient support. Some participants expressed anger about the way they had been given their diagnosis. Many felt they had not received sufficient information about their illness at this time and had responded by conducting their own searches for information to satisfy this need. Conclusion Improving the way in which doctors communicate with patients experiencing diagnostic delay and at the point of diagnosis deserves further study, in order to avoid later adjustment problems.

Objective To determine the relationship between physicians’ communication behaviors and patients’ overall satisfaction with hospital care using a novel instrumental variable to address possible confounding of this association by patient attributes.

This article analyzes expanded responses to statistical-epidemiological questions at a mental health outpatient service at a public hospital in Buenos Aires, Argentina. Bureaucratic questioning is a highly routine activity which supplies information to the biopolitical apparatus of the modern State. We understand that expanded answers are meaningful actions which not only serve individual, local tactics (such as raising personal concerns), but also index higher contextual levels. In this sense, resisting the constraints of a question may also imply resisting State-defined policies of biopolitical classification and exclusion. We examine, from a discursive interactional point of view, 41 admission interviews held at the outpatient mental health care service. We observe four types of expanded answers which: (a) display competence in bureaucratic discourse; (b) move from the sphere of the public to the private; (c) deal with potential facethreats; and (d) pre-empt rejection. Although the former is actually an optimized way of collaboration with the biopolitical order, the latter three types can be seen as actions of resistance to classification, not only symbolically but also in material terms: resisting statistical criteria of exclusion allows clients to negotiate access to mental healthcare. en este art ıculo analizamos respuestas expandidas a preguntas estad ıstico epidemiologicas en un hospital publico de buenos aires, argentina. los cuestionarios burocraticos son una actividad rutinaria que alimenta el aparato biopol ıtico del estado moderno. consideramos que este tipo de respuesta es una accion significativa que no solo responde a tacticas locales individuales (como presentar preocupaciones personales), sino que tambi en indexicaliza niveles contextuales mas altos. en ese sentido, responder resistiendo los condicionamientos impuestos por una pregunta puede tambi en suponer una resistencia a las pol ıticas estatales de clasificacion y exclusion. examinamos, desde una perspectiva discursiva interaccional, 41 entrevistas de admision a los consultorios externos de salud mental. observamos cuatro tipos de expansion, las cuales: muestran competencia en el discurso burocratico; se desplazan de la esfera publica a la privada; enfrentan amenazas potenciales a la autoimagen; buscan anticiparse al rechazo. aunque el primero pueda verse como una forma optima de colaboracion, los otros tres tipos pueden verse como forma de resistencia a la clasificacion, no solo en t erminos simbolicos, sino tambi en materiales: resistirse a los criterios estad ısticos de exclusion le permite a los pacientes negociar el acceso a la salud mental. Fil: Bonnin, Juan Eduardo. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Saavedra 15. Centro de Estudios e Investigaciones Laborales; Argentina

Background The pivotal role of doctor–patient communication in effective health care delivery led the Educational Commission for Foreign Medical Graduates (ECFMG) to incorporate the assessment of interpersonal skills and spoken English proficiency into its Clinical Skills Assessment (CSA). Furthermore, it was decided that to pass the CSA, a candidate would need to meet or surpass defined performance standards for doctor–patient communication as a discrete component. This requirement, among others, is designed to ensure the readiness of graduates of foreign medical schools (FMGs) to enter postgraduate medical education programmes in the United States. Objective The primary focus of this study was to determine the extent to which performance in a simulated testing environment is related to performance in the clinical setting. Method Nurses were trained to rate the communication skills of residents from the patient’s perspective. A total of 43 first-year residents were evaluated. The survey ratings (n=225) were compared with the residents’ CSA communication scores. Results Corrected correlations between CSA ratings and those obtained from nurses ranged from 0·61 to 0·73. Conclusion This study provides evidence for the validity of the communication ratings provided by standardized patients. The reasonably strong associations between ratings obtained during testing and those obtained through observation of ‘real’ patient interactions suggest that external observers can provide accurate evaluations of doctor–patient communication.

Traditional decision research shows that when people are told the probability of a rare event (e.g. the chance of side effects), they generally treat this event as if it were more likely than its objective probability (overweighting). In contrast, recent studies indicate that when outcomes are experienced firsthand, people tend to underweight the probability of rare events. In this paper, we suggest that the distinction between described and experienced information can play a significant role in shared decision making, and can provide a plausible explanation for some discrepancies between the perspectives of doctors and patients. We highlight some of the advantages and disadvantages of experiential and description-based information, and how knowledge of these might be used to improve risk communication.

Evaluation of genetic counseling requires a clear consensus about its objectives, which is not evident in published definitions and guidelines. This study aims to investigate clinical geneticists' beliefs and thoughts about their practice. Structured interviews with eight clinical geneticists addressed the aims, skills, and expectations of genetic counseling. Analysis of transcribed interviews revealed four key themes, with contradictory aspects: 1. Providing information that is objective, full, and accurate versus information that is contingent on circumstances and tailored to individual needs. 2. Eliciting emotion and dealing with it directly versus dampening down and containing emotion. 3. Communicating nondirectively versus directively. 4. Expecting to perform a range of sophisticated tasks while having minimal training in the necessary skills to achieve these. These results have implications for the nature of the professional role, the development of training required for it, and the evaluation of genetic counseling.

The aims of this prospective study were to determine (a) the concordance between patient concerns and genetic counselors' judgments of these concerns, (b) the predictors of patient and counselor judgments, and (c) the relationship between concordance and patient outcomes. Patients' and counselors' views were sought before and after 131 routine genetic consultations. Before consultations, there was concordance about level of patient concern to within one point in 63% (82/131) of consultations and about type of patient concern in 60-84% of consultations. Lack of concordance in judging level and type of concern was associated with lower satisfaction with information and higher anxiety after the consultation. The biggest predictor of counselor judgment of concern was professional background: doctors judged patients to be more concerned than did nurses. Concordance of concern was predicted by counselors' experience in genetics: less experienced counselors overestimated patient concern. Future research needs to determine whether improving judgment of concern improves patient outcome.

This study examined the practice of writing to parents following paediatric outpatients consultation (general practitioners (GPs) receive a copy of the letter to parents). One hundred and three questionnaires were sent to both parents and GPs in order to elicit their views. Fifty-one parents responded (RR 50.5%) and 56 GPs (RR 54.4%). All parents were in favour of the idea of specialists writing directly to parents/patients and none of the parents were in favour of the letter being sent to the GP alone. The majority of GPs considered that the letter(s) would improve parental satisfaction (85.7%) and improve compliance with medical advice (83.3%); 83.6% of GPs stated that the copy of the letter to parents was at least as helpful, if not more so, than the usual type of clinic letters they receive. Despite this, GPs expressed mixed feelings about the idea of all specialists writing direct to patients/parents, with 46.3% in favour of the idea and 40.7% against.

A total of 117 women attending a gynaecological oncology follow-up clinic completed the Hospital Anxiety and Depression Scale (HADS), the Courtauld Emotional Control Scale (CECS) and a 72-item ad hoc questionnaire designed to assess their evaluation of doctor-patient communication and the perceived impact of diagnosis and treatment. Women who were anxious and/or depressed at follow-up were more critical of doctor—patient interaction, particularly regarding the amount of information given. Young women, and married or widowed women, had more emotional difficulties and needs, as did those who had had a long remission. Although 47% of the women reported being too shocked to take in details at the time the diagnosis was confirmed, only 3% felt that they had been given too much information at that time and 23% would have preferred more information. During the ensuing month, 39% would have liked further information although 21% did not wish this. In many cases, therefore, there is a need for repeated information giving consultations. Routine use of HADS and CECS may help the clinician to identify and monitor patients most at risk of psychological problems.

Summary Detailed study of a series of tape-recorded interviews enabled the author to carry out a critical self-audit of his consultations. The analysis of categories of verbal interaction in doctor-patient consultations proved to be a practical and reliable method of studying the doctor-patient relationship. The methods and techniques used in this research could, with advantage, be employed in the fields of undergraduate and postgraduate teaching. Since a satisfactory doctor-patient relationship is of great value, study in depth of the verbal interaction between doctor and patient in general practice consultations can provide guide lines to those who seek an improvement in doctor-patient communication.