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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Undertreatment of pain is common even when caused by serious illness. We examined whether physician-patient communication (particularly language indicating physician certainty) was associated with incomplete (i.e., premature closure) of pain assessment among patients with serious illness. Standardized patients (SPs) trained to portray patients with serious illness conducted unannounced, covertly audio-recorded visits to 20 consenting family physicians and 20 medical specialists. We coded extent of pain assessment, physician voice tone, and a measure of the degree to which physicians explored and validated patient concerns. To assess physician certainty, we searched transcripts for use of words that conveyed certainty using the Linguistic Inquiry and Word Count program. SP role fidelity was 94%, and few physicians were suspicious that they had seen an SP (14% of visits). Regression analyses showed that physicians who used more certainty language engaged in less thorough assessment of pain (β = -0.48, p < .05). Conversely, physicians who engaged in more exploring and validating of patient concerns (β = 0.27, p < .05) had higher ratings on anxiety/concerned voice tone (β = 0.25, p

Breast cancer survivors often use clues to convey their concerns to their oncologists. The authors conducted a randomized trial of a communication coaching intervention in which 22 female breast cancer survivors were randomized to the coaching and 22 to treatment as usual. They hypothesized that the intervention would increase breast cancer self-efficacy, improve mood, and reduce fears of recurrence. Through a series of ANCOVAs they found that the intervention led to increases in self-efficacy. Changes in self-efficacy predicted changes in anxiety, depression, and womanhood fears. This coaching intervention shows promise but requires additional studies to establish is efficacy and effectiveness.

The purpose of this study was to investigate the relationship between attachment security and health outcomes of cardiac patients and their spouses. Dyadic coping and relationship quality were proposed to mediate this relationship. Participants were 72 couples in which one member of the couple was participating in cardiac rehabilitation. Results showed that participants with higher attachment avoidance perceived their general and mental health worse and were less likely to exercise. Patients with higher attachment avoidance perceived their partner as less supportive and this was negatively associated with their general and mental health. Spouses’ positive support and marital happiness partially mediated the relationship between their attachment anxiety and mental health. Patients with spouses with higher attachment anxiety exercised more; whereas spouses of patients with higher attachment anxiety exercised less.

This pilot study explored the associations between parent and adolescent reports of adolescent attachment and glycemic control in adolescents with Type 1 diabetes. We hypothesized that more secure attachment would correlate with more optimal diabetes control. Thirty-one families completed written self-report questionnaires about adolescent attachment, demographic data, and diabetes control. Adolescents and parents reported on their perceptions of adolescents' attachment to mothers and fathers. Mean HbA1c for the sample was 7.6% (SD = 1.14). Mothers' perceptions of adolescents' attachment were significantly correlated with adolescents' hemoglobin A1c (r = -.42, p = .022), indicating that maternal perceptions of more secure attachment was associated with better glycemic control. Neither fathers' perceptions nor adolescents' reports of attachment was significantly correlated with glycemic control. Attachment appears to be associated with glycemic control in this population though the mechanisms are unclear. Mothers' perceptions of attachment had the strongest associations with control, not adolescent reports. Further research is needed to understand the mechanisms through which parent reports of adolescent attachment are associated with glycemic control.

Schizophrenia is a debilitating mental illness that affects 1 percent of the population in all cultures. It affects equal numbers of men and women, but the onset is often later in women than in men. Schizophrenia is characterized by positive and negative symptoms. Positive symptoms include hallucinations, voices that converse with or about the patient, and delusions that are often paranoid. Negative symptoms include flattened affect, loss of a sense of pleasure, loss of will or drive, and social withdrawal. Both types of symptoms affect patients' families; therefore, it is important for physicians to provide guidance to all persons affected by the disease. Psychosocial and family interventions can improve outcomes. Medications can control symptoms, but virtually all antipsychotics have neurologic or physical side effects (e.g., weight gain, hypercholesterolemia, diabetes). There is a 10 percent lifetime risk of suicide in patients with schizophrenia.

Previous work suggests that exploration and validation of patients' concerns is associated with greater patient trust, lower health care costs, improved counseling, and more guideline-concordant care.To describe physicians' responses to patients' worries, how their responses varied according to clinical context (straightforward versus medically unexplained symptoms [MUS]) and associations between their responses and patients' ratings of interpersonal aspects of care.Multimethod study. For each physician, we surveyed 50 current patients and covertly audiorecorded 2 unannounced standardized patient (SP) visits. SPs expressed worry about "something serious" in 2 scenarios: straightforward gastroesophageal reflux or poorly characterized chest pain with MUS.One hundred primary care physicians and 4,746 patients.Patient surveys measuring interpersonal aspects of care (trust, physician knowledge of the patient, satisfaction, and patient activation). Qualitative coding of 189 transcripts followed by descriptive, multivariate, and lag-sequential analyses.Physicians offered a mean of 3.1 responses to each of 613 SP prompts. Biomedical inquiry and explanations, action, nonspecific acknowledgment, and reassurance were common, whereas empathy, expressions of uncertainty, and exploration of psychosocial factors and emotions were uncommon. Empathy expressed during SP visits was associated with higher patient ratings of interpersonal aspects of care. After adjusting for demographics and comorbidities, the association was only statistically significant for the MUS role. Empathy was most likely to occur if expressed at the beginning of the conversational sequence.Empathy is associated with higher patient ratings of interpersonal care, especially when expressed in situations involving ambiguity. Empathy should be expressed early after patient expressions of worry.

PURPOSE This study examined moderating effects of physician communication behaviors on relationships between patient requests for antidepressant medications and subsequent prescribing. METHODS We conducted a secondary analysis of a randomized trial. Primary care physicians (N = 152) each had 1 or 2 unannounced visits from standardized patients portraying the role of major depression or adjustment disorder. Each standardized patient made brand-specific, general, or no requests for antidepressants. We coded covert visit audio recordings for physicians’ exploration and validation of patient concerns (EVC). Effects of communication on prescribing (the main outcome) were evaluated using logistic regression analysis, accounting for clustering and for site, physician, and visit characteristics, and stratified by request type and standardized patient role. RESULTS In the absence of requests, high-EVC visits were associated with higher rates of prescribing of antidepressants for major depression. In low-EVC visits, prescribing was driven by patient requests (adjusted odds ratio [AOR] for request vs no request = 43.54, 95% confidence interval [CI], 1.69–1,120.87; P ≤ .005), not clinical indications (AOR for depression vs adjustment disorder = 1.82; 95% CI, 0.33–9.89; P = NS). In contrast, in high-EVC visits, prescribing was driven equally by requests (AOR = 4.02; 95% CI, 1.67–9.68; P ≤ .005) and clinical indications (AOR = 4.70; 95% CI, 2.18–10.16; P ≤ .005). More thorough history taking of depression symptoms did not mediate these results. CONCLUSIONS Quality of care for depression is improved when patients participate more actively in the encounter and when physicians explore and validate patient concerns. Communication interventions to improve quality of care should target both physician and patient communication behaviors. Cognitive mechanisms that link patient requests and EVC to quality of care warrant further study.

The purpose of this study was to evaluate racial differences in preference for life-sustaining interventions in the context of various physical and mental health scenarios.Data were collected by using an investigator-administered survey.Consecutive patients who self-identified as African American or Caucasian were recruited from two private primary care practices in Rochester, New York.Patients were asked to decide whether they would accept or decline life-sustaining intervention in eight scenarios, each involving a different combination of mental and physical disability. Information on religiousness, family integration, and experience with creating a healthcare proxy was also collected, as these variables were believed to be potential confounders of the relationship between race and preference.Data from 77 patients (50 Black patients and 27 White patients) were analyzed. In multivariate log linear modeling, race was a significant predictor of preference for life-sustaining therapy, even after controlling for degree of mental and physical disability. Religiousness, family integration, and experience with creating a healthcare proxy did not explain racial differences in preference for life-sustaining therapy.We have shown that ambulatory Black patients agedor = 50 years are more likely than White patients to prefer life-sustaining care, and that these preferences persist across a wide range of mental and physical disabilities. This attitude conflicts with the prevailing ethic regarding end-of-life care, and Black patients and their families may consequently find have difficulty obtaining medical care that is consistent with their cultural values and beliefs. Policy decisions regarding end-of-life care must reflect a culturally diverse perspective.

PURPOSE We wanted develop a reliable and valid objective measure of patient- physician collaborative decision making, the Rochester Participatory Decision-Mak- ing Scale (RPAD). METHODS Based on an informed decision-making model, the RPAD assesses physician behavior that encourages patient participation in decision making. Data were from a study of physician-patient communication of 100 primary care physicians. Physician encounters with 2 standardized patients each were audio recorded, resulting in 193 useable recordings. Transcribed recordings were coded both with RPAD and the Measure of Patient-Centered Communication (MPCC), which includes a related construct, Finding Common Ground. Two sets of depen- dent variables were derived from (1) surveys of the standardized patients and (2) surveys of 50 patients of each physician, who assessed their perceptions of the physician-patient relationship. RESULTS The RPAD was coded reliably (intraclass correlation coeffi cient (ICC) = 0.72). RPAD correlated with Finding Common Ground (r = 0.19, P

Observational studies using patient reports suggest associations between physician interpersonal styles and patient outcomes. Possible confounding of these associations has not been carefully examined.Approximately 4,700 patients of 96 physicians completed a survey instrument that included reported health status changes during the previous year, perceptions of their physician (satisfaction, trust, knowledge of patient, and autonomy support), and sociodemographic and clinical covariates. We examined the adjusted relationship between patient perceptions of their physicians and reported health status changes. Using multilevel analyses, we then explored differences among physicians in patient perceptions of their physicians and whether these differences were explained by the relationship between patient perceptions and reported health status changes.There were significant adjusted relationships between patient perceptions of their physician and reported health status changes: better perceptions were associated with a smaller risk of health status decline (adjusted odds ratio = 1.14; 95% confidence interval [CI], 1.05-1.24; P.01). Multilevel analysis showed significant differences between physicians in patient perceptions of their physicians (rho = 0.10; 95% CI, 0.07-0.13; P.01), but these physician differences were unrelated to reported health status decline (rho = 0; P.99).Using methods similar to those of previous studies, we found a relationship between patient perceptions of their physicians and reported health status declines. Multilevel analysis, however, suggested that this relationship is not a physician effect; it may reflect unmeasured patient confounding. Multilevel analyses may help to examine the relationships between physician styles and outcomes.

The associations between social relationships and health have been examined using two major research traditions. Using a social epidemiological approach, much research has shown the beneficial effect of social supports on health and health behaviors. Family interaction research, which has grown out of a more clinical tradition, has shown the complex effects of family functioning on health, particularly mental health. No studies have examined the relative power of these two approaches in explicating the connections between social relationships and health. We hypothesized that social relationships (social support and family functioning) would exert direct and indirect (through depressive symptoms) effects on health behaviors. We also hypothesized that the effects of social relationships on health would be more powerfully explicated by family functioning than by social support. We mailed a pilot survey to a random sample of patients attending a family practice center, including questions on depressive symptoms, cardiovascular health behaviors, demographics, social support using the ISEL scale, and family functioning using the FEICS scale. FEICS is a self-report questionnaire designed to assess family emotional involvement and criticism, the media elements of family expressed emotion. Eighty-three useable responses were obtained. Regression analyses and structural modelling showed both direct and indirect statistically significant paths from social relationships to health behaviors. Family criticism was directly associated (standardized coefficient = 0.29) with depressive symptoms, and family emotional involvement was directly associated with both depressive symptoms (coefficient = 0.35) and healthy cardiovascular behaviors (coefficient = 0.32). The results support the primacy of family functioning factors in understanding the associations among social relationships, mental health, and health behaviors. The contrasting relationships between emotional involvement and depressive symptoms on the one hand and emotional involvement and health behaviors on the other suggest the need for a more complex model to understand the connections between social relationships and health.