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Objective: To report how patient viewpoints on caring inform curriculum development for teaching sessions on delivering bad news, making the transition to palliative care, and communicating about a medical error., Methods: We conducted focus groups that used patients recruited from the surrounding community to view videotapes of physicians delivering bad news, talking with a patient about palliative care, and communicating about a medical error. We used focus group results, combined with evidence from the medical literature to inform curriculum content for workshops conducted with Internal Medicine and Family Medicine residents at the University of Massachusetts Medical School., Results: Patient perspectives on caring gathered through focus groups differed in significant ways from the existing medical literature on caring when providers are communicating in the challenging situations that were depicted. Our data pointed out that individual reactions were unique and sometimes contradictory in that one person saw behavior as caring that others thought was uncaring. Participants often used qualifiers in their comments like "appropriate" amounts of information, "measured" empathy, chooses words carefully to reflect the relative nature of caring. "Arranges to meet healthcare needs," an issue that extends beyond the encounter, was seen as a new component of caring not previously described. Applying these concepts to curriculum required that we not only focus on the behavioral skills involved in these tasks, but also the processes of assessing patient's informational and emotional needs, and then taking steps to meet them, while adjusting behavior in real time to meet patients needs for caring. Workshops delivered were highly evaluated by residents., Conclusion: Patient perspectives on caring when providers deliver bad news, discuss transitions to palliative care, and communicate about a medical error reinforce that patient expectations for caring are highly contextualized and physician behavior needs to be individualized. We taught residents not only behavioral skills, but also the process skills of anticipating patient reactions, recognizing patient clues, planning and choosing effective strategies on the fly, and assessing one's own performance characteristic of communication expertise., Practice Implications: Teaching caring attitudes with challenging communication tasks requires that learners appreciate and value not only caring behaviors but also learn the process by which they must adjust and titrate their actions to meet patient needs.

Objective: Caring is closely associated with reduced malpractice litigation, adherence to treatment and even symptom relief. Caring also is included in pay for performance formulas as well as widely utilized for quality improvement purposes. Our objective in this prospective qualitative study was to define caring behaviors associated with three challenging encounters: discussing the transition from curative to palliative care, delivering bad news (cancer), and discussing a medical error (misplaced test result). The purpose was to lay the groundwork for the creation of a 'patient-centered' caring attitude checklist that could help the healthcare provider understand and ultimately enhance the patient's experience of care., Methods: Groups of randomly selected lay people, henceforth referred to as patients: (1) engaged in 'think aloud' exercises to help create a 15-item caring behavior checklist; (2) used the checklist to rate videotapes of simulated challenging encounters conducted by twenty primary care physicians (total of 600 ratings sets); and (3) participated in 12 separate 1.5 h focus groups discussing the caring (and non-caring) behaviors exhibited in videotapes of the highest and lowest rated encounters., Results: Thirteen behaviors emerged as focal for describing a doctor's caring attitude but with disagreement as to whether specific examples of these behaviors were 'caring' or 'uncaring.' For example, although the concept of empathic inquiry was considered important by most patients, the physician question, "Is there someone you can call or talk with" (about a cancer diagnosis) was interpreted by one patient as 'very caring' while another was 'impressed with how uncaring' the statement appeared., Conclusion: At the conceptual level there is a set of behaviors that represent caring, however, the manifestation of these behaviors is 'in the eye of the beholder.' The most important element of caring may not be the set of behaviors but a set of underlying abilities that include taking the patient's perspective and reflecting on the patient's responses., Practice Implications: Medical education must focus on the underlying abilities of caring.

Background: Disclosure of medical errors is encouraged, but research on how patients respond to specific practices is limited., Objective: This study sought to determine whether full disclosure, an existing positive physician-patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influenced patients' responses to medical errors., Participants: Four hundred and seven health plan members participated in a randomized experiment in which they viewed video depictions of medical error and disclosure., Design: Subjects were randomly assigned to experimental condition. Conditions varied in type of medication error, level of disclosure, reference to a prior positive physician-patient relationship, an offer to waive costs, and clinical outcome., Measures: Self-reported likelihood of changing physicians and of seeking legal advice; satisfaction, trust, and emotional response., Results: Nondisclosure increased the likelihood of changing physicians, and reduced satisfaction and trust in both error conditions. Nondisclosure increased the likelihood of seeking legal advice and was associated with a more negative emotional response in the missed allergy error condition, but did not have a statistically significant impact on seeking legal advice or emotional response in the monitoring error condition. Neither the existence of a positive relationship nor an offer to waive costs had a statistically significant impact., Conclusions: This study provides evidence that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. The clinical outcome also influences patients' responses. The impact of an existing positive physician-patient relationship, or of waiving costs associated with the error remains uncertain.

Uncontrolled hypertension is a significant health problem, due in part to patients' under-use of antihypertensive medications. This study explored what factors influence patients' decisions to accept or resist initiation of pharmacologic therapy for hypertension. A total of 210 subjects reviewed a clinical vignette and a hypothetical physician-patient dialogue. They then self-reported their likelihood of accepting the physician's recommendation to initiate therapy with an antihypertensive. Additional measures included trust in the physician, satisfaction, beliefs about medication effectiveness, safety and side-effects, and beliefs about hypertension. Analyses included bivariate correlations and multivariate linear regression. Findings suggest that the strongest correlates of intent to begin therapy were trust in the physician (r = 0.65, p< 0.01), satisfaction with communication (r= 0.53, p< 0.01), and belief that medications can effectively treat hypertension (r = 0.45, p< 0.01). Three other beliefs were also correlated with acceptance of treatment: the belief that physicians do not prescribe unsafe medications (r=0.25, p<0.01), worry about having hypertension (r = 0.18, p<0.01) and belief that hypertension is a very serious disease (r= 0.26, p<0.01). Acceptance of treatment was not correlated with worry about medication side-effects or belief that medications cause problems (p> 0.01). The tone of the dialogue (positive versus negative) did not result in statistically significant differences in subjects' responses on any measures. The study concludes that attention to patients' perceptions and beliefs about hypertension and medication efficacy may help patients accept pharmacologic treatment. [ABSTRACT FROM AUTHOR]

BACKGROUND: Disclosure of medical errors is encouraged, but research on how patients respond to specific practices is limited. OBJECTIVE: This study sought to determine whether full disclosure, an existing positive physician-patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influenced patients' responses to medical errors. PARTICIPANTS: Four hundred and seven health plan members participated in a randomized experiment in which they viewed video depictions of medical error and disclosure. DESIGN: Subjects were randomly assigned to experimental condition. Conditions varied in type of medication error, level of disclosure, reference to a prior positive physician-patient relationship, an offer to waive costs, and clinical outcome. MEASURES: Self-reported likelihood of changing physicians and of seeking legal advice: satisfaction, trust, and emotional response. RESULTS: Nondisclosure increased the likelihood of changing physicians, and reduced satisfaction and trust in both error conditions. Nondisclosure increased the likelihood of seeking legal advice and was associated with a more negative emotional response In the missed allergy error condition, but did not have a statistically significant impact on seeking legal advice or emotional response in the monitoring error condition. Neither the existence of a positive relationship nor an offer to waive costs had a statistically significant impact. CONCLUSIONS: This study provides evidence that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. The clinical outcome also influences patients' responses. The impact of an existing positive physician-patient relationship, or of waiving costs associated with the error remains uncertain. [ABSTRACT FROM AUTHOR]