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Context: Discordance in prognostic understanding between caregivers of adults with advanced cancer and the oncologist may shape caregivers' views of the oncologist and bereavement outcomes., Objectives: We examined prospective associations of caregiver-oncologist discordance with caregiver-oncologist therapeutic alliance and caregiver anxiety after patient death., Methods: We conducted a secondary analysis of data collected in a cluster randomized controlled trial from August 2012 to June 2014 in Western New York and California. At enrollment, caregivers and oncologists used a seven-point scale to rate their beliefs about the patient's curability and living two years or more: 100%, about 90%, about 75%, about 50 of 50, about 25%, about 10%, and 0%. Discordance was defined as a difference of two points or more. Outcomes at seven months after patient death included caregiver-oncologist therapeutic alliance (The Human Connection scale, modified into five items) and caregiver anxiety (Generalized Anxiety Disorder-7). We conducted multivariable linear regression models to assess the independent associations of discordance with alliance and anxiety., Results: We included 97 caregivers (mean age 63) and 38 oncologists; 41% of caregiver-oncologist dyads had discordant beliefs about the patient's curability, and 63% of caregiver-oncologist dyads had discordant beliefs about living two years or more. On multivariate analysis, discordance in beliefs about curability was associated with lower anxiety (β = -2.20; SE 0.77; P = 0.005). Discordance in beliefs about length of life was associated with a weaker alliance (β = -5.87; SE = 2.56; P = 0.02)., Conclusion: A better understanding of how caregivers understand and come to terms with poor prognoses will guide interventions to improve cancer care delivery and outcomes of cancer treatment., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Care teams are increasingly expected to attend to the needs of patient's personal caregivers (e.g., family members). Improving communication among oncologists, patients with advanced cancer, and their personal caregivers might enhance caregivers' experiences of end-of-life (EoL) cancer care and bereavement outcomes. Objective: To explore the effects of the Values and Options in Cancer Care intervention on caregivers' experiences of EoL care and bereavement outcomes. Design : We developed a brief behavioral intervention to improve communication among oncologists, patients with advanced cancer, and their personal caregivers. The intervention was designed to help patients/caregivers ask questions, express concerns, and help oncologists respond effectively. We randomly assigned oncologists (and their patients/caregivers) to the intervention or usual care. Setting/Subjects: Medical oncologists in NY and CA; patients/personal caregivers with advanced cancer. Measurements: Two months after the patient's death, caregivers completed three instruments assessing their experiences of EoL care. Seven months after the patient's death, caregivers completed the Prolonged Grief Disorder-13 (PG-13; primary prespecified outcome), the Purpose-in-Life scale, and scales assessing mental health function, depression, and anxiety. Results : The intervention did not significantly improve caregivers' scores on the PG-13 ( p  = 0.21), mental health function, depression, or anxiety, but it did improve purpose-in-life scores ( p  = 0.018). Cohen's d (95% confidence interval) for all three experiences of EoL care outcomes were promising, ranging from 0.22 (-0.19 to 0.63) to 0.39 (-0.07 to 0.86) although none was statistically significant. Conclusion: Preliminary findings show promise that scalable interventions in cancer care settings may improve caregiver experiences with cancer care and some bereavement outcomes.

Purpose Some research has suggested that discussion of prognosis can disrupt the patient-physician relationship. This study assessed whether physician discussion of prognosis is associated with detrimental changes in measures of the strength of the patient-physician relationship. Methods This was a longitudinal cohort study of 265 adult patients with advanced cancer who visited 38 oncologists within community- and hospital-based cancer clinics in Western New York and Northern California. Prognostic discussion was assessed by coding transcribed audio-recorded visits using the Prognostic and Treatment Choices (PTCC) scale and by patient survey at 3 months after the clinic visit. Changes in the strength of the patient-physician relationship were computed as differences in patient responses to The Human Connection and the Perceived Efficacy in Patient-Physician Interactions scales from baseline to 2 to 7 days and 3 months after the clinic visit. Results Prognostic discussion was not associated with a temporal decline in either measure. Indeed, a one-unit increase in PTCC during the audio-recorded visit was associated with improvement in The Human Connection scale at 2 to 7 days after the visit (parameter estimate, 0.10; 95% CI, -0.02 to 0.23) and 3 months after the visit (parameter estimate, 0.18; 95% CI, 0.02 to 0.35) relative to baseline. Standardized effect sizes (SES) associated with an increase of two standard deviations in the PTCC at each time point were consistent with small beneficial effects (SES, 0.14 [95% CI, -0.02 to 0.29] at 2 to 7 days; SES, 0.24 [95% CI, 0.02 to 0.45] at 3 months), and lower bounds of CIs indicated that substantial detrimental effects of prognostic discussion were unlikely. Conclusion Prognostic discussion is not intrinsically harmful to the patient-physician relationship and may even strengthen the therapeutic alliance between patients and oncologists.

Background: The present study protocol describes the trial design of a clinician training intervention to improve physical activity counseling in underserved primary care settings using the 5As. The 5As (Ask, Advise, Agree, Assist, Arrange) are a clinical tool recommended for health behavior counseling in primary care., Methods/design: The study is a two-arm randomized pilot pragmatic trial to examine a primary care clinician communication intervention on use of the 5As in discussion of physical activity in audio-recorded office visits in an ethnically diverse, low-income patient population. The study setting consists of two federally qualified community health centers in Rochester, NY. Eligible clinicians (n=15) are recruited and randomized into two groups. Group 1 clinicians participate in the training intervention first; Group 2 clinicians receive the intervention six months later. The intervention and its outcomes are informed by self-determination theory and principles of patient-centered communication. Assessment of outcomes is blinded. The primary outcome will be the frequency and quality of 5As discussions as judged by evaluating 375 audio-recorded patient visits distributed over baseline and in the post-intervention period (immediately post and at six months). Secondary outcomes will be changes in patients' perceived competence to increase physical activity (Aim 2) and patients and clinicians beliefs regarding whether pertinent barriers to promoting exercise have been reduced. (Aim 3). Exploratory outcomes (Aim 4) are potential mediators of the intervention's effect and whether the intervention affects actual enrollment in the community program recommended for exercise. The analysis will use repeated measures (in the form of recorded office visits) from each clinician at each time point and aggregate measures of Groups 1 and 2 over time., Discussion: Results will help elucidate the role of 5As communication training for clinicians on counseling for physical activity counseling in primary care. Results will explore the effectiveness of the 5As model linked to community resources for physical activity promotion for underserved groups.

Background: Family and friends may help patients seek out and engage in depression care. However, patients' social networks can also undermine depression treatment and recovery. In an effort to improve depression care in primary care settings, we sought to identify, categorize, and alert primary care clinicians to depression-related messages that patients hear from friends and family that patients perceive as unhelpful or detrimental., Methods: We conducted 15 focus groups in 3 cities. Participants (n = 116) with a personal history or knowledge of depression responded to open-ended questions about depression, including self-perceived barriers to care-seeking. Focus group conversations were audio-recorded and analyzed using iterative qualitative analysis., Results: Four themes emerged related to negatively-received depression messages delivered by family and friends. Specifically, participants perceived these messages as making them feel labeled, judged, lectured to, and rejected by family and friends when discussing depression. Some participants also expressed their interpretation of their families' motivations for delivering the messages and described how hearing these messages affected depression care., Conclusions: The richness of our results reflects the complexity of communication within depression sufferers' social networks around this stigmatized issue. To leverage patients' social support networks effectively in depression care, primary care clinicians should be aware of both the potentially beneficial and detrimental aspects of social support. Specifically, clinicians should consider using open-ended queries into patients' experiences with discussing depression with family and friends as an initial step in the process. An open-ended approach may avoid future emotional trauma or stigmatization and assist patients in overcoming self-imposed barriers to depression discussion, symptom disclosure, treatment adherence and follow-up care.

Purpose: In addition to structural transformations, deeper changes are needed to enhance physicians' sense of meaning and satisfaction with their work and their ability to respond creatively to a dynamically changing practice environment. The purpose of this research was to understand what aspects of a successful continuing education program in mindful communication contributed to physicians' well-being and the care they provide., Method: In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians who had recently completed a 52-hour mindful communication program demonstrated to reduce psychological distress and burnout while improving empathy. Interviews with a random sample of 20 of the 46 physicians in the Rochester, New York, area who attended at least four of eight weekly sessions and four of eight monthly sessions were audio-recorded, transcribed, and analyzed qualitatively. The authors identified salient themes from the interviews., Results: Participants reported three main themes: (1) sharing personal experiences from medical practice with colleagues reduced professional isolation, (2) mindfulness skills improved the participants' ability to be attentive and listen deeply to patients' concerns, respond to patients more effectively, and develop adaptive reserve, and (3) developing greater self-awareness was positive and transformative, yet participants struggled to give themselves permission to attend to their own personal growth., Conclusions: Interventions to improve the quality of primary care practice and practitioner well-being should promote a sense of community, specific mindfulness skills, and permission and time devoted to personal growth.

Objective: We examined how navigation, defined as the assessment and alleviation of barriers to adequate health care, influences patients' perspectives on the quality of their cancer care., Methods: We conducted post-study patient interviews from a randomized controlled trial (usual care vs. patient navigation services) from cancer diagnosis through treatment completion. Patients were recruited from 11 primary care, hospital and community oncology practices in New York. We interviewed patients about their expectations and experience of patient navigation or, for non-navigated patients, other sources of assistance., Results: Thirty-five patients newly diagnosed with breast or colorectal cancer. Valued aspects of navigation included emotional support, assistance with information needs and problem-solving, and logistical coordination of cancer care. Unmet cancer care needs expressed by patients randomized to usual care consisted of lack of assistance or support with childcare, household responsibilities, coordination of care, and emotional support., Conclusion: Cancer patients value navigation. Instrumental benefits were the most important expectations for navigation from navigated and non-navigated patients. Navigated patients received emotional support and assistance with information needs, problem-solving, and logistical aspects of cancer care coordination., Practice Implications: Navigation services may help improve cancer care outcomes important to patients by addressing fragmented, confusing, uncoordinated, or inefficient care., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Context: Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; data on these programs are scarce., Objective: To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients., Design, Setting, and Participants: Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo)., Main Outcome Measures: Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months., Results: Over the course of the program and follow-up, participants demonstrated improvements in mindfulness (raw score, 45.2 to 54.1; raw score change [Delta], 8.9; 95% confidence interval [CI], 7.0 to 10.8); burnout (emotional exhaustion, 26.8 to 20.0; Delta = -6.8; 95% CI, -4.8 to -8.8; depersonalization, 8.4 to 5.9; Delta = -2.5; 95% CI, -1.4 to -3.6; and personal accomplishment, 40.2 to 42.6; Delta = 2.4; 95% CI, 1.2 to 3.6); empathy (116.6 to 121.2; Delta = 4.6; 95% CI, 2.2 to 7.0); physician belief scale (76.7 to 72.6; Delta = -4.1; 95% CI, -1.8 to -6.4); total mood disturbance (33.2 to 16.1; Delta = -17.1; 95% CI, -11 to -23.2), and personality (conscientiousness, 6.5 to 6.8; Delta = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; Delta = 0.5; 95% CI, 0.3 to 0.7). Improvements in mindfulness were correlated with improvements in total mood disturbance (r = -0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = -0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001)., Conclusions: Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care. Because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians.

Background: Physicians' use of patient-centered communication (PCC) affects important outcomes of care. Although there is evidence that both patient and physician gender affect the process of care, there is limited information about their impact on PCC. Our objective was to investigate the influence of patient and physician gender, as well as gender concordance between patient and physician, on the patient centeredness of primary care visits., Methods: Participating primary care physicians (100 family physicians and internists) with clinical practices in the Rochester, New York area, had two unannounced covertly audiorecorded standardized patients' visits. Encounters were analyzed using the Measure of Patient-Centered Communication (MPCC), which measures three aspects of physician communication: Component 1 (Exploring both the disease and illness experience), Component 2 (Understanding the whole person), and Component 3 (Finding common ground)., Results: Compared with male patients, females had interactions characterized by greater PCC (total and Component 2 scores). Whereas female physicians exhibited higher Component 1 scores, male physicians had higher Component 2 scores, and gender-concordant visits also exhibited higher Component 2 scores. However, there were no significant differences in total MPCC scores for encounters of female vs. male physicians or for gender-concordant compared with discordant patient-physician dyads., Conclusions: These findings add further evidence that patient gender can affect the interactions between physicians and patients. More research is needed to understand why male patients are less likely to have medical encounters in which their physicians employ a patient-centered practice style.

Context: Subjective rating scales for communication skills may yield more personally meaningful responses than more standardised rating schemes. It is unclear, however, whether such evaluations may be overly biased by respondents' rating styles, which may lead to unreliable measurement of examinees' communication skills., Methods: Our study involved 212 students from the classes of 2005 and 2006 at the University of Rochester School of Medicine and Dentistry. All students were rated by actors depicting standardised patients (SPs) on the same seven cases using the 19-item Rochester Communication Rating Scale (RCRS). Different students were assigned to different actors playing the same SP. We assessed the extent to which actors' personal rating styles influenced the scores they assigned to students. Main outcome measures were: between-actor variability in responses; the degree to which actors' response styles contribute to overall scores, and improvements in reliability achieved by standardising actors' ratings., Results: There were statistically significant differences between actors in their mean assigned scores. Scores aggregated over 18 separate SP cases have an expected generalisability coefficient of 0.79. If raw RCRS scores are used, a total of 27 replications of the RCRS are required to achieve a Cronbach's alpha of 0.8; standardisation reduces this number to 18., Conclusions: Although actors are variable in their use of a standardised subjective scale of communication, such differences contribute to an acceptably small proportion of the total variance if scores are combined across a large number of cases. Reliability can be markedly improved by standardising scores across raters.

Background: It is known that male and female medical students have different experiences in their clinical training., Aims: To assess whether male and female medical students change in their self-rated work habits and interpersonal habits during the first year of clinical training., Method: Longitudinal study of self- and peer-assessment among 224 medical students in 3 consecutive classes at a private US medical school. Students rated themselves on global work habits (WH) and interpersonal attributes (IA). Students also rated and were rated by 6-12 peers on the same scale., Results: In the second year of medical school, there were no differences between men and women in quartiles of self-assessed WH or IA. At the end of the third year, however, women were more likely to be in the lower quartiles of self-assessed WH (X(2) = 6.77; p = 0.03), as well as the highest quartiles of self-assessed IA (X(2) = 11.36; p = 0.003). In both years, women rated their own WH skills significantly lower than they rated their peers, while men rated themselves similarly to peers. There were no sex differences in self-assessed IA., Conclusions: Although second-year male and female medical students appear similar to one another in terms of self-assessed WH and IA, by the end of the third year women rate themselves relatively lower in WH, while men rate themselves relatively lower in IA.

Background: The value of physician self-disclosure (MD-SD) in creating successful patient-physician partnerships has not been demonstrated., Methods: To describe antecedents, delivery, and effects of MD-SD in primary care visits, we conducted a descriptive study using sequence analysis of transcripts of 113 unannounced, undetected, standardized patient visits to primary care physicians. Our main outcome measures were the number of MD-SDs per visit; number of visits with MD-SDs; word count; antecedents, timing, and effect of MD-SD on subsequent physician and patient communication; content and focus of MD-SD., Results: The MD-SDs included discussion of personal emotions and experiences, families and/or relationships, professional descriptions, and personal experiences with the patient's diagnosis. Seventy-three MD-SDs were identified in 38 (34%) of 113 visits. Ten MD-SDs (14%) were a response to a patient question. Forty-four (60%) followed patient symptoms, family, or feelings; 29 (40%) were unrelated. Only 29 encounters (21%) returned to the patient topic preceding the disclosure. Most MD-SDs (n=62; 85%) were not considered useful to the patient by the research team. Eight MD-SDs (11%) were coded as disruptive., Conclusions: Practicing primary care physicians disclosed information about themselves or their families in 34% of new visits with unannounced, undetected, standardized patients. There was no evidence of positive effect of MD-SDs; some appeared disruptive. Primary care physicians should consider when self-disclosing whether other behaviors such as empathy might accomplish their goals more effectively.

Objective: There is considerable interest in the influences on patients' ratings of physicians., Methods: In this cross-sectional study, patients (n = 4616; age range: 18-65 years) rated their level of satisfaction with their primary care physicians (n = 96). Patients and physicians were recruited from primary care practices in the Rochester, NY metropolitan area. For analytic purposes, length of the patient-physician relationship was stratified (< or =1, 1-4, > or =5 years). Principal components factor analysis of items from the Health Care Climate Questionnaire, the Primary Care Assessment Survey and the Patient Satisfaction Questionnaire yielded a single factor labeled "Satisfaction" that served as the sole dependent variable. Higher scores mean greater satisfaction. Predictors of interest were patient demographics and morbidity as well as physician demographics and personality, assessed with items from the NEO-FFI., Results: Patients treated by a physician for 1 year or less rated male physicians higher than female physicians. This gender difference disappeared after 1 year, but two physician personality traits, Openness and Conscientiousness, were associated with patients' ratings in lengthier patient-physician relationships. Patients report being more satisfied with physicians who are relatively high in Openness and average in Conscientiousness. Older patients provide higher ratings than younger patients, and those with greater medical burden rated their physicians higher., Conclusion: Patients' ratings of physicians are multidetermined. Future research on patient satisfaction and the doctor-patient relationship would benefit from a consideration of physician personality. Identifying physician personality traits that facilitate or undermine communication, trust, patient-centeredness, and patient adherence to prescribed treatments is an important priority., Practice Implications: Learning environments could be created to reinforce certain traits and corresponding habits of mind that enhance patient satisfaction. Such a shift in the culture of medical education and practice could have implications for patient care.

Background: It is not known to what extent the dean's letter (medical student performance evaluation [MSPE]) reflects peer-assessed work habits (WH) skills and/or interpersonal attributes (IA) of students., Objective: To compare peer ratings of WH and IA of second- and third-year medical students with later MSPE rankings and ratings by internship program directors., Design and Participants: Participants were 281 medical students from the classes of 2004, 2005, and 2006 at a private medical school in the northeastern United States, who had participated in peer assessment exercises in the second and third years of medical school. For students from the class of 2004, we also compared peer assessment data against later evaluations obtained from internship program directors., Results: Peer-assessed WH were predictive of later MSPE groups in both the second (F = 44.90, P < .001) and third years (F = 29.54, P < .001) of medical school. Interpersonal attributes were not related to MSPE rankings in either year. MSPE rankings for a majority of students were predictable from peer-assessed WH scores. Internship directors' ratings were significantly related to second- and third-year peer-assessed WH scores (r = .32 [P = .15] and r = .43 [P = .004]), respectively, but not to peer-assessed IA., Conclusions: Peer assessment of WH, as early as the second year of medical school, can predict later MSPE rankings and internship performance. Although peer-assessed IA can be measured reliably, they are unrelated to either outcome.

Context: Although peer-assessment appears promising as a method to assess interpersonal skills among medical students, results may be biased by method of peer selection, particularly if different kinds of classmates are assigned systematically by different methods. It is also unclear whether students with lower interpersonal skills may be more negative towards their classmates than students with higher levels of interpersonal skills and, if so, how much bias this may introduce into the results of peer assessment. It is also unclear whether low-rated students are more likely to ask to rate one another., Design, Setting, and Participants: Participants were 296 medical students from the classes of 2004, 2005 and 2006 at the University of Rochester School of Medicine and Dentistry. All participants were evaluated by between 6 and 12 classmates near the end of both their second and third years. In some classes peer-raters were assigned from class lists, while in other classes students were asked to recommend classmates to rate and be rated by., Main Outcome Measures: Mean numerical ratings of interpersonal-attributes scores received from peers, compared with mean scores simultaneously assigned to peers. We also examined students' selection of peer-raters, as well as scores received by their peer-raters., Results: For all 3 classes in both second and third years, students in the lowest quartile of received scores were significantly more likely to simultaneously assign lower scores to their peers. Among third-year students, such low-scoring students were significantly more likely to ask to rate and be rated by other low-scoring students. Among third-year students, low-rated students were more likely to rate and be rated by other low-rated students, irrespective of how rater assignments are made. Most students who were originally in the lowest quartile of received scores remained so after removing the scores assigned by low-rated raters. Among pre-clinical second-year students, however, low-rated students were no more likely than high-rated students to be rated by other low-rated students., Conclusion: Students with low levels of peer-assessed interpersonal attributes are more negative in their judgements of classmates. Third-year medical students with low levels of interpersonal attributes are more likely to be rated by other students with low levels of interpersonal attributes, irrespective of method of rater assignment. This effect was not seen in the second year of medical school. Biases in selection of raters among third-year students, however, do not appear to affect the results of peer assessment. Thus, medical schools that choose to institute peer assessment can select the method of peer-rater assignment based on practicality and logistical considerations. Students' affiliations with one another in the third year appear to be related to peer-assessed interpersonal attributes.

Peer assessment has been increasingly recommended as a way to evaluate the professional competencies of medical trainees. Prior studies have only assessed single groups measured at a single timepoint. Thus, neither the longitudinal stability of such ratings nor differences between groups using the same peer-assessment instrument have been reported previously. Participants were all members of 2 consecutive classes of medical students (n = 77 and n = 85) at the University of Rochester School of Medicine and Dentistry who completed Years 2 and 3 of medical school consecutively. All participants were evaluated by 6-12 classmates near the end of both Years 2 and 3. Main outcome measures were mean numerical ratings on peer-assessed scales of professional work habits (WH) and interpersonal attributes (IA). Both scales had high internal consistencies in both years (Cronbach's alpha 0.84-0.94). The IA and WH scales were moderately correlated with one another (r = 0.36 in Year 2, r = 0.28 in Year 3). Year 2 scores were predictive of Year 3 scores for both scales (WH: r = 0.64; IA; r = 0.62). Generalisability and decision analyses revealed that 1 class was consistently more discriminating with the WH scale, while the other was more discriminating with of the IA scale. Depending on the class, year and scale, the number of raters needed to achieve a reasonable reliability ranged between 7 and 28. Although Year 3 peer ratings were consistently higher than Year 2 peer ratings for both WH and IA, individual scores were highly correlated across the 2 years, despite the fact that different individuals were chosen as peer raters. Abilities appear to be stable between Years 2 and 3 of medical school. Groups may differ in their ability to discriminate different kinds of skills. Generalisability analysis can be used to discover these patterns within groups.

Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.

Background: 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., Methods: 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., Results: 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., Conclusions: 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

Background: A required 2-week comprehensive assessment (CA) for 2nd-year medical students that integrates basic science, clinical skills, information management, and professionalism was implemented., Description: The CA links standardized patients (SPs) with computer-based exercises, a teamwork exercise, and peer assessments; and culminates in student-generated learning plans., Evaluation: Scores assigned by SPs showed acceptable interrater reliability. Factor analyses defined meaningful subscales of the peer assessment and communication rating scales. Ratings of communication skills were correlated with information gathering, patient counseling, and peer assessments; these, in turn, were strongly correlated with the written exercises. Students found the CA fair, with some variability in opinion of the peer and written exercises. Useful learning plans and positive curricular changes were undertaken in response to the CA results., Conclusion: A CA that integrates multiple domains of professional competence is feasible, useful to students, and fosters reflection and change. Preliminary data suggest that this format is reliable and valid.