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Introduction: Mindfulness-based interventions for health professionals have been linked to improvements in burnout, well-being, empathy, communication, patient-centered care, and patient safety, but the optimal formats and intensity of training have been difficult to determine because of the paucity of studies and the heterogeneity of programs. A 4-days residential "Mindful Practice" workshop for physicians and medical educators featuring contemplative practices, personal narratives, and appreciative dialogs about challenging experiences may hold promise in improving participants' well-being while also improving compassionate care, job satisfaction, work engagement, and teamwork. Methods: We collected baseline and 2-month follow-up data during four workshops conducted in 2018 to 2019 at conference centers in the United States and Europe. Primary outcomes were burnout, work-related distress, job satisfaction, work engagement, patient-centered compassionate care, and teamwork. Results: Eighty-five of 120 participants (71%) completed both surveys (mean age was 49.3 and 68.2% female). There were improvements (P <.01) in two of three burnout components (emotional exhaustion and depersonalization), work-related distress, job satisfaction, patient-centered compassionate care, work engagement and meaning, teamwork, well-being, positive emotion, mindfulness, somatic symptoms, and spirituality. Effect sizes (standardized mean difference of change) ranged from 0.25 to 0.61. With Bonferroni adjustments (P <.0031), teamwork, general well-being, and mindfulness became nonsignificant. Discussion: An intensive, multiday, mindfulness-based workshop for physicians had clinically significant positive effects on clinician well-being, quality of interpersonal care and work satisfaction, and meaning and engagement, all important indicators of improved health and sustainability of the health care workforce. Future iterations of the program should increase the focus on teamwork. [ABSTRACT FROM AUTHOR]

Background: Although many older patients with end-stage renal disease and limited prognoses prefer conservative management (CM), it is not widely offered in the United States. Moreover, there is a dearth of US-based literature reporting clinical experience with shared decision making regarding CM of advanced chronic kidney disease (CKD).Methods: We describe the clinical experience of 13 patients who opted for CM at the University of Rochester Medical Center's CKD clinic during 2016-2017. Main outcomes include: (1) reason for choosing CM, (2) completion of advance directives, (3) location of death, and (4) utilization of hospice service. Patients' reasons for choosing CM were categorized into 4 broad categories based on a review of their electronic medical records. A retrospective chart review conducted by 2 reviewers determined the status of advance care planning, hospice referral, and place of death.Results: The mean age of these patients was 81.8 years (SD 7.3). Their reasons for choosing CM included: poor prognoses; a wish to maintain their quality of life; their desire for a dignified life closure; and the intention to protect family members from having to see them suffer, based on their own memory of having witnessed a relative on dialysis previously. A total of 8 patients died: all received hospice services, 6 died at home, one at a nursing home, and one at a hospital. Advance care planning was completed in 100% of the cases. Symptoms were managed in collaboration with primary care physicians.Conclusion: Patients' decisions to choose CM were influenced by their values and previous experience with dialysis, in addition to comorbidities and limited prognoses. Promoting the choice of CM in the United States will require training of clinicians in primary palliative care competencies, including communication and decision-making skills, as well as basic symptom management proficiencies. [ABSTRACT FROM AUTHOR]

The article discusses the challenges involved in prognosis and end-of-life care. It states that misunderstanding one's prognosis add to bad decision making. An expert panel used a question prompt list to study this. Patients with advanced cancer and health professionals participated. Analysis identified themes including reinforcement of known benefits of question prompt list, appraisal of content and suggestions for further development, and contrast feedbacks in Australian and U. S. patients.

Background: Cancer health disparities affecting low-income and minority patients are well documented. Rootcauses are multifactorial, including diagnostic and treatment delays, social and financial barriers, and poor communication. Patient navigation and communication coaching (activation) are potential interventions to address disparities in cancer treatment. The purpose of this clinical trial is to test the effectiveness of an intervention combining patient navigation and activation to improve cancer treatment. Methods/Design: The Rochester Patient Navigation Research Program (PNRP) is a National Cancer Institutesponsored, patient-level randomized trial (RCT) of patient navigation and activation, targeting newly-diagnosed breast and colorectal cancer patients in Rochester, NY. The goal of the program is to decrease cancer health disparities by addressing barriers to receipt of cancer care and promoting patient self-efficacy. The intervention uses trained, paraprofessional patient navigators recruited from the target community, and a detailed training and supervisory program. Recruited patients are randomly assigned to receive either usual care (except for baseline and follow-up questionnaires and interviews) or intervention. The intervention patients receive tailored assistance from their patient navigators, including phone calls, in-person meetings, and behind-the-scenes coordination of care. A total of 344 patients have been recruited. Outcomes measured at three month intervals include timeliness of care, patient adherence, patient satisfaction, quality of life, self-efficacy, health literacy, and cancer knowledge. Discussion: This unique intervention combining patient navigation and patient activation is designed to address the multifactorial problem of cancer health disparities. If successful, this study will affect the design and implementation of patient navigation programs. Trials Registration: clinicaltrials.gov identifier NCT00496678. [ABSTRACT FROM AUTHOR]

The article discusses the lack of primary care for patients in the U.S. It mentions that visiting physicians for 15 minutes is not enough to fully examine a patient. In addition, it emphasizes the need to focus on health care of less fortunate people because they are the ones who have often afflicted with diseases. According to the authors, training of health care workforce is vital to attend to every patient with different disorders and illnesses. They likewise mention the importance of preventive care to avoid further complications.

The article reports on the physician's sharing their decision-making behaviors in depression care. It discusses that readmission after heart failure hospitalization is the altering focus for physicians and policy manufacturers and that the statistical models are demanded to evaluate patient risk and to equate hospital operation. It infers that the performed systematic review is used to report the models which are planned to compare hospital rates of readmission and to anticipate the patient's risk of readmission.

Medical family therapy grew out of the experiences of family therapists working with other professionals to provide comprehensive, integrated healthcare for patients (McDaniel, Hepworth, & Doherty, 1992). This is the story of one such patient, her son, and those of us who were the three primary participants on her treatment team. To provide an account that comes closest to the experience itself, we have taken quotes from videotaped sessions and electronic mail communications that occurred throughout the course of therapy. Each provider tells part of the story in his or her own voice. The commentary is provided by Susan McDaniel. [ABSTRACT FROM AUTHOR]

Objective: To evaluate feasibility and to validate a rating scale for two educational programs that use standardized patient-instructors (SPIs) in the office setting to improve physicians' HIV risk communication skills.Design: Pilot randomized trial of announced and unannounced SPIs.Participants/settings: Twenty four primary care physicians in the Rochester, NY, area.Measurements: The Rochester HIV Interview Rating Scale (RHIRS), HIV test ordering, physician satisfaction questionnaire.Results: Physicians found the intervention useful, and predicted a positive effect on their future HIV-related communication. HIV test ordering and RHIRS scores increased similarly in both intervention groups. Announced SPI visits were more convenient and preferred by physicians. Cost for each SPI visit was $75.Conclusions: A brief office-based intervention using SPIs was feasible, well-accepted, convenient, and inexpensive. Announced SPIs were preferred to unannounced SPIs. Pilot results suggesting improvement in HIV-related communication should be confirmed in a larger randomized trial. [ABSTRACT FROM AUTHOR]

Discusses the need to preserve patient-physician communication in the United States in the light of health care reform proposals. Importance of patient-physician communication; Communication skills for practicing physicians; Implications of health care reform on patient-physician relationship; Opportunities provided by health care reform to strengthen patient-physician relationship.

Growing enthusiasm about patient-centered medical homes, fueled by the Patient Protection and Affordable Care Act's emphasis on improved primary care, has intensified interest in how to deliver patient-centered care. Essential to the delivery of such care are patient-centered communication skills. These skills have a positive impact on patient satisfaction, treatment adherence, and self-management. They can be effectively taught at all levels of medical education and to practicing physicians. Yet most physicians receive limited training in communication skills. Policy makers and stakeholders can leverage training grants, payment incentives, certification requirements, and other mechanisms to develop and reward effective patient-centered communication. [ABSTRACT FROM AUTHOR]

Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Tr anstheoretical Model of I rrational B iomedical E xuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients' outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization. • Many interventions, treatments and procedures confer more harm than benefit at the End-of-Life. • To explain why this happens, we developed the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). • The TRIBE model highlights the role of moral emotions (e.g., guilt), motives (regret-avoidance) and processes (e.g., compassion) in healthcare. • TRIBE underscores the critical need for psychological innovation in healthcare delivery and the education of health professionals. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To explore patients’ perspectives across two cultures (Australia and USA) regarding communication about prognosis and end-of-life care issues and to consider the ways in which these discussions can be optimised. Methods: Fifteen Australian and 11 US patients completed individual semi-structured qualitative interviews. A further 8 US patients participated in a focus group. Interviews and focus group recordings were transcribed verbatim and interpreted using thematic text analysis with an inductive, data-driven approach. Results: Global themes identified included readiness for and outcomes of discussions of prognosis and end-of-life issues. Contributing to readiness were sub themes including patients’ adjustment to and acceptance of their condition (together with seven factors promoting this), doctor and patient communication skills, mutual understandings and therapeutic relationship elements. Outcomes included sub themes of achievement of control and ability to move on. A model of the relationships between these factors, emergent cross cultural differences, and how factors may help to optimise these discussions are presented. Conclusion: Identified optimising factors illustrate Australian and US patients’ perspectives regarding how prognosis and end-of-life issues can be discussed with minimised negative impact. Practice implications: Recognition of factors promoting adjustment, acceptance and readiness and use of the communication skills and therapeutic relationship elements identified may assist in optimising discussions and help patients plan care, achieve more control of their situation and enjoy an optimal quality-of-life. [Copyright &y& Elsevier]

Importance: Older patients with cancer and their caregivers worry about the effects of cancer treatment on aging-related domains (eg, function and cognition). Quality conversations with oncologists about aging-related concerns could improve patient-centered outcomes. A geriatric assessment (GA) can capture evidence-based aging-related conditions associated with poor clinical outcomes (eg, toxic effects) for older patients with cancer., Objective: To determine whether providing a GA summary and GA-guided recommendations to oncologists can improve communication about aging-related concerns., Design, Setting, and Participants: This cluster-randomized clinical trial enrolled 541 participants from 31 community oncology practices within the University of Rochester National Cancer Institute Community Oncology Research Program from October 29, 2014, to April 28, 2017. Patients were aged 70 years or older with an advanced solid malignant tumor or lymphoma who had at least 1 impaired GA domain; patients chose 1 caregiver to participate. The primary outcome was assessed on an intent-to-treat basis., Interventions: Oncology practices were randomized to receive either a tailored GA summary with recommendations for each enrolled patient (intervention) or alerts only for patients meeting criteria for depression or cognitive impairment (usual care)., Main Outcomes and Measures: The predetermined primary outcome was patient satisfaction with communication about aging-related concerns (modified Health Care Climate Questionnaire [score range, 0-28; higher scores indicate greater satisfaction]), measured after the first oncology visit after the GA. Secondary outcomes included the number of aging-related concerns discussed during the visit (from content analysis of audiorecordings), quality of life (measured with the Functional Assessment of Cancer Therapy scale for patients and the 12-Item Short Form Health Survey for caregivers), and caregiver satisfaction with communication about aging-related patient concerns., Results: A total of 541 eligible patients (264 women, 276 men, and 1 patient did not provide data; mean [SD] age, 76.6 [5.2] years) and 414 caregivers (310 women, 101 men, and 3 caregivers did not provide data; mean age, 66.5 [12.5] years) were enrolled. Patients in the intervention group were more satisfied after the visit with communication about aging-related concerns (difference in mean score, 1.09 points; 95% CI, 0.05-2.13 points; P = .04); satisfaction with communication about aging-related concerns remained higher in the intervention group over 6 months (difference in mean score, 1.10; 95% CI, 0.04-2.16; P = .04). There were more aging-related conversations in the intervention group's visits (difference, 3.59; 95% CI, 2.22-4.95; P < .001). Caregivers in the intervention group were more satisfied with communication after the visit (difference, 1.05; 95% CI, 0.12-1.98; P = .03). Quality of life outcomes did not differ between groups., Conclusions and Relevance: Including GA in oncology clinical visits for older adults with advanced cancer improves patient-centered and caregiver-centered communication about aging-related concerns., Trial Registration: ClinicalTrials.gov identifier: NCT02107443.

The phrase "patient-centered care" is in vogue, but its meaning is poorly understood. This article describes patient-centered care, why it matters, and how policy makers can advance it in practice. Ultimately, patient-centered care is determined by the quality of interactions between patients and clinicians. The evidence shows that patient-centered care improves disease outcomes and quality of life, and that it is critical to addressing racial, ethnic, and socioeconomic disparities in health care and health outcomes. Policy makers need to look beyond such areas as health information technology to shape a coordinated and focused national policy in support of patient-centered care. This policy should help health professionals acquire and maintain skills related to patient-centered care, and it should encourage organizations to cultivate a culture of patient-centeredness.

Objective: To assess the message preferences of individuals affected by depression as part of a project that will evaluate interventions to encourage at-risk patients to talk to their physicians about depression., Methods: Adaptive Conjoint Analysis (ACA) of 32 messages defined by 10 message attributes. Messages were developed based on input from three focus groups comprised of individuals with a personal and/or family history of depression, then tested using volunteers from an Internet health community. In an online conjoint survey, 249 respondents with depression rated their liking of the messages constructed for each attribute. They were then presented with two message sets and rated their preferences. Preference utilities were generated using hierarchical Bayes estimation., Results: The optimal communication approach described both psychological and physical symptoms of depression, recognized multiple treatment options, offered lifetime prevalence data, noted that depression can affect anyone, and acknowledged that finding an effective treatment can take time., Conclusion: Individuals with depression respond differently to depression care messages, underscoring the need for careful message development and evaluation., Practice Implications: ACA, used in conjunction with focus groups, is a promising approach for developing and testing messages in the formative research stage of intervention development., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

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.

The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.

Purpose: Observational studies using patient reports suggest associations between physician interpersonal styles and patient outcomes. Possible confounding of these associations has not been carefully examined., Methods: 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., Results: 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)., Conclusions: 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.

Context: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized., Objective: To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms., Design: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none)., Setting: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004., Participants: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%., Interventions: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits., Main Outcome Measures: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics., Results: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001)., Conclusions: Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.

This paper charts a course for assessing the impact of healing relationships in clinical medicine. The system of healing relationships is multidimensional, longitudinal, contextual, and emergent. In a new conceptual model, healing relationships are identified in terms of the conditions of healing intention, motivation, and information transfer, and in terms of the attributes of emotional engagement, mindfulness, and trust. Five components of quality in healing relationships--adaptability, cohesion, growth, caring-in-relation, and commitment--are noted, and the importance of timing, attunement, and cultural meaning systems are described. Communication, clinical method, caring, competence, and treatment characteristics are differentiated as mediating processes; expectancy and conditioning are positioned as antecedents of healing relationships. Multiple personal and contextual outcomes are addressed with a recommendation for assessing a minimal set of each, including symptom resolution, health status, sense of coherence, patient enablement, cost effectiveness, quality of care, efficiency, access, and healer satisfaction. A wheel of knowledge connects 3 ways of knowing--personal, connected, and objective--with appropriate methodology and research designs. Applying this wheel to the issue of assessing impact in healing relationships reveals the need for multiple methods, perspectives, and triangulations. A critical multiplist strategy is one means for advancing this area of research. A double-helix trial design is introduced, in which one strand consists of a standard quantitative approach and the other consists of qualitative methods. The 2 strands are bonded by the questions addressed and by the participants in the study.