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BACKGROUND: Clinician stress is common, but few studies have examined its relationship with communication behaviors. OBJECTIVE: To investigate associations between clinician stress and patient-clinician communication in primary HIV care. DESIGN: Observational study. PARTICIPANTS: Thirty-three primary HIV clinicians and 350 HIV-infected adult, English-speaking patients at three U.S. HIV specialty clinic sites. MAIN MEASURES: Clinicians completed the Perceived Stress Scale, and we categorized scores in tertiles. Audio-recordings of patient-clinician encounters were coded using the Roter Interaction Analysis System. Patients rated the quality of their clinician's communication and overall quality of medical care. We used regression with generalized estimating equations to examine associations between clinician stress and communication outcomes, controlling for clinician gender, clinic site, and visit length. KEY RESULTS: Among the 33 clinicians, 70 % were physicians, 64 % were women, 67 % were non-Hispanic white, and the mean stress score was 3.9 (SD 2.4, range 0-8). Among the 350 patients, 34 % were women, 55 % were African American, 23 % were non-Hispanic white, 16 % were Hispanic, and 30 % had been with their clinicians > 5 years. Verbal dominance was higher for moderate-stress clinicians (ratio = 1.93, p < 0.01) and high-stress clinicians (ratio = 1.76, p = 0.01), compared with low-stress clinicians (ratio 1.45). More medical information was offered by moderate-stress clinicians (145.5 statements, p < 0.01) and high-stress clinicians (125.9 statements, p = 0.02), compared with low-stress clinicians (97.8 statements). High-stress clinicians offered less psychosocial information (17.1 vs. 19.3, p = 0.02), and patients of high-stress clinicians rated their quality of care as excellent less frequently than patients of low-stress clinicians (49.5 % vs. 66.9 %, p < 0.01). However, moderate-stress clinicians offered more partnering statements (27.7 vs. 18.2, p = 0.04) and positive affect (3.88 vs. 3.78 score, p = 0.02) than low-stress clinicians, and their patients' ratings did not differ. CONCLUSIONS: Although higher stress was associated with verbal dominance and lower patient ratings, moderate stress was associated with some positive communication behaviors. Prospective mixed methods studies should examine the complex relationships across the continuum of clinician well-being and health communication. © 2012 Society of General Internal Medicine.

Purpose: This study aims to explore the role of interactants' nonverbal sensitivity, anxiety and sociodemographic characteristics in learning and satisfaction within the genetic counseling context. Design/methodology/approach: This is a combined simulation and analogue study. Simulations were videotaped with 152 prenatal and cancer genetic counselors and nine simulated clients. The videotapes were shown to 559 subjects recruited to act as analogue clients (ACs) with the instruction to imagine themselves as the client in the simulation. The profile of nonverbal sensitivity (PONS), a video and audio test of accuracy in the interpretation of nonverbal cues, was administered to both the genetic counselors and ACs. In addition, the ACs completed a literacy screen and post session measures of learning and session satisfaction. Findings: The study finds that ACs' post-session knowledge score was positively associated with both their own and the counselors' audio PONS scores. Also related to knowledge were clients' literacy, younger age and non-minority ethnicity. Ratings of session satisfaction were inversely related to ACs' and counselors' video PONS scores and ACs' literacy and anxiety. Research limitations/implications: While based on the performance of a large number of practicing genetic counselors, simulated and analogue clients are used to explore study questions. Practical implications: The nonverbal sensitivity of both providers and ACs plays a role in medical communication and its cognitive and affective consequences. These findings warrant greater attention to nonverbal dynamics in future research and interventions. Originality/value: No similar studies have investigated the role of nonverbal sensitivity in predicting learning and satisfaction for users of health care services. (Contains 5 tables.)

Objective: This study characterized psychiatrist and patient communication behaviors and affective voice tones during pharmacotherapy appointments with depressed patients at four community-based mental health clinics where psychiatrists provided medication management and other mental health professionals provided therapy ("split treatment").Methods: Audiorecordings of 84 unique pairs of psychiatrists and patients with a depressive disorder were analyzed with the Roter Interaction Analysis System, which identifies 41 discrete speech categories that can be grouped into composites representing broad conceptual communication domains. Cluster analysis identified psychiatrist communication patterns. T test and chi square analyses compared the clusters for verbal dominance, affective voice tone, and characteristics of psychiatrist and patients.Results: On average, 53% of psychiatrist talk was devoted to partnering and relationship building, and 67% of patient talk was about biomedical subjects, such as depression symptoms, and psychosocial information giving. Psychiatrist communication patterns were characterized by two clusters, a biomedical-centered cluster that emphasized biomedical questions (η²=.22, df=82, p<.001) and education or counseling (η²=.20, df=82, p<.001) and a patient-centered cluster focused on psychosocial and lifestyle questions (η²=.24, df=82, p<.001) and information giving (η²=.17, df=82, p<.001). The patient-centered cluster was associated with patients' expression of distress, anger, or other negative affects (t=3.22, df= 82, p=.002).Conclusions: Psychiatrists devoted much of their talk to partnering and relationship building while maintaining a focus on symptoms or psychosocial issues. However, patient behaviors did not reflect a similar level of partnering. Future studies should identify psychiatrist communication behaviors that activate collaborative patient communications or improve treatment outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Standardized or simulated patients are widely used in medical training, however, little is known about these individuals and their work experience. The current study was designed to describe the SP workforce and gain insight into the routine tasks, challenges and rewards associated with their work. METHODS: Using the full 2005 membership list (n=450) of Association of Standardized Patient Educators (ASPE), one SP educator for each medical school across all states was identified, representing a total of 87 different medical schools. Fifty-seven (65%) of the SP educators approached agreed to participate in the study and distribute surveys to 10 SPs in each program. RESULTS: 255 (45%) of the distributed surveys were returned representing the experience of SPs in 57 medical schools across all 6 ASPE geographic regions. Specifics in regard to work scheduling and compensation are reported with some regional differences noted in pay. On the whole, SPs were highly satisfied with their work, but roughly half reported some difficulty with elements of case mastery and providing feedback to learners. CONCLUSION: SP satisfaction is high but challenges in case mastery and feedback tasks are evident. PRACTICE IMPLICATIONS: Meeting training needs can enhance the utility and effectiveness of this workforce. [ABSTRACT FROM AUTHOR]

Purpose: With improved access to health information via the Internet, an increasing number of women with breast cancer are using this venue to obtain information about their illness and treatment from physicians. This study aims to identify the needs of women with breast cancer who communicate with physicians on the Internet.Methods: From a total of 4,424 requests posted by Korean women with breast cancer to a physician run Internet Q&A board during 2003 to 2007, we sampled 1,355 representative requests according to different type of online user identification and analyzed these using a qualitative content analytic approach to identify the nature of the requests.Results: The vast majority of women (93.5%) used the online Q&A board to seek informational support from physicians. They requested information across a broad range of topics, including treatment (38.4% of requests), physical condition (31.7%), and lifestyle/self-care (24%).Women at different disease stages made requests indifferent informational domains. Few (<5%) postings were direct requests for emotional support, but emotional requests were often embedded within informational requests. Over 63% of requests expressed concern and worry, and about 75% of the requests included at least one emotional expression. There was no difference by type of online user identification with respect to the subject and purpose of the requests.Conclusions: Korean women with breast cancer expressed diverse needs related to their physical and psychological conditions in their online requests to physicians via a Q&A board. While future research should establish and evaluate the role of internet communications for cancer management,we conclude that an online Q&A board can be a valuable tool in assisting breast cancer patients in managing their physical and psychosocial needs as well as communicating these needs to physicians. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Within the context of medical care there is no greater reflection of the information revolution than the electronic medical record (EMR). Current estimates suggest that EMR use by Israeli physicians is now so high as to represent an almost fully immersed environment. This study examines the relationships between the extent of electronic medical record use and physician-patient communication within the context of Israeli primary care. METHODS: Based on videotapes of 3 Israeli primary care physicians and 30 of their patients, the extent of computer use was measured as number of seconds gazing at the computer screen and 3 levels of active keyboarding. Communication dynamics were analyzed through the application of a new Hebrew translation and adaptation of the Roter Interaction Analysis System (RIAS). RESULTS: Physicians spent close to one-quarter of visit time gazing at the computer screen, and in some cases as much as 42%; heavy keyboarding throughout the visit was evident in 24% of studied visits. Screen gaze and levels of keyboarding were both positively correlated with length of visit (r = .51, p < .001 and F(2,27) = 2.83, p < .08, respectively); however, keyboarding was inversely related to the amount of visit dialogue contributed by the physician (F(2,27) = 4.22, p < .02) or the patient (F(2,27) = 3.85, p < .05). Specific effects of screen gaze were inhibition of physician engagement in psychosocial question asking (r = -.39, p < .02) and emotional responsiveness (r = -.30, p < .10), while keyboarding increased biomedical exchange, including more questions about therapeutic regimen (F(2,27) = 4.78, p < .02) and more patient education and counseling (F(2,27) = 10.38, p < .001), as well as increased patient disclosure of medical information to the physician (F(2,27) =3.40, p < .05). A summary score reflecting overall patient-centered communication during the visit was negatively correlated with both screen gaze and keyboarding (r = -.33, p < .08 and F(2,27) = 3.19, p < .06, respectively). DISCUSSION: The computer has become a 'party' in the visit that demanded a significant portion of visit time. Gazing at the monitor was inversely related to physician engagement in psychosocial questioning and emotional responsiveness and to patient limited socio-emotional and psychosocial exchange during the visit. Keyboarding activity was inversely related to both physician and patient contribution to the medical dialogue. Patients may regard physicians' engrossment in the tasks of computing as disinterested or disengaged. Increase in visit length associated with EMR use may be attributed to keyboarding and computer gazing. CONCLUSIONS: This study suggests that the way in which physicians use computers in the examination room can negatively affect patient-centered practice by diminishing dialogue, particularly in the psychosocial and emotional realm. Screen gaze appears particularly disruptive to psychosocial inquiry and emotional responsiveness, suggesting that visual attentiveness to the monitor rather than eye contact with the patient may inhibit sensitive or full patient disclosure. PRACTICAL IMPLICATIONS: We believe that training can help physicians optimize interpersonal and educationally effective use of the EMR. This training can assist physicians in overcoming the interpersonal distancing, both verbally and non-verbally, with which computer use is associated. Collaborative reading of the EMR can contribute to improved quality of care, enhance the decision-making process, and empower patients to participate in their own care. [ABSTRACT FROM AUTHOR]

BACKGROUND: The extent of communication skills training (CST) in American oncology fellowship programs is unknown. METHODS: A survey was sent to program directors of medical oncology, radiation oncology, gynecologic oncology, and surgical oncology training programs regarding (1) the presence and method(s) of CST in their programs, (2) their attitude about mandatory CST, and (3) their attitude about a mandatory assessment of communication skills competence as a prerequisite for specialty certification. RESULTS: Only a third of programs contained some form of CST. Surgical oncology programs were particularly lacking. Lack of faculty time was cited as the major barrier to implementing CST. A majority of program directors support mandatory CST but not a core competence requirement for certification. CONCLUSIONS: There is a current deficiency in CST in American oncology fellowship training. Given the importance of communication skills in the provision of high-quality cancer care, initiatives to address this deficiency are a priority. [ABSTRACT FROM AUTHOR]

A literature search was conducted to collect published articles reporting correlates of HIV medication adherence or interventions designed to increase HIV medication adherence. Proceedings from seven HIV/AIDS-related conferences were searched for relevant abstracts. We found 18 descriptive studies in published articles and 57 in conference proceedings producing over 200 separate variables falling into four broad areas: (1) factors related to treatment regimen; (2) social and psychological factors; (3) institutional resources; and (4) personal attributes. More complex regimens were related to decreased adherence, but were often successfully mitigated by regimen aids. Social and psychological factors reflecting emotional adjustment to HIV/AIDS and provider support were related to adherence. Access to institutional resources was associated with better adherence. Personal attributes showed a mixed relationship; gender was not consistently related to adherence, but younger age, minority status, and a history of substance abuse were often related to non-adherence. The intervention search yielded 16 interventions employing a wide range of behavioral, cognitive and affective strategies. Evidence of effectiveness was weak. We conclude the abstracts are a useful source of information as part of a systematic review, particularly when available published literature is limited, if results and study characteristics are reported in an adequate and standard manner. [ABSTRACT FROM AUTHOR]

Objective: Our goal was to provide health-care providers, patients, and the general public with an assessment of currently available data regarding the use of adjuvant therapy for breast cancer.Participants: The participants included a non-Federal, non-advocate, 14-member panel representing the fields of oncology, radiology, surgery, pathology, statistics, public health, and health policy as well as patient representatives. In addition, 30 experts in medical oncology, radiation oncology, biostatistics, epidemiology, surgical oncology, and clinical trials presented data to the panel and to a conference audience of 1000.Evidence: The literature was searched with the use of MEDLINE(TM) for January 1995 through July 2000, and an extensive bibliography of 2230 references was provided to the panel. Experts prepared abstracts for their conference presentations with relevant citations from the literature. Evidence from randomized clinical trials and evidence from prospective studies were given precedence over clinical anecdotal experience.Consensus Process: The panel, answering predefined questions, developed its conclusions based on the evidence presented in open forum and the scientific literature. The panel composed a draft statement, which was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the World Wide Web immediately after its release at the conference and was updated with the panel's final revisions. The statement is available at http://consensus.nih.gov.Conclusions: The panel concludes that decisions regarding adjuvant hormonal therapy should be based on the presence of hormone receptor protein in tumor tissues. Adjuvant hormonal therapy should be offered only to women whose tumors express hormone receptor protein. Because adjuvant polychemotherapy improves survival, it should be recommended to the majority of women with localized breast cancer regardless of lymph node, menopausal, or hormone receptor status. The inclusion of anthracyclines in adjuvant chemotherapy regimens produces a small but statistically significant improvement in survival over non-anthracycline-containing regimens. Available data are currently inconclusive regarding the use of taxanes in adjuvant treatment of lymph node-positive breast cancer. The use of adjuvant dose-intensive chemotherapy regimens in high-risk breast cancer and of taxanes in lymph node-negative breast cancer should be restricted to randomized trials. Ongoing studies evaluating these treatment strategies should be supported to determine if such strategies have a role in adjuvant treatment. Studies to date have included few patients older than 70 years. There is a critical need for trials to evaluate the role of adjuvant chemotherapy in these women. There is evidence that women with a high risk of locoregional tumor recurrence after mastectomy benefit from postoperative radiotherapy. This high-risk group includes women with four or more positive lymph nodes or an advanced primary cancer. Currently, the role of postmastectomy radiotherapy for patients with one to three positive lymph nodes remains uncertain and should be tested in a randomized controlled trial. Individual patients differ in the importance they place on the risks and benefits of adjuvant treatments. Quality of life needs to be evaluated in selected randomized clinical trials to examine the impact of the major acute and long-term side effects of adjuvant treatments, particularly premature menopause, weight gain, mild memory loss, and fatigue. Methods to support shared decision-making between patients and their physicians have been successful in trials; they need to be tailored for diverse populations and should be tested for broader dissemination. [ABSTRACT FROM AUTHOR]

Family members are an integral part of a patient's cancer care from the moment the diagnosis is delivered to the conclusion of treatment. Family members bring with them a range of emotional reactions, interpersonal dynamics and expectations for the care the patient receives. This study is part of a multi-institutional project to continue to improve the process of cancer care. In this study, 19 focus groups (11 patient and 8 provider) were conducted concerning issues related to doctor–patient communication in eight cancer centers in the United States. The content of the conversations was analyzed and thematic categories emerged that highlight the various strengths and difficulties associated with family involvement. The focus groups' comments support the need for explicit conversations between professional caregivers, patients and their loved ones, in order to negotiate the expectations and needs of each team member. Implications for clinical practice and strategies for working with family members are offered. Copyright © 2000 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]