Empathic communication between clinicians, patients, and care partners in palliative care encounters.

OBJECTIVE: Palliative care encounters often involve empathic opportunities conveyed by patients and their care partners. In this secondary analysis, we examined empathic opportunities and clinician responses with attention to how presence of multiple care partners and clinicians shapes empathic communication. METHODS: We used the Empathic Communication Coding System (ECCS) to characterize emotion-focused, challenge-focused, and progress-focused empathic opportunities and responses in 71 audio-recorded palliative care encounters in the US. RESULTS: Patients expressed more emotion-focused empathic opportunities than did care partners; care partners expressed more challenge-focused empathic opportunities than did patients. Care partners initiated empathic opportunities more frequently when more care partners were present, though they expressed fewer as the number of clinicians increased. When more care partners and more clinicians were present, clinicians had fewer low-empathy responses. CONCLUSION: The number of care partners and clinicians present affect empathic communication. Clinicians should be prepared for empathic communication focal points to shift depending on the number of care partners and clinicians present. PRACTICE IMPLICATIONS: Findings can guide development of resources to prepare clinicians to meet emotional needs in palliative care discussions. Interventions can coach clinicians to respond empathically and pragmatically to patients and care partners, particularly when multiple care partners are in attendance.

Anatomy of diagnosis in a clinical encounter: how clinicians discuss uncertainty with patients.

BACKGROUND: Studies consider the clinical encounter as linear, comprising six phases (opening, problem presentation, history-taking, physical examination, diagnosis, treatment and closing). This study utilizes formal conversation analysis to explore patient-physician interactions and understanding diagnostic utterances during these phases. METHODS: This study is a qualitative sub-analysis that explores how the diagnosis process, along with diagnostic uncertainty, are addressed during 28 urgent care visits. We analyzed physicians' hypothesis-generation process by focusing on: location of diagnostic utterances during the encounter; whether certain/uncertain diagnostic utterances were revised throughout the encounter; and how physicians tested their hypothesis-generation and managed uncertainty. We recruited 7 primary care physicians (PCPs) and their 28 patients from Brigham and Women's Hospital (BWH) in 3 urgent care settings. Encounters were audiotaped, transcribed, and coded using NVivo12 qualitative data analysis software. Data were analyzed inductively and deductively, using formal content and conversation analysis. RESULTS: We identified 62 diagnostic communication utterances in 12 different clinical situations. In most (24/28, 86%) encounters, the diagnosis process was initiated before the diagnosis phase (57% during history taking and 64% during physical examination). In 17 encounters (61%), a distinct diagnosis phase was not observed. Findings show that the diagnosis process is nonlinear in two ways. First, nonlinearity was observed when diagnostic utterances occurred throughout the encounter, with the six encounter phases overlapping, integrating elements of one phase with another. Second, nonlinearity was noted with respect to the resolution of diagnostic uncertainty, with physicians acknowledging uncertainty when explaining their diagnostic reasoning, even during brief encounters. CONCLUSIONS: Diagnosis is often more interactive and nonlinear, and expressions of diagnostic assessments can occur at any point during an encounter, allowing more flexible and potentially more patient-centered communication. These findings are relevant for physicians' training programs and helping clinicians improve their communication skills in managing uncertain diagnoses.

Empathic Communication in Specialty Palliative Care Encounters: An Analysis of Opportunities and Responses.

Background: Although empathic responding is considered a core competency in specialty palliative care (PC), patterns of empathic communication in PC encounters are not well understood. Objectives: In this secondary analysis, we delineate types and frequency of empathic communication and examine relationships between patient empathic opportunities and clinician responses. Design: We used the Empathic Communication Coding System to analyze empathic opportunities across three types: emotion (i.e., negative affective state), progress (i.e., stated recent positive life event or development), and challenge (i.e., stated problem or recent, negative life-changing event) and clinician responses. Setting/Subjects: Transcripts from a pilot randomized trial of communication coaching in specialty PC encounters (N = 71) audio-recorded by 22 PC clinicians at two sites in the United States: an academic health system and a community-based hospice and PC organization. Results: Empathic opportunities were frequent across encounters; clinicians often responded empathically to those opportunities (e.g., confirming or acknowledging patients' emotions or experiences). Even though challenge empathic opportunities occurred most frequently, clinicians responded empathically more often to progress opportunities (i.e., 93% of the time) than challenge opportunities (i.e., 75% of the time). One in 12 opportunities was impeded by the patient or a family member changing the topic before the clinician could respond. Conclusions: PC patients frequently express emotions, share progress, or divulge challenges as empathic opportunities. Clinicians often convey empathy in response and can differentiate their empathic responses based on the type of empathic opportunity. PC communication research and training should explore which empathic responses promote desired patient outcomes.

Applying a multidimensional approach to understanding clinical conversations: A deprescribing case study in primary care.

OBJECTIVE: To describe and evaluate the contribution of multiple coding approaches applied to a clinical conversation on deprescribing in primary care (PC). METHODS: Seven distinct coding approaches were applied to one audiotaped consultation. Only exchanges related to deprescribing a benzodiazepine (BZD) were coded for: content, interaction, arguments, connectors, transitions, orientation towards deprescribing and concordance with a deprescribing algorithm. A discursive map presents the unfolding of the exchanges. RESULTS: The deprescribing conversation was broken down into 31 utterances divided into three segments: opening (n = 6), development (n = 16) and closing (n = 9). The family physician dominated the last two segments and most of her utterances were favorable to BZD deprescribing while the patient's utterances were generally unfavorable in the first two segments. The number of distinct codes assigned to utterances varied according to the coding approach. The map illustrates how each utterance can be viewed through different lenses revealing the dynamics and complexity of the deprescribing conversation. CONCLUSION: This multidimensional methodological approach with its proposed way of presenting results, either quantitatively or qualitatively, and its map offer a comprehensive evaluation of the deprescribing process in this PC setting. PRACTICE IMPLICATIONS: This novel multidimensional coding approach has potential to be applied to a range of other topics in clinical communications.

Multi-parametric analysis of speech timing in inter-talker identical twin pairs and cross-pair comparisons: Some forensic implications.

The purpose of this study was to assess the speaker-discriminatory potential of a set of speech timing parameters while probing their suitability for forensic speaker comparison applications. The recordings comprised of spontaneous dialogues between twin pairs through mobile phones while being directly recorded with professional headset microphones. Speaker comparisons were performed with twins speakers engaged in a dialogue (i.e., intra-twin pairs) and among all subjects (i.e., cross-twin pairs). The participants were 20 Brazilian Portuguese speakers, ten male identical twin pairs from the same dialectal area. A set of 11 speech timing parameters was extracted and analyzed, including speech rate, articulation rate, syllable duration (V-V unit), vowel duration, and pause duration. Three system performance estimates were considered for assessing the suitability of the parameters for speaker comparison purposes, namely global Cllr, EER, and AUC values. These were interpreted while also taking into consideration the analysis of effect sizes. Overall, speech rate and articulation rate were found the most reliable parameters, displaying the largest effect sizes for the factor "speaker" and the best system performance outcomes, namely lowest Cllr, EER, and highest AUC values. Conversely, smaller effect sizes were found for the other parameters, which is compatible with a lower explanatory potential of the speaker identity on the duration of such units and a possibly higher linguistic control regarding their temporal variation. In addition, there was a tendency for speech timing estimates based on larger temporal intervals to present larger effect sizes and better speaker-discriminatory performance. Finally, identical twin pairs were found remarkably similar in their speech temporal patterns at the macro and micro levels while engaging in a dialogue, resulting in poor system discriminatory performance. Possible underlying factors for such a striking convergence in identical twins' speech timing patterns are presented and discussed.

Humpback whale song recordings suggest common feeding ground occupation by multiple populations.

Humpback whale males are known to sing on their low-latitude breeding grounds, but it is well established that songs are also commonly produced 'off-season' on the feeding grounds or during migration. This opens exciting opportunities to investigate migratory aggregations, study humpback whale behavioral plasticity and potentially even assign individual singers to specific breeding grounds. In this study, we analyzed passive acoustic data from 13 recording positions and multiple years (2011-2018) within the Atlantic sector of the Southern Ocean (ASSO). Humpback whale song was detected at nine recording positions in five years. Most songs were recorded in May, austral fall, coinciding with the rapid increase in sea ice concentration at most recording positions. The spatio-temporal pattern in humpback whale singing activity on Southern Ocean feeding grounds is most likely shaped by local prey availability and humpback whale migratory strategies. Furthermore, the comparative analyses of song structures clearly show a differentiation of two song groups, of which one was solely recorded at the western edge of the ASSO and the other song group was recorded throughout the ASSO. This new finding suggests a common feeding ground occupation by multiple humpback whale populations in the ASSO, allowing for cultural and potentially even genetic exchange among populations.

Improved Estimation of Parkinsonian Vowel Quality through Acoustic Feature Assimilation.

This paper investigated the performance of a number of acoustic measures, both individually and in combination, in predicting the perceived quality of sustained vowels produced by people impaired with Parkinson's disease (PD). Sustained vowel recordings were collected from 51 PD patients before and after the administration of the Levodopa medication. Subjective ratings of the overall vowel quality were garnered using a visual analog scale. These ratings served to benchmark the effectiveness of the acoustic measures. Acoustic predictors of the perceived vowel quality included the harmonics-to-noise ratio (HNR), smoothed cepstral peak prominence (CPP), recurrence period density entropy (RPDE), Gammatone frequency cepstral coefficients (GFCCs), linear prediction (LP) coefficients and their variants, and modulation spectrogram features. Linear regression (LR) and support vector regression (SVR) models were employed to assimilate multiple features. Different feature dimensionality reduction methods were investigated to avoid model overfitting and enhance the prediction capabilities for the test dataset. Results showed that the RPDE measure performed the best among all individual features, while a regression model incorporating a subset of features produced the best overall correlation of 0.80 between the predicted and actual vowel quality ratings. This model may therefore serve as a surrogate for auditory-perceptual assessment of Parkinsonian vowel quality. Furthermore, the model may offer the clinician a tool to predict who may benefit from Levodopa medication in terms of enhanced voice quality.

Surgical data recording in the operating room: a systematic review of modalities and metrics.

INTRODUCTION: Operating room recording, via video, audio and sensor-based recordings, is increasingly common. Yet, surgical data science is a new field without clear guidelines. The purpose of this study is to examine existing published studies of surgical recording modalities to determine which are available for use in the operating room, as a first step towards developing unified standards for this field. METHODS: Medline, EMBASE, CENTRAL and PubMed databases were systematically searched for articles describing modalities of data collection in the operating room. Search terms included 'video-audio media', 'bio-sensing techniques', 'sound', 'movement', 'operating rooms' and others. Title, abstract and full-text screening were completed to identify relevant articles. Descriptive statistical analysis was performed for included studies. RESULTS: From 3756 citations, 91 studies met inclusion criteria. These studies described 10 unique data-collection modalities for 17 different purposes in the operating room. Data modalities included video, audio, kinematic and eye-tracking among others. Data-collection purposes described included surgical trainee assessment, surgical error, surgical team communication and operating room efficiency. CONCLUSION: Effective data collection and utilization in the operating room are imperative for the provision of superior surgical care. The future operating room landscape undoubtedly includes multiple modalities of data collection for a plethora of purposes. This review acts as a foundation for employing operating room data in a way that leads to meaningful benefit for patient care.

Informed Consent and Informed Decision-Making in High-Risk Surgery: A Quantitative Analysis.

BACKGROUND: Informed consent is an ethical and legal requirement that differs from informed decision-making-a collaborative process that fosters participation and provides information to help patients reach treatment decisions. The objective of this study was to measure informed consent and informed decision-making before major surgery. STUDY DESIGN: We audio-recorded 90 preoperative patient-surgeon conversations before major cardiothoracic, vascular, oncologic, and neurosurgical procedures at 3 centers in the US and Canada. Transcripts were scored for 11 elements of informed consent based on the American College of Surgeons' definition and 9 elements of informed decision-making using Braddock's validated scale. Uni- and bivariate analyses tested associations between decision outcomes as well as patient, consultation, and surgeon characteristics. RESULTS: Overall, surgeons discussed more elements of informed consent than informed decision-making. They most frequently described the nature of the illness, the operation, and potential complications, but were less likely to assess patient understanding. When a final treatment decision was deferred, surgeons were more likely to discuss elements of informed decision-making focusing on uncertainty (50% vs 15%, p = 0.006) and treatment alternatives (63% vs 27%, p = 0.02). Conversely, when surgery was scheduled, surgeons completed more elements of informed consent. These results were not associated with the presence of family, history of previous surgery, location, or surgeon specialty. CONCLUSIONS: Surgeons routinely discuss components of informed consent with patients before high-risk surgery. However, surgeons often fail to review elements unique to informed decision-making, such as the patients' role in the decision, their daily life, uncertainty, understanding, or patient preference.

What symptoms tell us: A multiple case study of oncology consultations.

OBJECTIVES: While patients' symptom experiences have been widely investigated, there is a lack of contextualized studies investigating how symptoms circulate in the medical consultation, how patients present them, what they convey, how physicians respond, and how patients and physicians negotiate with each other to find ways to address them. The aim of this study is to explore patients and physicians handling of symptoms throughout oncological consultations with a multiple case study approach. METHODS: Five consultations, purposively selected from an existing dataset of audiotaped consultations with patients with advanced cancer, were analyzed by means of an inductive analytical approach based on a sensitive framework from the literature. RESULTS: Patients' symptoms showed multiple dimensions such as medical, cognitive, emotional, psychological, interactional, symbolic, experiential, and existential. SIGNIFICANCE OF RESULTS: Different symptom dimensions remained unnoticed and unaddressed in the consultations. The physician-centered symptom approach that was observed leads to consumed time and missed opportunities for relationship building with the patient. Physicians showed a lack of sensitivity regarding the multiple dimensions of symptoms. Based on the findings, strategies for a more comprehensive symptom approach can be conceived.

Evaluating relationships between lung cancer stigma, anxiety, and depressive symptoms and the absence of empathic opportunities presented during routine clinical consultations.

OBJECTIVE: Empathic communication in clinical consultations is mutually constructed, with patients first presenting empathic opportunities (statements communicating emotions, challenges, or progress) to which clinicians can respond. We hypothesized that lung cancer patients who did not present empathic opportunities during routine consultations would report higher stigma, anxiety, and depressive symptoms than patients who presented at least one. METHODS: Audio-recorded consultations between lung cancer patients (N = 56) and clinicians were analyzed to identify empathic opportunities. Participants completed questionnaires measuring sociodemographic and psychosocial characteristics. RESULTS: Twenty-one consultations (38 %) did not contain empathic opportunities. Unexpectedly, there was a significant interaction between presenting empathic opportunities and patients' race on disclosure-related stigma (i.e., discomfort discussing one's cancer; F = 4.49, p = .041) and anxiety (F = 8.03, p = .007). Among racial minority patients (self-identifying as Black/African-American, Asian/Pacific Islander, or other race), those who did not present empathic opportunities reported higher stigma than those who presented at least one (t=-5.47, p = .038), but this difference was not observed among white patients (t = 0.38, p = .789). Additional statistically significant findings emerged for anxiety. CONCLUSION: Disclosure-related stigma and anxiety may explain why some patients present empathic opportunities whereas others do not. PRACTICE IMPLICATIONS: Clinicians should intentionally elicit empathic opportunities and encourage open communication with patients (particularly from diverse racial backgrounds).

Elite athletes' experiences of musculoskeletal pain management using neuroanatomical dry needling: A qualitative study in Swedish track and field.

OBJECTIVES: To investigate how elite track and field athletes with a history of musculoskeletal pain (MSKP) describe their perceptions of clinical treatments based on dry needling guided by a neurological map (neuroanatomical dry needling (naDN)). DESIGN: Qualitative study. METHODS: In-depth interviews were conducted with eight elite Swedish track and field athletes (6 males, 2 females, median age 28.5) treated at a clinic specialised in MSKP management. All interviews were audio recorded and transcribed verbatim. The data were structured and analysed using a thematic method. RESULTS: The athletes approached clinical MSKP treatment from a performance-orientated perspective. They explained that they inevitably suffered MSKP episodes due to the intense physical demands of their sport. The use of naDN was considered an integral part of their sports practice and the study clinic's services were readily utilised when MSKP caused minor reductions in physical capacity. The athletes appreciated an unambiguous anatomical diagnosis, preferably supported by imaging scans, as this increased their confidence in clinical services. They valued the naDN treatment as it was perceived to provide fast-acting analgesia that enabled rapid return-to-play. These factors combined to reduce performance-related stress. CONCLUSIONS: Elite track and field athletes with a history of MSKP sought and appreciated clinical treatment with naDN largely because it provided fast-acting analgesia that enabled rapid return-to-play at a high-performance level. These athletes' expectations of MSKP diagnosis and management appear incongruent with current research indicating that MSKP sensitivity within the nervous system does not accurately reflect musculoskeletal tissue state or recovery following tissue damage.

Artificial intelligence for the measurement of vocal stereotypy.

Both researchers and practitioners often rely on direct observation to measure and monitor behavior. When these behaviors are too complex or numerous to be measured in vivo, relying on direct observation using human observers increases the amount of resources required to conduct research and to monitor the effects of interventions in practice. To address this issue, we conducted a proof of concept examining whether artificial intelligence could measure vocal stereotypy in individuals with autism. More specifically, we used an artificial neural network with over 1,500 minutes of audio data from 8 different individuals to train and test models to measure vocal stereotypy. Our results showed that the artificial neural network performed adequately (i.e., session-by-session correlation near or above .80 with a human observer) in measuring engagement in vocal stereotypy for 6 of 8 participants. Additional research is needed to further improve the generalizability of the approach.

Automatic Assessment of Cognitive Tests for Differentiating Mild Cognitive Impairment: A Proof of Concept Study of the Digit Span Task.

BACKGROUND: Current conventional cognitive assessments are limited in their efficiency and sensitivity, often relying on a single score such as the total correct items. Typically, multiple features of response go uncaptured. OBJECTIVES: We aim to explore a new set of automatically derived features from the Digit Span (DS) task that address some of the drawbacks in the conventional scoring and are also useful for distinguishing subjects with Mild Cognitive Impairment (MCI) from those with intact cognition. METHODS: Audio-recordings of the DS tests administered to 85 subjects (22 MCI and 63 healthy controls, mean age 90.2 years) were transcribed using an Automatic Speech Recognition (ASR) system. Next, five correctness measures were generated from Levenshtein distance analysis of responses: number correct, incorrect, deleted, inserted, and substituted words compared to the test item. These per-item features were aggregated across all test items for both Forward Digit Span (FDS) and Backward Digit Span (BDS) tasks using summary statistical functions, constructing a global feature vector representing the detailed assessment of each subject's response. A support vector machine classifier distinguished MCI from cognitively intact participants. RESULTS: Conventional DS scores did not differentiate MCI participants from controls. The automated multi-feature DS-derived metric achieved 73% on AUC-ROC of the SVM classifier, independent of additional clinical features (77% when combined with demographic features of subjects); well above chance, 50%. CONCLUSION: Our analysis verifies the effectiveness of introduced measures, solely derived from the DS task, in the context of differentiating subjects with MCI from those with intact cognition.

Estimation of Parkinson's disease severity using speech features and extreme gradient boosting.

In recent years, there is an increasing interest in building e-health systems. The systems built to deliver the health services with the use of internet and communication technologies aim to reduce the costs arising from outpatient visits of patients. Some of the related recent studies propose machine learning-based telediagnosis and telemonitoring systems for Parkinson's disease (PD). Motivated from the studies showing the potential of speech disorders in PD telemonitoring systems, in this study, we aim to estimate the severity of PD from voice recordings of the patients using motor Unified Parkinson's Disease Rating Scale (UPDRS) as the evaluation metric. For this purpose, we apply various speech processing algorithms to the voice signals of the patients and then use these features as input to a two-stage estimation model. The first step is to apply a wrapper-based feature selection algorithm, called Boruta, and select the most informative speech features. The second step is to feed the selected set of features to a decision tree-based boosting algorithm, extreme gradient boosting, which has been recently applied successfully in many machine learning tasks due to its generalization ability and speed. The feature selection analysis showed that the vibration pattern of the vocal fold is an important indicator of PD severity. Besides, we also investigate the effectiveness of using age and years passed since diagnosis as covariates together with speech features. The lowest mean absolute error with 3.87 was obtained by combining these covariates and speech features with prediction level fusion. Graphical Abstract Framework for the proposed UPDRS estimation model.

Evaluation of train and test performance of machine learning algorithms and Parkinson diagnosis with statistical measurements.

Parkinson's disease is a neurological disorder that causes partial or complete loss of motor reflexes and speech and affects thinking, behavior, and other vital functions affecting the nervous system. Parkinson's disease causes impaired speech and motor abilities (writing, balance, etc.) in about 90% of patients and is often seen in older people. Some signs (deterioration of vocal cords) in medical voice recordings from Parkinson's patients are used to diagnose this disease. The database used in this study contains biomedical speech voice from 31 people of different age and sex related to this disease. The performance comparison of the machine learning algorithms k-Nearest Neighborhood (k-NN), Random Forest, Naive Bayes, and Support Vector Machine classifiers was performed with the used database. Moreover, the best classifier was determined for the diagnosis of Parkinson's disease. Eleven different training and test data (45 × 55, 50 × 50, 55 × 45, 60 × 40, 65 × 35, 70 × 30, 75 × 25, 80 × 20, 85 × 15, 90 × 10, 95 × 5) were processed separately. The data obtained from these training and tests were compared with statistical measurements. The training results of the k-NN classification algorithm were generally 100% successful. The best test result was obtained from Random Forest classifier with 85.81%. All statistical results and measured values are given in detail in the experimental studies section.Graphical abstract.

Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System.

Importance: Evidence-based care plans can fail when they do not consider relevant patient life circumstances, termed contextual factors, such as a loss of social support or financial hardship. Preventing these contextual errors can reduce obstacles to effective care. Objective: To evaluate the effectiveness of a quality improvement program in which clinicians receive ongoing feedback on their attention to patient contextual factors. Design, Setting, and Participants: In this quality improvement study, patients at 6 Department of Veterans Affairs outpatient facilities audio recorded their primary care visits from May 2017 to May 2019. Encounters were analyzed using the Content Coding for Contextualization of Care (4C) method. A feedback intervention based on the 4C coded analysis was introduced using a stepped wedge design. In the 4C coding schema, clues that patients are struggling with contextual factors are termed contextual red flags (eg, sudden loss of control of a chronic condition), and a positive outcome is prospectively defined for each encounter as a quantifiable improvement of the contextual red flag. Data analysis was performed from May to October 2019. Interventions: Clinicians received feedback at 2 intensity levels on their attention to patient contextual factors and on predefined patient outcomes at 4 to 6 months. Main Outcomes and Measures: Contextual error rates, patient outcomes, and hospitalization rates and costs were measured. Results: The patients (mean age, 62.0 years; 92% male) recorded 4496 encounters with 666 clinicians. At baseline, clinicians addressed 413 of 618 contextual factors in their care plans (67%). After either standard or enhanced feedback, they addressed 1707 of 2367 contextual factors (72%), a significant difference (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .01). In a mixed-effects logistic regression model, contextualized care planning was associated with a greater likelihood of improved outcomes (adjusted odds ratio, 2.5; 95% CI, 1.5-4.1; P < .001). In a budget analysis, estimated savings from avoided hospitalizations were $25.2 million (95% CI, $23.9-$26.6 million), at a cost of $337 242 for the intervention. Conclusions and Relevance: These findings suggest that patient-collected audio recordings of the medical encounter with feedback may enhance clinician attention to contextual factors, improve outcomes, and reduce hospitalizations. In addition, the intervention is associated with substantial cost savings.