Has telemedicine come to fruition? Parents' and pediatricians' perceptions and preferences regarding telemedicine.

BACKGROUND: Telemedicine has increasingly become a viable option for patient care and may increase access to care. The aim of our study was to evaluate both parent and pediatrician perceptions, preferences, and acceptability regarding the use of different telemedicine modalities. METHODS: We conducted a cross-sectional survey of both parents and pediatricians in Geneva, Switzerland in 2021. The questionnaire focused on digital literacy, preferences, acceptability, advantages, and disadvantages regarding telemedicine (phone, email, video, and instant message). Descriptive statistics and comparisons of preferences and perceptions (Pearson Chi2 and logistic regression) were performed. RESULTS: Two hundred and twenty-two parents and 45 pediatricians participated. After face-to-face consultations, parents and pediatricians preferred the phone for simple medical advice, discussion of parameters, acute or chronic problems, and psychological support. Email was preferred for communication of results and prescription renewal. Main reasons for using telemedicine were avoiding travel and saving time. Disadvantages were lack of physical examination, technical problems, and unsuitability of the reason for consultation. CONCLUSIONS: Understanding the factors that influence acceptance and satisfaction with telemedicine is vital for its successful implementation. Convenience, quality of care, trust, strong pediatrician-parent relationships, technical reliability, user-friendliness, and privacy considerations play significant roles in shaping parent and pediatrician attitudes toward telemedicine. IMPACT: The COVID-19 pandemic spurred the expansion of the use of telemedicine in pediatric care. Few studies have addressed parent and pediatrician perceptions and preferences regarding telemedicine. Both parents and pediatricians consider certain telemedicine modalities (phone, email, video, and instant message) pertinent in only specific clinical situations. Advantages of telemedicine outweigh disadvantages with parents and pediatricians appreciating the increased access to care, time savings, and avoiding transport. However, the lack of a physical examination remains a significant disadvantage. Convenience, quality of care, trust, strong pediatrician-parent relationship, technical reliability, user-friendliness, and privacy considerations play significant roles in shaping attitudes towards telemedicine.

Does it make sense to use written instruments to assess communication skills? Systematic review on the concurrent and predictive value of written assessment for performance.

OBJECTIVES: To evaluate possible associations between learners' results in written and performance-based assessments of communication skills (CS), either in concurrent or predictive study designs. METHODS: Search included four databases for peer-reviewed studies containing both written and performance-based CS assessment. Eleven studies met the inclusion criteria. RESULTS: Included studies predominantly assessed undergraduate medical students. Studies reported mainly low to medium correlations between written and performance-based assessment results (Objective Structured Clinical Examinations or encounters with simulated patients), and gave correlation coefficients ranging from 0.13 to 0.53 (p < 0.05). Higher correlations were reported when specific CS, like motivational interviewing were assessed. Only a few studies gave sufficient reliability indicators of both assessment formats. CONCLUSIONS: Written assessment scores seem to predict performance-based assessments to a limited extent but cannot replace them entirely. Reporting of assessment instruments' psychometric properties is essential to improve the interpretation of future findings and could possibly affect their predictive validity for performance. PRACTICE IMPLICATIONS: Within longitudinal CS assessment programs, triangulation of assessment including written assessment is recommended, taking into consideration possible limitations. Written assessments with feedback can help students and trainers to elaborate on procedural knowledge as a strong support for the acquisition and transfer of CS to different contexts.

What do we know about written assessment of health professionals' communication skills? A scoping review.

OBJECTIVE: The aim of this scoping review was to investigate the published literature on written assessment of communication skills in health professionals' education. METHODS: Pubmed, Embase, Cinahl and Psychnfo were screened for the period 1/1995-7/2020. Selection was conducted by four pairs of reviewers. Four reviewers extracted and analyzed the data regarding study, instrument, item, and psychometric characteristics. RESULTS: From 20,456 assessed abstracts, 74 articles were included which described 70 different instruments. Two thirds of the studies used written assessment to measure training effects, the others focused on the development/validation of the instrument. Instruments were usually developed by the authors, often with little mention of the test development criteria. The type of knowledge assessed was rarely specified. Most instruments included clinical vignettes. Instrument properties and psychometric characteristics were seldom reported. CONCLUSION: There are a number of written assessments available in the literature. However, the reporting of the development and psychometric properties of these instruments is often incomplete. Practice implications written assessment of communication skills is widely used in health professions education. Improvement in the reporting of instrument development, items and psychometrics may help communication skills teachers better identify when, how and for whom written assessment of communication should be used.

Assessing communication skills during OSCE: need for integrated psychometric approaches.

BACKGROUND: Physicians' communication skills (CS) are known to significantly affect the quality of health care. Communication skills training programs are part of most undergraduate medical curricula and are usually assessed in Objective Structured Clinical Examinations (OSCE) throughout the curriculum. The adoption of reliable measurement instruments is thus essential to evaluate such skills. METHODS: Using Exploratory Factor Analysis (EFA), Multi-Group Confirmatory Factor Analysis (MGCFA) and Item Response Theory analysis (IRT) the current retrospective study tested the factorial validity and reliability of a four-item global rating scale developed by Hodges and McIlroy to measure CS among 296 third- and fourth-year medical students at the Faculty of Medicine in Geneva, Switzerland, during OSCEs. RESULTS: EFA results at each station showed good reliability scores. However, measurement invariance assessments through MGCFA across different stations (i.e., same students undergoing six or three stations) and across different groups of stations (i.e., different students undergoing groups of six or three stations) were not satisfactory, failing to meet the minimum requirements to establish measurement invariance and thus possibly affecting reliable comparisons between students' communication scores across stations. IRT revealed that the four communication items provided overlapping information focusing especially on high levels of the communication spectrum. CONCLUSIONS: Using this four-item set in its current form it may be difficult to adequately differentiate between students who are poor in CS from those who perform better. Future directions in best-practices to assess CS among medical students in the context of OSCE may thus focus on (1) training examiners so to obtain scores that are more coherent across stations; and (2) evaluating items in terms of their ability to cover a wider spectrum of medical students' CS. In this respect, IRT can prove to be very useful for the continuous evaluation of CS measurement instruments in performance-based assessments.

General principles to consider when designing a clinical communication assessment program.

OBJECTIVES: Assessment of clinical communication helps teachers in healthcare education determine whether their learners have acquired sufficient skills to meet the demands of clinical practice. The aim of this paper is to give input to educators when planning how to incorporate assessment into clinical communication teaching by building on the authors' experience and current literature. METHODS: A summary of the relevant literature within healthcare education is discussed, focusing on what and where to assess, how to implement assessment and how to choose appropriate methodology. RESULTS: Establishing a coherent approach to teaching, training, and assessment, including assessing communication in the clinical context, is discussed. Key features of how to implement assessment are presented including: establishing a system with both formative and summative approaches, providing feedback that enhances learning and establishing a multi-source and longitudinal assessment program. CONCLUSIONS: The implementation of a reliable, valid, credible, feasible assessment method with specific educational relevance is essential for clinical communication teaching. PRACTICE IMPLICATIONS: All assessment methods have strengths and limitations. Since assessment drives learning, assessment should be aligned with the purpose of the teaching program. Combining the use of different assessment formats, multiple observations, and independent measurements in different settings is advised.

A teaching skills assessment tool inspired by the Calgary-Cambridge model and the patient-centered approach.

OBJECTIVE: The aim of this study was to develop a descriptive tool for peer review of clinical teaching skills. Two analogies framed our research: (1) between the patient-centered and the learner-centered approach; (2) between the structures of clinical encounters (Calgary-Cambridge communication model) and teaching sessions. METHOD: During the course of one year, each step of the action research was carried out in collaboration with twelve clinical teachers from an outpatient general internal medicine clinic and with three experts in medical education. The content validation consisted of a literature review, expert opinion and the participatory research process. Interrater reliability was evaluated by three clinical teachers coding thirty audiotaped standardized learner-teacher interactions. RESULTS: This tool contains sixteen items covering the process and content of clinical supervisions. Descriptors define the expected teaching behaviors for three levels of competence. Interrater reliability was significant for eleven items (Kendall's coefficient p<0.05). CONCLUSION: This peer assessment tool has high reliability and can be used to facilitate the acquisition of teaching skills.

[Computers in the consultation: can we stay patient-centered?]. / L'ordinateur en consultation: peut-on rester centré sur le patient?

Eletronic health records (EHR) are now part of most medical practices in many countries including Switzerland. Their use facilitates access and exchange of information among health professionals, improves the quality of medical care and decreases the number of medical errors. Even patients express their satisfaction with the use of EHR. However, it has been observed that use of EHR can modify patient-physician communication. The present article describes the different elements linked to EHR which can enhance or inhibit patient-physician communication. It also suggests strategies for improving it.

[Driving ability: how not to lose control?]. / Aptitude au volant: comment ne pas perdre les pédales?

Any primary care doctor should be able to decide on the fitness to drive of a given patient. The issue of an older driver, patients addicted to alcohol or drugs, under current psychotropic drug treatment, or diabetic, is discussed in the light of legal provisions and current recommendations. This article also discusses aspects associated with neurological, cardiac and orthopedic issues.

Interpreter-mediated diabetes consultations: a qualitative analysis of physician communication practices.

BACKGROUND: Patient-provider communication, in particular physicians' ability to listen to their patients, and support them in making difficult lifestyle changes, is an essential component of effective diabetes care. Clinical communication around diabetes can be especially challenging when language barriers are present, and may contribute to poor diabetes management and outcomes. Clinicians need to be aware of and address potential communication difficulties associated with interpreter-mediated consultations. The purpose of our study was to explore how physicians communicate in interpreter-mediated consultations with diabetic patients, and how their communication behaviors may impact diabetes communication and care. METHOD: We analyzed transcripts from 8 audio recorded, outpatient consultations at the Basel University Hospital general medicine outpatient clinic involving Turkish-speaking patients, German-speaking physicians, and Turkish-German interpreters (both community interpreters and family members). RESULTS: Clinicians used closed questions when asking about symptoms and glucose control. When providing information and explanation, they spoke in long and complex speech turns. They often directed their speech to interpreters or became sidetracked by family members' questions or requests for information. Patients' participation in the consultation was minimal, and limited to brief answers to clinicians' questions. CONCLUSIONS: Clinicians need to be aware of common pitfalls that diminish patient-centeredness during interpreter-mediated consultations, and learn strategies to avoid them. Attention to established guidelines on triadic communication is recommended, as is hands-on training with interpreters.

Including patients in resuscitation decisions in Switzerland: from doing more to doing better.

BACKGROUND: Decisions regarding Cardio-Pulmonary Resuscitation (CPR) and Do Not Attempt Resuscitation (DNAR) orders remain demanding, as does including patients in the process. OBJECTIVES: To explore physicians' justification for CPR/DNAR orders and decisions regarding patient inclusion, as well as their reports of how they initiated discussions with patients. METHODS: We administered a face-to-face survey to residents in charge of 206 patients including DNAR and CPR orders, with or without patient inclusion. RESULTS: Justifications were provided for 59% of DNAR orders and included severe comorbidity, patients and families' resuscitation preferences, patients' age, or poor prognosis or quality of life. Reasons to include patients in CPR/DNAR decisions were provided in 96% and 84% of cases, and were based on respect for autonomy, clinical assessment of the situation as not too severe, and the view that such inclusion was required. Reasons for not including patients were offered in 84% of cases for CPR and in 70% for DNAR. They included absent decision-making capacity, a clinical situation viewed as good (CPR) or offering little hope of recovery (DNAR), barriers to communication, or concern that discussions could be emotionally difficult or superfluous. Decisions made earlier in the patient's management were infrequently viewed as requiring revision. Residents reported a variety of introductions to discussions with patients. CONCLUSIONS: These results provide better understanding of reasons for CPR/DNAR decisions, reasons for patient inclusion or lack thereof, and ways in which such inclusion is initiated. They also point to potential side-effects of implementing CPR/DNAR recommendations without in-depth and practical training. This should be part of a regular audit and follow-up process for such recommendations.

Self-assessed competency at working with a medical interpreter is not associated with knowledge of good practice.

BACKGROUND: Specific knowledge and skills are needed to work effectively with an interpreter, but most doctors have received limited training. Self-assessed competency may not accurately identify training needs. PURPOSES: The purpose of this study is to explore the association between self-assessed competency at working with an interpreter and the ability to identify elements of good practice, using a written vignette. METHODS: A mailed questionnaire was sent to 619 doctors and medical students in Geneva, Switzerland. RESULTS: 58.6% of respondents considered themselves to be highly competent at working with a professional interpreter, but 22% failed to mention even one element of good practice in response to the vignette, and only 39% could name more than one. There was no association between self-rated competency and number of elements mentioned. CONCLUSIONS: Training efforts should challenge the assumption that working with an interpreter is intuitive. Evaluation of clinicians' ability to work with an interpreter should not be limited to self-ratings. In the context of large-scale surveys, written vignettes may provide a simple method for identifying knowledge of good practice and topics requiring further training.

Self-assessment of intercultural communication skills: a survey of physicians and medical students in Geneva, Switzerland.

BACKGROUND: Physicians working with multicultural populations need to know how to elicit the patient's understanding of the illness; determine the patient's sociocultural context and identify any issues that might affect care; communicate effectively across patient-provider social and cultural differences; and collaborate effectively with an interpreter. Skills self-assessment can contribute to identifying training needs and monitoring skills development in these areas. METHODS: As part of a larger study exploring the knowledge, attitudes and practices of Geneva physicians and medical students regarding the care of immigrant patients, we asked respondents to self-rate their ability to perform a range of common yet challenging intercultural communication tasks. RESULTS: Overall, respondents rated themselves less competent at intercultural tasks than at basic medical skills and less competent at specific intercultural communication skills than at general intercultural skills. Qualified doctors (as opposed to students), those with greater interest in caring for immigrants, and those who rarely encountered difficulties with immigrants rated themselves significantly more competent for all clinical tasks. Having a higher percentage of immigrant patients and previous cultural competence training predicted greater self-rated intercultural communication skills. CONCLUSION: Our self-assessment results suggest that students and physicians should be provided with the opportunity to practice intercultural skills with immigrant patients as part of their cultural competence training. To strengthen the validity of self-assessment measures, they should ideally be combined with more objective methods to assess actual skills.

[General internal medicine: important articles about ambulatory care published in 2010]. / Médecine interne générale: articles importants pour la pratique ambulatoire en 2010.

This review of articles published in 2010 covers the new role of dabigatran in atrial fibrillation, the lack of efficacy on pain of chondroïtine/ glucosamine in knee arthrosis, the risk of thrombosis with antipsychotics, the increase cardiovascular risk in case of migraine with aura and the insufficient prescription of adjuvant chemotherapy in elderly with colon cancer. Authors also highlight public health topics such as the association of poor oral hygiene and increased cardiovascular risk, the positive effect of opioid substitution therapy by primary care practitioners on mortality, the high frequency of prenatal violence on pregnant women and the negative impact of financial constraint on the risk of hospitalization.

Reduction of missed appointments at an urban primary care clinic: a randomised controlled study.

BACKGROUND: Missed appointments are known to interfere with appropriate care and to misspend medical and administrative resources. The aim of this study was to test the effectiveness of a sequential intervention reminding patients of their upcoming appointment and to identify the profile of patients missing their appointments. METHODS: We conducted a randomised controlled study in an urban primary care clinic at the Geneva University Hospitals serving a majority of vulnerable patients. All patients booked in a primary care or HIV clinic at the Geneva University Hospitals were sent a reminder 48 hrs prior to their appointment according to the following sequential intervention: 1. Phone call (fixed or mobile) reminder; 2. If no phone response: a Short Message Service (SMS) reminder; 3. If no available mobile phone number: a postal reminder. The rate of missed appointment, the cost of the intervention, and the profile of patients missing their appointment were recorded. RESULTS: 2123 patients were included: 1052 in the intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded at the clinic. The sequential intervention significantly reduced the rate of missed appointments: 11.4% (n = 122) in the control group and 7.8% (n = 82) in the intervention group (p < 0.005), and allowed to reallocate 28% of cancelled appointments. It also proved to be cost effective in providing a total net benefit of 1846. - EUR/3 months. A satisfaction survey conducted with 241 patients showed that 93% of them were not bothered by the reminders and 78% considered them to be useful. By multivariate analysis, the following characteristics were significant predictors of missed appointments: younger age (OR per additional decade 0.82; CI 0.71-0.94), male gender (OR 1.72; CI 1.18-2.50), follow-up appointment >1 year (OR 2.2; CI: 1.15-4.2), substance abuse (2.09, CI 1.21-3.61), and being an asylum seeker (OR 2.73: CI 1.22-6.09). CONCLUSION: A practical reminder system can significantly increase patient attendance at medical outpatient clinics. An intervention focused on specific patient characteristics could further increase the effectiveness of appointment reminders.

Measuring physicians' and medical students' attitudes toward caring for immigrant patients.

It is generally believed that culturally competent clinical practice depends in part on the development of positive attitudes toward the care of immigrant patients. However, few tools exist to measure such attitudes in physicians. The authors operationalized ''culturally competent attitudes'' to include a high level of interest in caring for immigrant patients, an acceptance of the responsibility of doctors and hospitals to adapt to immigrant patients' needs, and the opinion that understanding the patient's psychosocial context is particularly important when caring for immigrant patients. The authors then assessed these attitudes and opinions among a sample of 619 Geneva doctors and medical students using a self-administered questionnaire and explored their association to respondents' personal characteristics and professional experience. The authors found that both personal characteristics and professional experience were associated with attitudes toward caring for immigrant patients. In particular, the perceived importance of understanding the psychosocial context when caring for migrants was higher among medical students, women, Swiss nationals, those with greater interest in caring for immigrant patients and those who had received training in cultural competence. However, it is unclear whether cultural competence training and clinical context lead to the development of more positive attitudes or whether medical students and physicians who already have positive attitudes are more likely to participate in such training.

Use of a computer-based simulated consultation tool to assess whether doctors explore sociocultural factors during patient evaluation.

RATIONALE, AIMS AND OBJECTIVES: The delivery of patient-centred care to diverse populations requires that doctors identify sociocultural factors that may affect care. We adapted a computer-based simulated consultation tool and tested its utility for assessing whether doctors explore sociocultural factors during a patient evaluation, and whether they include such information in their case conclusions and follow-up recommendations. METHODS: We developed two detailed patient 'stories' that involved sociocultural issues that doctors needed to identify and consider for adequate clinical management. They were incorporated into an existing 'Virtual Internet Patient Simulation' (VIPS) program designed to test clinical reasoning skills. Doctors and medical students (n = 618) were invited to access the program via Internet. For each consultation, participants were assigned a sociocultural score, corresponding to the number of sociocultural domains explored. Scores were then compared with subjective ratings of participants' performance by expert doctors. RESULTS: 118 respondents completed at least one virtual consultation (19%), 92 conducted both. The mean number of sociocultural dimensions explored by doctors (i.e. sociocultural score) was 3.9 (standard deviation 2.6) for case 1, and 5.2 (standard deviation 2.3) for case 2. The two sociocultural scores were moderately correlated (Spearman r = 0.65, P < 0.001). Sociocultural scores correlated positively with experts' subjective ratings of participants' performance (Spearman r = 0.84 for case 1 and 0.78 for case 2, both P < 0.001). CONCLUSIONS: The adapted computer-based simulated consultation tool provided a feasible means to assess doctors' exploration of sociocultural issues during a clinical evaluation. Further validation of this method should be conducted by comparing VIPS results with other skills assessment methods such as objective structured clinical examination or direct observation of clinical performance.

[Interprofessional training: a key component of integrated care]. / Formation interprofessionnelle: une exigence pour une approche intégrée des soins?

The aging of the population and the rising prevalence of chronic diseases mandate improved collaboration among different health professionals. Interprofessional training is one way to improve it, because it encourages health professionals to learn with, from and about one another and respects the integrity and contribution of each profession. Few medical or health professional schools develop such dimensions in their curricula, while postgraduate and continuous training seldom offer such opportunities. Institutional and political commitment may significantly contribute to the development of such dimensions in medical and other health profession education. Having a same mission, sharing responsibility for the team success, defining clear member roles and task, and communicating on a routine basis represent other key factors of success.

Pain management in a medical walk-in clinic: link between recommended processes and pain relief.

BACKGROUND: While most recommended pain management practices have been developed for hospitalised patients, little is known about their relevance for ambulatory patients presenting with acute pain. OBJECTIVE: In this study, we explored the relationship between patients' reported use of recommended pain management practices and pain relief in outpatients. METHOD: 703 adult patients who presented with pain at the medical walk-in clinic of the University Hospitals of Geneva, Switzerland, were included in a mailed cross-sectional survey. They completed a self-administered questionnaire with specific items on self reports of pain and pain management processes. MAIN OUTCOME MEASURES: Patient's self reports on pain and pain management processes. RESULTS: Of the 703 patients presenting with pain, 40% reported complete pain relief after their visit at the medical walk-in clinic. After adjustment for age, sex, origin, general health and intensity of pain, patients' self-report of complete pain relief was associated with availability of medical doctors (OR = 5.6; 95% CI 2.1-14.7 for excellent vs. poor availability), availability of nurses (OR = 2.6; 95% CI 1.2-6.0 for excellent vs. poor availability), waiting < 10 min for pain medication (OR = 4.6; 95% CI 2.2-9.8), regular assessment of pain (OR = 1.7; 95% CI 1.02-2.7) and having received information about pain and its management (OR = 3.0; 95% CI 1.8-4.9). CONCLUSIONS: Self-reported pain relief was associated with more frequent use of recommended pain management processes. These recommendations initially developed for hospitalized patients should also be encouraged for ambulatory care patients.