Internists' ambivalence toward their role in health counseling and promotion: A qualitative study on the internists' beliefs and attitudes.

Crucial to its success is that physicians enhance their competence in Lifestyle Medicine and take on their role as Health Advocates in Health Counseling and Promotion (HC&P). However, studies on patients' views of lifestyle counseling in clinical practice demonstrate that many patients neither perceived a need to adopt a healthy lifestyle nor having had any discussion with their physician about their lifestyle. This study is part of a participatory action research project focusing on identifying areas of improvement for health promotion in the practice of internists. Within this project, we interviewed 28 internists from six different subspecialties of an academic medical center in the Netherlands. This study aims to gain insight into how internists understand their role in HC&P by a qualitative analysis of their beliefs and attitudes in the interview data. Participants claimed that promoting a healthy lifestyle is important. However, they also reflected a whole system of beliefs that led to an ambivalent attitude toward their role in HC&P. We demonstrate that little belief in the success of HC&P nurtured ambivalence about the internists' role and their tasks and responsibilities. Ambivalence appeared to be reinforced by beliefs about the ability and motivation of patients, the internists' motivational skills, and the patient-doctor relationship, and by barriers such as lack of time and collaboration with General Practitioners. When participants viewed HC&P as a part of their treatment and believed patients were motivated, they were less ambivalent about their role in HC&P. Based on our data we developed a conceptual framework that may inform the development of the competences of the Health Advocate role of internists in education and practice.

Effects on patient-reported outcomes of "Screening of Distress and Referral Need" implemented in Dutch oncology practice.

PURPOSE: This study investigated the effect of the "Screening for Distress and Referral Need" (SDRN) process (completing a screening instrument; patient-caregiver discussion about the patient's responses, regardless of distress level, and possible referral to specialized care), implemented in Dutch oncology practice on patient-reported outcomes (PROs). METHODS: A non-randomized time-sequential study was conducted to compare two cohorts. Cohort 1 respondents (C1) were recruited before and cohort 2 respondents (C2) after SDRN implementation in nine Dutch hospitals. Participants completed the EORTC-QLQ-C30, HADS, Patient Satisfaction Questionnaire-III, and the Distress Thermometer and Problem List (DT&PL). Descriptive analyses and univariate tests were conducted. RESULTS: C2 respondents (N = 422, response = 54%) had significantly lower mean scores on the practical (t = 2.3; p = 0.02), social (t = 2.3; p = 0.03), and emotional PL domains (t = 2.9; p = 0.004) compared with C1 (N = 518, response = 53%). No significant differences were found on quality of life, anxiety, depression, satisfaction with care, distress level, the spiritual and physical PL domains, or on referral wish. CONCLUSIONS: After implementation of SDRN, patients report significantly fewer psychosocial (practical, social, and emotional) problems on the DT/PL but responses on the other patient-reported outcomes were comparable. These results add to the mixed evidence on the beneficial effect of distress screening. More and better focused research is needed.

[The bad-news consultation: 10 tips]. / Het slechtniewsgesprek: 10 tips.

A bad-news conversation often evokes strong emotions in a patient and those close to her or him. These emotions may inhibit mental processing of additional information. During a bad-news conversation, you should therefore not only provide information, but also help your patient to cope with these emotions and provide support. All this is necessary if your patient is to come to well-considered decisions in consultation with you.

Cancer patients' experiences with and opinions on the process 'Screening of Distress and Referral Need' (SDRN) in clinical practice: A quantitative observational clinical study.

OBJECTIVE: This observational clinical study investigated patients' experiences with and opinions on the Dutch 'Screening of Distress and Referral Need' (SDRN) process implemented in oncology practice. Insight into these can guide improvement of the SDRN process. METHODS: Patients from hospitals that had implemented SDRN for at least a year completed questions on experiences with essential SDRN process steps (1: completion of the Distress Thermometer and Problem List as screening instrument (DT&PL), 2: information on SDRN+DT&PL, 3: information on referral options, 4: discussing DT&PL responses, 5: referral when needed), and on opinions about SDRN and DT&PL. Descriptive and univariate analyses were conducted. RESULTS: Of the 498 participants (response = 54%), 81% completed a DT&PL, of whom 86-87% was exposed to steps 2-3 and 76% discussed responses; only three needing care were not offered referral. Sixty-one percent encountered all SDRN steps and 78% would recommend SDRN to others. Recommending SDRN is related to more frequent DT&PL completion (t = -2.5; p≤0.01), receipt of information on SDRN+DT&PL and referral options (X2 = 4.9; p≤0.05 and X2 = 5.9; p≤0.05 respectively), discussion of responses (X2 = 10.2; p≤0.001), and fuller exposure to SDRN process steps (X2 = 14.8; p≤0.01). Percentages (strongly) agreeing were highest on the DT&PL being useful (90%) and suitable (88%), and lowest on burdensome (31%) and time-consuming (28%). CONCLUSION: The majority of participating patients encountered the steps of the SDRN process considered essential, with 3/5 having encountered all steps. Referral is largely targeted to patients' need. Patients' perceived benefit of SDRN increases with fuller exposure to all process steps. Therefore, improvements, particularly in DT&PL completion and discussion of responses should be made.

Internists' dilemmas in their interactions with chronically ill patients; A comparison of their interaction strategies and dilemmas in two different medical contexts.

BACKGROUND: Internists appear to define productive interactions, key concept of the Chronic Care Model, as goal-directed, catalyzed by achieving rapport, and depending on the medical context: i.e. medically explained symptoms (MES) or medically unexplained symptoms (MUS). OBJECTIVE: To explore internists' interaction strategy discourses in the context of MES and MUS. METHODS: We interviewed twenty internists working in a Dutch academic hospital, identified relevant text fragments in the interview transcripts and analyzed the data based on a discourse analysis approach. RESULTS: We identified four interaction strategy discourses: relating, structuring, exploring, and influencing. Each was characterized by a dilemma: relating by 'creating nearness versus keeping distance'; structuring by 'giving space versus taking control'; exploring by 'asking for physical versus psychosocial causes'; and influencing by 'taking responsibility versus accepting a patient's choice. The balance sought in these dilemmas depended on whether the patient's symptoms were medically explained or unexplained (MES or MUS). Towards MUS the internists tended to maintain greater distance, take more control, ask more cautiously questions related to psychosocial causes, and take less responsibility for shared decision making. DISCUSSION AND CONCLUSIONS: Adopting a basic distinction between MES and MUS, the internists in our study appeared to seek a different balance in each of four rather fundamental clinical dilemmas. Balancing these dilemmas seemed more difficult regarding MUS where the internists seemed more distancing and controlling, and tended to draw on their medical expertise. Moving in this direction is counterproductive and in contradiction to guidelines which emphasize that MUS patients warrant emotional support requiring a shift towards interpersonal, empathic communication.

Education on organ donation and transplantation in primary school; teachers' support and the first results of a teaching module.

Organ and tissue donation can also involve children. Because of its sensitivity, this topic requires careful decision making. Children have the ability to carefully reflect on this subject and enjoy participating in family discussions about it. Therefore, what children need is proper information. When schools are used to educate children about this subject, information about teacher support for this type of lesson along with its effects on the depth of family discussions is important. METHODS: A questionnaire was sent to all 7,542 primary schools in the Netherlands. The goal was to gather information on teachers' perspectives about a neutral lesson devoted to organ and tissue donation, and also on the best age to start giving such a lesson. The second part of our study examined the effects of a newly developed lesson among 269 primary school pupils. The school response was 23%. Of these, 70% were positive towards a lesson; best age to start was 10-11 years. Pupils reported 20% more family discussions after school education and enjoyed learning more about this topic. There is significant support in primary schools for a school lesson on organ and tissue donation. Educational programs in schools support family discussions.

Supervisors' and residents' patient-education competency in challenging outpatient consultations.

OBJECTIVES: We compared supervisors' and residents' patient-education competency in challenging consultations in order to establish whether supervisors demonstrate sufficient patient-education competency to act credibly as role models and coaches for residents. METHODS: All consultations conducted at one, two, or three of the outpatient clinics of each of the participating physicians were videoed. Each participant selected two challenging consultations from each clinic for assessment. We assessed their patient-education competency using the CELI instrument, we calculated net consultation length for all videoed consultations and we measured patient opinion about the patient education received using a questionnaire. RESULTS: Forty-four residents and fourteen supervisors participated in the study. They selected 230 consultations for assessment. On average, supervisors and residents demonstrated similar patient-education competency. Net consultation length was longer for supervisors. Patient opinion did not differ between supervisors and residents. CONCLUSIONS: Supervising consultants generally do not possess sufficient patient-education competency to fulfill their teaching roles in workplace-based learning that is aimed at improving residents' patient-education competency. PRACTICE IMPLICATIONS: Not only residents but also supervising consultants should improve their patient-education competency. Workplace-based learning consisting of self-assessment of and feedback on videoed consultations could be useful in attaining this goal.

Transcutaneous electrical nerve stimulation as an additional treatment for women suffering from therapy-resistant provoked vestibulodynia: a feasibility study.

INTRODUCTION: The current approach to women with provoked vestibulodynia (PVD) comprises a multidimensional, multidisciplinary therapeutic protocol. As PVD is considered to be a chronic pain disorder, transcutaneous electrical nerve stimulation (TENS) can be used as an additional therapy for women with otherwise therapy-resistant PVD. AIMS: The aims of this study were to evaluate whether TENS has a beneficial effect on vulvar pain, sexual functioning, and sexually-related personal distress in women with therapy-resistant PVD and to assess the effect of TENS on the need for vestibulectomy. METHODS: A longitudinal prospective follow-up study was performed on women with therapy-resistant PVD who received additional domiciliary TENS. Self-report questionnaires and visual analog scales (VASs) were completed at baseline (T1), post-TENS (T2), and follow-up (T3). MAIN OUTCOME MEASURES: Vulvar pain, sexual functioning, and sexually-related personal distress were the main outcome measures. RESULTS: Thirty-nine women with therapy-resistant PVD were included. Mean age was 27 ± 5.6 years (range: 19 to 41); mean duration between TENS and T3 follow-up was 10.1 ± 10.7 months (range: 2 to 32). Vulvar pain VAS scores directly post-TENS (median 3.4) and at follow-up (median 3.2) were significantly (P < 0.01) lower than at baseline (median 8.0). Post-TENS, sexual functioning scores on the Female Sexual Functioning Index questionnaire had improved significantly (P = 0.2); these scores remained stable at follow-up. Sexually-related personal distress scores had improved significantly post-TENS (P = 0.01). Only 4% of the women who received TENS needed to undergo vestibulectomy vs. 23% in our previous patient population. CONCLUSION: The addition of self-administered TENS to multidimensional treatment significantly reduced the level of vulvar pain and the need for vestibulectomy. The long-term effect was stable. These results not only support our hypothesis that TENS constitutes a feasible and beneficial addition to multidimensional treatment for therapy-resistant PVD, but also the notion that PVD can be considered as a chronic pain syndrome.

Effects of communication styles on marital satisfaction and distress of parents of pediatric cancer patients: a prospective longitudinal study.

OBJECTIVE: The aim of this study was to examine the longitudinal effects of communication styles on marital satisfaction and distress of parents of children treated for cancer. METHODS: Marital dissatisfaction (Maudsley Marital Questionnaire), intimacy, avoidance, destructive and incongruent communication (Communication Skills Inventory) and psychological distress (General Health Questionnaire) were assessed in 115 parents of pediatric cancer patients shortly after diagnosis (T1) and 5 years later (T2). RESULTS: Only mothers' marital dissatisfaction increased significantly over time. No gender differences in dissatisfaction were found. Mothers had a significantly higher lack of intimacy score than fathers. All T1 communication styles were significantly univariately related to fathers' and mothers' T2 marital dissatisfaction, while not to T2 distress. Mothers' T1 marital dissatisfaction accounted for 67% and fathers' for 12% in the explained variance of T2 dissatisfaction. T1 destructive communication uniquely affected fathers' T2 marital dissatisfaction and T1 avoidant communication that of mothers. CONCLUSIONS: Five years after cancer diagnosis in their children, the quality of parents' marital relationships seemed largely unchanged. Parents' use of communication skills at diagnosis appeared to have limited effect on their marital dissatisfaction and no effect on their distress 5 years later. While avoidant communication seemed indicative of mothers' marital distress, fathers' seemed affected by destructive communication.

[Unexpected good news after major surgery: a lesson in communication]. / Onverwacht goed nieuws na ingrijpende operatie: een les in communicatie.

When dealing with choices concerning life-threatening or major surgery shared decision making, continuous tuning in with colleagues and monitoring direction is a necessity. The gastroenterologist detected a pancreatic tumour in a 53-year-old man. The patient was told that this tumour was almost surely malignant and that he would die within a year. A pylorus-preserving pancreatoduodenectomy was advised and performed. However, the final outcome was an IgG4-mediated autoimmune pancreatitis. The patient felt betrayed by the doctors. Crucial episodes of communication were analysed and we concluded the following. First, in decision-making on life and death, most doctors unconsciously assume a paternalistic attitude, which is not always preferred by the patient. Second, excessive emotional distress of the patient impedes counselling. Third, even in a case of perceived medical urgency, most patients should be allowed some time for reflection. Finally, multidisciplinary consultation may lead to an indistinct ownership of responsibilities by the doctors.

The effects of self-assessment and supervisor feedback on residents' patient-education competency using videoed outpatient consultations.

OBJECTIVES: To determine the effects of residents' communication self-assessment and supervisor feedback on residents' communication-competency awareness, on their patient-education competency, and on their patients' opinion. METHODS: The program consisted of the implementation of a communication self-assessment and feedback process using videoed outpatient consultations (video-CAF). Residents wrote down communication learning objectives during the instruction and after each video-CAF session. Residents' patient-education competency was assessed by trained raters, using the CELI instrument. Participating patients completed a questionnaire about the contact with their physician. RESULTS: Forty-four residents and 21 supervisors participated in 87 video-CAF sessions. After their first video-CAF session, residents wrote down more learning objectives addressing their control and rapport skills and their listening skills. Video-CAF participation improved residents' patient-education competency, but only in their control and rapport skills. Video-CAF participation had no effect on patients' opinion. CONCLUSIONS: Video-CAF appears to be a feasible procedure and might be effective in improving residents' patient-education competency in clinical practice. PRACTICE IMPLICATIONS: Video-CAF could fill the existing deficiency of communication training in residency programs.

Estudio exploratorio en línea sobre las opiniones de los padres respecto de la donación de órganos: de las decisiones individuales a las conversaciones en familia / An online explorative study towards parents' opinions about organ donation: from individual decisions to family discussions

Introducción. Muchos factores influyen sobre las decisiones de los padres acerca de la donación de órganos de sus hijos. Uno de tantos factores puede ser una conversación previa en un contexto no crítico. La pregunta que surge es si los padres han considerado este tema con respecto a ellos mismos y si han hablado del tema entre sí o con sus hijos. Métodos. Encuesta exploratoria inicial realizada a través de Internet para investigar estas charlas, las opiniones de los padres sobre brindar clases en la escuela acerca de la donación, el umbral de edad para que un niño decida respecto de la donación y los factores determinantes que influyen en estos aspectos. Se envió el cuestionario a 14 000 miembros del panel. Se seleccionó a los encuestados que tenían hijos menores de 16 años. Resultados. La tasa de respuesta del cuestionario fue del 35%. De los 1146 encuestados con hijos, el 84% habían conversado sobre este tema con su pareja y, en promedio, el 46,5% habían conversado con sus hijos de 10 a 16 años de edad. No se halló una relación con la religión y el nivel educativo de los padres. El 69% de los padres tuvieron una opiniónpositiva acerca de dar clases en la escuela sobre la donación de órganos. A la mayoría de los niños se les permitió decidir por sí mismos a los 15-16 años. Conclusión. Las conversaciones en familia sobre la donación son frecuentes entre los miembros de la pareja, sin embargo, es posible mejorar las charlas con los niños. Si se quisiera, podrían ofrecerse factores desencadenantes de estas conversaciones a través de la información pública y de la enseñanza, lo que también ayudaría a educar sobre esta cuestión de salud.

Background: Parental decisions about organ donation by their child are influenced by many factors. One of these factors may be a previous discussion under non-crisis circumstances. The question then arises whether parents have thought about this topic for themselves and discussed it with each other or with their child. Methods: An initial exploratory Internet survey to explore these discussions, parental opinions about school lessons on donation, the age threshold for a child to decide about donation, and determinants that influence these aspects. Questionnaire was sent to 14,000panel members. We selected respondents with children younger than 16 years old. Results: Questionnaire response rate was 35%. Of all 1146 respondents with children, 84% had discussed the topic with their partner and, on average, 46.5% had discussed this with their child aged 10-16 years old. Religion and educational level of the parents were not related. Sixty-nine percent of parents were positive towards school lessons. Most of the children were allowed to decide for themselves at the age of 15/16 years old. Conclusion: Family discussions between spouses about donation do occur frequently, however, discussion with children can be improved. If desired, triggers for beginning these conversations could be provided through public information and school education, which would also contribute to health literacy on this subject.

An online explorative study towards parents' opinions about organ donation: from individual decisions to family discussions.

BACKGROUND: Parental decisions about organ donation by their child are influenced by many factors. One of these factors may be a previous discussion under non-crisis circumstances. The question then arises whether parents have thought about this topic for themselves and discussed it with each other or with their child. METHODS: An initial exploratory Internet survey to explore these discussions, parental opinions about school lessons on donation, the age threshold for a child to decide about donation, and determinants that influence these aspects. Questionnaire was sent to 14,000 panel members. We selected respondents with children younger than 16 years old. RESULTS: Questionnaire response rate was 35%. Of all 1146 respondents with children, 84% had discussed the topic with their partner and, on average, 46.5% had discussed this with their child aged 10-16 years old. Religion and educational level of the parents were not related. Sixty-nine percent of parents were positive towards school lessons. Most of the children were allowed to decide for themselves at the age of 15/16 years old. CONCLUSION: Family discussions between spouses about donation do occur frequently, however, discussion with children can be improved. If desired, triggers for beginning these conversations could be provided through public information and school education, which would also contribute to health literacy on this subject.

Inconsistency of residents' communication performance in challenging consultations.

OBJECTIVE: Communication performance inconsistency between consultations is usually regarded as a measurement error that jeopardizes the reliability of assessments. However, inconsistency is an important phenomenon, since it indicates that physicians' communication may be below standard in some consultations. METHODS: Fifty residents performed two challenging consultations. Residents' communication competency was assessed with the CELI instrument. Residents' background in communication skills training (CST) was also established. We used multilevel analysis to explore communication performance inconsistency between the two consultations. We also established the relationships between inconsistency and average performance quality, the type of consultation, and CST background. RESULTS: Inconsistency accounted for 45.5% of variance in residents' communication performance. Inconsistency was dependent on the type of consultation. The effect of CST background training on performance quality was case specific. Inconsistency and average performance quality were related for those consultation combinations dissimilar in goals, structure, and required skills. CST background had no effect on inconsistency. CONCLUSION: Physician communication performance should be of high quality, but also consistent regardless of the type and complexity of the consultation. PRACTICE IMPLICATIONS: In order to improve performance quality and reduce performance inconsistency, communication education should offer ample opportunities to practice a wide variety of challenging consultations.

How to attain expertise in clinical communication?

Several factors complicate the attainment of expertise in clinical communication. Medical curricula and postgraduate training insufficiently provide the required learning conditions of deliberate practice to overcome these obstacles. In this paper we provide recommendations for learning objectives and teaching methods for the attainment of professional expertise in patient education. Firstly, we propose to use functional learning objectives derived from the goals and strategies of clinical communication. Secondly, we recommend using teaching and assessment methods which: (1) contain stimulating learning tasks with opportunities for immediate feedback, reflection and corrections, and (2) give ample opportunity for repetition, gradual refinements and practice in challenging situations. Video-on-the-job fits these requirements and can be used to improve the competency in patient education of residents and medical staff in clinical practice. However, video-on-the-job can only be successful if the working environment supports the teaching and learning of communication and if medical staff which supervises the residents, is motivated to improve their own communication and didactic skills.

Education in patient-physician communication: how to improve effectiveness?

OBJECTIVE: Despite educational efforts expertise in communication as required by the CanMEDS competency framework is not achieved by medical students and residents. Several factors complicate the learning of professional communication. METHODS: We adapted the reflective-impulsive model of social behaviour to explain the complexities of learning professional communication behaviour. We formulated recommendations for the learning objectives and teaching methods of communication education. Our recommendations are based on the reflective-impulsive model and on the model of deliberate practice which complements the reflective-impulsive model. Our recommendations are substantiated by those we found in the literature. RESULTS: The reflective-impulsive model explains why the results of communication education fall below expectations and how expertise in communication can be attained by deliberate practice. The model of deliberate practice specifies learning conditions which are insufficiently fulfilled in current communication programmes. CONCLUSION: The implementation of our recommendations would require a great deal of effort. Therefore we doubt whether expertise in professional communication can be fully attained during medical training. PRACTICE IMPLICATIONS: We propose that the CanMEDS communication competencies not be regarded as endpoints in medical education but as guidelines to improve communication competency through deliberate practice throughout a professional career.

Children as donors: a national study to assess procurement of organs and tissues in pediatric intensive care units.

A shortage of size-matched organs and tissues is the key factor limiting transplantation in children. Empirical data on procurement from pediatric donors is sparse. This study investigated donor identification, parental consent, and effectuation rates, as well as adherence to the national protocol. A national retrospective cohort study was conducted in all eight Dutch pediatric intensive care units. Records of deceased children were analyzed by an independent donation officer. Seventy-four (11%) of 683 deceased children were found to be suitable for organ donation and 132 (19%) for tissue donation. Sixty-two (84%) potential organ donors had been correctly identified; the parental consent and effectuation rate was 42%. Sixty-three (48%) potential tissue donors had been correctly identified; the parental consent and effectuation rate was 27%. Correct identification increased with age (logistic regression, organs: P = .024; tissues: P = .011). Although an overall identification rate of 84% of potential organ donors may seem acceptable, the variation observed suggests room for improvement, as does the overall low rate of identification of pediatric tissue donors. Efforts to address the shortage of organs and tissues for transplantation in children should focus on identifying potential donors and on the reasons why parents do not consent.

Key factors in paediatric organ and tissue donation: an overview of literature in a chronological working model.

There is a growing shortage of size-matched organs and tissues for children. Although examples of substandard care are reported in the literature, there is no overview of the paediatric donation process. The aim of the study is to gain insight into the chain of events, practices and procedures in paediatric donation. Method; a survey of the 1990-2010 literature on paediatric organ and tissue donation and categorization into a coherent chronological working model of key events and procedures. Studies on paediatric donation are rare. Twelve empirical studies were found, without any level I or level II-1 evidence. Seventy-five per cent of the studies describe the situation in the United States. Literature suggests that the identification of potential donors and the way in which parental consent is requested may be substandard. We found no literature discussing best practices. Notwithstanding the importance of looking at donation care as an integrated process, most studies discuss only a few isolated topics or sub-processes. To improve paediatric donation, more research is required on substandard factors and their interactions. A chronological working model, as presented here, starting with the identification of potential donors and ending with aftercare, could serve as a practical tool to optimize paediatric donation.

Children's opinions about organ donation: a first step to assent?

BACKGROUND: Parents have to decide about organ donation after the death of their child. Although most parents probably would like to respect their child's intentions, parents often are not aware of their child's wishes. This requires insight into children's opinions about donation. METHODS: An internet survey that investigated whether Dutch children in the age range of 12 through 15 years had heard about organ donation, what their opinions were on donation and whether the topic had been discussed at home. Questionnaire response rate 38%. RESULTS: Around 99% of 2016 responders had heard about organ donation and about the possibility of becoming a donor, 75% preferred to decide for themselves about donation, 43% had discussed organ donation more than once at home, 66% were willing to donate. The willingness to donate was positively associated with age and socio-economic status. CONCLUSION: This survey indicates that these children at 12 through 15 years of age are capable and willing to think about organ donation. Thought should be given about how to raise awareness and how to enable parents and children to develop some sort of health literacy concerning the concept of organ donation. Children and their parents should be given adequate opportunities to receive appropriate information, suited to their psychological and moral developmental status.