Physicians criticizing physicians to patients.

BACKGROUND: Teamwork is critical to providing excellent healthcare, and effective communication is essential for teamwork. Physicians often discuss patient referrals from other physicians, including referrals from outside their primary institution. Sharing conflicting information or negative judgments of other physicians to patients may be unprofessional. Poor teamwork within healthcare systems has been associated with patient mortality and lower staff well-being. OBJECTIVE: This analysis explored how physicians talk to patients with advanced cancer about care rendered by other physicians. DESIGN: Standardized patients (SPs) portraying advanced lung cancer attended covertly recorded visits with consenting oncologists and family physicians. PARTICIPANTS: Twenty community-based oncologists and 19 family physicians had encounters with SPs. APPROACH: Physician comments about care by other physicians were extracted from transcriptions and analyzed qualitatively. These comments were categorized as Supportive or Critical. We also examined whether there were differences between physicians who provide supportive comments and those who provided critical comments. KEY RESULTS: Fourteen of the 34 encounters (41 %) included in this analysis contained a total of 42 comments about the patient's previous care. Twelve of 42 comments (29 %) were coded as Supportive, twenty-eight (67 %) as Critical, and two (4 %) as Neutral. Supportive comments attributed positive qualities to another physician or their care. Critical comments included one specialty criticizing another and general lack of trust in physicians. CONCLUSION: This study described comments by physicians criticizing other physicians to patients. This behavior may affect patient satisfaction and quality of care. Healthcare system policies and training should discourage this behavior.

Improving identification and management of partner violence: examining the process of academic detailing: a qualitative study.

BACKGROUND: Many physicians do not routinely inquire about intimate partner violence. PURPOSE: This qualitative study explores the process of academic detailing as an intervention to change physician behavior with regard to intimate partner violence (IPV) identification and documentation. METHOD: A non-physician academic detailer provided a seven-session modular curriculum over a two-and-a-half month period. The detailer noted written details of each training session. Audiotapes of training sessions and semi-structured exit interviews with each physician were recorded and transcribed. Transcriptions were qualitatively and thematically coded and analyzed using Atlas ti®. RESULTS: All three study physicians reported increased clarity with regard to the scope of their responsibility to their patients experiencing IPV. They also reported increased levels of comfort in the effective identification and appropriate documentation of IPV and the provision of ongoing support to the patient, including referrals to specialized community services. CONCLUSION: Academic detailing, if presented by a supportive and knowledgeable academic detailer, shows promise to improve physician attitudes and practices with regards to patients in violent relationships.

Instructional curriculum improves medical staff knowledge and efficacy for patients experiencing intimate partner violence.

OBJECTIVES: This study assesses Veterans Affairs mental health providers' understanding of intimate partner violence (IPV) and the perception of patient benefit of routine inquiry and service referral. The impact of an instructional curriculum was also examined following an interactive training. METHODS: An evidence-based curriculum was offered to Veterans Affairs mental health providers. The curriculum utilized didactic methods, case scenarios, and resources regarding referrals and statutes regarding crimes related to violence and abuse. The participants completed pre- and post-training surveys to assess their perceptions about IPV and to evaluate the training. RESULTS: Seventy-three individuals completed the training. Fifty-four of the participants were female, and thirty-three were over the age of 45 years. Fifty-one individuals completed both surveys. There were no differences between participants' views of the seriousness of IPV in the community or their practices before or after the training. However, participants scored significantly higher on the knowledge and efficacy measures after the training (p < 0.001). CONCLUSION: Following an educational intervention, providers demonstrate more knowledge and efficacy regarding routine inquiry and referral for IPV. Barriers to universal implementation still warrant attention.

Empathy and boundary turbulence in cancer communication.

OBJECTIVES: To describe and deepen our understanding of patient-centeredness, empathy, and boundary management in challenging conversations. Previous studies show frequent physician self-disclosure, while empathy and boundary management are infrequent. METHODS: Three standardized patients (SPs) portrayed cancer patients consulting a new community-based physician, resulting in 39 audio-recorded SP visits to 19 family physicians and 20 medical oncologists. Transcripts underwent qualitative iterative thematic analysis, informed by grounded theory, followed by directed content analysis. We further defined the identified communicative categories with descriptive and correlational calculations. RESULTS: We identified patient-centered physician response categories--empathy, affirmation, and acknowledgement; and physician-centered categories-transparency, self-disclosure, and projection. Acknowledgement and affirmation responses were frequent and empathy rare. Physician transparency and self-disclosure were common. Useful and not useful self-disclosures were highly correlated; empathy, useful and not useful transparency, and projection were moderately correlated. Most physicians used self-disclosure but few of these were judged patient-centered. CONCLUSIONS: Physicians expressing empathy and patient-centered transparency were also more likely to use projection and physician-centered transparency, thus engaging in communication "boundary turbulence." Patients may benefit from physicians' improved use of empathy and boundary management.

Medical inquiry for intimate partner violence as reported by women in a shelter.

The purpose of this study was to review medical inquiry rates for intimate partner violence (IPV). A review was carried out of year 2003 intake documentation at an IPV shelter. We reviewed self-reported 1) medical inquiry about partner abuse, 2) physician awareness of IPV, and 3) helpfulness of physician contact for women who sought care from either a primary care provider or an emergency medicine provider. Charts were reviewed for 89.3% of shelter residents from the year 2003. The self-report survey was completed by 49.5% of these shelter residents. Thirty-eight percent of the respondents reported that medical providers were unaware of their abusive relationship. Twenty-two percent of the respondents sought medical care after their last episode of partner abuse. Seventy-two percent of all those seeking care were asked if their injuries were due to abuse; 71% of those who sought medical care specifically in an emergency department were asked if their injuries were due to abuse. Thirty-two percent of respondents who had a primary care provider were asked about partner abuse during office visits. Sixty-six percent of all respondents who sought care after their last episode of partner abuse thought the medical care they received was helpful. Medical inquiry for IPV after an episode of partner abuse occurred for the majority of shelter residents who sought care in an emergency department, whereas inquiry for IPV among primary care providers at routine visits remained low.

Intimate partner violence resource materials: assessment of information distribution.

OBJECTIVE: To determine the educational impact of placing partner violence resource information in a medical setting. METHOD: A cross-sectional study with a structured interview. SETTING: Emergency department (ED) in an urban academic medical center. PARTICIPANTS: adult patients and visitors. INTERVENTIONS: Educational materials and community resource information. RESULTS: 51 patients and 71 visitors (N = 122) met the inclusion criteria and consented to enrollment during a 2-week study period. Of the participants, 71% were female and 29% were male. Sixty-five (53%) of the participants noticed the literature or cards. Ten (8%) read the materials. Seven (6%) retained a copy of the literature. Nineteen (16%) of the participants acknowledged knowing someone who could benefit from the information. Nine (7%) revealed that some of the information was new to them. CONCLUSIONS: Placing intimate partner violence resource pamphlets and cards in a medical setting is one means of educating the community and promoting violence prevention.

Improving coordinated responses for victims of intimate partner violence: law enforcement compliance with state-mandated intimate partner violence documentation.

New York State law mandates specific intimate partner violence (IPV) documentation under all circumstances meeting the enumerated relationship and crime criteria at the scene of a domestic dispute. Law enforcement compliance with this mandate is unknown. We reviewed law enforcement completion rates of Domestic Violence Incident Reports (DVIRs) and assessed correlations with individual or legal factors. Law enforcement officers filed DVIRs in 54% of the cases (n = 191), more often when injury occurred (p < .01) and the defendant had prior court contact (p < .05). The discussion explores policy implications and potential means to rectify the gap between mandated processes and implementation.

Protection order petitioners' health care utilization.

Little work has explored the extent to which female victims of intimate partner violence use medical and legal services. In this cross-sectional study of a sample of women seeking orders of protection at family court (N = 95), we report descriptive, self-report data on health care utilization and insurance coverage. Although 85% of the petitioners had private or public health insurance, 39% reported delayed medical care, and 14% had not obtained medical care of any kind. The response to address interpersonal violence victimization should attempt to connect women using the courts with needed health care services.

Missed opportunities for interval empathy in lung cancer communication.

BACKGROUND: Empathy is important in patient-physician communication and is associated with improved patient satisfaction and adherence to physicians' recommendations. METHODS: To evaluate empathic opportunities and physician responses, we conducted a qualitative thematic analysis of 20 audiorecorded, transcribed consultations between patients with lung cancer and their thoracic surgeons or oncologists, from a larger observational study of 137 patients in a Veterans Affairs hospital in the southern United States. Using qualitative analysis, we collaboratively developed themes and subthemes until saturation. Then, each transcript was coded, using grounded theory methods, until consensus was achieved, counting and sequentially analyzing patient empathic opportunities and physician responses. RESULTS: Subthemes regarding patients' statements about lung cancer included (1) morbidity or mortality concerns, (2) cancer-related symptoms, (3) relationship to smoking, (4) decisions about treatment, (5) beliefs about or mistrust of medical care, (6) factors limiting ability to treat cancer, and (7) confusion regarding cancer status and treatment. We identified 384 empathic opportunities and found that physicians had responded empathically to 39 (10%) of them. Otherwise, physicians provided little emotional support, often shifting to biomedical questions and statements. We defined this phenomenon as missed opportunities for "interval empathy." When empathy was provided, 50% of these statements occurred in the last one-third of the encounter, whereas patients' concerns were evenly raised throughout the encounter. CONCLUSIONS: Physicians rarely responded empathically to the concerns raised by patients with lung cancer, and empathic responses that did occur were more frequently in the last third of the encounter. Our results may provide a typologic approach to help physicians recognize empathic opportunities and with further development may aid in improving physicians' communication skills.

Structured practice opportunities with a mnemonic affect medical student interviewing skills for intimate partner violence.

BACKGROUND: Low rates of partner violence inquiry and detection are reported in the medical setting. PURPOSE: To determine if a teaching module with a mnemonic improves interviewing skills. METHOD: Prospective randomized trial. A total of 43 medical students were assigned to either the intervention group (teaching module with guided discussion and practice highlighting use of a mnemonic) or the control group (general discussion and provision of the mnemonic at the end of the session). These students subsequently interviewed simulated patients. RESULTS: A total of 75% of the intervention group and 62% of the control group reported the mnemonic was helpful. A total of 68% of the intervention group and 45% of the control group asked a direct question about partner violence. Students who obtained a history of abuse consistently asked direct, nonjudgmental question(s). CONCLUSIONS: Students learn to perform desired interviewing skills more frequently when they have the benefit of guided discussion, practice, and memory aids.

Family perspective of medical care and grief support after field termination by emergency medical services personnel: a preliminary report.

OBJECTIVE: To determine the acceptance by family members regarding nontransport of patients in cardiac arrest following unsuccessful resuscitation occurring in private residences. METHODS: This was a survey with a structured telephone interview. Inclusion criteria included adult patients in asystolic nontraumatic cardiac arrest. The setting was an urban multitiered emergency medical services (EMS) system. Termination of field resuscitation efforts was authorized by an emergency medicine physician at a medical control base station after set protocol criteria. Support services were provided by trained personnel. RESULTS: Thirty-three follow-up interviews were completed with a family member. Thirty-two (97%) of the contacted family members expressed satisfaction with the services provided by EMS personnel. Twenty-one (64%) patients were not transported to the hospital. All 21 family members of the nontransported were satisfied with both the medical care and the emotional support provided by EMS. Additionally, family members of three of the 12 (25%) transported patients stated they would have preferred to have the patient die at home instead of being transported. CONCLUSIONS: In this small sample, family members accept the nontransport of patients by trained EMS personnel after asystolic nontraumatic cardiac arrest occurring in private residences. This may positively impact emergency department resources for other critically ill patients.

Pilot educational outreach project on partner violence.

BACKGROUND: To assess the impact of a multimodal educational outreach on physician screening and documentation of intimate partner violence (IPV) in primary care. METHODS: Pre- and post-intervention assessment of physician screening and chart documentation of IPV. Physician screening was assessed by post-visit survey of patients and documentation was assessed by medical record review. SETTING: Three medical offices in an urban community of approximately 1 million. PARTICIPANTS: Three primary care physicians (one internist, one obstetrician, and one family physician) and 100 patients from each of these practices. INTERVENTIONS: Multimodal educational outreach to physicians and their office staff regarding appropriate screening and management of IPV. A trained IPV educator made periodic office visits in 2002 to educate the physician and office staff regarding appropriate screening and management of IPV. RESULTS: Before the intervention, 36/150 (24%) of sample patients reported having been previously asked about IPV and 24/150 (16%) reported being asked in a written format. After the intervention, 100/149 (67%) and 41/108(28%) reported being asked verbally or in writing, respectively. CONCLUSIONS: This pilot study of three physicians suggests educational outreach represents a promising and feasible means of improving physician screening and documentation of IPV in primary care.