Emotional, cognitive and social factors of antimicrobial prescribing: can antimicrobial stewardship intervention be effective without addressing psycho-social factors?

There is increasing evidence that psycho-social factors can influence antimicrobial prescribing practice in hospitals and the community, and represent potential barriers to antimicrobial stewardship interventions. Clinicians are conditioned both by emotional and cognitive factors based on fear, uncertainty, a set of beliefs, risk perception and cognitive bias, and by interpersonal factors established through social norms and peer and doctor-patient communication. However, a gap is emerging between research and practice, and no stewardship recommendation addresses the most appropriate human resource allocation or modalities to account for psycho-social determinants of prescribing. There is a need for translation of the evidence available from human behaviour studies to the design and implementation of stewardship interventions and policies at hospital and community levels. The integration of behaviour experts into multidisciplinary stewardship teams seems essential to positively impact on prescribers' communication and decision-making competencies, and reduce inappropriate antibiotic prescribing.

Cardiovascular assessment of supportive doctor-patient communication using multi-scale and multi-lag analysis of heartbeat dynamics.

Emphatic doctor-patient communication has been associated with improved psycho-physiological well-being involving cardiovascular and neuroendocrine responses. Nevertheless, a comprehensive assessment of heartbeat linear and nonlinear dynamics throughout the communication of a life-threatening disease has not been performed yet. To this extent, we studied linear heartbeat dynamics through the extraction of time-frequency domain measurements, as well as heartbeat nonlinear and complex dynamics through novel approaches to compute multi-scale and multi-lag series analyses: namely, the multi-scale distribution entropy and lagged Poincaré plot symbolic analysis. Heart rate variability series were recorded from 54 healthy female subjects who were blind to the aim of the experiment. Participants were randomly assigned into two groups: 27 subjects watched a video where an oncologist discloses the diagnosis of a cancer metastasis to a patient, whereas the remaining 27 watched the same video including four additional supportive comments by the clinician. Considering differences between the beginning and the end of each communication video, results from non-parametric Wilcoxon tests demonstrated that, at a group level, significant differences occurred in heartbeat linear and nonlinear dynamics, with lower complexity during nonsupportive communication. Furthermore, a support vector machine algorithm, validated using a leave-one-subject-out procedure, was able to discern the supportive experience at a single-subject level with an accuracy of 83.33% when nonlinear features were considered, dropping to 51.85% when using standard HRV features only. In conclusion, heartbeat nonlinear and complex dynamics can be a viable tool for the psycho-physiological evaluation of supportive doctor-patient communication. Graphical Abstract Scheme of the three main stages of the study: signal acquisition during doctor-patient communication, ECG signal processing and pattern recognition results.

Characterization of doctor-patient communication using heartbeat nonlinear dynamics: A preliminary study using Lagged Poincaré Plots.

Emphatic doctor-patient communication has been associated with an improved psycho-physiological well-being involving cardiovascular and neuroendocrine responses. Nevertheless, a comprehensive assessment of heartbeat linear and nonlinear/complex dynamics throughout the communication of a life-threatening disease has not been performed yet. To this extent, we here study heart rate variability (HRV) series gathered from 17 subjects while watching a video where an oncologist discloses the diagnosis of a cancer metastasis to a patient. Further 17 subjects watched the same video including additional affective emphatic contents. For the assessment of the two groups, linear heartbeat dynamics was quantified through measures defined in the time and frequency domains, whereas nonlinear/complex dynamics referred to measures of entropy, and combined Lagged Poincare Plots (LPP) and symbolic analyses. Considering differences between the beginning and the end of the video, results from non-parametric statistical tests demonstrated that the group watching emphatic contents showed HRV changes in the LF/HF ratio exclusively. Conversely, the group watching the purely informative video showed changes in vagal activity (i.e., HF power), LF/HF ratio, as well as LPP measures. Additionally, a Support Vector Machine algorithm including HRV nonlinear/complex information was able to automatically discern between groups with an accuracy of 76.47%. We therefore propose the use of heartbeat nonlinear/complex dynamics to objectively assess the empathy level of healthy women.

Asking questions during breast cancer consultations: does being alone or being accompanied make a difference?

PURPOSE: Companions often accompany patients to cancer consultations. The number of questions asked by patients and companions is an indicator of their active participation. The present study aims to provide first descriptive evidence on the characteristics of unaccompanied and accompanied Italian breast cancer patients that attend the first consultation after surgery and to analyse companions contribution to the type and quantity of questions asked during the consultation. METHOD: Seventy consultations of female patients with breast cancer were audio taped. Questions were transcribed and coded by content. Companion's questions were also classified in terms of function. Socio-demographic and clinical data, patients' role preference and confidence in decision making measures were gathered for each patient. Post consultation satisfaction with decision and the perceived level of shared decision making were collected either for the patient and the companion. RESULTS: 69% of patients were accompanied, usually by one close family member, either husband or adult child. Non employed or retired patients and those with a preference for passive role in decision making were more likely to be accompanied. Unaccompanied patients and accompanied patients had comparable levels of anxiety, emotional distress and depression and were equally active in asking questions. These levels were far greater than those reported for other cancer patients in the literature. Companions did not increase significantly the number of questions per consultation. CONCLUSION: Accompanied and non accompanied patients differed more in socio-demographic than clinical characteristics. Companions sustained the patient and shared information without reducing the level of patient involvement.

People-centred care: new research needs and methods in doctor-patient communication. Challenges in mental health.

Communication in psychiatry is nowadays called to create bridges between different levels of observation (biological, functional and relational levels) and therapeutic intervention (social and educational) with important implications for therapeutic practice and communication research in the mental health context. New research challenges and windows of opportunity for therapeutic practice will be addressed in this contribution, as they relate to the three main tasks that psychiatrists have to meet when talking with their patients: understanding patient's problems and concerns; establishing the therapeutic alliance by acknowledging and responding to patient's emotion; informing and involving patients and their families, when appropriate. Therapeutic decisions need the elaboration of valid strategies of shared decision-making, which still have to be implemented and adapted to psychiatric context. Moreover, in the research field, emerging biomarker research may contribute to better explain what makes the difference in an empathic relationship either in terms of psycho-physiological reactions and in brain changes. Finally, the influence of new technologies and of Internet has to be more and more considered during clinical consultations.

The evaluation of training in patient-centred interviewing skills for psychiatric residents.

BACKGROUND: Communication skills are considered 'core skills' in the curriculum of psychiatry but studies evaluating the effectiveness of a time-limited training course in interviewing skills in psychiatry have remained rare. The aim was to assess the effectiveness of training in patient-centred interviewing on the interview performance of psychiatric residents. METHOD: Psychiatric residents (n=10) each interviewed 12 different anonymized standardized patients (SPs), eight before and another four after training. SPs simulated psychiatric out-patients who attended for a first visit to the psychiatric out-patient clinic. The consultations were videotaped, transcribed and coded with a classification scheme developed for psychiatric consultations from which an interview performance index was derived. An interrupted time-series design and a segmented regression analysis with multilevel analysis explored the performance trend within the series of consultations. RESULTS: The regression model evidenced a horizontal slope at pre- and post-training, with a significant level change. These findings excluded the presence of a practice effect and indicated a significant effect of training. Performance variability between and within residents over the series of consultations increased at post-training. CONCLUSIONS: The training improved patient-centred interviewing performance. More post-training exercise time and supervised practice are necessary to establish consistent performance patterns at a higher skill level.

Decisional strategies for the attribution of emotional distress in primary care.

BACKGROUND: In primary care the General Health Questionnaire (GHQ) is used to provide an independent assessment of probable caseness of psychological disorder against which to test the ability of the general practitioner (GP) to recognize patients with current emotional problems. METHOD: The aim of the present study was to identify those clinical and psychosocial data on patients that increase the likelihood of GPs' attribution of emotional distress (GP model) and those that predict patients' emotional distress as defined by the GHQ-12 (GHQ model). The associations were explored using a classification tree technique (CHAID) and compared using bivariate logistic regression. Six GPs and 444 primary care patients took part. RESULTS: The accuracy indices of the hierarchical GP and GHQ models were 72% and 69% respectively. The availability of information on patients' psychopharmacological and psychiatric/psychological treatment in the last year was the most important predictor of attribution. Occupational, financial and housing problems and life events of loss were the most important predictors of the GHQ-12 case definition. The overall accuracy of the bivariate model was 73%. Compared with the GHQ-12, GPs gave significantly more importance to psychiatric treatment, psychopharmacological drug use and chronic illness. CONCLUSIONS: The findings suggest that to improve the detection of current emotional distress in primary care patients GPs should pay foremost and systematic attention to social problems and recent life events of loss. These problems are important clues for the possible presence of emotional distress, whereas critical patient data, in particular psychiatric history and psychopharmacological treatment, increase the probability of attribution errors.

Differences in verbal behaviours of patients with and without emotional distress during primary care consultations.

BACKGROUND: In primary care consultations patients with emotional distress tend to give verbal cues or symptom reports with psychological or psychiatric contents. This study examined the cue behaviour defined not only by psychological, but also by medical, social and life episodes related contents in patients with and without emotional distress, recognized and not by their GP. The GP's verbal behaviour in relation to patients' cue emission was also investigated. METHOD: For the six participating GPs two groups of matched pairs of patients (N = 238) were created. The two groups comprised either patients considered by GPs as being without emotional distress or patients considered as emotionally distressed. Within each pair, one patient was a case (GHQ-12 score > 2) and the other was the matched control (GHQ-12 score < 3). The medical interviews with these patients were transcribed and classified according to the Verona Medical Interview Classification System (VR-MICS). RESULTS: GHQ positive patients of both groups gave more cues in terms of total proportion than their matched controls (GHQ negative patients). The proportion of cues given by patients was related also to GP's verbal behaviour, increasing with closed psychosocial questions and decreasing with the use of active interview techniques. Attribution of emotional distress was more frequent when patients were high attenders and had a past psychiatric history. The content of cues changed in relation to GP's attribution: recognized patients gave more cues and more often with psychological content, patients not recognized as distressed gave mainly cues related to their lifestyle and life episodes. CONCLUSIONS: To improve the recognition of those emotionally distressed patients most likely to be missed GPs should increase their attention to cues related to life style and life episodes.

[Patient-centered interviews in general practice]. / Il colloquio con il paziente in medicina generale.

Many studies have confirmed that the interview approach adopted by the physician influences the quality of the doctor-patient relationship as well as the accuracy and validity of information which is elicited during the medical interview. A correct interview approach is also the basis for diagnosis and treatment. This paper summarizes the main characteristics of the patient-centred interview approach which has to integrate the doctor centred approach in order to render the medical interview efficient in terms of data collection, doctor-patient relationship and time. The first part of the interview with the patient has always to be patient-centred. The patient is facilitated to report all the information regarding his symptoms and their psychosocial context and to express his ideas and expectations, after which the interview style becomes more directive and doctor-led. In this phase the doctor remaining however attentive to patient's cues. Some data are presented which describe the prevailing interview approach of general practitioners without any formal training in patient-centred interview techniques. The analysis of doctors' verbal behaviour during the consultation confirmed the necessity of educational interventions focalized on the improvement of doctors' interview skills.

[Psychosocial problem disclosure during primary care consultations]. / La presentazione di problemi psicosociali durante la consultazione in medicina generale.

OBJECTIVE: To examine how primary care patients with psychosocial problems actually introduce and present these topics. To examine the influence of some personality traits (emotional dependency and health locus of control) on psychosocial problem disclosure. DESIGN: "Case control". Cases had a GHQ-12 score equal or higher than three. Controls were matched with cases according to GP, GPs' attribution of absence or presence of emotional distress sex, age and presence of chronic illness. SETTING: Six single handed primary care practices. MEASURES: Clinical and Socio-demographic data, Social Problems List, List of 12 Threatening Life Events, GHQ-12, Multidimensional Health Locus of Control, Interpersonal Dependency Inventory and a Social Support Index. RESULTS: The introduction of psychosocial topics by patients is related to the attribution of emotional distress by GP. Patients identified correctly as not distressed present less often psychosocial topics compared to patients recognised as distressed. Distressed patients not recognised as such more often than the others did not offer any psychosocial cue. The personality measures did not influence the presentation of psychosocial problems. CONCLUSIONS: The lack of psycho-social cues from patients and of patient-centred skills contributed to the non recognition of emotional distressed patients. GPs' active facilitation of the presentation of psychosocial topics in such patients would improve the recognition of emotional distress.

Focal cognitive impairment in mitochondrial encephalomyopathies: a neuropsychological and neuroimaging study.

Mitochondrial encephalomyopathies (ME) are a multisystemic group of diseases characterized by a wide range of biochemical and genetic mitochondrial defects with a variable mode of inheritance. We studied the neuropsychological profile, magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT) data in a group of ME patients in order to look for common or specific cognitive defects and a possible correlation with related brain areas. Three main cognitive areas were assessed: general intelligence, memory functions and visuo-perceptual skills. Our sample included 16 ME patients (nine males, seven females) aged 25-68 years (mean age 45.2, SD 13.0). No sign of mental deterioration was found in the group of elderly subjects. Despite subjects showing no global cognitive impairment they scored lower in nonverbal versus verbal tasks. Visuo-spatial skills and short-term memory were selectively impaired. There was no correlation between neuropsychological results and age, illness duration, age of onset, clinical phenotypes, genetic mitochondrial alterations and pharmacological therapy. The most frequent SPECT pattern observed was the hypoperfusion of temporal lobes, with a direct localization in the temporal cortex and with prevalent mesial involvement. The neuropsychological profile and SPECT imaging revealed similarities with focal defects.

[The Verona Medical Interview Classification System/Patient (VR-MICS/P): the tool and its reliability]. / Il Verona-Medical Interview Classification System/Patient (VR-MICS/P). Presentazione dello strumento e studio di attendibilità.

OBJECTIVE: To assess the reliability and to describe the categories and the procedure to apply the VR-MICS/P (Verona-Medical Interview Classification System/Patient). SETTING: The interviews used for the reliability study were audiotaped. Five general practitioners (GPs) working in two general practices in South-Verona recorded their consultations. SAMPLE: 50 interviews selected randomly from 120, 10 for each GP. The selection criterion for the participating patients was a GHQ-12 score of 3 and the consultation for a new illness episode. MAIN OUTCOME MEASURES: The VR-MICS/P classifies patients' verbal behaviours into 21 categories, 15 of them are defined by form (cue or statement) and content. PROCEDURE: Two trained raters classified 50 interviews. Before applying the classification system each interview is divided into units which are numbered to define doctor's and patient's sequence of speech. RESULTS: The reliability of VR-MICS/P was satisfactory (Kappa 0.85). Similarity Index (Dice, 1945) for categories varied between 0.71 and 0.94. Reliability for form and content classification was satisfactory too (Similarity Index between 0.81 and 0.89 and between 0.84 and 0.94, respectively). CONCLUSIONS: The VR-MICS/P is a reliable measure for describing patients' verbal behaviours during medical interviews. It can be used together with the VR-MICS/D (Verona-Medical Interview Classification System/Doctor; Saltini et al., 1998) to describe the medical interview, the quality of doctor-patient interview and can be used as a measure of patient centredness.

Which patients talk about stressful life events and social problems to the general practitioner?

BACKGROUND: Life events and social problems are common in primary-care attenders and contribute to the high rate of emotional distress observed in this setting but are often not disclosed during the consultation. Physicians' characteristics associated with patients' disclosure of psychosocial problems are well documented, but less empirical evidence is available on the contribution of patients' variables. METHOD: Logistic regression analyses were performed on a set of clinical and psychosocial data from 319 primary-care attenders with stressful life events and/or social problems in the presence or absence of emotional distress, in order to identify the variables that predict disclosure of such problems during the consultation. RESULTS: Two-thirds of patients with stressful life events and social problems had mentioned them to their GP. In both sexes a positive attitude about confiding and emotional distress were the best predictors of confiding. In men they accounted for 76% of correct predictions and, in women, together with past confiding, long-lasting relationship with GP, and coexistence of life events and social problems, for 81%. A positive confiding attitude was related in males to age and severity of medical condition and in females to age and experience of past confiding. CONCLUSIONS: In view of the high prevalence of positive attitude towards confiding the efforts by GPs should focus on the reduction of disclosure thresholds. This would require increased abilities to elicit psychosocial information and show emphatic understanding of patients' life difficulties. By contrast there is a need to promote a positive attitude in confiding that concerns only a minority of primary-care patients. More data are needed for shaping more specific strategies for these patients.

[Physician-patient interactions: a comparison of analysis systems]. / L'interazione medico-paziente: sistemi di analisi a confronto.

OBJECTIVE: The medical interview has important diagnostic and therapeutic functions and requires the integration of doctor-centred and patient-centred interviewing techniques to collect accurate and complete biopsychosocial data from the patient. Analysis of the interaction between patient and doctors which occur during the medical interview allow to evaluate physicians' interview techniques and to eventually improve them. OBJECTIVE: 1. To review different Interaction Analysis Systems (IAS) used to describe doctor-patient communication in terms of clinical relevance, observational strategy, reliability and behavioural and verbal contents. 2. To critically evaluate these IASs on the basis of their relevant research outcomes. METHOD: Previous reviews on interaction and keywords for Medline research (HealthGate) listed above were utilised to collect the relevant literature. RESULTS: Seventeen classification systems were identified and ten were discussed in a chronological order. Starting from a general sociological or psycholinguistic approach, the IASs over the years have became more specific and detailed, focusing more on the medical interview and on specific topics, such as cancer or hospital medical consultations. CONCLUSIONS: When studying interactions in general practice medicine, it is important to define the significant units of interaction which allow to identify a "patient-centred approach", since this is relevant not only for obtaining reliable and complete medical and social data, but also for the recognition of patients with emotional disorders and their correct diagnosis. Listening to the patient and facilitating the expression of emotions is an important aspect of patient education too, as patients learn that talking about psychological problems to their physician is appropriate and may be therapeutic.

[An instrument for evaluating th medical interview in general practice: VR-MICS/D (Verona-Medical Interview Classification System/Doctor)]. / Uno strumento per la valutazione dell'intervista medica nel contesto della medicina generale: il VR-MICS/D (Verona-Medical Interview Classification System/Doctor).

OBJECTIVE: To assess the reliability of the VR-MICS/D (Verona-Medical Interview Classification System/Doctor) and to identify the verbal behaviour by general practitioners in interviews conducted with primary care attenders with medical complaints and emotional distress. SETTING: Two general practices in South-Verona. SAMPLE: 100 primary care patients attending for a new illness episode with a GHQ-12 score > or = 3. The five participating GPs contributed each with 20 audiotaped interviews of 10 patients judged by GP as emotionally distressed and of 10 judged without emotional distress. MAIN OUTCOME MEASURES: The VR-MICS/D classifies GPs' verbal behaviour during the medical interview into 16 categories in terms of form (question or statement) and content and allows to assess their interview skills. PROCEDURE: Two raters classified 30 interviews (15 with patients judged by their GP as emotionally distressed and 15 with patients judged without emotional distress). Having established satisfactory reliability, the overall verbal performance, based on 100 interviews, was assessed and GPs' verbal behaviours with patients judged as emotionally distressed was compared with that adopted with patients judged without emotional distress. RESULTS: The reliability was satisfactory (Kappa 0.93). Percentage agreements for categories varied between 78.2% and 96.4%. The most frequent verbal behaviours were closed ended questions and information giving (58% of a total of 5522 classified verbal units). Interviews with patients judged as emotional distressed contained a greater number of psychological and psychosocial contents, facilitating comments and clarifications. These differences, however, were small, despite their statistical significance. CONCLUSIONS: The VR-MICS/D is a reliable measure for describing GPs' verbal behaviour during the interview with emotional distressed patients. The interview style of the GPs in this study was similar to that reported in the literature for GPs without formal training in communication skills and was characterised by a prevalently doctor-centred approach. This approach, particularly with emotional distressed patients, has severe limitations and underlines the necessity of the introduction of communication skills training.