Residents' Communication With Attendings About Uncertainty: A Single-Site Longitudinal Survey.

OBJECTIVE: Managing uncertainty is a core competency of pediatric residents. However, discussing uncertainty with attending physicians can be challenging. Research is needed to understand residents' goals when communicating about uncertainty with attending physicians and how residents' perceptions of communication change during residency. Therefore, we assessed changes in residents' perceptions of their own ability to communicate uncertainty and their perceptions of attending physicians' willingness to discuss uncertainty effectively. We also identify residents' goals and challenges communicating uncertainty. METHODS: We conducted a 3-year (2018-2021) survey with 2 cohorts of residents at a US children's hospital. Of the 106 eligible residents, 100 enrolled and completed Phase I (94% response rate), 61 of the enrolled residents completed Phase II (61% response rate), and 53 completed Phase III (53% response rate). We employed hierarchical linear modeling to account for clustering of the data (Phases within residents) and to assess changes in communication efficacy and target efficacy over time. We coded open-ended responses to identify residents' communication goals and challenges. RESULTS: Communication efficacy and target efficacy significantly increased over time. Open-ended responses indicated that residents managed multiple task, identity, and relational goals. Residents described persistent challenges related to wanting to appear competent and working with attending physicians who were unwilling to discuss uncertainty. CONCLUSIONS: Although residents may grow more confident communicating uncertainty, such conversations are complex and can present challenges throughout residency. Our results support the value of training on communication about uncertainty, not only for residents, but also attending physicians.

Dyadic coping experiences of parents of children with vascular anomalies.

BACKGROUND: Vascular anomalies (VAs) are a spectrum of rare pediatric disorders that require coordinated care from multiple subspecialists. Parents often struggle to coordinate care for their child's complex rare disorder. Even when they do access expert care, parents of children with VAs report high levels of stress and uncertainty. While previous research has explored parents' experiences navigating care for VAs, we know very little about how parents cope with stress together. Given the effect that dyadic coping can have on individual, couple, family, and child outcomes, we aimed to gain a better understanding of dyadic coping in the context of VAs. PROCEDURES: We collected data using semi-structured interviews with 27 parents (13 dyads and one individual parent). Data were analyzed using dyadic thematic analysis. RESULTS: Parents experienced stress related to medical, personal, logistical, and financial aspects of their child's healthcare. They relied on eight coping strategies: active coping, seeking emotional support, seeking informational support, cognitive avoidance, distraction, cognitive reframing, acceptance, and internalization. When analyzed together, we found evidence of five dyadic coping dynamics: collaborative, supportive, delegated, separate, and negative. CONCLUSION: Dyadic coping is complex and multilayered for parents of children with VAs. While the child's diagnosis is considered a shared stressor, both parents may not share preferred coping strategies. Parents of the same child may also be coping with different medical, relational/social, personal, or logistical stressors altogether. Psychosocial interventions designed to facilitate parental coping should address these complex coping dynamics.

The role of primary care in rare disorders: A qualitative study of parents and patients managing complex vascular anomalies.

Background: Patients with complex rare disorders often require the care of multiple specialists. Effective coordination between primary and specialty care is needed to ensure patients receive high-quality care. Previous research has documented the importance of primary care clinicians providing referrals to specialty care and the importance of specialists in helping patients reach a diagnosis. However, little is known about primary care clinicians' roles in the ongoing care of patients with rare disorders. In the current study, we explored the role of primary care clinicians in the care of rare and complex vascular anomalies. Materials and Methods: Data were collected using semi-structured qualitative interviews with 34 parents and 25 adult patients recruited from advocacy groups for patients with complex vascular anomalies participated. We asked participants about their diagnosis, care experiences, and communication with clinicians. We used thematic analysis to identify themes illustrating the roles of primary care clinicians. Results: PCC roles were characterized by four behaviors. Supporting behaviors included learning more about vascular anomalies and asking participants about the care they received from specialists. Facilitating included providing referrals, ordering tests, and engaging in problem-solving. Interfering included failing to provide referrals or help participants coordinate care, ordering incorrect tests, or making inappropriate recommendations. Disregarding included focusing narrowly on primary care needs and not showing concern about the vascular anomaly. Conclusions: The results reveal opportunities to improve primary care for patients with vascular anomalies. Disregarding and interfering behaviors furthered the division between primary and specialty care for patients with vascular anomalies and prevented patients from receiving comprehensive primary care. Supporting and facilitating behaviors convey genuine interest in the care of the vascular anomaly and a commitment to helping the patient and parent.

The Impact of Health Communication Research on Medical and Health Professional Education and Training.

In this essay, we review how health communication scholarship has been translated into various communication skills trainings (CSTs), we present four case studies of how health communication research informed the development and implementation of specific CSTs, and we reflect on how we can productively define "impact" in looking back as well as looking forward within this line of research.

Factors affecting the ability of patients with complex vascular anomalies to navigate the healthcare system.

BACKGROUND: Vascular anomalies (VAs) are rare congenital disorders that can cause pain, disfigurement, coagulopathy, asymmetric growth, and disability. Patients with complex VAs experience multiple barriers to accessing expert care. It is imperative to understand which factors support these patients' ability to navigate the healthcare system. RESULTS: We surveyed adult patients with VAs using previously validated measures, recruiting participants from five patient advocacy groups and multidisciplinary VA clinics. The primary outcome was self-reported ability to access needed medical care, using the "Navigating the Healthcare System" subscale of the Health Literacy Questionnaire. We evaluated factors associated with the ability to navigate the healthcare system using multivariate linear regression (n = 136). We also performed an exploratory model that included the primary care doctor's knowledge of VAs for the subset of participants with a primary care doctor (n = 114). Participants were predominantly women (n = 90, 66%), White and non-Hispanic (n = 109, 73%), and college-educated (n = 101, 73%). Most participants had PIK3CA-Related Overgrowth Spectrum (n = 107, 78%). Most participants reported that navigating the healthcare system was "sometimes" or "usually difficult" (mean score 16.4/30, standard deviation 5.6). In multivariate linear regression, ability to navigate the healthcare system was associated positively with quality of information exchange (ß = 0.38, 95% Confidence Interval (CI) 0.22 to 0.55, p <.001) and whether patients had VA specialists (ß = 2.31, 95% CI 0.35 to 4.28, p =.021), but not associated with patient self-advocacy, anxiety, education, age, race and ethnicity, gender, or having a primary care doctor. In exploratory analysis of participants with primary care doctors, ability to navigate the healthcare system was positively associated with quality of information exchange (ß = 0.27, 95% CI 0.09 to 0.45, p =.004), having a VA specialist (ß = 2.31, 95% CI 0.22 to 4.39, p =.031), and primary care doctors' VA knowledge (ß = 0.27, 95% CI 0.04 to 0.50, p =.023). CONCLUSION: Patients with VAs struggle to navigate the healthcare system. High-quality information from clinicians and more knowledgeable primary care doctors might help patients to access needed care. Relying on patient self-advocacy is insufficient. Future efforts should focus on patient-directed and clinician-directed educational interventions. Additionally, future work should assess the structural barriers that impede healthcare access for these patients.

Mental and physical health of adult patients affected by complex vascular anomalies.

OBJECTIVE: We examined care and communication factors that affect physical and mental health for patients with complex vascular anomalies (VAs). METHODS: VA patients (N = 135) completed an online survey with measures of ability to navigate healthcare, quality of information exchange, perceived stigma, and demographic variables. We performed linear regression to determine if these variables were associated with mental and physical health. RESULTS: Physical and mental health were associated with information exchange (ß = .41, 95% CI=.12 -.69; ß = .33, 95% CI=.04 -.62), stigma (ß = -.49, 95% CI=-.74 to -.24; ß = -.63, 95% CI=-.89 to -.38), and education (ß = 4.00, 95% CI=.63 - 7.38; ß = 3.44, 95% CI=.06 to 6.82). Ability to navigate healthcare was associated with health outcomes in our bivariate model, but not significant in a multivariate model. CONCLUSION: The results underscore the importance of effective information exchange. Poor information exchange was associated with worse physical and mental health. VA patients with lower education levels and higher perceived stigma reported poorer health outcomes and likely face many struggles accessing care. PRACTICE IMPLICATIONS: Patient-centered information exchange between clinicians and patients is needed to address unmet information needs. Clinicians can also reduce perceived stigma by validating patients, and should provide resources to reduce disparities related to education.

Identity influences on medical students' orientation to feedback during third year clinical rotations.

Medical students' feedback orientation (their attitudes about and preferences for feedback from preceptors) may change over the course of the third year of medical school and is likely influenced by identity-related factors. This study proposed that both how students view themselves personally (i.e., impostor syndrome) and how they view themselves in relation to the group (i.e., identification with the profession) are identity factors related to related to feedback orientation during clinical rotations. 177 third-year medical students enrolled in a four-phase longitudinal survey study beginning at the start of clinical rotations and continuing every twelve weeks of the academic year thereafter. Feedback orientation was conceptualized and measured as comprising aspects of utility (i.e., feedback is valuable and useful), sensitivity (i.e., feeling intimidated or threatened by corrective feedback), confidentiality (i.e., public/private context of feedback), and retention (i.e., feedback remembered). Results indicated that these aspects of feedback orientation did not significantly change during the third year. Instead, impostor syndrome was at least marginally, significantly associated with all aspects of feedback orientation across phases. Group identity was associated with feedback utility and retention, and female-identifying students reported significantly greater feedback confidentiality and feedback retention. Interventions may be needed to improve medical students' attitudes about feedback, particularly for those who experience impostor syndrome. Fostering group cohesion among medical students may influence how well students remember feedback and find it useful.

US Medical Students' Attitudes, Subjective Norms, and Perceived Behavioral Control Regarding Social Media and Online Professionalism: A Single Institution Study.

Phenomenon: In 2011, the American Medical Association added a section on professionalism and social media (i.e., e-professionalism) to the Code of Medical Ethics. Given the constantly evolving nature of social media use, research is needed to explore the attitudes and behaviors of current medical students, for most of whom social media has been a central facet of interpersonal communication and society since they were born. The goal of the current study is to examine students' social media use and attitudes related to online professionalism. Approach: Two-hundred-twenty-two medical students completed a mixed-methods cross-sectional online survey assessing perceptions of professionalism on social media. The survey was informed using the theory of planned behavior and included validated measures of attitudes, norms, and perceived behavioral control related to social media use and online professionalism. We analyzed data using thematic analysis and descriptive statistics and t-tests were conducted using SPSS 26. Qualitative and quantitative data were integrated during the data interpretation phase. Findings: Quantitative results revealed that students had a positive attitude toward having a social media presence as medical students and future physicians. Students reported: positive attitudes toward sharing positive thoughts, posting photos with family members, and posting photos in white coats or scrubs; neutral attitudes toward posting personal and political opinions; negative attitudes toward posting photos with alcohol, commenting about colleagues or the workplace, using profanity, connecting with patients, and commenting about patients. T-tests revealed significant differences between what students consider to be professional online behaviors for themselves as medical students versus what they believe society will expect of them as a physician. Students reported strong perceived behavioral control regarding professional social media behavior. While students reported they would face some difficulty "cleaning up" some previous content, students strongly disagreed that people's opinions of their online professional image were beyond their control. The qualitative analysis revealed students' perceptions of (a) what it means to demonstrate "online professionalism," (b) the challenges they face related to social media, and (c) training and standards related to social media use. Insights: Overall, our study confirms that students would benefit from e-professionalism training that is not merely disciplinary, but offers them evidence-based recommendations for maintaining medical professionalism while also embracing their personal identity and the benefits of social media as a (future) physician. Policies, guidelines, and training programs should constantly evolve as social norms regarding online communication and online identities evolve.

Burdens of disease and caregiver burden in complex vascular malformations.

INTRODUCTION: Vascular malformations (VMs) are rare diseases that affect a wide age range of patients and require complicated care and management. The strain these conditions put on patients and their caretakers is not well understood. This study aims to characterize those burdens in young adult patients and parents of patients with VMs to improve communication, health-related quality of life, and caregiver burden. METHODS: We performed semi-structured interviews with patients and parents of patients with VMs. Interviews were conducted via telephone or video-call software, recorded, and transcribed. The transcriptions were analyzed to identify burden themes through multiple rounds of codebook development and refinement. The final codebook was applied to all interviews. RESULTS: Twenty-five young adult patients and 34 parent interviews were performed and led to the identification of four primary themes of disease burden that showed up in almost every interview: burdens of the disease process, logistical and financial burdens, psychological and emotional burdens, and social burdens. Persistent uncertainty was prominent and exacerbated all other burdens as well. DISCUSSION: We found that patients and parents struggle with burdens in a wider breadth of life experiences than have been previously characterized in the literature. They feel stressors of isolation, struggles with their identity, and even traumatic experiences from prior medical encounters. It is critical for providers of these patients and families to be aware of the burdens that they face outside of the immediate medical context. Acknowledging and providing space to address these burdens has the potential to greatly improve therapeutic relationships.

Navigating care for rare diseases: Caregiver and patient advice for families and clinicians managing care for vascular malformations.

OBJECTIVE: Families affected by rare diseases face many challenges finding adequate care and often report poor communication with clinicians. In the current study, we explore patient and caregiver advice for families and clinicians in the context of complex vascular malformations (VMs), a condition that is frequently misunderstood and misdiagnosed. METHODS: We performed semi-structured interviews with 21 adult patients with complex VMs and 24 caregivers of children with VMs. We analyzed the transcripts using thematic analysis. RESULTS: Participants advised patients and caregivers to advocate for care, address mental and emotional well-being, seek social support, and promote self-management and self-care. Participants advised clinicians to show care and concern, show commitment, empower and validate, communicate information clearly, address mental/emotional well-being, acknowledge the broad impact of disease and treatment, acknowledge your limitations, work as a team, and commit to learning. CONCLUSION: Participants' advice revealed challenges related to family-centered communication and patient and caregiver quality of life and demonstrated the importance of self-advocacy and social support. PRACTICE IMPLICATIONS: The result of this study can help newly-diagnosed families overcome challenges related to care and communication. Clinicians can also use the results to support families by offering them our accompanying handout to validate families' experiences and relay this advice.

Pediatricians' Communication about Medical Uncertainty: Goal-Oriented Communication and Uncertainty Management.

Despite the prevalence of uncertainty in medicine, many physicians experience anxiety as a result of medical uncertainty and are reluctant to discuss uncertainty with others. When pediatricians do disclose uncertainty to parents, they are managing both the parents' and their own feelings of uncertainty. The current study applies uncertainty management theory and multiple goals theory to explore pediatricians' communication about uncertainty. We collected data using in-depth semi-structured interviews with 18 pediatricians. The results suggest that pediatricians prioritize task and relational goals with parents and task and identity goals with fellow physicians. Though, their appraisal of uncertainty influences their goal-oriented communication. The results highlight the relationship between uncertainty management theory and a multiple goals framework. These frameworks provide a valuable approach for gaining a more thorough understanding of pediatrician communication in the context of uncertainty.

Medical Students' Stress and Uncertainty During the COVID-19 Pandemic.

The COVID-19 pandemic triggered extraordinary levels of stress and uncertainty nationwide. In the current study, we use stress and coping theory and uncertainty management theory to examine how medical students coped with the stress and uncertainty associated with the disruption COVID-19 created in their training. Students completed a mixed-methods cross-sectional online survey one week after shifting to online instruction due to COVID-19. The survey included a measure of coping strategies and a series of open-ended questions designed to capture barriers and facilitators of coping and uncertainty management. In total, 360 students from one US medical school completed the survey. Students relied most frequently on coping strategies of distraction, acceptance, planning, positive reframing, and emotional support. However, coping strategies differed significantly by year in training. Personal uncertainty emerged as the most salient form of uncertainty. This uncertainty resulted from the loss of structure and resources, disruption of academic timelines, and, ultimately, disrupted identity as a (future) physician. Students described important barriers and facilitators of coping and uncertainty management. The barriers included constant exposure, inadequate information, rumination, and extreme responses. The facilitators included distraction, avoidance, instrumental support, emotional support, network support, and positive reframing. Overall, our results suggest that medical students experienced significant uncertainty related to their professional skills and identities as future physicians and faced many dilemmas coping with stress and managing uncertainty, mainly related to information and social support.

Family Communication in Autism Spectrum Disorder: Applying the Family Caregiver Communication Typology to Parent Caregivers.

Parents of children with Autism Spectrum Disorder (ASD) experience greater stress and caregiver burden than parents of children with other disabilities. To cope with the stress of long-term caregiving, they rely on professionals for support and guidance. However, parents continue to report unmet communication and support needs. To inform tailored communication for parents of a child with ASD, this study used the existing Family Caregiver Communication Typology framework which identifies four caregiver communication types (manager, carrier, partner, and lone) and their unique communication and support needs. In-depth, structured interviews were conducted with parents (n = 22) and ASD professionals (n = 28) to explore communication characteristics of ASD parent caregivers. A thematic analysis revealed communication behaviors among four ASD parent caregiver types, further validating the typology. Future research is needed to develop targeted interventions for improving family-centered care based on ASD parent caregiver types.

"I Want Them to Still Trust Me with Their Child's Care": A Longitudinal Study of Pediatric Residents' Reactions to and Communication with Parents about Medical Uncertainty across Residency.

Physicians in residency training experience high levels of medical uncertainty, yet they are often hesitant to discuss uncertainty with parents. Guided by the theory of motivated information management and a multiple goals perspective, this mixed-methods longitudinal study examines associations among residents' tolerance of and reactions to uncertainty, efficacy communicating about uncertainty, and perceptions of parents' trust in them as physicians. To contextualize these associations, we also examined residents' task, identity, and relational goals when communicating about uncertainty with parents. We surveyed 47 pediatric residents at the beginning of each year of their residency program. As they progressed through their training, residents' uncertainty-related anxiety and reluctance to communicate uncertainty to parents decreased, and their efficacy communicating uncertainty with parents increased. Residents' concerns about bad outcomes remained unchanged. Residents pursued multiple, often conflicting, conversational goals when communicating uncertainty with parents. Results reveal important considerations for addressing how residents can manage their uncertainty in productive ways.

The effect of postgraduate osteopathic manipulative treatment training on practice: a survey of osteopathic residents.

CONTEXT: Osteopathic medical students receive an abundance of training in osteopathic manipulative treatment (OMT) during their first 2 years of medical school and less during the second 2 years. Family Medicine residency programs often include significantly more OMT training during residency, but it is less frequently applied in other residencies. OBJECTIVES: This survey was designed utilizing the theory of planned behavior to see whether specific training in osteopathic manipulative medicine (OMM) after osteopathic medical school was an influence in changing behavior, attitudes, and knowledge around OMT in osteopathic residents. METHODS: A total of 188 osteopathic medicine residents were invited to complete an anonymous cross-sectional online survey. The survey asked residents about their postgraduate OMT training and their knowledge, attitudes, norms, intentions, and behavior regarding OMT. Inferential statistics were utilized to determine whether significant differences existed by specialty and by type of training. RESULTS: Sixty residents (31.9% response rate) completed the survey. This response rate is consistent with previous online survey studies, but it may indicate that residents chose not to participate due to survey fatigue or a lack of interest in OMM. Overall, residents who completed postgraduate training reported significantly stronger positive attitudes about the value of OMT in patient care (t=3.956; p<0.001). Primary care residents talk to their patients about OMT and perform OMT more frequently than residents in surgical (p<0.01) and other subspecialties (p<0.01). Residents who completed postgraduate training (n=41) reported significantly more knowledge about the fundamental principles (p=0.04), benefits (p=0.03), and common techniques (p=0.01) of OMT, and rated their ability to perform OMT (p=0.001) higher than those who had not completed postgraduate training. Trained residents also talked to patients about OMT (p<0.001), referred patients for OMT (p=0.01), and performed OMT (p<0.001) more frequently. They also reported significantly stronger subjective norms (p=0.000; p<0.001), perceived behavioral control (p=0.02; p=0.004), positive attitudes (p=0.004; p=0.003), and intentions (p<0.001; p<0.001) regarding talking to patients and performing OMT, respectively. Residents who completed in-person training reported talking to their patients about OMT (p=0.002) and performing OMT (p=0.001) more frequently, and having more confidence in their ability to perform OMT (p=0.02). Residents who completed in-person training reported significantly stronger subjective norms (p<0.001; p<0.001), perceived behavioral control (p=0.001; p=0.002), positive attitudes (p=0.05; p=0.03), and intentions (p<0.001; p=0.001) regarding talking to patients about OMT and performing OMT, respectively. Residents who completed in-person training reported stronger subjective norms (p=0.05) related to referring patients for OMT. CONCLUSIONS: Residents who complete postgraduate training perform OMT, talk to their patients about OMT, and refer patients for OMT more frequently. Residents who participate in training, particularly in-person training, have stronger subjective norms, perceived behavioral control, positive attitudes, and behavioral intentions regarding talking with patients about OMT and performing OMT. These variables are validated predictors of behavior, making them important outcomes for training to promote OMT in patient care.

Medical Students' Reactions to Uncertainty During Clinical Rotations.

BACKGROUND AND OBJECTIVES: Family physicians routinely manage uncertainty in their clinical practice. During their first year of clinical rotations, medical students learn communication and patient care skills that will influence the care they provide as future physicians. However, little is known about how their reactions to uncertainty change during this formative year, and medical education often fails to teach students how to manage uncertainty effectively. This study employs a repeated measures analysis of students' reactions to uncertainty over the course of their third year. METHODS: We surveyed 273 medical students at four time points during their third year and employed hierarchical linear modeling to analyze a series of models in which phase and intolerance of uncertainty were entered as covariates. We modeled age and gender as control variables. RESULTS: Analyses revealed that students' affective reactions to uncertainty did not significantly change during the third year, but reluctance to disclose uncertainty to physicians and patients significantly decreased across phases. Analyses also showed that general intolerance of uncertainty predicted affective reactions to medical-specific uncertainty. CONCLUSIONS: These findings confirm that students experience negative reactions to uncertainty during clinical rotations. Students would benefit from curriculum designed to mitigate consequences of negative affective reactions to uncertainty, particularly those students characteristically higher in intolerance of uncertainty. Given that students demonstrated more willingness to communicate about their uncertainty over time, medical school should equip students with the communication skills needed to discuss their uncertainty effectively with patients and preceptors.

A longitudinal study of third-year medical students' communication competence, communication anxiety, and attitudes toward patient-centered care.

OBJECTIVE: We investigated changes in medical students' communication competence and communication anxiety during their third year of training when they are immersed in formative clinical experiences that shape their patient-centered care and communication skills. METHODS: We invited 282 students to complete a longitudinal, four-phase online survey during their third-year. Our response rate was 62.8% at Phase I (n = 177), 34.0% at Phase II (n = 96), 37.9% at Phase III (n = 107), and 48.9% at Phase IV (n = 138). Measures included communication competence, communication anxiety, and patient-centered attitudes and orientation. We employed hierarchical linear modeling to analyze the data. RESULTS: Students' communication competence and anxiety improved over time. Female students reported greater communication anxiety and less competence related to information giving. At each phase, patient-centered attitudes significantly predicted communication competence and communication anxiety. CONCLUSION: Students' competence and anxiety regarding communication during medical encounters improve during their third year and are significantly influenced by their attitudes and orientation towards patient-centered care and communication. PRACTICE IMPLICATIONS: Schools should integrate curriculum that fosters positive attitudes toward patient-centered communication and provides opportunities to practice complex communication skills, which may increase competence and recognition that patient-centered communication is an important clinical skill.

Fostering Interdisciplinary Boundary Spanning in Health Communication: A Call for a Paradigm Shift.

Scholarship in the field of health communication is broad, with interdisciplinary contributions from researchers trained in a variety of fields including communication, nursing, medicine, pharmacy, public health, and social work. In this paper, we explore the role of "health communication boundary spanners" (HCBS), individuals whose scholarly work and academic appointment reflect dual citizenship in both the communication discipline and the health professions or public health. Using a process of critical reflective inquiry, we elucidate opportunities and challenges associated with HCBS across the spectrum of health communication in order to provide guidance for individuals pursuing boundary spanning roles and those who supervise and mentor them. This dual citizen role suggests that HCBS have unique skills, identities, perspectives, and practices that contribute new ways of being and knowing that transcend traditional disciplinary boundaries. The health communication field is evolving in response to the need to address significant healthcare and policy problems. No one discipline has the ability to single-handedly fix our current healthcare systems. Narrative data from this study illustrate the importance of seeing HCBS work beyond simply being informed by disciplinary knowledge. Rather, we suggest that adapting ways of knowing and definitions of expertise is an integral part of the solution to solving persistent health problems.