The influence of dispositional optimism on post-visit anxiety and risk perception accuracy among breast cancer genetic counselees.

OBJECTIVE: Much is unknown about the influence of dispositional optimism and affective communication on genetic counselling outcomes. This study investigated the influence of counselees' optimism on the counselees' risk perception accuracy and anxiety, while taking into account the affective communication during the first consultation for breast cancer genetic counselling. METHODS: Counselees completed questionnaires measuring optimism, anxiety and the perceived risk that hereditary breast cancer runs in the family before, and anxiety and perceived risk after the first consultation. Consultations were videotaped. The duration of eye contact was measured, and verbal communication was rated using the Roter Interaction Analysis System. RESULTS: Less-optimistic counselees were more anxious post-visit (ß = -.29; p = .00). Counsellors uttered fewer reassuring statements if counselees were more anxious (ß = -.84; p = .00) but uttered more reassurance if counselees were less optimistic (ß = -.76; p = .01). Counsellors expressed less empathy if counselees perceived their risk as high (ß = -1.51; p = .04). An increase in the expression of reassurance was related to less post-visit anxiety (ß = -.35; p = .03). More empathy was related to a greater overestimation of risk (ß = .92; p = .01). CONCLUSIONS: Identification of a lack of optimism as a risk factor for high anxiety levels enables the adaptation of affective communication to improve genetic counselling outcomes. Because reassurance was related to less anxiety, beneficial adaptation is attainable by increasing counsellors' reassurance, if possible. Because of a lack of optimally adapted communication in this study, further research is needed to clarify how to increase counsellors' ability to adapt to counselees.

Preferences and opinions of patients with Type 2 diabetes on education and self-care: a cross-sectional survey.

OBJECTIVE: To assess the preferences of patients with Type 2 diabetes regarding self-care activities and diabetes education. RESEARCH DESIGN AND METHODS: Questionnaire survey carried out in general practices and outpatient clinics across the Netherlands. OUTCOMES: preferred setting for education, preferred educator, and preferred and most burdensome self-care activity. Multinomial logistic regression analysis assessed associations between outcomes and patient characteristics, preferences and opinions. RESULTS: Data of 994 consecutive individuals were analysed (mean 65 years; 54% male; 97% Caucasian; 21% low education level; 80% primary care). Of these, 19% thought they had poor to average glycaemic control, 61% thought they were over-weight and 32% thought they took too little exercise. Eighty per cent of respondents preferred diabetes education during regular diabetes check-ups. Patients taking insulin preferred education to be given by nurses [odds ratio (OR) 2.45; 95% confidence interval (CI) 1.21-4.96]. Individuals who thought their health to be poor/average preferred education to be given by doctors (OR 1.65; 95% CI 1.08-2.53). Physical exercise was the preferred self-care activity of those who thought they took too little exercise (OR 1.97; 95% CI 1.32-2.93) but was preferred less by patients with mobility problems (OR 0.65; 95% CI 0.43-0.97). Patients with eating disinhibition reported keeping to a healthy diet (OR 4.63; 3.00-7.16) and taking medication (OR 1.66; 95% CI 1.09-2.52) as the most burdensome self-care activities. Age was not an independent determinant of any preference. CONCLUSIONS: When providing education for patients with newly diagnosed Type 2 diabetes, healthcare providers should consider making a tailored education plan, irrespective of the patient's age.

The effect of communication skills training on patient outcomes in cancer care: a systematic review of the literature.

The objective of this review was to determine whether communication training for healthcare professionals (HCP), including nurses and medical doctors, in cancer care improves patient outcomes. Eligible studies with a focus on patient outcomes and a controlled or single group pretest-posttest design were identified according to Cochrane Collaboration Guidelines. Seven studies, encompassing 10 papers and involving five randomised controlled trials, were included. Studies involved 411 HCP, including a total of 1677 encounters with adult cancer patients. Forty-nine papers were excluded, primarily because no patient outcomes were reported. Regarding patient satisfaction outcomes, estimated effects in favour of communication training ranged from 0.07 (95% CI: -0.30 to 0.44) for satisfaction with information and support to 0.70 (95% CI: 0.16 to 1.24) for satisfaction with assessment of concerns. No evidence was found for the effectiveness of communication training on patient distress outcomes. We concluded that the current review reveals inconclusive evidence to prove the effectiveness of communication training on patient satisfaction and patient distress. More high-quality studies are needed.

Does training general practitioners result in more shared decision making during consultations?

OBJECTIVE: We conducted a clustered randomised controlled trial to study the effects of shared decision making (SDM) on patient recovery. This study aims to determine whether GPs trained in SDM and reinforcing patients' treatment expectations showed more trained behaviour during their consultations than untrained GPs. METHODS: We compared 86 consultations conducted by 23 trained GPs with 89 consultations completed by 19 untrained GPs. The primary outcomes were SDM, as measured by the OPTION scale, and positive reinforcement, as measured by global observation. Secondary outcomes were the level of autonomy in decision making and the duration of the consultation. RESULTS: Intervention consultations scored significantly higher on most elements of the OPTION scale, and on the autonomy scale; however, they were three minutes longer in duration, and the mean OPTION score of the intervention group remained below average. CONCLUSION: Training GPs resulted in more SDM behaviour and more autonomy for the patient; however, this increase is not attributable to the adoption of a patient perspective. Furthermore, while we aimed to demonstrate that SDM facilitates the reinforcement of patients' positive expectations, the measurement of this behaviour was not reliable. PRACTICE IMPLICATIONS: In supporting SDM, professionals should give greater attention to patients' treatment expectations.

[The placebo effects of good communication]. / De placebo-effecten van goede communicatie.

- Good communication is important for patients and can elicit placebo effects: true psychobiological effects not attributable to the medical-technical intervention.- It is, however, often unclear which communication behaviours influence specific patient outcomes.- In this article we present insights into the potential effect of specific communication, via specific mechanisms, on specific patient outcomes, including patients' perception of pain.- A recent systematic review and additional literature demonstrate that (a) manipulating patients' expectations, (b) demonstrating empathy, and (c) providing procedural information, might influence patient outcomes.- These placebo effects probably occur via (a) neurobiological responses comparable to the effects of pain medication, (b) reduction of anxiety and stress, and

Cancer patients seeking a second surgical opinion: results of a study on motives, needs, and expectations.

PURPOSE: To explore the sociodemographic and clinical characteristics of cancer patients seeking a second-opinion consultation and to analyze their second opinion-related motives, needs, and expectations. PATIENTS AND METHODS: In 212 consecutive patients seeking a second opinion at the Surgical Oncology Outpatient Clinic, satisfaction with the first specialist, motivation for the second opinion, need for information, preference for decision participation, and hope for and expectation of a different second opinion were assessed with a questionnaire. RESULTS: The mean age was 53 years. Most patients were women (82%), of whom 76% were diagnosed with breast cancer. Half of the patients (51%) had a low educational level. The majority of patients (62%) only had internal motives for second-opinion seeking associated with the need for reassurance and more certainty, whereas a substantial minority of patients (38%) also had external motives related to negative experiences or unfulfilled needs. The externally motivated patients had a higher anxiety disposition, were less satisfied with their first specialist, preferred a more active role in medical decision making, and more often hoped for and expected a different second opinion. CONCLUSION: Motives for second-opinion consultations differ greatly. Understanding the difference between internal and external motivation is necessary to develop strategies to prevent unnecessary second-opinion seeking. Additional studies are warranted to evaluate the objective and subjective outcomes of second-opinion consultations.

Electronic diary assessment of pain, disability and psychological adaptation in patients differing in duration of pain.

Computerized diary measurement of pain, disability and psychological adaptation was performed four times a day for 4 weeks in 80 patients with various duration of unexplained pain. Reported are (1) the temporal characteristics and stability of pain report during the 4-week measurement period, (2) the association between pain duration and pain report, disability and general psychopathology, and (3) the accordance between diary assessment versus questionnaire assessment of pain, disability and psychological adaptation. No evidence of instrument reactivity was found: pain report was stable across the 4-week period. However, pain report appeared to be highly variable both between and within days. About half the patients showed a clear increasing trend in pain during the day. Several differences were found between subgroups of patients varying in pain duration. Patients with less than 6 months of pain reported significantly less pain intensity, disability and fatigue than patients whose pain persisted for more than 6 months. Pain coping and responses to pain behaviors by the spouse also differed for the subgroups: longer pain duration was associated with increased catastrophizing and solicitous responses from the spouse. Comparison of scores obtained with diary versus questionnaire assessment indicated moderate correlations for most variables. Retrospective (questionnaire) assessment of pain intensity yielded significantly higher pain scores than diary assessment.

Unexplained severe chronic pain in general practice.

The aim of this study was to estimate the prevalence of unexplained severe chronic pain (USCP) in general practice and to report medical as well as psychological descriptions of patients suffering from this condition.A total of 45 GPs in 35 different practices included patients throughout the year 1996. Patients were included according to the following criteria: between 18 and 75 years of age; pain which had lasted at least 6 months; pain is the most prominent aspect in the clinical presentation; pain is serious enough to justify clinical attention; pain has led to obvious discomfort and disability in daily life for at least for 1 month. Medical aspects were measured with the IASP taxonomy while psychological aspects were derived from the MPI. The overall prevalence of USCP was 7.91 per 1000 enlisted patients. Estimates ranged between 1.87 in the youngest age group and 13.50 in the 55-59 age category. The lower back and lower limbs were most frequently affected and 31% of the patients had pain in more than three major body sites. Pain was most frequently associated by the musculoskeletal system and most often (nearly) continuous. Mean severity of current pain was 3.7 on a scale from 0 (indicating no pain) to 6 (indicating a lot of pain). Mean rating of 'average pain in the last week' was 4.1. Regarding the psychosocial and behavioural aspects of pain, 27% of the patients could be described as perceiving severe pain while gaining social support for it. Fourteen per cent felt in the category 'pain combined with affective and relational distress' and 10% was classified as 'coping well with pain intensities lower than those of the other groups'. The other half of the patients were on average or not classifiable on these aspects. Unexplained severe chronic pain lasting more than 6 months had on overall prevalence of 7.91 per 1000 enlisted patients, ranging from 1.87 in the youngest to 13.50 in the oldest patients in these 35 general practices in The Netherlands. Our prevalence estimate of USCP is low compared to other studies on chronic pain. Probably for three reasons: Firstly, our study was confined to unexplained pain and not all chronic pain. Secondly, our inclusion criteria focused the attention of very severe chronic pain patients, and thirdly, we have defined 'chronic' as more than 6 months, while others have been using shorter time spans.

Evaluation of an interview training course for general practitioners.

This article describes the evaluation of an experimental training in doctor-patient communication for general practitioners. The training was based on Rogerian theory and accommodated to the specific situation of the general practitioner. The main concept of this theory is the notion of 'unconditional positive regard'. It was expected that doctors would change their communication behaviour and that as a result patients would talk more about their psychosocial problems. The training was restricted to the diagnostic process, no therapeutic interventions were taught. The effects of this training have been measured by comparing video-tapes of live doctor-patient consultations, before and 3 months after the training. The most important result of this evaluation study turned out to be the change of the doctor's behaviour in the expected direction, but surprisingly the outcome of the consultation did not change at all: the doctors were empathically listening, but the patients did not talk more about their problems. Creating room for patients is not sufficient to induce them to discuss their personal problems with their doctors. Perhaps they do not feel like discussing their personal problems with them at all.

Patient preference for genders of health professionals.

Preferences for physicians' gender is an obvious and well documented example of considerations of patients' attitudes. But research carried out in this field is rather limited to the domain of family medicine. This article describes preferences for 13 different health professions: surgeons, neurologists, anaesthetists, internists, general practitioners, psychiatrists, psychologists, social workers, hospital and district nurses, home helps, gynaecologists and midwives. Our investigation also concerns the reasons for people's preferences. In February 1993 a self-administered survey was completed and returned by 961 out of 1113 (response 86%) participants of the Dutch Health Care Consumers Panel, a panel resulting from a random sample of Dutch households. On a range of different health professions a varying minority of patients prefer a care provider of a particular gender. There are virtually no sex preferences for the more "instrumental" health professions (e.g. surgeons, anaesthetists). Gender preferences are stronger for those health professions more likely engaged in intimate and psychosocial health problems (e.g. gynaecologists and GPs). Preferences expressed do not relate to sex stereotypes of gender differences in instrumentality, expertise, efficiency, consultation length, and personal interest. The majority of persons who prefer female health professionals indicate that they talk more easily to females than to males, and feel more at ease during (internal) examination by females than by males. Persons who prefer male health professionals use the same reasons in favour of males. The discussion relates to gender differences in the communication style of male and female physicians.

General practitioners' attributions of fatigue.

In this paper general practitioners' (GPs') somatic-psychosocial attributions of fatigue are examined. The attribution process during medical consultations was studied by relating the GPs' judgements of the somatic-psychosocial character of their patients' fatigue to patient-related characteristics, on the one hand, and medical-consultation characteristics on the other hand. The study was based on 2097 contact registrations from the Dutch National Study of Morbidity and Intervention in General Practice by the NIVEL (Netherlands Institute of Primary Health Care). In order to explain the GPs' attributions, patient-related characteristics were added stepwise in a multiple regression analysis. Sociodemographic characteristics explained only 1.8% of the variance. Other complaints explained an additional 14.3% with psychosocial complaints being most influential. Knowledge of an underlying disease/problem explained an additional 9.9% of the variance. All of the characteristics together explained 26.0% of the attributions by the GPs. More psychosocially-attributed fatigue was found to correlate with consultations characterized by less physical examination, more diagnostic procedures to reassure, fewer diagnostic procedures to discover underlying pathology, more counselling, less medical treatment, less prescription and a longer duration than consultations with more somatically attributed fatigue. It is concluded that GPs do not discriminate between social groups when attributing fatigue to either somatic or psychosocial causes. The presence and character of other complaints and underlying diseases/problems, rather, relate to the GPs' somatic psychosocial attributions, which are then associated with particular aspects of the consultation.

What is behind "I'm so tired"? Fatigue experiences and their relations to the quality and quantity of external stimulation.

In the present study, it is hypothesized that both low quality and high quantity of external stimulation are related to elevated levels of fatigue. This is proposed by the Quality-Quantity model for understanding fatigue (QQuF model). The relations between the quality and quantity of external information and the Multidimensional Fatigue Inventory (MFI-20) are examined. Moreover, the role of depression (measured with the CES-D) in relation to the QQuF model is explored. The results show low quality of external stimulation, that is, low "attractiveness of external stimulation," relating to all five dimensions of fatigue. A high quantity of external stimulation, that is, high "experienced overload," related primarily to general and mental fatigue. The QQuF model was only slightly moderated by depression, but depression directly and strongly related to all dimensions of fatigue. It is concluded that fatigue related to low quality of external stimulation can be distinguished from fatigue related to a high quantity of external stimulation. This distinction is useful when considering theoretical issues and treatment of fatigue.

Consultations for women's health problems: factors influencing women's choice of sex of general practitioner.

AIM: This study set out to examine the degree to which women choose to visit a woman doctor for women's health problems and the determinants of this choice. The differences between women and men doctors with regard to treating women's health problems were also studied. METHOD: Data from the Dutch national survey of general practice were used. All group practices with both women and men general practitioners were selected. Analyses were restricted to consultations among women aged 15-65 years about menstruation, the menopause, vaginal discharge, breast examination and cervical smear tests. RESULts. Given the size of their female practice population, women doctors saw considerably more women with women's health problems than did their male colleagues. Women were more likely to consult a woman general practitioner if she was more available (that is, working longer hours), and younger women were more likely than older women to choose women general practitioners. Sex differences in the treatment of women's health problems were small and mainly related to the verbal part of the consultation: counselling and providing information. The doctors' availability and their certainty about the working diagnosis explained differences in the verbal aspects of consultations. Women general practitioners had longer consultations than their male colleagues mainly because more health problems were presented per consultation. CONCLUSION: In order to increase the possibility of patients choosing women general practitioners, policy should be directed towards the education of more women general practitioners and women general practitioners should be encouraged to work more days a week.

Patient education in The Netherlands.

This article presents the development of patient education (PE) in The Netherlands from a historical perspective. A description is given of the first pioneering years from the 70s till the late 80s, in which early topics like the organization of PE, the orchestration of PE between different disciplines, the role of the social environment, the provision of PE in difficult patient groups and--most of all--the technical development of educational materials took the time and attention of the growing group of professionals that were engaged in patient education. Recent developments concern the legal aspects of PE, national policy, the role of health insurance, the position of patient organizations and the development of patient education in specific professional groups, e.g. general practitioners, nurses, physiotherapists, pharmacists, and dentists. There is no doubt that patient education has been professionalized considerably during the last decades. Nevertheless, new issues emerge and some old issues still need to be solved. The effective use of information material, the need for counseling as part of PE, and the relevance of coordination of care are longtime, but still actual problems in PE. More recent issues are the pressures on PE because of capacity restraints, the influence of the media and perhaps most of all: the apparent need for a patient-centered attitude and a more two-sided way of communication. Finally, the future policy topics in the Dutch patient education are discussed.

Effects of video interaction analysis training on nurse-patient communication in the care of the elderly.

This paper describes an empirical evaluation of communication skills training for nurses in elderly care. The training programme was based on Video Interaction Analysis and aimed to improve nurses' communication skills such that they pay attention to patients' physical, social and emotional needs and support self care in elderly people. The effects of the training course were measured in an experimental and control group. They were rated by independent observers, by comparing videotapes of nursing encounters before and after training. Forty nurses participated in 316 videotaped nursing encounters. Multi-level analysis was used to take into account similarity among same nurse encounters. It was found that nurses who followed the training programme, provided the patients with more information about nursing and health topics. They also used more open-ended questions. In addition, they were rated as more involved, warmer and less patronizing. Due to limitations in the study design, it could not be demonstrated that these findings can entirely be ascribed to the training course. Further research, incorporating a randomized controlled design and larger sample sizes, is recommended to determine whether the results can be attributed to this specific type of training.

Evaluation of communication training programs in nursing care: a review of the literature.

An important aspect of nursing care is communication with patients. Nurses' major communication tasks are not only to inform the patient about his/her disease and treatment, but also to create a therapeutically effective relationship by assessing patients' concerns, showing understanding, empathy, and providing comfort and support. In this review, 14 studies, which focus on the evaluation of the effects of communication training programs for nurses, have been evaluated. The selected studies were screened on several independent, process and outcome variables as described by Francke et al. [8]. In this way not only is the training program taken into account as a variable which may be responsible for nurses' behavioural change and for changes in patient outcomes, but also a range of other variables which can give more nuanced explanations for a training program's degree of effectiveness. On the whole, the studies reviewed showed limited or no effects on nurses' skills, on nurses' behavioural changes in practice, and on patient outcomes. Finally, the majority of the studies had a weak design. The use of experimental research designs should be pursued in future studies in order to eliminate the influence of confounding variables.

Doctor-patient communication in different European health care systems: relevance and performance from the patients' perspective.

Our aim is to investigate differences between European health care systems in the importance attached by patients to different aspects of doctor-patient communication and the GPs' performance of these aspects, both being from the patients' perspective. 3658 patients of 190 GPs in six European countries (Netherlands, Spain, United Kingdom, Belgium, Germany, Switzerland) completed pre- and post-visit questionnaires about relevance and performance of doctor-patient communication. Data were analyzed by variance analysis and by multilevel analysis. In the non-gatekeeping countries, patients considered both biomedical and psychosocial communication aspects to be more important than the patients in the gatekeeping countries. Similarly, in the patients' perception, the non-gatekeeping GPs dealt with these aspects more often. Patient characteristics (gender, age, education, psychosocial problems, bad health, depressive feelings, GPs' assessment of psychosocial background) showed many relationships. Of the GP characteristics, only the GPs' psychosocial diagnosis was associated with patient-reported psychosocial relevance and performance. Talking about biomedical issues was more important for the patients than talking about psychosocial issues, unless the patients presented psychosocial problems to the GP. Discrepancies between relevance and performance were apparent, especially with respect to biomedical aspects. The implications for health policy and for general practitioners are discussed.

Nurse-patient communication in cancer care. A review of the literature.

Patients with cancer seem to experience distress particularly in the first period after diagnosis, and are likely to develop an affective disorder in the first 2 to 3 months. Communicative behaviors of nurses seem to play an important role in meeting the cognitive and affective needs of patients with cancer. This review of the literature examines the communicative behaviors of nurses during care activities with patients who have cancer. The studies show that emphasis is placed on the affective side, in which facilitating behaviors such as empathy, touch, comforting, and supporting are considered essential in caring for patients with cancer. Unfortunately, further studies in this review demonstrate that communication in oncologic care is complicated by such emotionally laden issues as the consequences associated with the life-threatening character of the disease and the far-reaching consequences of the medical treatment. This results in barriers to effective communication between patients with cancer and nurses. It is important, therefore, that nurses working with patients who have cancer are provided both structurally and repeatedly with continuing education programs in communication. Finally, most of the studies covered in this review have an explorative character. Future research in this area should pay attention to the use of controlled studies, large sample sizes, and observational instruments.

Adaptive tasks, coping and quality of life of chronically ill patients: the cases of Parkinson's disease and chronic fatigue syndrome.

This article is a report of a larger study on the relationship between adaptive tasks, coping and quality of life, taking Parkinson's disease and chronic fatigue syndrome (CFS) as examples. The concept of adaptive tasks or disease-related stressors testing the adaptive capacities of chronically ill patients (N=134) was explored by applying the method of concept mapping. Results show that patients both with Parkinson's disease and with CFS generally refer to the same themes when asked for the adaptive tasks their disease brings about. However, the actual contents of these adaptive tasks differ as well as their impact on coping and quality of life. In the case of patients with Parkinson's disease, objective disease characteristics appear to be more important in predicting quality of life than in the case of patients with CFS, whose evaluation of adaptive tasks is predictive of quality of life.

Cue-responding in a Simulated Bad News Situation: Exploring a Stress Hypothesis.

The stress-coping paradigm of Folkman and Lazarus (1984) was applied to investigate if the communicative reactions of the physician in a bad news transaction are related to the stressfulness of the situation. A standardized video bad news consultation was presented to 88 medical students. To examine their communicative reactions we selected 10 patient cues with different levels of expressed emotion to which the participants responded from the physician's point of view. A strongly positive relationship between expressed emotion and perceived difficulty of the cues and a gender effect occurred, confirming that handling emotions is stressful for physicians. The reluctance of physicians to address the emotionally laden issues of the consultation can be understood as a lack of a frame of reference. The problem-solving strategies, which they apply in the instrumental domain of the consultation, are ineffective when dealing with psychosocial suffering.