Improving the quality of physician communication with rapid-throughput analysis and report cards.

OBJECTIVE: Problems with clinician-patient communication negatively impact newborn screening, genetics, and all of healthcare. Training programs teach communication, but educational methods are not feasible for entire populations of clinicians. To address this healthcare quality gap, we developed a Communication Quality Assurance intervention. METHODS: Child health providers volunteered for a randomized controlled trial of assessment and a report card. Participants provided telephone counseling to a standardized parent regarding a newborn screening result showing heterozygous status for cystic fibrosis or sickle cell disease. Our rapid-throughput timeline allows individualized feedback within a week. Two encounters were recorded (baseline and after a random sample received the report card) and abstracted for four groups of communication quality indicators. RESULTS: 92 participants finished both counseling encounters within our rapid-throughput time limits. Participants randomized to receive the report card improved communication behaviors more than controls, including request for teach-back (p<0.01), opening behaviors (p=0.01), anticipate/validate emotion (p<0.001) and the ratio of explained to unexplained jargon words (p<0.03). CONCLUSION: The rapid-throughput report card is effective at improving specific communication behaviors. PRACTICE IMPLICATIONS: Communication can be taught, but this project shows how healthcare organizations can assure communication quality everywhere. Further implementation could improve newborn screening, genetics, and healthcare in general.

Frequency of high-quality communication behaviors used by primary care providers of heterozygous infants after newborn screening.

OBJECTIVE: To examine the quality of communication likely to be experienced by parents when being first informed about how newborn screening identified heterozygous "carrier" status for cystic fibrosis or sickle cell disease. METHODS: Primary care providers (PCPs) of infants found to have carrier status were telephoned over a 48-month period, and asked to rehearse with a standardized patient how they would inform the infants' parent(s). 214 rehearsal transcripts were abstracted using explicit criteria methods to measure the frequency of five categories of high-quality communication behaviors. RESULTS: Overall, PCPs used large amounts of jargon and failed to use high quality communication behaviors. On average, PCPs used 18.6 total jargon words (8.7 unique words), but explained 2.4 jargon words. The most frequent assessment of understanding was the close-ended version, although it was only seen in 129 of 214 transcripts. The most common organizing behavior was importance emphasis (121/214). Precautionary empathy was rare; the most frequent behavior was "instruction about emotion" (33/214). CONCLUSION: The limited use of high-quality communication behaviors in rehearsals raises concern about parental understanding, decision-making, and psychosocial outcomes after newborn screening. PRACTICE IMPLICATIONS: Measurement of specific behaviors may help PCPs to improve communication, and thereby improve the patient experience.

A qualitative secondary evaluation of statewide follow-up interviews for abnormal newborn screening results for cystic fibrosis and sickle cell hemoglobinopathy.

PURPOSE: The purpose of this qualitative analysis was to assess parental acceptability of large-scale, telephone follow-up regarding their infants' newborn screening (NBS) results, indicating carrier status for sickle cell hemoglobinopathy (SCH) and cystic fibrosis (CF). METHODS: Analysis of 195 interview transcripts focused on parents' responses to two open-ended questions: "What was your reaction to being called by me?" and "What do you think of the state NBS program having follow-up people calling parents like you?" Responses were coded using conventional content analysis procedures, and nonparametric tests were performed to analyze quantitative data. RESULTS: Most parents reported favorable opinions about the follow-up. Favorable opinions were associated with several emotional reactions to receiving follow-up (P <0.001) and three reasons why parents found the interview beneficial (P < 0.05): it provided information, clarified NBS results, and answered questions. Seventeen parents of SCH carriers reportedly had not been told their infant's NBS results and received them for the first time during the follow-up interview. CONCLUSION: Parents of CF and SCH carrier infants had favorable opinions and identified specific benefits to receiving follow-up contact. This analysis demonstrates an information deficit among carrier parents and illustrates the importance of NBS follow-up and need for comprehensive communication and counseling.

Improving communication between doctors and parents after newborn screening.

BACKGROUND: Newborn screening (NBS) enables early treatment, and some consider it a natural vehicle for genetic screening. Bioethicists argue for caution since families of infants with carrier status can develop psychosocial complications. This paper describes the methods and feasibility of Wisconsin's statewide project for quality improvement of communication and psychosocial outcomes after NBS. METHODS: When NBS identifies carrier status for cystic fibrosis or sickle cell, we contact primary care providers (PCPs), answer questions, and invite them to rehearse informing the parents. Three months later, we telephone the parents, assess knowledge and psychosocial outcomes, provide counseling, and assist with self-referral to further resources. Afterward, evaluation surveys are provided to the parents, to be returned anonymously. RESULTS: Birthing facilities provided accurate PCP names for 73% of 817 infants meeting inclusion criteria; we identified PCPs for 21% more. We reached 47.3% of PCPs in time to invite a rehearsal; 60% of these accepted. We successfully called 50.2% of eligible parents; 61% recalled a PCP explanation, and 48.5% evaluated the explanation favorably. Evaluations by parents with limited health literacy were less favorable. CONCLUSION: It is feasible to follow parents for psychosocial outcomes after NBS. Preliminary data about communication is mixed, but further data will describe psychosocial outcomes and investigate outcomes' associations with communication.

The relationship between nurses' religiosity and willingness to let patients control the conversation about end-of-life care.

OBJECTIVE: The study attempts to examine the relationship between nurses' religious beliefs and how nurses communicate with patients. METHOD: An online census survey was administered to graduate students in the School of Nursing at a Midwestern university. The survey was designed to measure: relational control, as measured by the subscales of dominance and task orientation in Burgoon and Hale's scale of relational communication; clinician empathy, as measured by the Jefferson scale of clinician empathy; and intrinsic and extrinsic religiosity, whether religious views are held for deep personal reasons or social reasons, as measured by the Maltby and Lewis scale. Data were analyzed using multiple regressions and one-way ANOVAs. RESULTS: Intrinsic religiosity and empathy were both associated with the willingness to relinquish relational control in certain, specific contexts, such as end-of-life care. CONCLUSION: Nurses who scored higher on a scale of intrinsic religious beliefs were more willing to let patients take control of conversations about end-of-life care. PRACTICE IMPLICATIONS: A nurse's religious beliefs can enhance the clinical experience without the nurse trying to impose his or her beliefs on the patient, as the nurse works to make sure the patient's religious beliefs are upheld.

A method to quantify and compare clinicians' assessments of patient understanding during counseling of standardized patients.

OBJECTIVE: To introduce a method for quantifying clinicians' use of assessment of understanding (AU) questions, and to examine medicine residents' AU usage during counseling of standardized patients about prostate or breast cancer screening. METHODS: Explicit-criteria abstraction was done on 86 transcripts, using a data dictionary for 4 AU types. We also developed a procedure for estimating the "load" of informational content for which the clinician has not yet assessed understanding. RESULTS: Duplicate abstraction revealed reliability kappa=0.96. Definite criteria for at least one AU were found in 68/86 transcripts (79%). Of these, 2 transcripts contained a request for a teach-back ("what is your understanding of this?"), 2 contained an open-ended AU, 46 (54%) contained only a close-ended AU, and 18 (21%) only contained an "OK?" question. The load calculation identified long stretches of conversation without an AU. CONCLUSION: Many residents' transcripts lacked AUs, and included AUs were often ineffectively phrased or inefficiently timed. Many patients may not understand clinicians, and many clinicians may be unaware of patients' confusion. PRACTICE IMPLICATIONS: Effective AU usage is important enough to be encouraged by training programs and targeted by population-scale quality improvement programs. This quantitative method should be useful in population-scale measurement of AU usage.

A method to quantify residents' jargon use during counseling of standardized patients about cancer screening.

BACKGROUND: Jargon is a barrier to effective patient-physician communication, especially when health literacy is low or the topic is complicated. Jargon is addressed by medical schools and residency programs, but reducing jargon usage by the many physicians already in practice may require the population-scale methods used in Quality Improvement. OBJECTIVE: To assess the amount of jargon used and explained during discussions about prostate or breast cancer screening. Effective communication is recommended before screening for prostate or breast cancer because of the large number of false-positive results and the possible complications from evaluation or treatment. PARTICIPANTS: Primary care internal medicine residents. MEASUREMENTS: Transcripts of 86 conversations between residents and standardized patients were abstracted using an explicit-criteria data dictionary. Time lag from jargon words to explanations was measured using "statements," each of which contains one subject and one predicate. RESULTS: Duplicate abstraction revealed reliability kappa = 0.92. The average number of unique jargon words per transcript was 19.6 (SD = 6.1); the total jargon count was 53.6 (SD = 27.2). There was an average of 4.5 jargon-explanations per transcript (SD = 2.3). The ratio of explained to total jargon was 0.15. When jargon was explained, the average time lag from the first usage to the explanation was 8.4 statements (SD = 13.4). CONCLUSIONS: The large number of jargon words and low number of explanations suggest that many patients may not understand counseling about cancer screening tests. Educational programs and faculty development courses should continue to discourage jargon usage. The methods presented here may be useful for feedback and quality improvement efforts.

Pediatric residents' use of jargon during counseling about newborn genetic screening results.

OBJECTIVE: The goal was to investigate pediatric residents' usage of jargon during discussions about positive newborn screening test results. METHODS: An explicit-criteria abstraction procedure was used to identify jargon usage and explanations in transcripts of encounters between residents and standardized parents of a fictitious infant found to carry cystic fibrosis or sickle cell hemoglobinopathy. Residents were recruited from a series of educational workshops on how to inform parents about positive newborn screening test results. The time lag from jargon words to explanations was measured by using "statements," each of which contained 1 subject and 1 predicate. RESULTS: Duplicate abstraction revealed reliability kappa of 0.92. The average number of unique jargon words per transcript was 20; the total jargon count was 72.3 words. There was an average of 7.5 jargon explanations per transcript, but the explained/total jargon ratio was only 0.17. When jargon was explained, the average time lag from the first usage to the explanation was 8.2 statements. CONCLUSION: The large number of jargon words and the small number of explanations suggest that physicians' counseling about newborn screening may be too complex for some parents.