"You Look Young! Are You a Doctor?" A Qualitative Content Analysis of Anesthesiology Resident Responses to Ageism in Clinical Encounters.

BACKGROUND: Healthcare trainees frequently report facing comments from their patients pertaining to their age. Exposure to ageist comments from patients may be related to greater stress and/or burnout in residents and may impact the quality of the resident-patient relationship. However, little empirical work has examined ageism expressed toward anesthesiology residents in clinical care, and therefore not much is known about how residents respond to these comments in practice. This research sought to determine how anesthesiology residents responded to ageist comments. METHODS: Anesthesiology residents (N = 60) engaged in a preoperative interaction with a standardized patient who was instructed to make an ageist comment to the resident. Resident responses were transcribed and coded using qualitative inductive content analysis to identify response themes. RESULTS: The most common resident response to the ageist comment, across gender and resident year, was to state their own experience. Some also described how they were still in training or that they were under supervision. Residents rarely reassured the patient that they would receive good care or identified the patient's anxiety as a cause of the ageist remark. CONCLUSIONS: These results provide a first step in understanding how ageism may be navigated by residents in clinical encounters. The authors discuss potential avenues for future research and education for responding to ageist remarks for both patients and clinicians.

Environmental Considerations for Effective Telehealth Encounters: A Narrative Review and Implications for Best Practice.

Introduction: Due to the reduction in-person visits, the COVID-19 pandemic has led to expansions in the use of telehealth technology to provide patient care, yet clinicians lack evidence-based guidance on how to most effectively use video communication to enhance patient experience and outcomes. Methods: A narrative review was conducted to describe environmental factors derived from research in social psychology and human-computer interaction (HCI) that may guide effective video-based clinician-patient telehealth communication. Results: Factors such as nonverbal cues, spatial proximity, professionalism cues, and ambient features play an important role in patient experience. We present a visual typology of telehealth backgrounds to inform clinical practice and guide future research. Discussion: A growing body of empirical evidence indicates that environmental cues may play an essential role in establishing psychological safety, improving patient experience, and supporting clinical efficacy in these virtual experiences. Conclusion: The expanded use of telehealth visits suggests the need for further research on the relative effects of these environmental factors on patient experience and outcomes.

Patient Preference for Telehealth Background Shapes Impressions of Physicians and Information Recall: A Randomized Experiment.

Introduction: Telehealth is increasing rapidly as a health care delivery platform, but we lack empirical evidence regarding how telehealth environments can affect patient experiences. The present research determined how physician's telehealth backgrounds affect various patient outcomes. Methods: Participants viewed a 30-s video of a physician with one of six different virtual backgrounds and reported various socioemotional and cognitive responses to the mock telehealth experience. Results: Although the telehealth background manipulation did not impact participants' socioemotional or cognitive responses, participants' subjective perceptions of the telehealth backgrounds were related to important clinical outcomes, such as their ability to remember critical information from the appointment and overall satisfaction with the experience. Discussion: Telehealth environments may result in tradeoffs between patient experience, subjective impressions of clinicians, and information recall. Conclusions: A physician's telehealth background can have measurable impact on patients' telehealth experiences, suggesting a need for careful background selection and design.

What is empathy? Oncology patient perspectives on empathic clinician behaviors.

BACKGROUND: Oncology patients and physicians value empathy because of its association with improved health outcomes. Common measures of empathy lack consistency and were developed without direct input from patients. Because of their intense engagement with health care systems, oncology patients may have unique perspectives on what behaviors signal empathy in a clinical setting. METHODS: As part of a cross-sectional study of patient perspectives on clinician empathy at an academic cancer center in the northeastern United States, the authors solicited up to 10 free-text responses to an open-ended question about what clinician behaviors define empathy. RESULTS: The authors categorized open-ended responses from 89 oncology patients into 5 categories representing 14 themes. These categories were relationship sensitivity, focus on the whole person, communication, clinician attributes, and institutional resources and care processes. Frequently represented themes, including listening, understanding, and attention to emotions and what matters most, aligned with existing measures of empathy; behaviors that were not well represented among existing measures included qualities of information sharing and other communication elements. Patients also associated clinician demeanor, accessibility, and competence with empathy. CONCLUSIONS: Oncology patients' perspectives on empathy highlight clinician behaviors and attributes that may help to refine patient experience measures and may be adopted by clinicians and cancer centers to enhance patient care and outcomes. High-quality communication skills training can promote active listening and paying attention to the whole person. A system-level focus on delivering empathic care may improve patients' experiences and outcomes. LAY SUMMARY: Oncology patients' responses to an open-ended question about empathic clinician behavior have revealed insights into a variety of behaviors that are perceived as demonstrative of empathy. These include behaviors that imply sensitivity to the clinician-patient relationship, such as listening and understanding and attention to the whole person. Participants valued caring communication and demeanor and clinician accessibility. Perspective taking was not common among answers. Many existing measures of clinical care quality do not include the behaviors cited by patients as empathic. These results can inform efforts to refine quality measures of empathy-associated behaviors in clinical practice. Cancer centers can use skills training to improve elements of communication.

Compassionate and Clinical Behavior of Residents in a Simulated Informed Consent Encounter.

BACKGROUND: Compassionate behavior in clinicians is described as seeking to understand patients' psychosocial, physical and medical needs, timely attending to these needs, and involving patients as they desire. The goal of our study was to evaluate compassionate behavior in patient interactions, pain management, and the informed consent process of anesthesia residents in a simulated preoperative evaluation of a patient in pain scheduled for urgent surgery. METHODS: Forty-nine Clinical Anesthesia residents in year 1 and 16 Clinical Anesthesia residents in year 3 from three residency programs individually obtained informed consent for anesthesia for an urgent laparotomy from a standardized patient complaining of pain. Encounters were assessed for ordering pain medication, for patient-resident interactions by using the Empathic Communication Coding System to code responses to pain and nausea cues, and for the content of the informed consent discussion. RESULTS: Of the 65 residents, 56 (86%) ordered pain medication, at an average of 4.2 min (95% CI, 3.2 to 5.1) into the encounter; 9 (14%) did not order pain medication. Resident responses to the cues averaged between perfunctory recognition and implicit recognition (mean, 1.7 [95% CI, 1.6 to 1.9]) in the 0 (less empathic) to 6 (more empathic) system. Responses were lower for residents who did not order pain medication (mean, 1.2 [95% CI, 0.8 to 1.6]) and similar for those who ordered medication before informed consent signing (mean, 1.9 [95% CI, 1.6 to 2.1]) and after signing (mean, 1.9 [95% CI, 1.6 to 2.0]; F (2, 62) = 4.21; P = 0.019; partial η = 0.120). There were significant differences between residents who ordered pain medication before informed consent and those who did not order pain medication and between residents who ordered pain medication after informed consent signing and those who did not. CONCLUSIONS: In a simulated preoperative evaluation, anesthesia residents have variable and, at times, flawed recognition of patient cues, responsiveness to patient cues, pain management, and patient interactions.

Preferences for mHealth physical activity interventions during chemotherapy for breast cancer: a qualitative evaluation.

PURPOSE: Physical activity has been shown to decline over the course of chemotherapy in breast cancer survivors; yet it may reduce treatment-related side effects and emerging evidence indicates it may improve disease outcomes. Mobile health (mHealth) interventions may be an effective, scalable strategy to increase physical activity during treatment. However, little is known about breast cancer patients' interests and preferences for these interventions. It is important to understand patients' interests and preferences prior to development of mHealth physical activity interventions to increase their relevance and efficacy. METHODS: Breast cancer survivors (n = 30) participated in a semi-structured phone interview and were asked about barriers and facilitators to physical activity during chemotherapy as well as their preferences on a range of potential mHealth intervention features. Transcribed interviews were coded and key themes were analyzed using an iterative, inductive approach. RESULTS: Five key themes were extracted from the interviews: (1) need for education about physical activity during chemotherapy; (2) treatment side effects inhibit physical activity; (3) a structured, home-based, tech-supported program with in-person elements is most feasible; (4) need for a personalized, highly tailored intervention; and (5) importance of social support from other breast cancer survivors, friends, and family. CONCLUSIONS: Breast cancer survivors are interested in mHealth physical activity interventions during chemotherapy, but preferences for intervention content and delivery varied. Future work should engage patients and survivors in intervention development and testing.

Clinicians, cooks, and cashiers: Examining health equity and the COVID-19 risks to essential workers.

In Spring/Summer 2020, most individuals living in the United States experienced several months of social distancing and stay-at-home orders because of the coronavirus (COVID-19) pandemic. Clinicians, restaurant cooks, cashiers, transit operators, and other essential workers (EWs), however, continued to work outside the home during this time in order to keep others alive and maintain a functioning society. In the United States, EWs are often low-income persons of color who are more likely to face socioeconomic vulnerabilities, systemic racism, and health inequities. To assess the various impacts of COVID-19 on EWs, an online survey was distributed to a representative sample of individuals residing in six states during May/June 2020. The sample included 990 individuals who identified as EWs and 736 nonessential workers (NWs). We assessed differences between EW and NW respondents according to three categories related to health equity and social determinants of health: (1) demographics (e.g. race/ethnicity); (2) COVID-19 exposure risk pathways (e.g. ability to social distance); and (3) COVID-19 risk perceptions (e.g. perceived risk of contracting COVID-19). EWs were more likely to be Black or Hispanic than NWs and also had lower incomes and education levels on average. Unsurprisingly, EWs were substantially more likely to report working outside the home and less likely to report social distancing and wearing masks indoors as compared to NWs. EWs also perceived a slightly greater risk of contracting COVID-19. These findings, which we discuss in the context of persistent structural inequalities, systemic racism, and health inequities within the United States, highlight ways in which COVID-19 exacerbates existing socioeconomic vulnerabilities faced by EWs.

To Know Another's Pain: A Meta-analysis of Caregivers' and Healthcare Providers' Pain Assessment Accuracy.

Background: Acute and chronic pain affects millions of adults yet it is often inadequately assessed and treated. Purpose: The purpose of the present meta-analysis was to examine the overall level of pain assessment accuracy among caregivers and providers and identify patient, observer, and assessment level factors that moderate pain assessment accuracy. Methods: A systematic literature search was conducted in PubMed and PsycINFO to identify studies addressing providers' pain assessment accuracy, or studies that compared patients' self-report of pain with observers' (healthcare providers, caregivers, and strangers) assessment of pain. We present two separate meta-analyses examining the overall effect of under-/overestimation of pain and correlational pain assessment accuracy. Results: Seventy-six articles meeting inclusion criteria yielded 94 independent effect sizes for the correlational accuracy meta-analysis. Ninety articles yielded 103 independent effect sizes for the paired comparison meta-analysis. The correlational pain assessment meta-analysis showed that in general, observers were significantly better than chance when assessing pain; however, the paired comparison meta-analysis showed that observers significantly underestimated patients' pain. Patient's age and gender, pain type, and provider type moderated these effects. Conclusions: Results suggest that certain healthcare providers and caregivers need training to more accurately assess patient pain and that there are particular groups of patients who may be at a greater risk for having their pain inaccurately assessed.

Nonverbal Communication as a Pain Reliever: The Impact of Physician Supportive Nonverbal Behavior on Experimentally Induced Pain.

Despite the evidence for the potential of supportive communication to alleviate physical pain, no study to date has assessed the impact of supportive nonverbal behavior on the objective and subjective experience of pain. This analogue study examined the impact of an actor-physician's supportive nonverbal behavior on experimentally induced pain. Participants (N = 205) were randomly assigned to interact with a videotaped physician conveying high or low supportive nonverbal behaviors. Participant pain was assessed with subjective and objective measures. Participants interacting with the high nonverbal support physicians showed increased pain tolerance and a reduction in the amount of pain expressed compared to those interacting with the low nonverbal support physicians. For subjectively rated pain, a gender difference existed such that for men, high physician nonverbal support decreased pain ratings and memory of pain, but for women, high physician nonverbal support increased pain ratings and memory of pain. These results highlight the importance of nonverbal communication in altering pain with broad implications for clinical care.

Behavioral Indicators on a Mobile Sensing Platform Predict Clinically Validated Psychiatric Symptoms of Mood and Anxiety Disorders.

BACKGROUND: There is a critical need for real-time tracking of behavioral indicators of mental disorders. Mobile sensing platforms that objectively and noninvasively collect, store, and analyze behavioral indicators have not yet been clinically validated or scalable. OBJECTIVE: The aim of our study was to report on models of clinical symptoms for post-traumatic stress disorder (PTSD) and depression derived from a scalable mobile sensing platform. METHODS: A total of 73 participants (67% [49/73] male, 48% [35/73] non-Hispanic white, 33% [24/73] veteran status) who reported at least one symptom of PTSD or depression completed a 12-week field trial. Behavioral indicators were collected through the noninvasive mobile sensing platform on participants' mobile phones. Clinical symptoms were measured through validated clinical interviews with a licensed clinical social worker. A combination hypothesis and data-driven approach was used to derive key features for modeling symptoms, including the sum of outgoing calls, count of unique numbers texted, absolute distance traveled, dynamic variation of the voice, speaking rate, and voice quality. Participants also reported ease of use and data sharing concerns. RESULTS: Behavioral indicators predicted clinically assessed symptoms of depression and PTSD (cross-validated area under the curve [AUC] for depressed mood=.74, fatigue=.56, interest in activities=.75, and social connectedness=.83). Participants reported comfort sharing individual data with physicians (Mean 3.08, SD 1.22), mental health providers (Mean 3.25, SD 1.39), and medical researchers (Mean 3.03, SD 1.36). CONCLUSIONS: Behavioral indicators passively collected through a mobile sensing platform predicted symptoms of depression and PTSD. The use of mobile sensing platforms can provide clinically validated behavioral indicators in real time; however, further validation of these models and this platform in large clinical samples is needed.

Cancer survivors as activated patients: Exploring the relationship between cancer history and patient activation.

Many cancer survivors experience long-term physical and psychosocial sequalae. As such, there is a need for survivors to be activated and participate in their own health care. Our study explores the relationship between cancer history and patient activation. We used data from the 2013 Health Information National Trends Survey (N = 3185, response rate = 35.19%). Survivors had approximately 70% higher odds of being highly activated compared to those with no cancer history. Level of activation did not vary across time since diagnosis. Future research should examine mechanisms for increased activation in survivors and ways to encourage more activation behaviors.

Communication between oncologists and lymphoma survivors during follow-up consultations: A qualitative analysis.

Cancer survivors often experience both short- and long-term challenges as a result of their cancer treatment. Many patients report feeling "lost in transition" following cancer treatment. The oncologist plays a key role in helping the patient to transition to survivorship. The purpose of this paper is to provide a descriptive understanding of the clinical care delivered during follow-up visits for lymphoma patients transitioning from active therapy into survivorship. We used thematic text analysis to identify themes in transcripts of audio recordings of 21 physicians and their patients in follow-up visits within 3 years of completing lymphoma treatment. Conversations between oncologists and patients during follow-up visits addressed a variety of themes, including specific health concerns, follow-up care, health promotion, prior treatment and test results, overall health status, emotional communication and affective tone, post-treatment rehabilitation, discussions occurring in the patient's physical examination, and social issues. However, the frequency with which these themes were discussed varied. In addition, there did not appear to be a consistent framework for these visits. The varied nature of the follow-up visits analyzed in this study suggests the need for increased structure in survivorship-care consultations.

Correlates of the positive psychological byproducts of cancer: Role of family caregivers and informational support.

OBJECTIVE: Experiencing a life-threatening illness such as cancer can elicit both negative (e.g., distress) and positive (e.g., growth) psychological responses. The present study sought to determine the correlates of four positive psychological byproducts in cancer survivors: becoming a stronger person, coping better with life's challenges, making positive changes in life, and adopting healthier habits. METHOD: Data for this cross-sectional study were taken from the Medical Expenditures Panel Survey (MEPS) Experiences with Cancer Survivorship Supplement (Yabroff et al., 2012). Cancer survivors (N = 785) reported their sociodemographic and cancer-related characteristics. Descriptive statistics were utilized to summarize cancer survivor characteristics, including demographic factors, cancer factors, and stressors and resources related to cancer. Multivariable logistic regressions were employed to assess the independent association of the stressors and resources with each psychological response, controlling for covariates. All analyses were weighted to account for the complex sampling design of the MEPS. RESULTS: In multivariable analyses, those with a family caregiver were 50% more likely to report better coping with challenges, and around 70% were more likely to report making positive changes in life or adopting healthier habits because of their cancer. Receiving informational support from healthcare providers was also consistently associated with positive byproducts (odds ratios ranging from 1.6 to 2.0). Few of the stressors were associated with positive byproducts: having insurance problems due to cancer was positively associated with becoming a stronger person, and work limitations were associated with making positive changes in life; those who reported high perceived chances of recurrence were less likely to report becoming a stronger person. SIGNIFICANCE OF RESULTS: Having a family caregiver and receiving detailed informational support from healthcare providers were associated with reporting positive experiences with cancer. The hypotheses and future research stimulated by these findings may improve our understanding of the process by which positive byproducts develop and may ultimately help improve psychological well-being among cancer survivors.

Cancer-Related Information Seeking Among Cancer Survivors: Trends Over a Decade (2003-2013).

The demonstrated benefits of information seeking for cancer patients, coupled with increases in information availability, underscore the importance of monitoring patient information seeking experiences over time. We compared information seeking among cancer survivors to those with a family history of cancer and those with no history of cancer. We identified characteristics associated with greater information seeking among cancer survivors, key sources of cancer-related information, and changes in information source use over time. Data from five iterations of the Health Information National Trends Survey (HINTS) spanning 2003 to 2013 were merged and analyzed. Frequencies, cross-tabulations, multivariate logistic regression, and multinomial regression analyses were conducted. All data were weighted to provide representative estimates of the adult US population. Cancer information seeking was reported most frequently by cancer survivors (69.8 %). The percentage of cancer survivors who reported information seeking increased from 66.8 % in 2003 to 80.8 % in 2013. Cancer information seeking was independently associated with age, education, and income; seeking was less likely among older adults, those with less education, and those with lower incomes. Compared to respondents in 2003, those in 2005 (odds ratio (OR) = 0.40, 95 % confidence interval (CI) = 0.24-0.65) and 2008 (OR = .43, 95 % CI = 0.26-0.70) were about half as likely to use the Internet as the first source of cancer information compared to a healthcare provider. Despite overall increases in cancer information seeking and access to health information from a variety of sources, healthcare providers remain a key source of health information for cancer survivors.

Socioeconomic and sociodemographic predictors of cancer-related information sources used by cancer survivors.

With 14 million cancer survivors in the United States, identifying and categorizing their use of sources of cancer-related information is vital for targeting effective communications to this growing population. In addition, recognizing socioeconomic and sociodemographic differences in the use of cancer-related information sources is a potential mechanism for reducing health disparities in survivorship. Fourteen sources of information survivors (N = 519) used for cancer-related information were factor-analyzed to create a taxonomy of source use. The association between social determinants and use of these source types was analyzed in regression models. Factor analysis revealed 5 categories of information source use (mass media; Internet and print; support organizations; family and friends; health care providers), and use varied based on sociodemographic and socioeconomic characteristics. Higher education predicted increased use of all source categories except mass media. African American cancer survivors turned to health care providers as a source for cancer-related information less often than did White survivors. Social determinants predicted differences in the type of cancer-related information sources used. Providers and health communicators should target communication platforms based on the demographic profile of specific survivor audiences.

How patient-centered do female physicians need to be? Analogue patients' satisfaction with male and female physicians' identical behaviors.

Previous research suggests that female physicians may not receive appropriate credit in patients' eyes for their patient-centered skills compared to their male counterparts. An experiment was conducted to determine whether a performance of higher (versus lower) verbal patient-centeredness would result in a greater difference in analogue patient satisfaction for male than female physicians. Two male and two female actors portrayed physicians speaking to a patient using high or low patient-centered scripts while not varying their nonverbal cues. One hundred ninety-two students served as analogue patients by assuming the patient role while watching one of the videos and rating their satisfaction and other evaluative responses to the physician. Greater verbal patient-centeredness had a stronger positive effect on satisfaction and evaluations for male than for female physicians. This pattern is consistent with the hypothesis that the different associations between patient-centeredness and patients' satisfaction for male versus female physicians occur because of the overlap between stereotypical female behavior and behaviors that comprise patient-centered medical care. If this is the case, high verbal patient-centered behavior by female physicians is not recognized as a marker of clinical competence, as it is for male physicians, but is rather seen as expected female behavior.

Cancer survivors' use of numerous information sources for cancer-related information: does more matter?

A large proportion of the 14 million cancer survivors in the USA are actively seeking health information. This study builds on the informed- and shared-decision making literature, examining cancer survivors' health information seeking behaviors to (1) quantify the number of health information sources used; (2) create a demographic profile of patients who report seeking cancer information from numerous sources versus fewer sources in five areas: cancer information overall, disease/treatment, self-care/management, health services, and work/finances; and (3) examine whether seeking cancer information from numerous sources is associated with self-efficacy, fear of recurrence, perceptions of information seeking difficulty, and resultant patient-provider communication. Data came from a survey of post-treatment cancer survivors (N = 501) who responded to a mailed questionnaire about health information seeking. Participants were divided into two groups using a median split: those who sought health information from more than five sources (numerous source seekers) and those that sought information from less than five sources (fewer source seekers). Multivariable logistic regression was used to model differential information seeking behaviors and outcomes for numerous versus fewer source seekers. On average, survivors sought cancer-related information from five different sources. Numerous source seekers were more likely to be women, have higher levels of education, and report fewer problems with cancer information-seeking. Overall, numerous source seekers were no more or less likely to discuss information with their providers or bring conflicting information to their providers. Understanding the characteristics, behaviors, and experiences of survivors who seek cancer-related information from numerous sources can contribute to informed decision making and patient-centered care.

Can naive viewers put themselves in the patients' shoes?: reliability and validity of the analogue patient methodology.

BACKGROUND: Analogue patients (APs) are untrained viewers given the task of viewing and rating their impressions of a medical interaction while taking on the patient role. This methodology is often used to assess patient perceptions when using real patient (RP) populations is unethical or impractical. OBJECTIVES: This study examines the reliability and validity of the AP methodology and its optimal implementation. RESEARCH DESIGN: Forty-six videotaped interactions of RP-physician interactions, where RP satisfaction scores existed, were viewed by 216 APs, who rated satisfaction. Interrater reliability for AP satisfaction scores was evaluated. AP and RP satisfaction scores were compared with each other and correlated with the physician's observer-coded patient-centeredness. MEASURES: RP satisfaction was measured with a 15-item scale after the whole interaction. Physicians' patient-centered behavior was coded with the Four Habits Coding Scheme. AP satisfaction was measured after viewing the entire interaction with a single satisfaction question, a 4-item satisfaction scale including that single item, and the original 15-item satisfaction scale used by the RPs. RESULTS: AP satisfaction ratings were reliable (=0.70 for 4 APs). AP satisfaction was a significant predictor of RP satisfaction (r=0.29, P=0.05), especially when the analysis was limited to the RPs who reported being less than perfectly satisfied (r=0.65, P=0.002). AP satisfaction was a better predictor than RP satisfaction of providers' patient-centered behaviors in the interaction. CONCLUSIONS: The AP methodology is a valid and reliable approach to gathering patient perception data about provider-patient interactions. Results suggest practical advice for researchers using the AP methodology.

Methodological innovations to strengthen evidence-based serious illness communication.

BACKGROUND/OBJECTIVE: A growing population of those affected by serious illness, prognostic uncertainty, patient diversity, and healthcare digitalization pose challenges for the future of serious illness communication. Yet, there is paucity of evidence to support serious illness communication behaviors among clinicians. Herein, we propose three methodological innovations to advance the basic science of serious illness communication. RESULTS: First, advanced computation techniques - e.g. machine-learning techniques and natural language processing - offer the possibility to measure the characteristics and complex patterns of audible serious illness communication in large datasets. Second, immersive technologies - e.g., virtual- and augmented reality - allow for experimentally manipulating and testing the effects of specific communication strategies, and interactional and environmental aspects of serious illness communication. Third, digital-health technologies - e.g., shared notes and videoconferences - can be used to unobtrusively observe and manipulate communication, and compare in-person to digitally-mediated communication elements and effects. Immersive and digital health technologies allow integration of physiological measurement (e.g. synchrony or gaze) that may advance our understanding of patient experience. CONCLUSION/PRACTICE IMPLICATIONS: New technologies and measurement approaches, while imperfect, will help advance our understanding of the epidemiology and quality of serious illness communication in an evolving healthcare environment.