An exploration of patient and family engagement in routine primary care visits.

BACKGROUND: Older adults are commonly accompanied to routine medical visits. Whether and how family companion behaviours relate to visit processes is poorly understood. OBJECTIVE: To examine family companion behaviours in relation to older adults' medical visit processes. DESIGN AND PARTICIPANTS: Observational study of 78 accompanied primary care patients ages 65 and older. MAIN OUTCOME MEASURES: Medical visit communication (coded using RIAS), patient verbal activity (as a proportion of visit statements) and visit duration (in min), from audio recordings. RESULTS: Companions' facilitation of patient involvement was associated with greater patient question asking (P = 0.017) and orienting statements, less passive agreement (P = 0.004) and social talk (P = 0.013) and visits that were 3.4 min longer (P = 0.025). Facilitation of patient understanding was associated with less physician question asking (P = 0.004), visits that were 3.0 min longer (P = 0.031), and lower patient verbal activity (30.3% vs. 36.9% of visit statements; P = 0.028). Facilitation of doctor understanding was associated with greater patient biomedical information giving (P = 0.049). Autonomy detracting behaviours were not associated with visit duration but were associated with lower levels of patient verbal activity (36.3% vs. 29.1% of visit statements; P = 0.041). When companions assumed more behaviours, medical visits were incrementally longer (16.1, 19.5, 21.7 min, corresponding to 0-1, 2-4 and 5+ behaviours; P < 0.001 both contrasts), and patients were less verbally active (35.6%, 33.9%, 27.1% of visit statements; P = 0.09 and P = 0.009, respectively). DISCUSSION: Behaviours assumed by patients' companions were associated with visit communication, patient verbal activity and visit duration. CONCLUSIONS: Interventions to capitalize on family companions' presence may benefit medical visit processes.

Now what should I do? Primary care physicians' responses to older adults expressing thoughts of suicide.

BACKGROUND: Many older adults who die by suicide have had recent contact with a primary care physician. As the risk-assessment and referral process for suicide is not readily comparable to procedures for other high-risk behaviors, it is important to identify areas in need of quality improvement (QI). OBJECTIVE: Identify patterns in physician-patient communication regarding suicide to inform QI interventions. DESIGN: Qualitative thematic analysis of video-taped clinical encounters in which suicide was discussed. PARTICIPANTS: Adult primary care patients (n = 385) 65 years and older and their primary care physicians. RESULTS: Mental health was discussed in 22% of encounters (n = 85), with suicide content found in less than 2% (n = 6). Three patterns of conversation were characterized: (1) Arguing that "Life's Not That Bad." In this scenario, the physician strives to convince the patient that suicide is unwarranted, which results in mutual fatigue and discouragement. (2) "Engaging in Chitchat." Here the physician addresses psychosocial matters in a seemingly aimless manner with no clear therapeutic goal. This results in a superficial and misleading connection that buries meaningful risk assessment amidst small talk. (3) "Identify, assess, and…?" This pattern is characterized by acknowledging distress, communicating concern, eliciting information, and making treatment suggestions, but lacks clearly articulated treatment planning or structured follow-up. CONCLUSIONS: The physicians in this sample recognized and implicitly acknowledged suicide risk in their older patients, but all seemed unable to go beyond mere assessment. The absence of clearly articulated treatment plans may reflect a lack of a coherent framework for managing suicide risk, insufficient clinical skills, and availability of mental health specialty support required to address suicide risk effectively. To respond to suicide's numerous challenges to the primary care delivery system, QI strategies will require changes to physician education and may require enhancing practice support.

Nonverbal communication in doctor-elderly patient transactions (NDEPT): development of a tool.

OBJECTIVE: There are several measurement tools to assess verbal dimensions in clinical encounters; in contrast, there is no established tool to evaluate physical nonverbal dimensions in geriatric encounters. The present paper describes the development of a tool to assess the physical context of exam rooms in doctor-older patient visits. METHOD: Salient features of the tool were derived from the medical literature and systematic observations of videotapes and refined during current research. RESULTS: The tool consists of two main dimensions of exam rooms: (1) physical dimensions comprising static and dynamic attributes that become operational through the spatial configuration and can influence the manifestation of (2) kinesic attributes. CONCLUSION: Details of the coding form and inter-rater reliability are presented. The usefulness of the tool is demonstrated through an analysis of 50 National Institute of Aging videotapes. Physicians in exam rooms with no desk in the interaction, no height difference and optimal interaction distance were observed to have greater eye contact and touch than physicians' in exam rooms with a desk, similar height difference and interaction distance. PRACTICE IMPLICATIONS: The tool can enable physicians to assess the spatial configuration of exam rooms (through Parts A and B) and thus facilitate the structuring of kinesic attributes (Part C).

Physician eye contact and elder patient perceptions of understanding and adherence.

OBJECTIVE: To Examine physician eye contact (EC), patient understanding and adherence. METHODS: Secondary analysis of National Institute of Aging videotapes (N=52) of physician-elder patients in two visit types: (1) routine (n=20); (2) anxiety-provoking (n=32) was conducted. Self-reports of understanding and adherence were used. History-taking segments were qualitatively and quantitatively analyzed for relationships between EC, understanding and adherence. RESULTS: Qualitative analysis showed: (1) two salient EC elements--frequency, type (brief or sustained)--and verbal synchronicity were commonly invoked; (2) conjoint unfolding of three communication elements--"looking, listening and talking"--may be salient for patient outcomes; (3) despite differing EC patterns in routine and anxiety provoking visits, statistical analyses showed patient understanding and adherence ratings were similar in the sample population comprising two visit types; no significant correlations between EC elements and understanding and adherence were found. CONCLUSIONS: Salience of EC for patient-centered communication is shown in prior research. Present findings broaden the significance of EC by including verbal synchronicity. Methodological limitations may account for no significant correlations between EC and patient outcomes. PRACTICE IMPLICATIONS: Using suggested framework for operationalizing EC elements, including verbally synchronous communication, may facilitate patient-centeredness and have positive implications for patient understanding and adherence.

Eye contact in patient-centered communication.

OBJECTIVE: To understand the relationship between eye contact and patient-centered communication (PC) in physician-elder patient interactions. METHODS: Two instruments-Patient-centered Behavior Coding Instrument (PBCI) and Eurocommunication Global Ratings Scale-were used to measure PC in 22 National Institute of Aging videotapes. Eye contact was measured using a refined eye contact scale in NDEPT. Qualitative observational techniques were used to understand how eye contact can implicate communication. RESULTS: 'High' eye contact tapes were found to be 'high' in PC using both instruments. However, the majority of 'low' tapes were also found to be 'high' in PC. Physicians' behavior distinctly differed in two ways: (1) high tapes were characterized by more 'sustained' eye contact episodes; low tapes consisted of a greater number of 'brief' episodes; (2) brief episode tapes showed a greater focus on 'charts', i.e. 'listening' was bereft of 'looking'; sustained episodes showed a focus on 'patients', i.e. 'listening' was accompanied by 'looking' indicating patient-centered communication. CONCLUSIONS: A comprehensive understanding of elder patient-physician interaction needs to include both-'listening' and 'looking'-components of patient-centered communication. PRACTICE IMPLICATIONS: Eye contact serves as a salient factor in the expression of PC, making it imperative to incorporate as a nonverbal dimension in PC instruments.

Discussion of depression in follow-up medical visits with older patients.

OBJECTIVES: To determine the frequency of discussion about depression in follow-up medical visits of older patients, who initiates these discussions, the quality of responsiveness of physicians and patients in these discussions, and patient and physician characteristics that influence these discussions. DESIGN: Convenience sample of 482 audiotaped follow-up visits. SETTING: Three community-based practice sites. PARTICIPANTS: Three hundred seventy-six community-dwelling older patients without dementia and 43 primary care physicians. MEASUREMENTS: Audiotapes were analyzed using the Multi-Dimensional Interaction Analysis system to determine the content and process of medical conversations; patients completed Medical Outcomes Study 36-item Short Form Survey questionnaires immediately after the visit. RESULTS: Depression was discussed in 7.3% of medical visits; physicians raised this topic in 41% of visits, patients raised it in 48% of visits, and accompanying persons raised it in 10% of visits. Visits were longer when the topic of depression was discussed. Depression was raised almost exclusively in the first 2.5 years of the patient-physician relationship. Physicians with some geriatric training were more likely to discuss depression, and these visits were shorter than visits to physicians without geriatric training. CONCLUSION: Depression was raised infrequently in follow-up visits. The high prevalence of depression in older people and the associated mortality merit discussion of depression early and later in the patient-physician relationship. Although visits were longer when depression was discussed, physicians with some geriatric training were more likely to raise depression, and more time-efficient when they did so, than physicians without geriatric training.

Two-minute mental health care for elderly patients: inside primary care visits.

OBJECTIVES: To assess how care is delivered for mental disorders using videotapes of office visits involving elderly patients. DESIGN: Mixed-method observational analysis of the nature of the topics discussed, content of discussion, and the time spent on mental health. SETTINGS: Three types of settings: an academic medical center, a managed care group, and fee-for-service solo practitioners. PARTICIPANTS: Thirty-five primary care physicians and 366 of their elderly patients. MEASUREMENTS: Videotapes of 385 visits covering 2,472 diverse topics were analyzed. Coding of the videotapes identified topics, determined talk time, and coded the dynamics of talk. RESULTS: Mental health topics occurred in 22% of visits, although patient survey indicated that 50% of the patients were depressed. A typical mental health discussion lasted approximately 2 minutes. Qualitative analysis suggested wide variations in physician effort in providing mental health care. Referrals to mental health specialists were rare even for severely depressed and suicidal patients. CONCLUSION: Little time is spent on mental health care for elderly patients despite heavy disease burdens. Standards of care based on a count of visits "during which a mental health problem is discussed" may need to be supplemented with guidelines about what should happen during the visit. System-level interventions are needed.

Prevalence and correlates of doctor-geriatric patient lifestyle discussions: analysis of ADEPT videotapes.

BACKGROUND: This study identifies the prevalence and correlates of physician-geriatric patient discussions about physical activity and nutrition lifestyle behaviors. METHODS: Between August 1998 and July 2000, 423 older patient visits to 36 physicians were videotaped in three different primary care settings. The patient sample was primarily white, female, well-educated, and financially sufficient, although 12.7% of the encounters occurred in an inner city clinic. The major dependent variable-lifestyle discussion-is based on observations of physician behavior. Descriptive and multivariate logistic regression analyses were conducted in 2004. RESULTS: Nutrition talk was most prevalent, occurring in almost half the encounters (48.2%) followed by physical activity discussions (39.2%) then conjoint mention (22%). Discussions were significantly less likely to occur in acute visits. While ethnicity, gender, and length of visit were not significantly related, physician interaction style and patient vitality and education were significant predictors in the multivariate analyses. CONCLUSIONS: Given the impact of lifestyle behaviors on myriad health outcomes, the current prevalence rates of physician discussion, while higher than in many previous studies, remain sub-optimal. Practical assessment tools, training in behavioral counseling, and reimbursement incentives are recommended strategies for raising physical activity and nutrition discussion prevalence in primary care settings.

The development and psychometric analyses of ADEPT: an instrument for assessing the interactions between doctors and their elderly patients.

BACKGROUND: The lack of instruments and methodologies designed specifically for assessing doctor-elderly patient interactions has constricted research on effective communication in the medical care of older adults. PURPOSE: This article reports on the development, qualitative analyses, and psychometric testing of the Assessment of Doctor-Elderly Patient Transactions (ADEPT), an instrument for assessing interactions between doctors and their elderly patients. METHODS: The ADEPT was based on the recommendations of an expert panel and designed around the three-function model of the medical interview. The ADEPT is meant to operationalize the research findings of interactional analysis studies of doctor-patient interaction. Following preliminary testing with standardized patients, the ADEPT was applied to videotaped visits of 433 patients 65 years of age and older to the doctor (n = 40) identified as their primary source of care. RESULTS: Four final scales derived from exploratory and confirmatory factor analyses were scored: Supporting, comprised of the 12 items from the first factor; Eliciting Needs, containing the 5 items from the second factor; and Informing, based on the final 6-item factor. Individual Cronbach's alphas across raters for this sample ranged from .71 to .79 for the first scale, from .83 to .88 for the second scale, and from .64 to .81 for the third scale. The reliability estimates for the total scale (23 items) ranged from .80 to .86 across raters. A fifth summed index composed of 46 binary checklist items also was computed. CONCLUSIONS: The findings indicate that credible scales can be developed for assessing communication behaviors.

Understanding primary care physicians' propensity to assess elderly patients for depression using interaction and survey data.

OBJECTIVE: The objective of this study was to examine primary care physicians' propensity to assess their elderly patients for depression using data from videotapes and patient and physician surveys. STUDY DESIGN: An observational study was informed by surveys of 389 patients and 33 physicians, and 389 videotapes of their clinical interactions. Secondary quantitative analyses used video data scored by the Assessment of Doctor-Elderly Patient Transactions system regarding depression assessment. A random-effects logit model was used to analyze the effects of patient health, competing demands, and racial and gender concordance on physicians' propensity to assess elderly patients for depression. RESULTS: Physicians assessed depression in only 14% of the visits. The use of formal depression assessment tools occurred only 3 times. White patients were almost 7 times more likely than nonwhite patients to be assessed for depression (odds ratio [OR], 6.9; P < 0.01). Depression assessment was less likely if the patient functioned better emotionally (OR, 0.95; P < 0.01). The propensity of depression assessment was higher in visits that covered multiple topics (OR, 1.3; P < 0.01) contrary to the notion of competing demands crowding out mental health services. Unexpectedly, depression assessment was less likely to occur in gender and racially concordant patient-physician dyads. CONCLUSIONS: Primary care physicians assessed their elderly patients for depression infrequently. Reducing the number of topics covered in visits and matching patients and physicians based on race and gender may be counterproductive to depression detection. Informed by videotapes and surveys, our findings offer new insights on the actual care process and present conclusions that are different from studies based on administrative or survey data alone.