Indicators of the dimensions of trust (and mistrust) in early primary care practice: a qualitative study.

BACKGROUND: Trust occurs when persons feel they can be vulnerable to others because of the sincerity, benevolence, truthfulness and sometimes the competence they perceive. This project examines the various types of trust expressed in written reflections of developing healthcare clinicians. Our goal is to understand the roles trust plays in residents' self-examination and to offer insight from relationship science to inform the teaching and clinical work for better trust in healthcare. METHODS: We analyzed 767 reflective writings of 33 residents submitted anonymously, to identify explicit or implicit indicators attention to trust or relationship development. Two authors independently coded the entries based on inductively identified dimensions. Three authors developed a final coding structure that was checked against the entries. These codes were sorted into final dimensions. RESULTS: We identified 114 written reflections that contained one or more indicators of trust. These codes were compiled into five code categories: Trust of self/trust as the basis for confidence in decision making; Trust of others in the medical community; Trust of the patient and its effect on clinician; Assessment of the trust of them exhibited by the patient; and Assessment of the effect of the patient's trust on the patient's behavior. DISCUSSION: Broadly, trust is both relationship-centered and institutionally situated. Trust is a process, built on reciprocity. There is tacit acknowledgement of the interplay among what the residents do is good for the patient, good for themselves, and good for the medical institution. An exclusive focus on moments in which trust is experienced or missed, as well as only on selected types of trust, misses this complexity. CONCLUSION: A greater awareness of how trust is present or absent could lead to a greater understanding and healthcare education for beneficial effects on clinicians' performance, personal and professional satisfaction, and improved quality in patients' interactions.

"Alexa, Can You Be My Family Medicine Doctor?" The Future of Family Medicine in the Coming Techno-World.

Even before social distancing disrupted normative expectations and prompted an immediate shift to remote doctor/patient interactions, technology companies-Amazon, Apple, and Google-were preparing to disrupt medical care through the innovative use of technology. This article presents a possible scenario for how technology, in the near future, will completely up-end primary care practice. What does face-to-face interaction accomplish that cannot be done remotely? What do family physicians offer that cannot be accomplished by technology? More than just relationship, family medicine brings the therapeutic use of the self to engage with people, an ability to advocate for patients, and the ability to step back and reflect on the power of relationships. In addition, family physicians bring wisdom, making decisions in the liminal state between patient and physician, the resulting product of the human connection but also the ability to manage complexity using the best evidence. The ability to do both gives family medicine physician the skills to leverage but also control the coming big data.

Cultivating the Inner Life of a Physician Through Written Reflection.

All of us have an "inner life" that forms the core of who we are. It shapes and is shaped by our actions and experiences. During physician training, attention to residents' inner life requires a focus on their beliefs and emotions as well as their ethical and spiritual development, topics often considered to be outside the realm of clinical training and practice. We suggest that written reflections, as part of medical residency curriculum, can allow residents to explore their inner lives. The depth and range of residents' explorations show the value of adding brief, protected time for residents to explore their hopes, joys, struggles, and feelings, and to develop meaning from their experiences with patients.

Learning to See Beneath the Surface: A Qualitative Analysis of Family Medicine Residents' Reflections About Communication.

Patients share straightforward statements with physicians such as describing their fears about their diagnosis. Physicians need to also understanding implicit, indirect, subtle communication cues that give broader context to patients' illness experiences. This project examines physicians' written reflections that offer insight into their interpretation of both the stated and the tacit aspects of their observations about communication, their resulting responses, and their intended actions. Tufts University Family Medicine residents (N = 33) of the Tufts Family Medicine Cambridge Health Alliance completed three reflective exercises each week over the course of 1 year (756 reflective entries). An interdisciplinary research team identified communication-related concepts within the reflections. Identified themes include (a) physicians recognizing and discovering mutual interplay of their communication with and patient disclosure, (b) physicians paying attention to subtleties of patient behavior as indicative of a fuller picture of patients' lives and their coping with illness, and (c) physician images of growth and awareness about communication indicative of their potential for growth and improvement. The project extends the literature in communication and medical education by examining explicit and tacit points of reflection about communication. The project (a) allows for unpacking the multifaceted aspects of reflection and (b) bridges reflective theory and medical education with communication foundations.

Family medicine residents' reactions to introducing a reflective exercise into training.

INTRODUCTION: Teaching residents how to reflect and providing ongoing experience in reflection may aid their development into adaptable, life-long learning professionals. We introduced an ongoing reflective exercise into the curriculum of a family medicine residency program. Residents were provided 15 minutes, three times a week, to complete these reflective exercises. We termed these reflective exercises "clinical blogs" since they were entered into a web-based computer portfolio, though they were not publicly available. The aim of this study is to explore family medicine residents' responses to the introduction of an ongoing reflective exercise and examine strengths and challenges of the reflective process. METHODS: We invited a cohort of family medicine residents (8 residents) who had all participated in the reflective exercises as part of their residency to participate in one of two offered focus groups to share their experience with the reflective exercise. An investigator not connected to the training program led each focus group using minimal structure in order to allow for the breadth of residents' experiences to be revealed. The focus groups were audio recorded, and the recordings were transcribed verbatim without identifying participants. We used a grounded theory approach, using open coding to analyze the focus group transcripts and to identify themes. RESULTS: Four residents participated in each focus group. We identified four main themes regarding family medicine residents' responses of the reflective practice exercises: (1) Residents viewed blogging (reflecting) as a method of enhanced personal and professional self-development; (2) Despite the reflective exercises being valued as self-development, residents see an inherent conflict between self-development and professional duties; (3) Residents recognize their emotional responses, but writing about emotional issues is difficult for some residents; and (4) Clinical blogging in our residency has not reached its potential due to the way it was introduced. DISCUSSION: The themes indicate that future efforts at integrating reflective practice should further test the methods through which regular reflective practices are introduced. Identified themes provide evidence for reflection as enhancing capacity for self-development and suggest the potential for clinical blogging as a method to build a cornerstone for the capacity for reflective practice in medicine.

When rapport building extends beyond affiliation: communication overaccommodation toward patients with disabilities.

INTRODUCTION: Physician rapport with patients is described as a vital component of relationship-centered care, but rapport-building communication behaviors may exceed boundaries and instead indicate patronizing behavior toward patients with disabilities. This paper addresses the types of communication behaviors and contexts for interpreting when rapport building extends beyond boundaries toward patients with disabilities. METHODS: Videotaped interactions between third- and fourth-year medical students (N = 142) and standardized patient educators with physical disabilities were qualitatively analyzed. RESULTS: Results suggest six primary themes of exceeding expected rapport boundaries, including baby talk (ie, exaggerated nonverbal gestures and "we" language to indicate "you"), kinesic movement (ie, stiff posture and awkward handshakes), vocalics (ie, volume or pitch that interfered with the flow of conversation), relationship assumptions (ie, communicating assumptions that relationships were grounded in care-receiving), emotional divergence from patient disclosure (ie, minimizing or embellishing disability), and inconsistency with patient emotional cues (ie, responding to negative or neutral disclosure by overly accentuating positive interpretation). DISCUSSION: This study suggests that communication behaviors generally described as positive, rapport-building behaviors can pose negative implications when they exceed the expected quantity or duration, when they are inconsistent with patient verbal disclosure, or when verbal and nonverbal messages are inconsistent. Identified themes serve as examples to understand when rapport building exceeds beyond affiliation and instead appears to indicate patronizing behavior toward patients with disabilities. Suggestions for interpreting communication behaviors within the context of patient disclosure and building capacity to distinguish attitudes and biases limiting communication are addressed.

Reinforcement and punishment of substance abuse during ongoing interactions: a conversational test of inconsistent nurturing as control theory.

This study is the first to examine inconsistent nurturing as control (INC) theory during ongoing interpersonal influence episodes between substance-abusive individuals and their romantic partners. This study sought to determine how nonverbal (i.e., kinesic and vocalic) and verbal reinforcement and punishment of substance-abusive behavior during actual interactions influenced substance-abusive individuals' recidivism and perceptions of non-using partners' persuasive effectiveness. The findings reveal that consistent verbal punishment of substance abuse (e.g., threats, nagging) predicted lower relapse, while verbal reinforcement (e.g., telling the partner they are more fun when they use) predicted higher relapse. With regard to nonverbal communication, vocalic punishment and vocalic reinforcement predicted relapse and persuasive effectiveness. Results suggest the combination of behaviors resemble intermittent reinforcement and punishment and should actually strengthen the substance-abusive behavior the partner is trying to curtail.