Attitudinal concordance toward uptake and disclosure of genetic testing for cancer susceptibility in patient-family member dyads.

Decisions for cancer susceptibility genetic testing (CSGT) uptake and dissemination of results occur within the family context. A national survey was performed with 990 patient-family member dyads (participation rate:76.2%), with paired questionnaires examining attitudes toward CSGT uptake and disclosure of results in response to a hypothetical scenario in which a reliable CSGT was available for the specific cancer a patient was being treated. While most patients and family members responded they would uptake or recommend CSGT if available, concordance between the dyads was poor for both patient's testing (agreement rate 77.5%, weighted κ=0.09) and first-degree relatives' testing(agreement rate 78.0%, weighted κ=0.09). Most patients (93.2%) and family members (92.9%) indicated that patients should disclose positive CSGT results to family members, with dyadic agreement of 89.1% (κ=0.15). However, there were substantial disagreement regarding when disclosure should take place, who should make the disclosure (the patient or the health care professionals), and to whom the results should be disclosed. Patients and family members may hold different attitudes toward CSGT uptake of and disclosure of results within the family. Our findings reinforce the need for a family system approach to incorporate perspectives of patients as well as their family members.

Recruitment of research participants from U.S. jury pools.

Psychological research is often criticized for routine use of a narrow and unrepresentative study population-college students. This study investigated the feasibility of recruiting research participants from U.S. jury pools, which by law must include a representative cross-section of the public. A questionnaire was mailed to the jury administrators in the 217 U.S. state court jurisdictions with populations of 250,000 or more. Court officials representing 79 jurisdictions in 30 states and the District of Columbia returned surveys (36% response rate). In addition, respondents who indicated in the mail survey that their court had previously allowed outside investigators to recruit jurors also completed a follow-up telephone interview. While the majority of jurisdictions (61%) opposed participation of jurors in research, 31 jurisdic tions (39%) did not object to this practice. Only 8 of the nonopposed jurisdictions had been asked to host research, and 7 had agreed to do so. The jurisdictions that opened their jury pools to researchers employed a number of strategies to circumvent potential problems and generally reported that hosting research was a positive experience. Jury pools represent a viable and relatively untapped source of research participants. Many courts are open to the possibility of hosting research but have never been asked to do so. Both researchers and court officials should be reassured by the positive experiences of courts that have hosted research.

An expectancy-value analysis of viewer interest in television prevention news stories.

Understanding what drives viewer interest in television news stories about prevention topics is vital to maximizing the effectiveness of interventions that utilize this medium. Guided by expectancy-value theory, this experiment used regression analysis to identify the salient beliefs associated with viewer attitudes towards these types of news stories. The 458 study participants were recruited over 30 days from a municipal jury pool in an eastern U.S. city. Out of the 22 beliefs included in the experiment, 6 demonstrated salience. Personal relevance, novelty, shock value, and the absence of exaggeration were the core values reflected in the identified salient beliefs. This study highlights the importance of explaining the relevance of prevention stories to viewers and framing these stories with a new spin or a surprising twist. However, such manipulations should be applied with savvy and restraint, as hyping prevention news was found to be counterproductive to educating the public.

Current perspectives on patient education in the US.

Patient education has evolved from its medically-dominated and narrow origin in patient teaching to support of patient empowerment in interpersonal, organizational, and policy domains relevant to health. This essay reflects on both the historical and contemporary context of patient education in the US and explores implications of the empowerment movement on new initiatives and directions in patient education. By using diabetes education as an exemplar, innovations in patient activation and empowerment are explored and future directions and challenges to the field are considered.

Measuring patient expectations: does the instrument affect satisfaction or expectations?

BACKGROUND: Fulfillment of patients' expectations may influence health care utilization, affect patient satisfaction, and be used to indicate quality of care. Several different instruments have been used to measure expectations, yet little is known about how different assessment methods affect outcomes. OBJECTIVE: The object of the study was to determine whether different measurement instruments elicit different numbers and types of expectations and different levels of patient satisfaction. DESIGN: Patients waiting to see their physician were randomly assigned to receive 1 of 2 commonly used instruments assessing expectations or were assigned to a third (control) group that was not asked about expectations. After the visit, patients in all 3 groups were asked about their satisfaction and services they received. SUBJECTS: The study subjects were 290 male, primary care outpatients in a VA general medicine clinic. MEASURES: A "short" instrument asked about 3 general expectations for tests, referrals, and new medications, while a "long" instrument nested similar questions within a more detailed list. Wording also differed between the 2 instruments. The short instrument asked patients what they wanted; the long instrument asked patients what they thought was necessary for the physician to do. Satisfaction was measured with a visit-specific questionnaire and a more general assessment of physician interpersonal skills. RESULTS: Patients receiving the long instrument were more likely to express expectations for tests (83% vs. 28%, P <0.001), referrals (40% vs. 18%, P <0.001), and new medications (45% vs. 28%, P <0.001). The groups differed in the number of unmet expectations: 40% of the long instrument group reported at least 1 unmet expectation compared with 19% of the short instrument group (P <0.001). Satisfaction was similar among the 3 groups. CONCLUSIONS: These different instruments elicit different numbers of expectations but do not affect patient satisfaction.

The medical interview: differences between adult and geriatric outpatients.

BACKGROUND: There is a perception that primary care physicians spend less time with older patients and little is known about physician and older patient satisfaction during clinical encounters. OBJECTIVE: To determine how primary care interviews of geriatric patients differ from those of other adults. DESIGN: Descriptive, analytic study. SETTING: Ten primary care sites in the United States and one in Canada, including public, voluntary, and private clinics and practices. PARTICIPANTS: Of the 544 patients, 45.6% were 65 and older and 17.8% were 75 or older. There were 127 participating physicians. MEASUREMENTS: Encounters were audiotaped and analyzed. Patients and physicians also completed exit questionnaires. RESULTS: Interview length increased significantly with age for men but not for women. Physician satisfaction did not change as patient age increased. Patient satisfaction, on the other hand decreased with age among women but not for men. Although physicians' and younger patients' perceptions of health were moderately associated, there was no association for men ages 75 and over. CONCLUSIONS: There is no evidence that physicians spend less time or are more uncomfortable with older patients. Both physician and male patient satisfaction remain stable with increasing patient age, despite greater disparity in patient and physician perceptions of health. Older female patients are less satisfied with physician visits than their younger counterparts, in the absence of changes in interview length or disparities between older female patients and their physicians in health perception.

Experts practice what they preach: A descriptive study of best and normative practices in end-of-life discussions.

BACKGROUND: Advance directives (ADs) are widely regarded as the best available mechanism to ensure that patients' wishes about medical treatment at the end of life are respected. However, observational studies suggest that these discussions often fail to meet their stated goals. OBJECTIVES: To explore best practices by describing what physicians who are considered expert in the area of end of-life bioethics or medical communication do when discussing ADs with their patients and to explore the ways in which best practices of the expert group might differ in content or style from normative practice derived from primary care physicians' discussions of ADs with their patients collected as part of an earlier study. DESIGN: Nonexperimental, descriptive study of audiotaped discussions. SETTING: Outpatient primary care practices in the United States. PARTICIPANTS: Eighteen internists who have published articles in the areas of bioethics or communication and 48 of their patients. Fifty-six academic internists and 56 of their established patients in 5 practice sites in 2 locations-Durham, NC, and Pittsburgh, Pa. Eligible patients were at least 65 years old or suffered from serious medical illness and had not previously discussed ADs with their physician. Expert clinicians had discretion regarding patient selection, while the internists chose patients according to a predetermined protocol. MEASUREMENTS: Coders applied the Roter Interaction Analysis System (RIAS) to audiotapes of the medical visits to describe communication dynamics. In addition, the audiotapes were scored on 21 items reflecting physician performance in specific skills related to AD discussions. RESULTS: Experts spent close to twice as much time (14.7 vs 8.1 minutes, P<.001) and were less verbally dominant (P<.05) than other physicians during AD discussions. When length of visit was controlled statistically, the expert physicians gave less information about treatment procedures and biomedical issues (P<.05) and asked fewer related questions (P<. 05) but tended toward more psychosocial and lifestyle discussion and questions. Experts engaged in more partnership building (P<.05) with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion (P<.001), and more positive talk (P<.05) than patients of community physicians. Expert physicians scored higher on the 21 items reflecting AD-specific skills (P<.001). CONCLUSIONS: Best practices as reflected in the performance of expert physicians reflect differences in measures of communication style and in specific AD-related proficiencies. Physician training in ADs must be broad enough to include both of these domains. Arch Intern Med. 2000;160:3477-3485.

"If it bleeds it leads"? Attributes of TV health news stories that drive viewer attention.

OBJECTIVE: Health advocates increasing y use the news media to educate the public. However, little is known about what motivates individuals to pay attention to health news. This study investigated which characteristics of TV health news stories attract viewer interest. METHODS: The authors surveyed airport patrons, the audience of a public health symposium, and municipal jurors, asking which attributes of TV heath news stories encouraged interest and which attributes discouraged interest. The authors ranked mean responses and compared them using Spearman rank correlations, RESULTS: The rankings assigned by the three samples were highly correlated. Respondents reported being most attracted to health stories about personally relevant topics. Interestingly, they also reported that sensational story elements such as "showing a bloody or injured person" and "being action packed" did not substantially influence their attention. CONCLUSIONS: This study suggests that viewers, regardless of their level of health knowledge, value the same attributes in TV health news stories. Emphasizing the personal relevance of health topics appears to be a viable strategy to capture viewer interest. Conversely, the tendency of broadcast news to sensationalize stories may be distracting in the case of health news.

Predictors of adherence to behavior change interventions in the elderly.

Considering factors at the individual, interpersonal, and environmental level may enhance adherence to interventions in the elderly. A collaborative practitioner-participant relationship is also essential. Control Clin Trials 2000;21:200S-205S

Using entertainment television to build a context for prevention news stories.

UNLABELLED: OBJECTIVE. A nationally syndicated television news series called "Following ER" was developed to educate viewers about the health issues dramatized on "ER," NBC's award-winning medical drama. This study investigated the impact of this prime-time link on viewer attention, satisfaction, information recall, and perceptions about the uses and gratifications delivered by a news story. METHODS: A total of 458 municipal jurors participated in a randomized 2 ("ER" tie-in vs no tie-in) x 2 (familiar vs novel story topic) experiment. The four experimental news stories required by this design were developed using footage of previously aired local newscasts. RESULTS: In the case of the familiar topic story, the "ER" tie-in enhanced the attention and satisfaction of viewers. Participants reported that the prime-time link added value by elevating the importance and relevance of the commonplace topic. However, the "ER" tie-in did not generate any beneficial effects when paired with the novel topic story. CONCLUSIONS: Framing news stories about familiar health concerns in the context of television drama represents a viable strategy for legitimizing them as important and timely topics for public consumption and debate.

The outpatient medical encounter and elderly patients.

There is little evidence of systematic negative bias against older patients in medical visits. The nature of the current narrative review, largely based on studies conducted after 1985, is consistent with the author's previous metaanalysis of over 40 studies published between 1965 and 1985. In that review, based on videotapes or audiotapes of medical visits, consistent relationships between patient age and physicians' interviewing skills were found. Older patients received more information, more total communication and questions concerning drugs, more courtesy, and perhaps more formality reflected in less laughter and joking than younger patients. Ultimately, the subtle ageism that may be present in medical visits with older patients is probably balanced somewhat by communication advantages afforded them challenging the negative views of older patients' care prevalent in the literature. This balance may help explain the ubiquitous finding that older patients are more satisfied with their health care, despite poorer health status, than younger patients. Nevertheless, other patients, especially those in the oldest cohorts, are at high risk for passive relationships and communication complications related to low literacy and poor health status and deserve the attention and special consideration of providers and health service researchers.

Inaccuracies in physicians' perceptions of their patients.

OBJECTIVE: The objective was to assess primary care physicians' awareness of their patients' rated emotions, satisfaction, and opinion of the quality of their communication. DESIGN: Diabetic patients (n = 261) and their primary care physicians (n = 44) each filled in a questionnaire following a routine medical visit. Patients were asked about the quality of communication with their physician, their satisfaction, and their experience of six emotions. Physicians were asked to estimate the patients' views on each of these questions. Physicians' awareness was measured by (1) correlating the physician and patient ratings, and (2) comparing mean ratings between physicians and patients. RESULTS: Correlations between patients' and physicians' views of patients' emotions and satisfaction were weak to moderate in magnitude; for patients' opinion of communication quality, there was no correlation. All ratings showed a substantial discrepancy between physicians and patients, such that physicians thought patients' responses were more negative than they actually were. CONCLUSIONS: Although the causes of physicians' weak awareness of their patients' responses are not known, the results suggest that the patients' affective responses may be an especially neglected aspect of communication in the medical visit.

Counseling by primary care physicians of patients who disclose psychosocial problems.

BACKGROUND: Most descriptive studies of psychosocial counseling by US primary care physicians (PCPs) have relied on the PCPs' recollections rather than researchers' observations of actual visit content. The latter approach should yield more accurate measurement of counseling frequency and duration. METHODS: Our sample consisted of 308 patients whose scores signified psychological distress on the 28-item General Health Questionnaire. Their visits to 69 community-based PCPs had been audiotaped for an earlier study of the benefits of communication skills training for PCPs. Using those tapes, we identified the disclosure of psychosocial problems by patients and subsequent counseling and psychotropic drug prescribing by their PCPs. We timed counseling and visit lengths. Effects of patient and PCP variables on visit duration and on counseling occurrence and duration were assessed using generalized estimating equations to accommodate the correlation among patients who shared PCPs. RESULTS: After adjusting for the effects of the communication skills training, we found that PCPs counseled 60% of patients who disclosed psychosocial problems. Given disclosure, counseling probability was lowest for new patients (P <.001); among patients with previous visits, counseling probability was inversely related to the number of visits (P <.001). When provided, counseling had a mean duration of 5.2 minutes. Counseling was associated with a 28% (95% confidence interval, 9%-49%) increase in visit duration after adjustment for the effects of other significant variables. PCPs prescribed psychotropic medications in 30% of visits with disclosure. CONCLUSIONS: PCPs treated psychosocial problems with brief counseling twice as often as with medication. Brief counseling interventions caused small but significant increases in visit durations.

Psychosocial problem disclosure by primary care patients.

The vast majority of psychologically distressed primary care patients present exclusively somatic concerns at the outsets of their visits. However, it is not known how often such patients subsequently disclose psychosocial problems to their primary care physicians (PCPs) and what variables predict such disclosures. Our objectives were to measure, among psychologically distressed primary care patients, the frequency of disclosure of psychosocial problems (disclosure), the effects of prior psychosocial inquiry (prior inquiry) by PCPs and various patient variables on disclosure, and the effect of disclosure on mental health problem recognition (recognition) by PCPs. The study was based in the practices of 69 community-based PCPs and involved 308 adult patients with 28-item General Health Questionnaire scores of 5 or greater, indicating significant psychological distress. Disclosure occurred during 51% of visits overall and 67% of visits with prior inquiry. The odds of disclosure were increased by prior inquiry (p < 0.001), greater physician-patient familiarity (p < 0.001) and greater severity of patient psychological distress (p < 0.001). Prior inquiry and physician-patient familiarity had a negative interaction (p < 0.05) of smaller size than either variable's main effect, so that their combined effect on disclosure exceeded the effect of either variable alone but was less than multiplicative. The estimated odds ratio for recognition given disclosure was 24.13 (95% confidence interval, 11.28-51.63) after adjustment for the effects of significant covariates. We conclude that if PCPs inquire, most psychologically distressed, somatically presenting patients will disclose psychosocial problems. Inquiry is particularly productive with unfamiliar patients. PCPs can engender a substantial increase in psychosocial disclosure simply by adding one or two questions about mood or interpersonal problems to their clinical interviews.

Effects of obstetrician gender on communication and patient satisfaction.

OBJECTIVE: To describe patient-obstetrician communication during the first prenatal visit and its relationship to physician gender and patient satisfaction. METHODS: The first prenatal visit of 87 women with 21 obstetricians (11 male and ten female) was audiotaped and analyzed using the Roter Interaction Analysis System. Patient satisfaction was measured by postvisit questionnaire. RESULTS: Communication during first prenatal visits was largely biomedical, with little psychosocial or social discussion. Male physicians conducted longer visits than females (26 minutes versus 21.9 minutes, P < .05) and engaged in more facilitative communication (ie, making sure they were understood and providing direction and orientation) and explicit statements of concern and partnership (z > 1.96, P < .05). Female physicians devoted more communication to agreements, disagreements, and laughter than males (z > 1.96, P < .05). Satisfaction with physicians' emotional responsiveness and informational partnership was related to female physician gender and a variety of task-focused and affective communication variables. CONCLUSION: Communication and satisfaction between women and obstetricians during initial prenatal visits is related to physician gender and patient satisfaction. Male physicians conducted longer visits but women were more satisfied with female physicians.

Why physician gender matters in shaping the physician-patient relationship.

Societal values regarding the nature and consequences of patient autonomy and medical paternalism underscore the current debates surrounding informed consent and shared decision making. The debate is significant in that it both reflects and determines normative expectations for physician and patient conduct as well as the nature and form of the therapeutic relationship. Analysis of the literature describing communication differences between physicians of different genders indicates that female physicians show a greater affinity for collaborative models of patient-physician relationship than do their male colleagues. Female physicians spend more time with their patients, are more likely to engage their patients in discussions of their social and psychologic context, and deal more often with feelings and emotions. Moreover, female physicians facilitate partnership and patient participation in the medical exchange more effectively than do male physicians. The authors propose that the quality of the interactive process is critical to the establishment of a therapeutic relationship and that this process is related to physician gender. They also suggest that physician gender matters in the shaping of the patient-physician relationship through this interactive process.