Reinforcing the humanity in healthcare: The Glasgow Consensus Statement on effective communication in clinical encounters.

Contemporary healthcare is characterized by multidisciplinary teamwork across a vast array of primary, secondary and tertiary services, augmented by progressively more technology and data. While these developments aim to improve care, they have also created obstacles and new challenges for both patients and health professionals. Indeed, the increasingly fragmented and transactional nature of clinical encounters can dehumanize the care experience across disciplines and specialties. Effective communication plays a pivotal role in reinforcing the humanity of healthcare through the delivery of person-centered care - compassionate, collaborative care that focuses on the needs of each patient as a whole person. After convening at the International Conference on Communication in Healthcare (Glasgow, 2022), an interdisciplinary group of researchers, educators and health professionals worked together to develop a framework for effective communication that both acknowledges critical challenges in contemporary health services and reinforces the humanity of healthcare. The Glasgow Consensus Statement is intended to function as a useful international touchstone for the training and practice of health professionals, fully recognizing and respecting that different countries are at different stages when it comes to teaching, assessment and policy. It also provides a vocabulary for monitoring the impact of system-level challenges. While effective communication may not change the structure of healthcare, it can improve the process if health professionals are supported in infusing the system with their own innate humanity and applying the framework offered within this consensus statement to reinforce the humanity in everyday practice.

How Do Physicians Frame Medical Information in Talks With Their Patients? An Inductive Microanalysis.

During medical consultations, physicians need to share a substantial amount of information with their patients. How this information is framed can be crucial for patient understanding and outcomes, but little is known about the details of how physicians frame information in practice. Using an inductive microanalysis approach in the study of videotaped medical interactions, we aimed to identify the information frames (i.e., higher-level ways of organizing and structuring information to reach a particular purpose) and the information-framing devices (i.e., any dialogic mechanism used to present information in a particular way that shapes how the patient might perceive and interpret it) physicians use spontaneously and intuitively while sharing information with their patients. We identified 66 different information-framing devices acting within nine information frames conveying: (1) Do we agree that we share this knowledge?, (2) I don't like where I (or where you are) am going with this, (3) This may be tricky to understand, (4) You may need to think, (5) This is important, (6) This is not important, (7) This comes from me as a doctor, (8) This comes from me as a person, and (9) This is directed to you as a unique person. The kaleidoscope of information-framing devices described in this study reveals the near impossibility for neutrality and objectivity in the information-sharing practice of medical care. It also represents an inductively derived starting point for further research into aspects of physicians' information-sharing praxis.

WITHDRAWN: If I say teach-back.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in , . The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

"The challenge is the complexity" - A qualitative study about decision-making in advanced lung cancer treatment.

INTRODUCTION: The value of shared decision-making and decision aids (DA) has been well documented yet remain difficult to integrate into clinical practice. We wanted to investigate needs and challenges regarding decision-making about advanced lung cancer treatment after first-line therapy, focusing on DA applicability. METHODS: Qualitative data from separate, semi-structured focus groups with patients/relatives and healthcare professionals were analysed using systematic text condensation. 12 patients with incurable lung cancer, seven relatives, 12 nurses and 18 doctors were recruited from four different hospitals in Norway. RESULTS: The participants described the following needs and challenges affecting treatment decisions: 1) Continuity of clinician-patient-relationships as a basic framework for decision-making; 2) barriers to information exchange; 3) negotiation of autonomy; and 4) assessment of uncertainty and how to deal with it. Some clinicians feared DA would steal valuable time and disrupt consultations, arguing that such tools could not incorporate the complexity and uncertainty of decision-making. Patients and relatives reported a need for more information and the possibility both to decline or continue burdensome therapy. Participants welcomed interventions supporting information exchange, like communicative techniques and organizational changes ensuring continuity and more time for dialogue. Doctors called for tools decreasing uncertainty about treatment tolerance and futile therapy. CONCLUSION: Our study suggests it is difficult to develop an applicable DA for advanced lung cancer after first-line therapy that meets the composite requirements of stakeholders. Comprehensive decision support interventions are needed to address organizational structures, communication training including scientific and existential uncertainty, and assessment of frailty and treatment toxicity.

What does shared decision making ask from doctors? Uncovering suppressed qualities that could improve person-centered care.

OBJECTIVE: Shared decision making (SDM) is infrequently seen in clinical practice despite four decades of efforts. We propose a need to explore what SDM asks from doctors in terms of enabling competencies and necessary, underlying qualities, and how these can be nurtured or suppressed in medical training. DISCUSSION: Key SDM tasks call for doctors to understand communication and decision mechanisms to carry them out well, including reflecting on what they know and do not know, considering what to say and how, and listening unprejudiced to patients. Different doctor qualities can support accomplishing these tasks; humility, flexibility, honesty, fairness, self-regulation, curiosity, compassion, judgment, creativity, and courage, all relevant to deliberation and decision making. Patient deference to doctors, lack of supervised training opportunities with professional feedback, and high demands in the work environment may all inflate the risk of only superficially involving patients. CONCLUSIONS: We have identified ten professional qualities and related competencies required for SDM, with each to be selected based on the specific situation. The competencies and qualities need to be preserved and nurtured during doctor identity building, to bridge the gap between knowledge, technical skills, and authentic efforts to achieve SDM.

First year junior doctors and medical uncertainty - a qualitative study. / LIS1-leger og medisinsk usikkerhet ­ en kvalitativ studie.

BACKGROUND: Few studies have investigated how doctors in Norway deal with medical uncertainty. The purpose of the study was to explore how first year junior doctors perceive and manage uncertainty in clinical practice. MATERIAL AND METHODS: Ten first year junior doctors at two hospitals in Norway were recruited for interviews following response pattern analysis from a mapping questionnaire. The interviews were analysed using systematic text condensation. RESULTS: The analysis revealed three main themes in the interviews: dealing with medical uncertainty, personal response to medical uncertainty, and working environment, feedback and preparation. Within all three thematic areas, the informants used the words 'certain/uncertain' and 'secure/insecure' interchangeably. INTEPRETATION: The first year junior doctors struggled with the inherent uncertainty of medicine and felt a marked sense of insecurity, particularly at the start of their training period. How the doctors were welcomed in the workplace and the feedback they were given were important factors. Their undergraduate medical education had not sufficiently prepared the first year junior doctors for how to deal with medical uncertainty in clinical practice.

Shared decision making: A novel approach to personalized treatment in obstructive sleep apnea.

Study objectives: i) To describe a novel approach of phenotyping by shared decision making (SDM) in obstructive sleep apnea (OSA) discharge consultations ii) to describe correlation between patient and observer based evaluations of SDM and iii) to describe treatment adherence. Methods: Consecutive patients referred to the otorhinolaryngology department at Akershus University Hospital with suspected OSA between 2015 and 2016 participated. Patients with body mass index >30 were oversampled. Four male communication-trained doctors aged from 30 to 60 years participated. SDM was evaluated by modified content analysis and by the CollaboRATE self-report questionnaire and the "Observer OPTION (Young et al., 2008) [5]" rating scale. Positive airway pressure (PAP) treatment adherence and weight reduction was assessed by interview at six year follow-up. Results: Eighteen consultations were video filmed. The content analysis revealed that the patient perspectives only briefly were explored. PAP was chosen by 17 of 18 patients. Median CollaboRATE questionnaire score was 29 (26, 30). Mean OPTION (Young et al., 2008) [5] score was 65.6 (SD 6.6, range 55-80). The correlation between SDM assessed by CollaboRATE self-report and by the "Observer OPTION (Young et al., 2008) [5]" rating scale was low (Pearson's r = 0.09). At follow up, 11 patients (64.7%) were PAP adherent and no one achieved 10% weight loss. Conclusions: Despite a high degree of SDM compared to studies of non-OSA populations, the sub-optimal exploration of the patient perspective by communication-trained doctors precluded identification of patients willing to cope actively. SDM assessed by self-report and by a rating scale may represent two different constructs. PAP adherence was good.

Physicians' responses to advanced cancer patients' existential concerns: A video-based analysis.

OBJECTIVE: In a recent study, we explored what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation and how they communicate such concerns. The current study builds on these results, investigating how the physicians responded to those concerns. METHODS: We analyzed video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue. RESULTS: We identified 185 immediate physician-responses to the 127 patient existential utterances we had previously identified. The responses demonstrated three approaches: giving the patient control over the content, providing support, and taking control over the content. The latter was by far the most common, through which the physicians habitually kept the discussion around biomedical aspects and rarely pursued the patients' existential concerns. CONCLUSIONS: Although the physicians, to some extent, allowed the patients to talk freely about their concerns, they systematically failed to acknowledge and address the patients' existential concerns. PRACTICE IMPLICATIONS: Physicians should be attentive to their possible habit of steering the agenda towards biomedical topics, hence, avoiding patients' existential concerns. Initiatives cultivating behavior enhancing person-centered and existential communication should be implemented in clinical practice and medical training.

Training physicians in providing complex information to patients with multiple sclerosis: a randomised controlled trial.

OBJECTIVE: To evaluate the effect of a specific communication training for neurologists on how to provide complex information about treatment options to patients with multiple sclerosis (MS). DESIGN: Single-centre, single-blind, randomised controlled trial. SETTING: One university hospital in Norway. PARTICIPANTS: Thirty-four patients with early-stage MS. INTERVENTION: A 3-hour training for neurologists on how to provide complex information about MS escalation therapy. MAIN OUTCOME MEASURES: Patient recall rate, measured with a reliable counting system of provided and recalled information about drugs. SECONDARY OUTCOME MEASURES: Number of information units provided by the physicians. Effects on patient involvement through questionnaires. METHODS: Patients with MS were instructed to imagine a disease development and were randomised and blinded to meet a physician to receive information on escalation therapy, before or after the physician had participated in a 3-hour training on how to provide complex information. Consultations and immediate patient recall interviews were video-recorded and transcribed verbatim. RESULTS: Patient recall rate was 0.37 (SD=0.10) pre-intervention and 0.39 (SD=0.10) post-intervention. The effect of the intervention on recall rate predicted with a general linear model covariate was not significant (coefficient parameter 0.07 (SE 0.04, 95% CI (-0.01 to 0.15)), p=0.099).The physicians tended to provide significantly fewer information units after the training, with an average of 91.0 (SD=30.3) pre-intervention and 76.5 (SD=17.4) post-intervention; coefficient parameter -0.09 (SE 0.02, 95% CI (-0.13 to -0.05)), p<0.001. There was a significant negative association between the amount of provided information and the recall rate (coefficient parameter -0.29 (SE 0.05, 95% CI (-0.39 to -0.18)), p<0.001). We found no significant effects on patient involvement using the Control Preference Scale, Collaborate or Four Habits Patient Questionnaire. CONCLUSION: A brief course for physicians on providing complex information reduced the amount of information provided, but did not improve patient recall rate. TRIAL REGISTRATION NUMBER: ISRCTN42739508.

"Eh - What type of cells are these - flourishing in the liver?" Cancer patients' disclosure of existential concerns in routine hospital consultations.

OBJECTIVE: Advanced cancer poses a threat to all aspects of being, potentially causing existential suffering. We explore what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation, and how they communicate such concerns. METHODS: We analyzed thirteen video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue. RESULTS: Nearly all patients disclosed how the illness experience included losses and threats of loss that are strongly associated with existential suffering, displaying uncertainty about future and insecurity about self and coping. Patients usually disclosed existential concerns uninvited, but they did so indirectly and subtly, typically hiding concerns in biomedical terms or conveying them with hesitation and very little emotion. CONCLUSIONS: Patients may have existential concerns they want to address, but they may be uncertain whether these are issues they can discuss with the physician. PRACTICE IMPLICATIONS: Health professionals should be attentive to underlying existential messages embedded in the patient's questions and concerns. Acknowledging these existential concerns provides an opportunity to briefly explore the patient's needs and may direct how the physician tailors information and support to promote coping, autonomy, and existential health.

Effects of Physicians' Information Giving on Patient Outcomes: a Systematic Review.

BACKGROUND: Providing diagnostic and treatment information to patients is a core clinical skill, but evidence for the effectiveness of different information-giving strategies is inconsistent. This systematic review aimed to investigate the reported effects of empirically tested communication strategies for providing information on patient-related outcomes: information recall and (health-related) behaviors. METHODS: The databases MEDLINE, Embase, PsycINFO (Ovid), Cochrane Central Register of Controlled Trials, and relevant bibliographies were systematically searched from the inception to April 24, 2020, without restrictions, for articles testing information-giving strategies for physicians (PROSPERO ID: CRD42019115791). Pairs of independent reviewers identified randomized controlled studies with a low risk of selection bias as from the Cochrane risk of bias 2 tool. Main outcomes were grouped into patient information recall and behavioral outcomes (e.g., alcohol consumption, weight loss, participation in screening). Due to high heterogeneity in the data on effects of interventions, these outcomes were descriptively reported, together with studies', interventions', and information-giving strategies' characteristics. PRISMA guidelines were followed. RESULTS: Seventeen of 9423 articles were included. Eight studies, reporting 10 interventions, assessed patient information recall: mostly conducted in experimental settings and testing a single information-giving strategy. Four of the ten interventions reported significant increase in recall. Nine studies assessed behavioral outcomes, mostly in real-life clinical settings and testing multiple information-giving strategies simultaneously. The heterogeneity in this group of studies was high. Eight of the nine interventions reported a significant positive effect on objectively and subjectively measured patients' behavioral outcomes. DISCUSSION: Using specific framing strategies for achieving specific communication goals when providing information to patients appears to have positive effects on information recall and patient health-related behaviors. The heterogeneity observed in this group of studies testifies the need for a more consistent methodological and conceptual agenda when testing medical information-giving strategies. TRIAL REGISTRATION: PROSPERO registration number: CRD42019115791.

Communication Skills Training: A Means to Promote Time-Efficient Patient-Centered Communication in Clinical Practice.

PURPOSE: We hypothesized that health care providers would behave in a more patient-centered manner after the implementation of communication skills training, without causing the consultation to last longer. METHODS: This study was part of the large-scale implementation of a communication skills training program called "Clear-Cut Communication With Patients" at Lillebaelt Hospital in Denmark. Audio recordings from real-life consultations were collected in a pre-post design, with health care providers' participation in communication skills training as the intervention. The training was based on the Calgary-Cambridge Guide, and audio recordings were rated using the Observation Scheme-12. RESULTS: Health care providers improved their communication behavior in favor of being more patient-centered. Results were tested using a mixed-effect model and showed significant differences between pre- and postintervention assessments, with a coefficient of 1.3 (95% Cl: 0.35-2.3; P=0.01) for the overall score. The consultations did not last longer after the training. CONCLUSIONS: Health care providers improved their communication in patient consultations after the implementation of a large-scale patient-centered communication skills training program based on the Calgary-Cambridge Guide. This did not affect the length of the consultations.

Evaluating a training intervention for improving alignment between emergency medical telephone operators and callers: a pilot study of communication behaviours.

BACKGROUND: Calls to emergency medical lines are an essential component in the chain of survival. Operators make critical decisions based on information they elicit from callers. Although smooth cooperation is necessary, the field lacks evidence-based guidelines for how to achieve it while adhering to strict parameters of index-driven questioning. We aimed to evaluate the effect of a training intervention for emergency medical operators at a call centre in Tønsberg, Norway. The course was designed to enhance operators' communication skills for smoothing cooperation with callers. METHODS: Calls were analyzed using inductively developed coding based on the course rationale and content. To evaluate whether the course generated consolidated behavioral change in everyday practice, the independent analyst evaluated 32 calls, selected randomly from eight operators, two calls before and two after course completion. To measure whether skill attainment delayed decision making, we compared the time to the first decision logged by intervention operators to eight control operators. Analysis included 3034 calls: 1375 to intervention operators (T1 = 815; T2 = 560) and 1659 to control operators (T1 = 683; T2 = 976). RESULTS: Operators demonstrated improved behaviours on how they greeted the caller (p < .001), acknowledged the caller (p < .001), and displayed empathy (p = 0.015). No change was found in the use of open-ended questions and agreeing with the caller. Contrary to expectations, operators who took the course logged first decisions more quickly than the control group (p < .001). CONCLUSIONS: This pilot study demonstrated that the training intervention generated behavioural change in these operators, providing justification for scaling up the intervention.

How well do doctors understand a scientific article in English when it is not their first language? A randomised controlled trial.

INTRODUCTION: English is the lingua franca of science. How well doctors understand English is therefore crucial for their understanding of scientific articles. However, only 5% of the world's population have English as their first language. METHODS: Objectives: To compare doctors' comprehension of a scientific article when read in their first language (Norwegian) versus their second language (English). Our hypothesis was that doctors reading the article in Norwegian would comprehend the content better than those reading it in English. DESIGN: Parallel group randomised controlled trial. We randomised doctors to read the same clinical review article in either Norwegian or English, before completing a questionnaire about the content of the article. SETTING: Conference in primary care medicine in Norway, 2018. PARTICIPANTS: 130 native Norwegian-speaking doctors, 71 women and 59 men. One participant withdrew before responding to the questionnaire and was excluded from the analyses. INTERVENTIONS: Participants were randomly assigned to read a review article in either Norwegian (n=64) or English (n=66). Reading time was limited to 7 min followed by 7 min to answer a questionnaire. MAIN OUTCOME MEASURES: Total score on questions related to the article content (potential range -9 to 20). RESULTS: Doctors who read the article in Norwegian had a mean total score of 10.40 (SD 3.96) compared with 9.08 (SD 3.47) among doctors who read the article in English, giving a mean difference of 1.32 (95% CI 0.03 to 2.62; p=0.046). Age was independently associated with total score, with decreased comprehension with increasing age. CONCLUSION: The difference in comprehension between the group who read in Norwegian and the group who read in English was statistically significant but modest, suggesting that the language gap in academia is possible to overcome.

How Physicians Manage Medical Uncertainty: A Qualitative Study and Conceptual Taxonomy.

BACKGROUND: Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described. OBJECTIVES: To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians' tolerance of medical uncertainty. DESIGN: Qualitative study using individual in-depth interviews. PARTICIPANTS: Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1-3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine-pediatrics), at a single large US teaching hospital. MEASUREMENTS: Semistructured interviews explored participants' strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies. RESULTS: Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness. CONCLUSIONS: Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.

Tested communication strategies for providing information to patients in medical consultations: A scoping review and quality assessment of the literature.

OBJECTIVES: To systematize the scientific knowledge of empirically tested strategies for verbally providing medical information in patient-physician consultations. METHODS: A scoping review searching for terms related to physician, information, oral communication, and controlled study. Four pairs of reviewers screened articles. For each selected study, we assessed the quality and summarized aspects on participants, study, intervention, and outcomes. Information provision strategies were inductively classified by types and main categories. RESULTS: After screening 9422 articles, 39 were included. The methodological quality was moderate. We identified four differently used categories of strategies for providing information: cognitive aid (n = 13), persuasive (n = 8), relationship- (n = 3), and objectivity-oriented strategies (n = 4); plus, one "mixed" category (n = 11). Strategies were rarely theoretically derived. CONCLUSIONS: Current research of tested strategies for verbally providing medical information is marked by great heterogeneity in methods and outcomes, and lack of theory-driven approaches. The list of strategies could be used to analyse real life communication. PRACTICE IMPLICATIONS: Findings may aid the harmonization of future efforts to develop empirically-based information provision strategies to be used in clinical and teaching settings.