The role of self-disclosure by peer mentors: Using personal narratives in depression care.

OBJECTIVE: Self-disclosure is recognized as an important aspect of peer support, but little is known about its use by peers. This study aimed to qualitatively understand peer self-disclosure in the context of depression care delivery to older adults. METHODS: 69 audio-recordings of peer-client meetings were coded for self-disclosure using the Roter Interaction Analysis System (RIAS). Peer self-disclosure was defined as a statement describing personal life experience with physical and/or emotional relevance for the client. A total of 3421 discrete statements were organized into 770 disclosure episodes. The episodes were qualitatively analyzed to identify themes related to the content and function of self-disclosure within the peer-counseling context. RESULTS: Peer self-disclosure was used to 1) counsel through reframing perspectives, modeling positive behaviors, offering coping skills, and sharing mental health resources and health information; 2) establish rapport by emphasizing similarities unrelated to depression; and 3) show empathy and understanding of personal struggles. In addition, self-disclosure rarely only focused on the peer experience without relevance for the client. CONCLUSIONS & PRACTICE IMPLICATIONS: Peer self-disclosure can be purposively used in depression care delivery with older adults. Training and supervision in appropriate self-disclosure should be provided to peers to ensure purposive use.

Better Respiratory Education and Treatment Help Empower (BREATHE) study: Methodology and baseline characteristics of a randomized controlled trial testing a transitional care program to improve patient-centered care delivery among chronic obstructive pulmonary disease patients.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of hospitalizations. Interventional studies focusing on the hospital-to-home transition for COPD patients are few. In the BREATHE (Better Respiratory Education and Treatment Help Empower) study, we developed and tested a patient and family-centered transitional care program that helps prepare hospitalized COPD patients and their family caregivers to manage COPD at home. METHODS: In the study's initial phase, we co-developed the BREATHE transitional care program with COPD patients, family-caregivers, and stakeholders. The program offers tailored services to address individual patients' needs and priorities at the hospital and for 3months post discharge. We tested the program in a single-blinded RCT with 240 COPD patients who were randomized to receive the program or 'usual care'. Program participants were offered the opportunity to invite a family caregiver, if available, to enroll with them into the study. The primary outcomes were the combined number of COPD-related hospitalizations and Emergency Department (ED) visits per participant at 6months post discharge, and the change in health-related quality of life over the 6months study period. Other measures include 'all cause' hospitalizations and ED visits; patient activation; self-efficacy; and, self-care behaviors. DISCUSSION: Unlike 1month transitional care programs that focus on patients' post-acute care needs, the BREATHE program helps hospitalized COPD patients manage the post discharge period as well as prepare them for long term self-management of COPD. If proven effective, this program may offer a timely solution for hospitals in their attempts to reduce COPD rehospitalizations.

Patient-provider communication in nephrology care for adolescents and young adults.

OBJECTIVE: To compare the relative quantity of talk between providers, caregivers, and adolescents and young adults (AYAs) with chronic kidney disease (CKD) and how communication differs by age. METHODS: During nephrology clinic visits, conversations between AYAs with CKD (N=99, ages 11-20, median=15), their caregivers, and providers (N=19) were audiotaped and coded using the Roter Interaction Analysis System. Linear mixed models tested AYA age differences in talk frequency by AYAs, caregivers, and providers. Post-hoc analyses tested differences in talk using AYA age groups. RESULTS: During clinic visits, providers spoke the most (63.7%), and caregivers spoke more (22.6%) than AYAs (13.7%). Overall talk differed by AYA age in AYAs (p<0.001) and caregivers (p<0.05), but not providers. Higher AYA age was associated with more AYA talk (biomedical information-giving, partnering, rapport-oriented) and less caregiver biomedical information-giving (ps<0.001-0.05). In post-hoc analyses, young adults talked more than adolescents; caregiver talk decreased in the middle-adolescent group. CONCLUSIONS: Increases in AYA talk occur primarily in young adulthood, whereas caregiver talk decreases in middle adolescence. This may indicate an appropriate developmental shift but raises concerns about conversational gaps during middle-adolescence. PRACTICE IMPLICATIONS: During transition-oriented treatment planning, providers should engage both AYAs and caregivers to avoid potential gaps in communication.

How doctors' communication style and race concordance influence African-Caribbean patients when disclosing depression.

OBJECTIVE: To determine the impact of doctors' communication style and doctor-patient race concordance on UK African-Caribbeans' comfort in disclosing depression. METHODS: 160 African-Caribbean and 160 white British subjects, stratified by gender and history of depression, participated in simulated depression consultations with video-recorded doctors. Doctors were stratified by black or white race, gender and a high (HPC) or low patient-centred (LPC) communication style, giving a full 2×2×2 factorial design. Afterwards, participants rated aspects of doctors' communication style, their comfort in disclosing depression and treatment preferences RESULTS: Race concordance had no impact on African-Caribbeans' comfort in disclosing depression. However a HPC versus LPC communication style made them significantly more positive about their interactions with doctors (p=0.000), their overall comfort (p=0.003), their comfort in disclosing their emotional state (p=0.001), and about considering talking therapy (p=0.01); but less positive about considering antidepressant medication (p=0.01). CONCLUSION: Doctors' communication style was shown to be more important than patient race or race concordance in influencing African Caribbeans' depression consultation experiences. Changing doctors' communication style may help reduce disparities in depression care. PRACTICE IMPLICATIONS: Practitioners should cultivate a HPC style to make African-Caribbeans more comfortable when disclosing depression, so that it is less likely to be missed.

Investigating the influence of African American and African Caribbean race on primary care doctors' decision making about depression.

This paper explores differences in how primary care doctors process the clinical presentation of depression by African American and African-Caribbean patients compared with white patients in the US and the UK. The aim is to gain a better understanding of possible pathways by which racial disparities arise in depression care. One hundred and eight doctors described their thought processes after viewing video recorded simulated patients presenting with identical symptoms strongly suggestive of depression. These descriptions were analysed using the CliniClass system, which captures information about micro-components of clinical decision making and permits a systematic, structured and detailed analysis of how doctors arrive at diagnostic, intervention and management decisions. Video recordings of actors portraying black (both African American and African-Caribbean) and white (both White American and White British) male and female patients (aged 55 years and 75 years) were presented to doctors randomly selected from the Massachusetts Medical Society list and from Surrey/South West London and West Midlands National Health Service lists, stratified by country (US v.UK), gender, and years of clinical experience (less v. very experienced). Findings demonstrated little evidence of bias affecting doctors' decision making processes, with the exception of less attention being paid to the potential outcomes associated with different treatment options for African American compared with White American patients in the US. Instead, findings suggest greater clinical uncertainty in diagnosing depression amongst black compared with white patients, particularly in the UK. This was evident in more potential diagnoses. There was also a tendency for doctors in both countries to focus more on black patients' physical rather than psychological symptoms and to identify endocrine problems, most often diabetes, as a presenting complaint for them. This suggests that doctors in both countries have a less well developed mental model of depression for black compared with white patients.

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.

The Genetic Counseling Video Project (GCVP): models of practice.

Genetic counseling is conceptualized as having both "teaching" and "counseling" functions; however, little is known about how these functions are articulated in routine practice. This study addresses the question by documenting, on videotape, the practices of a national sample of prenatal and cancer genetic counselors (GCs) providing routine pre-test counseling to simulated clients (SCs). One hundred and seventy-seven GCs recruited at two annual conferences of the National Society of Genetic Counselors (NSGC) were randomly assigned to counsel one of six female SCs of varying ethnicity, with or without a spouse, in their specialty. One hundred and fifty-two videotapes were coded with the Roter Interaction Analysis System (RIAS) and both GCs and SCs completed evaluative questionnaires. Two teaching and two counseling patterns of practice emerged from cluster analysis. The teaching patterns included: (1) clinical teaching (31%) characterized by low psychosocial, emotional and facilitative talk, high levels of clinical exchange, and high verbal dominance; and (2) psycho-educational teaching (27%) characterized by high levels of both clinical and psychosocial exchange, low levels of emotional and facilitative talk, and higher verbal dominance. The counseling patterns included: (1) supportive counseling (33%) characterized by low psychosocial and clinical exchange, high levels of emotional and facilitative talk, and low verbal dominance; and (2) psychosocial counseling (9%) with high emotional and facilitative talk, low clinical and high psychosocial exchange, and the lowest verbal dominance. SCs ratings of satisfaction with communication, the counselor's affective demeanor, and the counselor's use of non-verbal skills were highest for the counseling model sessions. Both the teaching and counseling models seem to be represented in routine practice and predict variation in client satisfaction, affective demeanor, and nonverbal effectiveness.

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.

Client communication behaviors with health care providers in Indonesia.

Patient participation in health care consultations can improve the quality of decision making and increase patients' commitment to the treatment plan. This study examines client participation, operationally defined as client active communication, during family planning consultations in Indonesia. Data were collected on 1203 consultations in the provinces of East Java and Lampung. Sessions were audiotaped and the conversation coded using an adaptation of the roter interaction analysis system (RIAS). Culturally acceptable ways for Indonesian clients to participate in consultations include asking questions, requesting clarification, stating opinions, and expressing concerns. Factors significantly associated with client active communication were, in order of importance, providers' information giving, providers' facilitative communication, providers' expressions of negative emotion, client educational level, and province. The latter suggests the influence of culture on client participation. The results suggest that a combination of provider training and client education on key communication skills could increase client participation in health care consultations.

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.

La comunicación con los adultos mayores en el contexto médico / Communication with older adults in the medical context

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Informe global del grupo de investigadores en el área de envejecimiento del encuentro Mahón-2000 / Global Report of the Investigator Group in the Area of Aging of the Mahon Meeting 2000

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National Institutes of Health Consensus Development Conference Statement: adjuvant therapy for breast cancer, November 1-3, 2000.

OBJECTIVE: Our goal was to provide health-care providers, patients, and the general public with an assessment of currently available data regarding the use of adjuvant therapy for breast cancer. PARTICIPANTS: The participants included a non-Federal, non-advocate, 14-member panel representing the fields of oncology, radiology, surgery, pathology, statistics, public health, and health policy as well as patient representatives. In addition, 30 experts in medical oncology, radiation oncology, biostatistics, epidemiology, surgical oncology, and clinical trials presented data to the panel and to a conference audience of 1000. EVIDENCE: The literature was searched with the use of MEDLINE(TM) for January 1995 through July 2000, and an extensive bibliography of 2230 references was provided to the panel. Experts prepared abstracts for their conference presentations with relevant citations from the literature. Evidence from randomized clinical trials and evidence from prospective studies were given precedence over clinical anecdotal experience. CONSENSUS PROCESS: The panel, answering predefined questions, developed its conclusions based on the evidence presented in open forum and the scientific literature. The panel composed a draft statement, which was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the World Wide Web immediately after its release at the conference and was updated with the panel's final revisions. The statement is available at http://consensus.nih.gov. CONCLUSIONS: The panel concludes that decisions regarding adjuvant hormonal therapy should be based on the presence of hormone receptor protein in tumor tissues. Adjuvant hormonal therapy should be offered only to women whose tumors express hormone receptor protein. Because adjuvant polychemotherapy improves survival, it should be recommended to the majority of women with localized breast cancer regardless of lymph node, menopausal, or hormone receptor status. The inclusion of anthracyclines in adjuvant chemotherapy regimens produces a small but statistically significant improvement in survival over non-anthracycline-containing regimens. Available data are currently inconclusive regarding the use of taxanes in adjuvant treatment of lymph node-positive breast cancer. The use of adjuvant dose-intensive chemotherapy regimens in high-risk breast cancer and of taxanes in lymph node-negative breast cancer should be restricted to randomized trials. Ongoing studies evaluating these treatment strategies should be supported to determine if such strategies have a role in adjuvant treatment. Studies to date have included few patients older than 70 years. There is a critical need for trials to evaluate the role of adjuvant chemotherapy in these women. There is evidence that women with a high risk of locoregional tumor recurrence after mastectomy benefit from postoperative radiotherapy. This high-risk group includes women with four or more positive lymph nodes or an advanced primary cancer. Currently, the role of postmastectomy radiotherapy for patients with one to three positive lymph nodes remains uncertain and should be tested in a randomized controlled trial. Individual patients differ in the importance they place on the risks and benefits of adjuvant treatments. Quality of life needs to be evaluated in selected randomized clinical trials to examine the impact of the major acute and long-term side effects of adjuvant treatments, particularly premature menopause, weight gain, mild memory loss, and fatigue. Methods to support shared decision-making between patients and their physicians have been successful in trials; they need to be tailored for diverse populations and should be tested for broader dissemination.

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.