Patient centred care for the medical treatment of lower urinary tract symptoms in patients with benign prostatic obstruction: a key point to improve patients' care - a systematic review.

BACKGROUND: Even though evidence based medicine, guidelines and algorithms still represent the pillars of the management of chronic diseases (i.e: hypertension, diabetes mellitus), a patient centred approach has been recently proposed as a successful strategy, in particular to improve drug adherence. Aim of the present review is to evaluate the unmet needs in LUTS/BPH management and the possible impact of a patient centered approach in this setting. METHODS: A National Center for Biotechnology Information (NCBI) PubMed search for relevant articles published from January 2000 until December 2016 was performed by combining the following MESH terms: patients centred medicine, patient centered care, person centered care, patient centered outcomes, value based care, shared decision making, male, Lower Urinary Tract Symptoms, Benign Prostatic Hyperplasia, treatment. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). All studies reporting on patient centred approach, shared decision making and evidence-based medicine were included in the review. All original article, reviews, letters, congress abstracts, and editorials comments were included in the review. Studies reporting single case reports, experimental studies on animal models and studies not in English were not included in the review. RESULTS: Overall 751 abstracts were reviewed, out of them 87 full texts were analysed resulting in 36 papers included. The evidence summarised in this systematic review confirmed how a patient centred visit may improve patient's adherence to medication. Although a patient centred model has been rarely used in urology, management of Low Urinary Tract Symptoms (LUTS) and Benign Prostatic Obstruction (BPO) may represent the perfect ground to experiment and improve this approach. Notwithstanding all the innovations in LUTS/BPO medical treatment, the real life picture is far from ideal. CONCLUSIONS: Recent evidence shows a dramatical low drug adherence and satisfaction to medical treatment in LUTS/BPH patients. A patient centred approach may improve drug adherence and some unmet needs in this area, potentially reducing complications and costs. However further well designed studies are needed to confirm this data.

Sudden unexpected death in epilepsy (SUDEP): a pilot study on truth telling among Italian epileptologists.

Sudden unexpected death in epilepsy (SUDEP) is a syndrome where a person with epilepsy dies suddenly and no other cause of death is found. The question of informing patients and their families about SUDEP remains a problematic issue. The aim of this study is to explore whether Italian physicians interested in epilepsy believe that they should discuss SUDEP with patients and/or their families. A total of 315 questionnaire were distributed, of which 195 (61.9%) were returned. Seventeen respondents (8.76%) discussed SUDEP with all of their patients, 38 (19.59%) with the majority of patients, 120 (61.85%) with very few of their patients and 15 (7.73%) with none of their patients. No statistical differences among groups were found for gender, professional age (≤ 10 years; ≥ 11 years ≤ 20 years; ≥ 21 years ≤ 30 years; ≥ 31 years) and medical specialty (neurologists vs. others). Open questions offered insights into the physicians' problem of managing the negative emotions of patients/family and why the physicians decided to give information.

How Italian students learn to become physicians: a qualitative study of the hidden curriculum.

BACKGROUND: A great deal of what medical students learn in terms of behaviors, values, and attitudes related to their profession is conveyed by the hidden curriculum. AIM: To explore the messages conveyed by the hidden curriculum as perceived by third-year students of the Milan School of Medicine, Italy, following their first clinical internship. METHOD: Three group interviews were conducted. Students were asked to reflect on values, attitudes, and implicit rules they noticed during their internship experiences. Verbatim transcripts of the group interviews were analyzed through content analysis using Nvivo8. RESULTS: Of the 81 students, 57 (70%) participated in the group interviews. Six themes were identified within the hidden curriculum: Physicians reassure and protect patients; power differential between physicians and patients; variable respect for patients; disease-centered medicine; respect for hierarchies; and delegation of patients' emotional needs to nurses. CONCLUSIONS: Our findings suggest that the hidden curriculum has a strong cultural component. In our students' experience, the hidden curriculum conveyed a paternalistic model of physician-patient relationships. Some of the messages conveyed by the actual hidden curriculum may compromise the standards formally taught in medical schools about doctor-patient relationships. Organizational culture change and student empowerment could be fostered to counteract the negative effects of the hidden curriculum.

Cross-cultural adaptation of an innovative approach to learning about difficult conversations in healthcare.

BACKGROUND: The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians' preparedness to engage in difficult conversations. AIM: To describe the implementation of PERCS in an Italian hospital and assess the program's efficacy. METHODS: The Italian PERCS program featured 4-h experiential workshops enrolling 10-15 interdisciplinary participants. The workshops were organized around the enactment and debriefing of realistic case scenarios portrayed by actors and volunteer clinicians. Before and after the workshop, participants rated their perceived preparation, communication and relational skills, confidence, and anxiety on 5-point Likert scales. Open-ended questions explored their reflections on the learning. T-tests and content analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS: 146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p < 0.001) after the workshops. The program had a different impact depending on the discipline. Participants valued the emphasis on group feedback, experiential and interdisciplinary learning, and the patient's perspective, and acquired: new communication skills, self-reflective attitude, reframed perspective, and interdisciplinary teamwork. CONCLUSION: PERCS proved culturally adaptable to the Italian context and effective in improving participants' sense of preparation, communication skills, and confidence.

An exploratory study on the Italian patients' preferences regarding how they would like to be told about their cancer.

GOAL: Major cross-cultural differences in truth-telling attitudes and practices have been demonstrated. Until recently, in Italy the doctor could conceal both diagnosis and prognosis to seriously ill patients out of beneficence. Signs of change have been reported, but the extent and way patients would be informed is still unknown. The aim of the study was to assess Italian patients' preferences regarding how they would like to be told about their cancer and its treatment. We examined the factor structure of the Measure of Patients' Preferences--Italian version (MPP-It) and whether demographical and medical variables were associated with the dimensions of patients' preferences. MATERIALS AND METHODS: Patients were invited to participate during a visit to the oncology department of the Lecco hospital (Italy) for chemotherapy or follow-up. An Italian version of the MPP-It was administered. Data were analyzed through a factor analysis. MAIN RESULTS: A total of 210 cancer patients agreed to participate. Three main factors were identified: (1) Information (Talking About the Disease). Items in this factor were concerned with the dialogue about the disease and treatment options; (2) Support (The Emotional World of the Patient). These items referred to the supportive and relational aspects of the physician-patient encounter; (3) Care (The Ideal Doctor). These items related to the patients' desires about the doctor's personal attributes. CONCLUSIONS: The first two factors, information and support, were comparable to those of similar American and Asian studies. The study suggests a cross-cultural uniformity among cancer patients who appreciate the informative and clearness of the communication aspects as being primarily important, while also giving high points to relationship aspects. The third factor appears unique to the Italian context.

[Between science and suffering: difficult conversations in healthcare]. / Tra scienza e sofferenza: le conversazioni difficili in sanità.

INTRODUCTION: This article describes the adaptation and implementation of the Program to Enhance Relational and Communication Skills (PERCS) in Italy. PERCS was originally developed at Children's Hospital Boston and aims to enhance clinicians' preparedness to engage in difficult conversations with patients/families. DESCRIPTION: After a period of collaboration by the first author with the Children's Hospital Boston, PERCS was launched at San Paolo Hospital, Milan, in 2008. To date, over 80 participants have voluntarily attended the program. The program features monthly 4-hour workshops geared around the enactment of a case scenario by trained actors and participants. Each workshop enrolls 10-13 interdisciplinary participants. After each enactment, participants receive feedback by actors, other participants and facilitators on the challenging junctures of the conversation. Pedagogical principles include: creating safety for learning; emphasizing moral and relational dimensions of care; suspending hierarchy among participants; valuing self-reflection; honoring multiple perspectives; and offering continuity of the educational offering. CONCLUSIONS: Implementing PERCS in Italy has demonstrated that it is possible to culturally adapt learning opportunities that embrace the relational and ethical experience of learners. The positive response of participants affirms that relational learning is meaningful and needed.

["Diabetes is for me ...": the health care workers perspective]. / "Il diabete e per me ...": la prospettiva degli operatori sanitari.

AIM: To analyze the representations and meanings of diabetes from the health workers perspective through an ethnographic approach. METHOD: Participants who attended a national conference on diabetes care were asked to write a narrative responding to the question: "For me, diabetes is...". Narratives were qualitatively analyzed by two researchers following the principles of content analysis. Nvivo software was used to organize and code the data. RESULTS: Of the 147 conference participants, 140 narratives were analyzed: 86 written by nurses, 54 by physicians. Six themes emerged: The disease which summarizes the biomedical and biopsychosocial definitions of diabetes; The patient's illness experience, which describes the impact of diabetes on the patients lives; The clinician's experience, where clinicians fear the impact (actual or potential) of diabetes on their families or themselves; The clinician-patient relationship, where the importance of a good patient-clinician relationship and the related emotions are described; and The social and healthcare system, which describes the healthcare system as an aid as well as an obstacle in patients' care. CONCLUSION: Despite some academic description of diabetes, our results showed that health care workers, especially nurses, have a profound comprehension of the patient illness experience that sometimes leads to the identification with patients. The relationship and patient education were described as a complex and challenging area of practice for both professions. Training on relational and emotional skills could improve the patients care.

[Efficacy of an emotional-based psycho-educational strategy for patients suffering from type 2 diabetes. An almost experimental pilot study]. / Efficacia di un intervento psicoeducativo a matrice emotiva per pazienti affetti da diabete di tipo 2. Uno studio pilota quasi sperimentale.

The authors discuss the creation of a psycho-educational course based on emotions in a group of diabetes type 2 patients. Its effects were assessed : biologically, by measuring blood sugar levels and body weight; cognitively, by behavioral tests; psycho-emotionally, by Moreno's Social Atom test that evaluates the patient's personal life in the light of his/her pathological conditions. 12 subjects were studied (10 patients and 2 spouses). Results showed: significant improvement in life-style; a marginal improvement of weight and level of coping with the illness; a non-significant improvement in blood sugar levels. The study showed that one particularly important aspect regards the role of nurses within the multidisciplinary team conducting the study.

Assumptions and blind spots in patient-centredness: action research between American and Italian health care professionals.

OBJECTIVE: To examine how patient-centredness is understood and enacted in an American (US) and an Italian group of health care professionals. METHODS: An action research methodology was used. Two interprofessional groups of US (n = 4) and Italian (n = 5) health care professionals independently wrote a patient-centred dialogue between a doctor and a patient based on the same scenario. The dialogues were then translated and exchanged. Both groups independently commented on the patient-centred aspects of the other's dialogue by completing a written questionnaire. Their respective comments were then shared by international videoconference. The transcript of the videoconference was analysed via content analysis. The participants' opinions about the study were then evaluated. RESULTS: Exploring the patient's illness experience and handling the patient's emotions were identified as core components of patient-centred care by both the US and Italian groups, but were expressed differently in their respective dialogues. Respecting the patient's autonomy was recognised as a component of patient-centred care only by the US group. The Italian group demonstrated a more implicitly paternalistic approach. Participants highlighted the usefulness of one another's feedback to uncover cultural assumptions of patient-centred care and increase self-awareness. CONCLUSIONS: Results suggest that the concept and practice of patient-centred care is variable and may be influenced by culture. The study methodology improved participants' self-awareness of cultural values, and has potential as a cost-effective, experiential educational approach.

[Difficult conversations in medicine: an experiential, optional course with medical students]. / Comunicazioni difficili in medicina: l'esperienza di un corso elettivo per studenti di medicina.

A 24 hrs optional course was realized with 15 students at the Medical School of Milan, with the aim of undertaking the management of the emotional aspects in a difficult communication in medicine. The course was realized through the use of active teaching tools; issues resulted from what literature consider as "difficult communication". Photolangage was used as pre-post test to assess the effects of the course; a satisfaction questionnaire was also used. From the content analysis of the data the course resulted effective both for the students' satisfaction and for the enhancing of their self reflective skills.

Conscious sedation in critically ill patients is associated with stressors perception lower than assessed by caregivers.

BACKGROUND: In ICU, the stay is frequently a stressful experience. Caregivers may help to understand patients' perceptions; however, their reliability is uncertain. Despite the recent recommendations of lighter sedation targets, little is known about the impact of "conscious sedation" on ICU patients memories. Purpose of this prospective, observational study is to analyze the stress perception in consciously-sedated ICU-patients, comparing it to caregivers and staff members. METHODS: Twenty-nine high-risk ICU-patients treated with awake/cooperative sedation were enrolled. Before discharge, patients received a validated questionnaire for ICU stressors evaluation, also administered to their main caregiver (N.=29), to caregivers of other ICU patients not enrolled in the study (N.=33) and to staff members (ICU nurses, attending physicians, residents, medical students, N.=56). RESULTS: Total stress score was: patients 141±41, patient relatives 210±63, other relatives: 202±73, ICU staff: 232±44, P<0.001. Among patients, older age (P=0.031), longer ICU-stay (P=0.018) and awake-sedation (P=0.022) were associated with lower stress; sex and illness severity had no effect; mechanical ventilation length (P=0.021) and agitation (P=0.029) were associated with higher stress. Nurses tended to overestimate stressors more than attending physicians and trainees. Within staff members, age (P=0.021) and years of experience (P=0.069) were positively associated with overestimation. CONCLUSIONS: Conscious sedation is associated with stress perception lower than stress assessed by caregivers: relatives and staff members tend to overestimate ICU patient stress, more so with increasing age or expertise. A number of stressors underestimated by staff and families could be target of specific interventions to ameliorate quality of life during ICU stay.

The effect of patient-centered contraceptive counseling in women who undergo a voluntary termination of pregnancy.

OBJECTIVE: The aim of the study was to evaluate, by means of a randomized controlled trial, whether a patient-centered contraceptive counseling intervention increased the use of contraception, and the knowledge and positive attitudes towards contraception, in women who undergo a termination of pregnancy (TOP). METHODS: The study was carried out at the San Paolo Hospital of Milan between the 1st of February and the 31st of May 2004. Participants (41 women; ages 20-44 years) were randomly divided into two groups: an experimental group (n = 20), who received patient-centered contraceptive counseling, and a control group (n = 21), who received the routine treatment in use at the San Paolo Hospital and were referred to the community health centers after the TOP. Both groups were administered a questionnaire at two points in time (before the counseling and 1 month later) which evaluated participants' knowledge, attitudes and use of contraception (the latter was also followed up 3 months later). The counseling intervention lasted 30 min and was carried out by a psychologist and a gynaecologist. RESULTS: It was found that knowledge, favorable attitudes and use of effective contraception increased significantly for the experimental group, whereas there was no significant change for the control group. CONCLUSION: The counseling intervention was therefore found to be efficacious in improving understanding and use of contraception in women who have undergone a TOP. The hope is that this will contribute to increased use of effective contraception in the future. PRACTICE IMPLICATIONS: Following the principles of patient-centered medicine, this study provides evidence for the importance of exploring woman's feelings, beliefs, wishes and expectations regarding contraception within a contraceptive counseling intervention.

[The doctor-patient and the doctor-patient-companion encounter in the General Medicine: a descriptive study]. / La visita in medicina generale: l'incontro medico-paziente e l'incontro medico-paziente-accompagnatore. Uno studio descrittivo.

The aim of the study is to describe the doctor-patient-companion interaction in the Italian General Practice compared to dyadic encounters. 819 videorecorded visits were included. 650 (79.4%) were dyadic visits. 153 (18.7%) were doctor-patient-companion encounters in which the third party was a legitimate companion (n = 24; 15.7%), or an "illegitimate" one (n = 77; 50.3%) or a patient him/herself (n = 52; 34%). In 16 visits (1.9%) more than two people interact with the doctor. The study constitutes a stimulus in order to favour an Italian contribution about a new international perspective on the doctor-patient relation that is clinically relevant.

[When a doctor must treat a collegue]. / Quando un medico cura un medico.

The literature about the physician emotional life underlined how to care a collegue generates stress. However this situation is not so much investigated. The aim of this article is to investigate the nature of the relation and of the physician inner life when the doctor meets a patient-doctor, by means of narratives and a qualitative analysis. Having a colleague as patient seems to be very challenging and to evocke struggling feelings difficult to handle with well known stategies.

Neurological assessment with validated tools in general ICU: multicenter, randomized, before and after, pragmatic study to evaluate the effectiveness of an e-learning platform for continuous medical education.

BACKGROUND: International guidelines recommend systematic assessment of pain, agitation/sedation and delirium with validated scales for all ICU patients. However, these evaluations are often not done. We have created an e-learning training platform for the continuous medical education, and assessed its efficacy in increasing the use of validated tools by all medical and nursing staff of the participating ICUs during their daily practice. METHODS: Multicenter, randomized, before and after study. The eight participating centers were randomized in two groups, and received training at different times. The use of validated tools (Verbal Numeric Rating or Behavioral Pain Scale for pain; Richmond Agitation-Sedation Scale for agitation; Confusion Assessment Method for the ICU for delirium) was evaluated from clinical data recorded in medical charts during a week, with follow-up up to six months after the training. All the operators were invited to complete a questionnaire, at baseline and after the training. RESULTS: Among the 374 nurses and physicians involved, 140 (37.4%) completed at least one of the three courses. The assessment of pain (38.1 vs. 92.9%, P<0.01) and delirium (0 vs. 78.6%, P<0.01) using validated tools significantly increased after training. Observation in the follow-up showed further improvement in delirium monitoring, with no signs of extinction for pain and sedation/agitation measurements. CONCLUSIONS: This e-learning program shows encouraging effectiveness, and the increase in the use of validated tools for neurological monitoring in critically ill patients lasts over time.

[Perception of the quality of emergency care by the users: expectations and satisfaction with the care received]. / La qualità percepita dall'utenza in pronto soccorso: aspettative e soddisfazione nel percorso di cura.

The aim of this study was to examine patient satisfaction with emergency care at a teaching hospital Emergency Department (ED) in Northern Italy. Level of patient satisfaction was compared with patient expectations at ED access. A questionnaire using a 6-point Likert scale format was administered to 427 patients. The mean general satisfaction index was 4,54+/-1,36. The rank order of "important" factors differed from that of 'satisfaction' factors. This study identified several critical areas perceived by patients to be of absolute importance and regarding which interventions are desirable.

Do occupational therapists' communication behaviours change with experience?

BACKGROUND: An increasing amount of literature has studied changes in communication skills in medical and nursing undergraduate students. AIM: To evaluate whether occupational therapists' communication behaviours change with experience. MATERIAL AND METHODS: A total of 45 participants (second-year OT students, final-year OT students, professional OTs) were enrolled and met three simulated clients. The role plays were video-recorded and analysed through OT-RIAS (Occupational Therapy-Roter Interaction Analysis System). Chi-square tests were used to analyse the statistical differences between groups for the OT-RIAS categories. RESULTS: Process represented 30.74% of communication for second-year students, 33.69% for final year students, and 35.58% for professional OTs; Occupational therapy ranged from 30.41% in the second-year students to 32.54% in the undergraduates and 37.04% in the professional OTs; Medical increased from 18.66% to 34.33% of the final-year students and 47.01% of the professional therapists. Personal and Psychosocial slightly decreased through experience. Emotional decreased gradually: 39.8% in the second-year students, 29.54% in final-year students, and 30.66% in professional OTs. CONCLUSION: During training in occupational therapy the communication skills changed, assuming a more technical shape, increasing control and content-related OT communication. Nevertheless, the therapists' communication behaviours showed the endurance of attention to the client's point of view.

The physician-patient-parent communication: a qualitative perspective on the child's contribution.

OBJECTIVE: The aim of the present study was to explore (1) how and with which specificity the young patient contributes to the visit; (2) the communicative-relational manner with which adults handle the child's interventions. METHODS: Ten videoed visits with patients aged 2-6 years were selected. A content and discourse analysis was realized. RESULTS: Results showed three macro-categories that seem to fully describe the young patient interventions: (1) The subjective experience regarding the illness; (2) The child's own learning process; (3) The child's medical knowledge. These contributions seem to be handled by the adults in processes that may or may not integrate the patient contributions. DISCUSSION: Results confirmed the quantitatively limited child's contribution, but they also showed an active child, who communicates with the adults about the subjective experience of the visit or the illness, and who autonomously handle the learning process about the roles in the visit. PRACTICE IMPLICATIONS: Physicians should improve their communication skills to integrate the child's interventions.

[Breaking unexpected bad news: pilot study on communication style of physicians]. / La cattiva notizia inattesa: uno studio pilota sulle strategie comunicative dei medici.

The aim of this study was to explore the physician's communication pattern when breaking a bad unexpected news. 30 videotaped consultations (VRM) were collected in which the physicians met an actress as a patient. The doctors received the x-ray report in which an apical mass was detected before (condition A) or during (condition B) the consultation. The VRM were analysed through the Roter Interaction Analysis System (RIAS). Data suggested in condition B a significant decrease in "process", "counselling" and "emotional" categories. In consultation where a bad unexpected news is communicated doctors seem to be less directive in the content and more emotionally defended.

[A very difficult question: a qualitative research from the nurses' perspective]. / Una domanda davvero difficile: una ricerca qualitativa secondo la prospettiva degli infermieri.

UNLABELLED: Aim of this paper is to identify what is a difficult question, according to nurses' perceptions. Since the knowledge on this area is limited, a qualitative method was preferred for a pilot study. METHODS: As part of a training exercise, fifty-one nurses were requested to recall, from their own experience, and to describe, a difficult question asked by a patient, that created problems to the nurse. Data were analysed with hermeneutical-interpretative methodology. RESULTS: Three main conceptual cores were identified: the characteristics of the difficult question; the "after the question"; and the source of the problem experienced. The first core is related to the content of the question but also to the characteristics of the person that formulates it, to the setting, and to the subjective perception of the time window. What happens after the question is related to the nurse's reactions. The third conceptual core is related to the interplay between different possible roles: patient, professional, and human being. The denominator of the three cores has to do with the emotional-relational dimension of the communication. This difficulty may partly be due to the lack of education in the management of the emotions.