Face-to-Face Relationships Still Matter in a Digital Age: A Call for a 5th C in the Core Tenets of Primary Care.

We primary care clinicians, scholars, and leaders ascribe value to Barbara Starfield's core tenets of primary care-the 4 Cs: first contact, comprehensiveness, coordination, and continuity. In today's era of rapid technological advancements and dwindling resources, what are the implications for face-to-face interactions of patient-clinician relationships? We propose adding a 5th C: "Contiguity." Contiguity-or physical proximity and presence-is a key dimension that not only enables the necessary technical aspects of a physical exam but also authenticates the most human aspects of a relationship and occurs specifically when we are physically vulnerable and responsible for the other before us. This, in turn, may best enable us to bridge difference and nurture trust with our patients. We measure what we value and, thus, naming Contiguity as a core tenet assures that we will not lose sight of this keystone in a patient's relationship with their personal physician.

The views of parents and carers on managing acute otitis media in urban Aboriginal and Torres Strait Islander children: a qualitative study.

OBJECTIVES: To explore the views of parents and carers regarding the management of acute otitis media in urban Aboriginal and Torres Strait Islander children who are at low risk of complications living in urban communities. STUDY DESIGN: Qualitative study; semi-structured interviews and short telephone survey. SETTING, PARTICIPANTS: Interviews: purposive sample of parents and carers of urban Aboriginal and Torres Strait Islander children (18 months - 16 years old) screened in Aboriginal medical services in Queensland, New South Wales, and Canberra for the WATCH study, a randomised controlled trial that compared immediate antibiotic therapy with watchful waiting for Aboriginal and Torres Strait Islander children with acute otitis media. SURVEY: parents and carers recruited for the WATCH trial who had completed week two WATCH surveys. RESULTS: We interviewed twenty-two parents and carers, including ten who had declined participation in or whose children were ineligible for the WATCH trial. Some interviewees preferred antibiotics for managing acute otitis media, others preferred watchful waiting, expressing concerns about side effects and reduced efficacy with overuse of antibiotics. Factors that influenced this preference included the severity, duration, and recurrence of infection, and knowledge about management gained during the trial and from personal and often multigenerational experience of ear disease. Participants highlighted the importance of shared decision making by parents and carers and their doctors. Parents and carers of 165 of 262 WATCH participants completed telephone surveys (63%); 81 were undecided about whether antibiotics should always be used for treating acute otitis media. Open-ended responses indicated that antibiotic use should be determined by clinical need, support for general practitioners' decisions, and the view that some general practitioners prescribed antibiotics too often. CONCLUSIONS: Parents and carers are key partners in managing acute otitis media in urban Aboriginal and Torres Strait Islander children. Our findings support shared decision making informed by the experience of parents and carers, which could also lead to reduced antibiotic use for managing acute otitis media.

Predicaments and coping strategies in implementing cancer truth-telling: a qualitative content analysis.

PURPOSE: The patient-centered communication principles in Western countries are widely esteemed. In Eastern countries, a family-centered approach to medical decision-making is preferred. However, the predicaments faced by attending physicians and their coping strategies in the process of truth-telling about cancer are unknown. Therefore, this study aimed to understand attending physicians' predicaments and coping strategies in implementing truth-telling for cancer in Taiwan. METHODS: This study used a qualitative description approach to conduct in-depth interviews with attending physicians. Data were collected from two medical centers in Taiwan. Purposive sampling was also conducted. A total of 17 attending physicians participated in individual semi-structured interviews. All interviews were audio recorded and transcribed verbatim. Inductive content analysis was used to analyze and develop the subcategories, generic categories, and main categories. RESULTS: Four main categories emerged: (1) Causing harm to the patient: Family members' cooperation is needed. (2) Family members' request to conceal the truth: Physicians should judge based on the patient's disease condition. (3) Delayed treatment: Physicians should prioritize establishing confidence. (4) Delivering bad news about relapse: Physicians have different coping strategies. CONCLUSION: Physicians in Taiwan face challenges but prioritize family-centered care despite having coping strategies to protect patients. When faced with a scenario in which family members request concealment of truth, most physicians cooperate with them to determine the level and method of disclosing unfavorable news to patients. Physicians should prioritize patients' psychological needs when they experience relapse or metastasis or face strong negative emotions.

Discordances in patients' and physicians' perspectives on which contextual factors should be accounted for during smoking cessation.

BACKGROUND: Smoking cessation interventions requires attending to the circumstances and needs of individual patients. We aimed at highlighting the discordances between patients' and physicians' perspectives on contextual factors that should be considered during smoking cessation. METHODS: We identified 36 contextual factors identified that should be considered during smoking cessation using PubMed and interviewing general practitioners. Physicians recruited through social networks campaigns and smoker or former smoker patients from the ComPaRe cohort selected the factors they considered most relevant in two online paired comparison experiment. Bradley Terry Luce models estimated the ability of each factor (i.e. the probability to be preferred). We calculated the Pearson's correlation and the intraclass correlation coefficients for the contextual factor from each perspective and compared the ranking of the 10 contextual factors with the highest abilities. RESULTS: Seven hundred and ninety-three patients' and 795 physicians' perspectives estimated the ability (i.e., importance) of the contextual factors in 11 963 paired comparisons. We found a high correlation between physicians' and patients' perspectives of the contextual factors to be considered for smoking cessation (r = 0.76, P < 0.0001). However, the agreement between the abilities of contextual factors was poor (ICC = 0.42 [-0.10; 0.75]; P = 0.09). Fine-grain analysis of participants' answers revealed many discrepancies. For example, 40% factors ranked in the top 10 most important for physicians were not in patients' top 10 ranking. CONCLUSION: Our results highlight the importance of patient-centered care, the need to engage discussions about patients' values, beyond what is thought to be important, to avoid overlooking their real context.

Public perception of participation in low-risk clinical trials in critical care using waived consent: a Canadian national survey.

PURPOSE: The acceptability of waiver of consent for participation in clinical research in intensive care unit (ICU) settings is uncertain. We sought to survey the Canadian public to assess levels of support, comfort, and acceptability for waived consent for low-risk clinical trials. METHODS: We performed a prospective cross-sectional survey of the Canadian public aged 18 yr or older. The survey was conducted by Ipsos between 19 and 23 November 2020. The survey content was derived from a literature review and in consultation with a patient and family partnership committee. The survey focused on attitudes and beliefs on waived consent for participation in low-risk clinical trials in ICU settings. The survey contained 35 items focused on sociodemographics, general health status, participation in medical research, and levels of support and comfort with research and with waived consent. The survey used a case study of a low-risk clinical trial intervention in ICU patients. Analysis was descriptive. RESULTS: We included 2,000 participants, 38% of whom reported experience with ICU and 16% with medical research. Participation in medical research was more common among those with postsecondary education, those with chronic disease, and those who were employed in health care. Most (80%) would support a model of waived consent for low-risk clinical trials, citing medical benefits (36%) and low perceived risk (34%). Most (77%) were comfortable with personally participating in a low-risk clinical trial. Most (80%) believed waived consent approaches were acceptable. Half (52%) believed the waived consent process should provide information about the research and include the option of opting out. When asked whether participants should always give full informed consent, regardless of the practicality or level of risk, 74% and 72% agreed, respectively. CONCLUSIONS: There is public support for models of waived consent for participation in low-risk pragmatic clinical trials in ICU settings in Canada; however, this is not universal. This information can inform and guide education, ethics, policy, and legal discussion on consent models.

RéSUMé: OBJECTIF: L'acceptabilité de la renonciation au consentement pour la participation à la recherche clinique à l'unité de soins intensifs (USI) est incertaine. Nous avons cherché à sonder la population canadienne afin d'évaluer les niveaux de soutien, de confort et d'acceptabilité de la renonciation au consentement pour les études cliniques à faible risque. MéTHODE: Nous avons réalisé un sondage transversal prospectif auprès de la population canadienne âgée de 18 ans et plus. Le sondage a été réalisé par Ipsos entre le 19 et le 23 novembre 2020. Le contenu du sondage a été élaboré à partir d'une revue de la littérature et en consultation avec un comité de partenariat composé de patient·es et de familles. Le sondage portait sur les attitudes et les croyances à l'égard de la renonciation au consentement pour participer à des études cliniques à faible risque dans les unités de soins intensifs. Le sondage comportait 35 questions axées sur les données sociodémographiques, l'état de santé général, la participation à la recherche médicale et les niveaux de soutien et de confort à l'égard de la recherche et de la renonciation au consentement. Le sondage s'est appuyé sur une étude de cas d'une intervention d'étude clinique à faible risque chez des patient·es des soins intensifs. L'analyse était descriptive. RéSULTATS: Nous avons inclus 2000 personnes, dont 38 % ont déclaré avoir eu des expériences en soins intensifs et 16 % en recherche médicale. La participation à la recherche médicale était plus fréquente chez les personnes ayant fait des études postsecondaires, celles atteintes de maladies chroniques et celles qui travaillaient dans le domaine des soins de santé. La plupart d'entre elles (80 %) appuieraient un modèle de renonciation au consentement pour les études cliniques à faible risque, citant les avantages médicaux (36 %) et le faible risque perçu (34 %). La majorité des personnes répondantes (77 %) étaient à l'aise à l'idée de participer personnellement à une étude clinique à faible risque. La plupart d'entre elles (80 %) croyaient que les approches fondées sur la renonciation au consentement étaient acceptables. La moitié (52 %) estimaient que le processus de renonciation au consentement devrait fournir des renseignements sur la recherche et inclure la possibilité de se retirer. Lorsqu'on leur a demandé si les participant·es devraient toujours donner un consentement éclairé complet, quel que soit l'aspect pratique ou le niveau de risque, 74 % et 72 % ont répondu par l'affirmative, respectivement. CONCLUSION: Il y a un appui public pour les modèles de renonciation au consentement quant à la participation à des études cliniques pragmatiques à faible risque dans les unités de soins intensifs au Canada; cet appui n'est toutefois pas universel. Ces renseignements peuvent éclairer et orienter l'éducation, l'éthique, les politiques et les discussions juridiques sur les modèles de consentement.

International survey of people living with chronic conditions (PaRIS survey): effects of general practitioner non-participation on the representativeness of the Norwegian patient data.

BACKGROUND: The International Survey of People living with Chronic Conditions (OECD-PaRIS survey), aims to systematically gather patient-reported experiences (PREMs) and - outcomes (PROMs) and potential predictors for these outcomes for persons with chronic conditions as well as information from professionals about health care provided. In such patient surveys, the advantages of a multilevel (nested) approach in which patients are sampled 'within providers' need to be balanced against the potential for bias if patient populations from participating GPs significantly differ from those of non-participating GPs. The objective was to assess the effects of general practitioner (GP) non-participation on the representativeness of the Norwegian patient data of the International Survey of People living with Chronic Conditions (OECD-PaRIS survey). METHODS: To test all aspects of the first main PaRIS survey, it was preceded by a field trial which this paper reports on the Norwegian part of. For the Norwegian part of the field trial in 2022, we randomly sampled and surveyed 75 GPs and 125 patients 45 years and older for each GP, regardless of whether their GP were also participating in the study. GPs were sampled from a national register that included all GPs. The surveys were primarily digital, but we sent postal questionnaires to non-digital patients and non-responding digital patients. We compared GP and patient characteristics as well as patient-reported experiences and outcomes according to GP participation status in bivariate analysis, supplemented with multiple linear regressions with PREMs/PROMs as dependent variables and participation status as independent adjusting for significant patient factors. RESULTS: 17 of 75 sampled GPs participated (22.7%), of which 993 of 2,015 patients responded (49.3%). 3,347 of 7,080 patients of non-responding GPs answered (47.3%). Persons with chronic conditions from participating GPs reported significantly better patient-centred coordinated care (p = 0.017), overall experiences with the GP office the last 12 months (p = 0.004), mental well-being (p = 0.039) and mental health (p = 0.013) than patients from non-participating GPs. The raw differences between participating and non-participating GPs on patient-reported experiences and - outcomes varied from 1.5 to 2.9 points on a 0-100 scale, and from 2.2 to 3.0 after adjustment for case-mix. CONCLUSIONS: The Norwegian field trial indicates that estimates based on participants in the PaRIS survey may modestly overestimate patient-reported experiences and -outcomes at the aggregated level and the need for more research within and across countries to identify and address this potential bias.

Relationally competent attitudes and actions: a systematic review of general practice literature.

OBJECTIVE: To explore core elements from Teachers' Relational Competence in general practice literature regarding building relationships in consultations, specifying actions doctors take to create and maintain relationship quality with patients. This systematic literature review aims to map and propose a similar framework for the doctor-patient relationship. BACKGROUND: The doctor-patient relationship, a well-researched yet complex field, often lacks clear descriptions. In recent definitions of patient-centred medicine, the responsibility of this relationship falls on the doctor, though how both relationship and responsibility is enacted needs clarification. Pedagogical literature on the student-teacher relationship provides a framework for relational competence, incorporating the needs and interactions between teacher and student and their alignment with institutional goals. METHODS: A systematic review of two databases yielded 1256 hits. After screening, 15 studies were included and assessed. A qualitative synthesis was conducted through iterative and thematic deductive analysis. RESULTS: Four relationally competent attitudes identified were: Attention to emotion, Devotion, Mentalization, and Time-oriented presence. Four relationally competent actions identitfied were: Being open, Attunement, Offering Support, and Using humor. Additionally, Trust and Continued connectedness were found as components of both attitudes and actions. CONCLUSION: An explanatory framework for professional relational competence for GPs includes concrete actions and specific attitudes before and during consultations. These consist of four key attitudes and four categories of actions with several subgroups of actions. Two additional components to the framework was found.

Patient-centredness is a concept widely known and used in healthcare, which doctors are expected to uphold, but some aspects of carrying out patient-centredness and relational work needs further research.Using inspiration from pedagogy, an explanatory framework can offer insights to how patient-centredness can be carried out in consultationsThe findings from our study can be used to further research into the doctor-patient relationship, as well as to strengthen education in communication in health care and consultations in general practice.This study found that an explanatory framework for professional relational competence for GP's consists of concrete actions in the consultation as well as attitudes toward the consultation, both before and during the interaction.

YouTube as a source of information on reactive arthritis: a quality analysis.

OBJECTIVE: YouTube is often used by patients and healthcare professionals to obtain medical information. Reactive arthritis (ReA) is a type of inflammatory arthritis triggered by infection, usually in the genitourinary or gastrointestinal tract. However, the accuracy and quality of ReA-related information on YouTube are not fully known. This study aimed to assess the reliability and quality of YouTube videos pertaining to ReA. MATERIALS AND METHODS: A YouTube search was performed on August 1, 2023, using the keywords "reactive arthritis," "Reiter's disease," and "Reiter's syndrome." The number of days since upload; the number of views, likes, and comments; and the duration of videos were recorded. The modified DISCERN tool (mDISCERN) and the global quality scale (GQS) were used to evaluate the reliability and quality of the videos. Two physicians independently classified videos as low, moderate, or high quality and rated them on a five-point GQS (1 = poor quality, 5 = excellent quality). The source of videos was also noted. RESULTS: Of the 180 videos screened, 68 met the inclusion criteria. The most common topic (61, 89.7%) was "ReA overview." Among the 68 videos analyzed, the main source of uploads was physicians 45 (66.2%), and 66 (97%) were categorized as useful. Around half of the YouTube videos about ReA were of high quality (33, 48.5%) according to the GQS. Upon comparing videos uploaded by rheumatologists, non-rheumatology healthcare professionals, and independent users, significant differences were found in mDISCERN and GQS but not in the number of views, likes, and comments or duration. Upon comparing high-, moderate-, and low-quality videos, significant differences were found in the number of views, likes, and comments; duration; and in mDISCERN and GQS. CONCLUSION: YouTube is a source of information on ReA of variable quality, with wide viewership and the potential to influence patients' knowledge and behavior. Our results showed that most YouTube videos on ReA were of high quality. Videos presented by physicians had higher quality. YouTube should consider avoiding low-quality videos by using validity scales such as mDISCERN and GQS.

Effects of prognostic communication strategies on emotions, coping, and appreciation of consultations: An experimental study in advanced cancer.

OBJECTIVES: We aimed to investigate effects of prognostic communication strategies on emotions, coping, and appreciation of consultations in advanced cancer. METHODS: For this experimental study, we created 8 videos of a scripted oncological consultation, only varying in prognostic communication strategies. Disease-naive individuals (n = 1036) completed surveys before and after watching 1 video, while imagining being the depicted cancer patient. We investigated effects of the type of disclosure (prognostic disclosure vs. communication of unpredictability vs. non-disclosure) and content of disclosure (standard vs. standard and best-case vs. standard, best- and worst-case survival scenarios; numerical vs. word-based estimates) on emotions, coping, and appreciation of consultations. Moderating effects of individual characteristics were tested. RESULTS: Participants generally reported more satisfaction (p < .001) after prognostic disclosure versus communication of unpredictability and less uncertainty (p = .042), more satisfaction (p = .005), and more desirability (p = .016) regarding prognostic information after numerical versus word-based estimates. Effects of different survival scenarios were absent. Prognostic communication strategies lacked effects on emotions and coping. Significant moderators included prognostic information preference and uncertainty tolerance. SIGNIFICANCE OF RESULTS: In an experimental setting, prognostic disclosure does not cause more negative emotions than non-disclosure and numerical estimates are more strongly appreciated than words. Oncologists' worries about harming patients should not preclude disclosing (precise) prognostic information, yet sensitivity to individual preferences and characteristics remains pivotal.

Assessing the attitudes and knowledge of medical students towards Patient-Centred Care across different study years: A cross-sectional study.

OBJECTIVE: To determine how medical students viewed the importance of patient-doctor communication, to assess their knowledge about patient-centred care, and to compare the attitudes of medical students in their pre-clinical and clinical years of study towards patient-centred care. METHODS: The cross-sectional study was conducted from April to September 2023 at Federal Medical and Dental College, Islamabad, and Rawalpindi Medical University, Rawalpindi, Pakistan, and comprised medical students of either gender from 2nd to 5th academic year. Data was collected using the Patient-Practitioner Orientation Scale. Data was analysed using SPSS 27. RESULTS: Of the 322 students, 178(55.3%) were males and 144(44.7%) were females. The mean score was 3.60±0.47, while the sharing and caring sub-scores were 3.23±0.66 and 3.99±0.52, respectively. The attitude of students overall was slightly patient-centred. Different study years showed variance in patient-centred scores which were also affected by cultural, demographic and gender parameters (p<0.05). CONCLUSIONS: The attitude of the students leaned slightly towards patient-oriented behaviour.

Communication About Complementary and Alternative Medicine When Patients Decline Conventional Cancer Treatment: Patients' and Physicians' Experiences.

BACKGROUND: Complementary and alternative medicine (CAM) is a broad set of nonconventional practices used alongside or instead of conventional treatment: The latter poses obvious risks related to cancer prognosis. Patient-physician dialogue about CAM is crucial for patient safety and mutual trust. Little is known about communication in the rare situations when patients decline recommended cancer treatment and consider using CAM. The objective of this study was to explore patients' and physicians' experiences from situations when patients decline recommended cancer treatment and consider using CAM. MATERIALS AND METHODS: Semi-structured interviews were carried out with 7 CAM-using cancer patients who had declined some or all conventional treatment as well as 10 physicians from oncology and palliative care. Framework analysis was used. RESULTS: Regarding treatment choices, there was a dissonance between physicians' focus on medical reasoning and patients' expression of complex values. Physicians' difficulty in understanding patients' treatment decline was exacerbated when patients considered using CAM, impairing communication even further. Inequalities in roles resulting in power struggles risked pushing both parties toward extreme and inflexible standpoints. Despite these challenges regarding treatment choices and hierarchical roles, both parties considered open and respectful communication as crucial. CONCLUSIONS: This study highlights the difficulty of shared decision-making in practice when patients' and physicians' views on treatment decisions deviate in clinically challenging situations. Our results point to a need to address the complexity of these situations, pay attention to patients' values, and improve knowledge among physicians about CAM.

Prevalence and Predictors of Physician-Patient Discordance in Prognostic Perceptions in Advanced Cancer.

BACKGROUND: Discordance between physicians' and patients' prognostic perceptions in advanced cancer care threatens informed medical decision-making and end-of-life preparation, yet this phenomenon is poorly understood. We sought to: (1) describe the extent and direction of prognostic discordance, patients' prognostic information preferences in cases of prognostic discordance, and physicians' awareness of prognostic discordance; and (2) examine which patient, physician, and caregiver factors predict prognostic discordance. MATERIALS AND METHODS: Oncologists and advanced cancer patients (median survival ≤12 months; n = 515) from 7 Dutch hospitals completed structured surveys in a cross-sectional study. Prognostic discordance was operationalized by comparing physicians' and patients' perceptions of the likelihood of cure, 2-year mortality risk, and 1-year mortality risk. RESULTS: Prognostic discordance occurred in 20% (likelihood of cure), 24%, and 35% (2-year and 1-year mortality risk) of physician-patient dyads, most often involving patients with more optimistic perceptions than their physician. Among patients demonstrating prognostic discordance, the proportion who preferred not knowing prognosis varied from 7% (likelihood of cure) to 37% (1-year mortality risk), and 45% (2-year mortality risk). Agreement between physician-perceived and observed prognostic discordance or concordance was poor (kappa = 0.186). Prognostic discordance was associated with several patient factors (stronger fighting spirit, self-reported absence of prognostic discussions, an information source other than the healthcare provider), and greater physician-reported uncertainty about prognosis. CONCLUSION: Up to one-third of the patients perceive prognosis discordantly from their physician, among whom a substantial proportion prefers not knowing prognosis. Most physicians lack awareness of prognostic discordance, raising the need to explore patients' prognostic information preferences and perceptions, and to tailor prognostic communication.

Association Between Physician Empathy and Difficult Patient Encounters: a Cross-Sectional Study.

BACKGROUND: Physicians frequently experience patients as difficult. Our study explores whether more empathetic physicians experience fewer patient encounters as difficult. OBJECTIVE: To investigate the association between physician empathy and difficult patient encounters (DPEs). DESIGN: Cross-sectional study. PARTICIPANTS: Participants were 18 generalist physicians with 3-8 years of experience. The investigation was conducted from August-September 2018 and April-May 2019 at six healthcare facilities. MAIN MEASURES: Based on the Jefferson Scale of Empathy (JSE) scores, we classified physicians into low and high empathy groups. The physicians completed the Difficult Doctor-Patient Relationship Questionnaire-10 (DDPRQ-10) after each patient visit. Scores ≥ 31 on the DDPRQ-10 indicated DPEs. We implemented multilevel mixed-effects logistic regression models to examine the association between physicians' empathy and DPE, adjusting for patient-level covariates (age, sex, history of mental disorders) and with physician-level clustering. KEY RESULTS: The median JSE score was 114 (range: 96-126), and physicians with JSE scores 96-113 and 114-126 were assigned to low and high empathy groups, respectively (n = 8 and 10 each); 240 and 344 patients were examined by physicians in the low and high empathy groups, respectively. Among low empathy physicians, 23% of encounters were considered difficulty, compared to 11% among high empathy groups (OR: 0.37; 95% CI = 0.19-0.72, p = 0.004). JSE scores and DDPRQ-10 scores were negatively correlated (r = -0.22, p < 0.01). CONCLUSION: Empathetic physicians were less likely to experience encounters as difficult. Empathy appears to be an important component of physician perception of encounter difficulty.

What do people affected by amyotrophic lateral sclerosis want from health communications? Evidence from the ALS Talk Project.

INTRODUCTION/AIMS: Health communication is central to effective, supportive amyotrophic lateral sclerosis (ALS) clinical care. Guidance for ALS communication is limited, focuses on diagnosis disclosure, and frequently relies on expert consensus and/or reviews. Patient-based evidence is needed to guide ALS health communication. We investigated how the experiences of ALS patients and family caregivers can inform effective communication practices from diagnosis to end-of-life. METHODS: Data were drawn from the ALS Talk Project, an asynchronous, online focus group study. Seven focus groups and five interviews (105 participants) were conducted. Data were qualitatively analyzed using directed content analysis and the constant-comparative approach. RESULTS: We found four primary themes: communication content, communication circumstances, information sufficiency, and communication manner. Data indicate participants relied on clinicians for medical information but also wanted practical information; health communication should attend to the circumstances within which conversations occur; information must be sufficient for individual needs, without overwhelming; and an empathetic, direct, and honest manner facilitated trust. Participants identified communication challenges and strategies to improve communication across major themes, including stepwise approaches and conversations tailored to individuals and their heterogeneous disease experiences. DISCUSSION: Healthcare professionals should discuss patient/caregiver communication preferences early in the therapeutic relationship, co-develop a communication agreement, and update the agreement in response to changing needs and disease progression. This will foster regular discussion of information needs and promote timely discussions of challenging topics, including advance care, while giving patients and families a sense of control. Findings may have implications for other neuromuscular disease and/or seriously ill populations.

The Seven Words That Changed My Perspective on Patient Care.

"I'm already in so much pain, I was stuck in the car for hours, and now I have to see a student instead of my doctor?" She scoffs, crosses her arms, and looks away. Trying to understand why she is in so much pain I ask, "Are you happy with the care you're receiving?" She looks at me for the first time and I see her shoulders drop. The response that followed is one I will never forget, and is part of a larger lesson I learned involving the power of open-ended questions and their ability to foster understanding of patients in the context of their life stories. Here, I share patient stories and the 7 words that taught me the gift of genuine curiosity.

Patient Communication Preferences for Prostate Cancer Screening Discussions: A Scoping Review.

PURPOSE: Prostate cancer screening guidelines have changed as new evidence showing an equivocal mortality benefit led many organizations to relax recommendations for this screening and instead suggest shared decision making. Presently, it is unknown how successfully these conversations happen. Our objective was to understand men's communication preferences when they discuss prostate cancer screening. METHODS: In this scoping review, we searched 4 electronic databases (Medline, Embase, PsycINFO, and CINAHL) and the gray literature. Additional studies were obtained from reference lists of included studies and relevant review articles. We included qualitative studies reporting patient perspectives relevant to the research question and published in English. Two independent researchers screened titles and abstracts based on these criteria, conducted a full-text review for final inclusion, evaluated the remaining articles for validity, extracted data, and used thematic analysis to build a thematic framework. A subgroup analysis was performed for Black men as many studies elicited their perspectives. RESULTS: Analyses were based on 29 studies. We identified 4 main themes that men described as critical for successful prostate cancer screening risk discussions with their primary care clinician: using everyday language, receiving a sufficient quantity of information, spending enough time, and having a trusting and respectful relationship. Three additional themes emerged that prohibited men from having any discussions at all: having already decided to pursue prostate cancer screening, being passive in medical encounters, and perceiving threat to one's well-being. Black men faced racism, which impacted medical interactions. CONCLUSIONS: Our findings point to strategies to support men's communication preferences and address preconceptions surrounding prostate cancer screening. More studies are needed in certain underrepresented populations given the propensity for disparity in health outcomes.

Patient and Health Care Professional Perspectives on Stigma in Integrated Behavioral Health: Barriers and Recommendations.

PURPOSE: Stigma related to mental health is well documented and a major barrier to using mental and physical health care. Integrated behavioral health (IBH) in primary care, in which behavioral/mental health care services are located within a primary care setting, may reduce the experience of stigma. The purpose of this study was to assess the opinions of patients and health care professionals about mental illness stigma as a barrier to engagement with IBH and to gain insight into strategies to reduce stigma, encourage discussion of mental health, and increase uptake of IBH care. METHODS: We conducted semistructured interviews with 16 patients referred to IBH in a prior year and 15 health care professionals (12 primary care physicians and 3 psychologists). Interviews were transcribed and inductively coded separately by 2 coders for common themes and subthemes under the topic headings of barriers, facilitators, and recommendations. RESULTS: We identified 10 converging themes from interviews with patients and the health care professionals, representing important complementary perspectives, with respect to barriers, facilitators, and recommendations. Barriers included professionals, families, and the public as sources of stigma, as well as self-stigma or avoidance, or internalizing negative stereotypes. Facilitators and recommendations included normalizing discussion of mental health and mental health care-seeking action, using patient-centered and empathetic communication strategies, sharing by health care professionals of their own experiences, and tailoring the discussion of mental health to patients' preferred understanding. CONCLUSIONS: Health care professionals can help reduce perceptions of stigma by having conversations with patients that normalize mental health discussion, use patient-centered communication, promote professional self-disclosure, and are tailored to patients' preferred understanding.

Patient and Clinician Sociodemographics and Sexual History Screening at a Multisite Federally Qualified Health Center: A Mixed Methods Study.

PURPOSE: In 2018, there were 68 million sexually transmitted infections in the United States. Sexual history screening is an evidence-based practice endorsed by guidelines to identify risk of these infections and adverse sexual health outcomes. In this mixed methods study, we investigated patient- and clinician-level characteristics associated with receipt of sexual history screening, and contextualized these differences in more depth. METHODS: We collected sociodemographics of patients from the electronic health record and sociodemographics of their primary care clinicians via a census survey. Semistructured interviews were conducted with key practice staff. We conducted multilevel crossed random effects logistic regression analysis and thematic analysis on quantitative and qualitative data, respectively. RESULTS: A total of 53,246 patients and 56 clinicians from 13 clinical sites participated. Less than one-half (42.4%) of the patients had any sexual history screening documented in their health record. Patients had significantly higher odds of documented screening if they were gay or lesbian (OR = 1.23), were cisgender women (OR = 1.10), or had clinicians who were cisgender women (OR = 1.80). Conversely, patients' odds of documented screening fell significantly with age (OR per year = 0.99) and with the number of patients their clinicians had on their panels (OR per patient = 0.99), and their odds were significantly lower if their primary language was not English (OR = 0.91). In interviews, key staff expressed discomfort discussing sexual health and noted assumptions about patients who are older, in long-term relationships, or from other cultures. Discordance of patient-clinician gender and patients' sexual orientation were also noted as barriers. CONCLUSIONS: Interventions are needed to address the interplay between the social and contextual factors identified in this study, especially those that elicited discomfort, and the implementation of sexual history screening.

Variations in Pre-exposure Prophylaxis (PrEP) Awareness and Healthcare Provider Interactions in a Nationally Representative Sample of American Men Aged 15-49 Years: A Cross-Sectional Study.

Awareness of and discussions with a healthcare provider (HCP) around pre-exposure prophylaxis (PrEP), an effective HIV prevention method, are associated with PrEP uptake, yet few studies utilize representative samples or report on these outcomes using distinct behavioral risk subgroups. This cross-sectional study utilized responses given by men on the 2017-2019 National Survey of Family Growth, a nationally representative survey of Americans aged 15-49 years. Multiple logistic regression models were used to determine how respondents' sociodemographic characteristics and HIV risk behaviors were related to PrEP awareness and HCP discussions. PrEP awareness was low (29.40%) as was the proportion who reported ever discussing PrEP with an HCP (4.48%). Odds of being PrEP aware and discussing PrEP with an HCP varied significantly within sexual behavior subgroups based on sociodemographic and behavioral characteristics highlighting the differential risks within distinct behavioral subgroupings of men. Sexual behavior subgroupings should be considered when promoting PrEP awareness and discussions as HIV risk behaviors vary considerably and sexual identity alone may not sufficiently capture one's HIV risk.

Coping with uncertainty in clinical practice: a narrative review.

Clinicians must make decisions amid the uncertainty that is ubiquitous to clinical practice. Uncertainty in clinical practice can assume many forms depending on its source, such as insufficient personal knowledge or scientific evidence, limited practical understanding or competence, challenging interpersonal relationships, and complexity and ambiguity in clinical encounters. The level and experience of uncertainty varies according to personal traits, clinical context, affective factors and sociocultural norms. Clinicians vary in their tolerance of uncertainty, and maladaptive responses may adversely affect patient care and clinician wellbeing. Various strategies can be used to minimise and manage, but not eliminate, uncertainty and to share uncertainty with patients without compromising the clinician-patient relationship or clinician credibility.