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Patient-Provider Dialogue With HIV Drugs

Patient-Provider Dialogue With HIV Drugs

Research has shown that race and ethnicity may be associated with differences in how healthcare providers communicate with patients. “In HIV, a key component to outcomes is adherence to antiretroviral therapy (ART),” says Michael Barton Laws, PhD, MA. “Investigators have hypothesized that clinical communication may be a factor in how well or poorly HIV patients adhere to ART regimens.” Examining Themes In a study published in AIDS and Behavior, Dr. Laws and colleagues reviewed more than 400 routine outpatient visits by people with HIV. Three themes emerged from the analysis of patient–provider conversations, depending on patients’ race and ethnicity: 1) Speech patterns: African Americans spoke less to their providers than Caucasians or Hispanics. Hence, there was greater provider verbal dominance in their discussions. They also less frequently expressed their goals or values. Healthcare providers asked Hispanics fewer open-ended questions. 2) ART adherence: Visits with African-American and Hispanic patients included more dialogue about adherence than visits with Caucasian patients. This difference occurred regardless of how adherent patients reported being to their ART regimens or whether laboratory tests showed that HIV was under control. 3) Problem solving: The more extensive dialogue about ART adherence between patients and healthcare providers was directive rather than problem solving. “There was more discussion about ART adherence with African Americans and Hispanics,” adds Dr. Laws, “but no more discussion about strategies to improve adherence.”   Possible Interpretations Dr. Laws says that several factors may influence why healthcare providers talked more with minority patients than with Caucasians about adherence. “It’s possible that healthcare providers are trying to compensate for what they’ve seen in studies about lower adherence...
Communication Etiquette in Medical Training

Communication Etiquette in Medical Training

Patient-centered communication can impact several aspects of the patient-doctor relationship, including disclosure of illness-related information and compliance with medical recommendations. Etiquette-based medicine involves simple patient-centered communication strategies that convey professionalism and respect to patients. “Research has shown that patients prefer physicians who practice etiquette-based medicine behaviors, most notably those who sit down and introduce themselves,” says Leonard S. Feldman, MD. Little is known, however, about  whether physicians in training are actually performing these easy-to-practice behaviors. An In-Depth Look In a study published in the Journal of Hospital Medicine, Dr. Feldman and colleagues sought to understand whether etiquette-based communication behaviors were practiced by trainees on inpatient medicine rotations. Trained observers followed 29 internal medicine interns in their first year out of medical school at Johns Hopkins Hospital and the University of Maryland Medical Center for 3 weeks. They witnessed 732 inpatient encounters and used an iPod Touch application to record whether the interns employed five key strategies in etiquette-based communication: 1) introducing oneself, 2) explaining one’s role in the patient’s care, 3) touching the patient, 4) asking open-ended questions, and 5) sitting down with the patient.   According to the findings, interns touched their patients—defined as either a physical exam or simply a handshake or a gentle, caring touch—during 65% of visits and asked open-ended questions 75% of the time. However, they introduced themselves only 40% of the time, explained their role in just 37% of cases, and sat down during only 9% of visits (Table). The study subjects performed all five of the recom-mended etiquette-based communication behaviors during just 4% of all patient encounters. Interns were only slightly more...
A Warning System for Colorectal Surgery Patients

A Warning System for Colorectal Surgery Patients

About 16% of all colorectal surgical patients on Medicare are readmitted to the hospital within 30 days. These readmissions last more than 1 week, on average, and cost the healthcare system $300 million each year. Unfortunately, the warnings of deteriorating condition that are given to patients at discharge after such surgeries are highly subjective. Discharge instructions are often generic, based on conventional wisdom, and lack systematic implementation. Ask the Experts My colleagues and I had a study published in the Journal of the American College of Surgeons that aimed to develop a consensus on warning indicators and recommended action plans for patients after colorectal surgery. For our analysis, 11 nationally recognized experts in colorectal surgery engaged in five rounds of intense deliberation about warning signs that were most important to notice when patients were home after surgery and what should be done when specific complications occurred. We employed the Delphi method, a structured communication technique that uses iterative question-feedback-discussion rounds, to guide the expert panel’s deliberation and reach a consensus. Consensus was defined as having at least 70% of the experts “agreeing” or “strongly agreeing” on a particular point.   A consensus was reached on several symptoms that should prompt patients to contact their surgeons: • Wound drainage, opening, or redness. • No bowel movement or lack of gas or stools from an ostomy for more than 24 hours. • Increasing abdominal pain. • Vomiting. • Abdominal swelling. • High ostomy output and/or dark urine or no urine. • Fever greater than 101.5 F°. • Not being able to take anything by mouth for more than 24 hours. Symptoms...
Knowledge Deficits at ED Discharge

Knowledge Deficits at ED Discharge

Effective communication between caregivers and patients is a critical element of providing high-quality patient care in the ED. In recent years, a greater emphasis has been placed on information delivery at ED discharge and its downstream implications for adherence and outcomes. “Despite recognizing the importance of communication, the complex ED environment can make it challenging to communicate effectively,” says Kirsten G. Engel, MD. “Many patients leave the ED with an incomplete understanding of their care and instructions.” (see also, Communicating More Effectively at ED Discharge) The causes of poor communication at ED discharge are multifactorial and likely reflect problems with both written and verbal communication. Written discharge instructions often exceed patients’ health literacy or reading levels, and verbal communication is frequently brief and incomplete. Previous research has suggested that the majority of patients have a comprehension deficit for at least one area of their ED care and instructions, with the most frequent deficits found in the domain of post-ED care. “The effect of poor discharge communication is profound because many patients are leaving the ED without the knowledge they need to properly care for themselves at home,” Dr. Engel says. “This increases their risk for adverse events, as well as repeat ED visits and hospitalization.” Deficits in Patient Understanding at Discharge To address problems with information delivery at ED discharge, Dr. Engel says it is essential to better define deficits in patients’ understanding of discharge instructions. “We need to characterize knowledge gaps that may put patients at risk for complications or poor outcomes following their ED visits,” she adds. “Identifying these areas serves as a critical next step in...

Positive Patient Perceptions of ED Communication

Investigators in Connecticut have found that patient perceptions of communication with ED medical teams appear to be positive. Results indicate that patients perceived ED teams to be respectful and willing to listen. “Excellent” scores were given most for the items on the survey, including: “Let me talk without interruptions” (76.1%). “Talked in terms I could understand” (75.2%). “Treated me with respect” (74.3%). Abstract: Journal of Emergency Medicine, September 17, 2012...
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