Small-group teaching emphasizing reflection can positively influence medical students' values.
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Education, Medical, Undergraduate↗
Biomedical subjects
R M Frankel
Publications and source records attributed to R M Frankel.
Cracking the code: theory and method in clinical communication analysis.
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Communication↗
The path to professionalism: cultivating humanistic values and attitudes in residency training.
Though few question the importance of incorporating professionalism and humanism in the training of physicians, traditional residency programs have given little direct attention to the processes by which professional and humanistic values, attitudes, and behaviors are cultivated. The authors discuss the underlying philosophy of their primary care internal medicine residency program, in which the development of professionalism and humanism is an explicit educational goal. They also describe the specific components of the program designed to create a learner-centered environment that supports the acquisition of professional values; these components include a communication-skills training program, challenging-case conferences, home visits with patients, a resident support group, and a mentoring program. The successful ten-year history of the program shows how a residency program can enable its trainees to develop not only the requisite excellent diagnostic and technical tools and skills but also the humane and professional attributes of the fully competent physician.
Attitude of Health Personnel↗
Teaching self-awareness enhances learning about patient-centered interviewing.
PURPOSE: To evaluate the effect of intensive attitudinal training on residents' learning the patient-centered interviewing skills required to establish a healthy provider-patient relationship and to communicate effectively. METHOD: While teaching 53 residents patient-centered interviewing skills, the authors also trained them to recognize previously unrecognized, negative attitudes that interfered with learning the skills. The authors, using an iterative, consensus-building process based on the residents' performances and personality data, identified a spectrum of responses to the educational intervention. Barriers to and facilitators of mastery of skills were analyzed and this information was used to help residents overcome skill deficits. RESULTS: To varying degrees, 44 residents became aware of previously unrecognized attitudes to the extent that they improved their patient-centered interviewing skills. Six residents failed to develop awareness of negative attitudes and showed little learning and clinical use of the interviewing skills being taught. Three residents who rapidly developed superb interviewing skills showed no negative attitude towards using them. CONCLUSIONS: Pending a confirmatory hypothesis-testing study, the authors believe that, as residents learn how to conduct patient-centered interviews, training in awareness of interfering attitudes should accompany training in skills.
Attitude of Health Personnel↗
Awkward moments in patient-physician communication about HIV risk.
BACKGROUND: Physicians frequently encounter patients who are at risk for HIV infection, but they often evaluate risk behaviors ineffectively. OBJECTIVE: To describe the barriers to and facilitators of comprehensive HIV risk evaluation in primary care office visits. DESIGN: Qualitative thematic and sequential analysis of videotaped patient-physician discussions about HIV risk. Tapes were reviewed independently by physician and patient and were coded by the research team. SETTING: Physicians' offices. PARTICIPANTS: Convenience sample of 17 family physicians and general internists. Twenty-six consenting patients 18 to 45 years of age who indicated concern about or risks for HIV infection on a 10-item questionnaire administered before the physician visit were included. MEASUREMENTS: A thematic coding scheme and a five-level description of the depth of HIV-related discussion. RESULTS: In 73% of the encounters, physicians did not elicit enough information to characterize patients' HIV risk status. The outcome of HIV-related discussions was substantially influenced by the manner in which the physician introduced the topic, handled awkward moments, and dealt with problematic language and the extent to which the physician sought the patient's perspective. Feelings of ineffectiveness and strong emotions interfered with some physicians' ability to assess HIV risk. Physicians easily recognized problematic communication during reviews of their own videotapes. CONCLUSIONS: Comprehensive HIV risk discussions included providing a rationale for discussion, effectively negotiating awkward moments, repairing problematic language, persevering with the topic, eliciting the patient's perspective, responding to fears and expectations, and being empathic. Educational programs should use videotape review and should concentrate on physicians' personal reactions to discussing emotionally charged topics.
Adolescent↗
Recruiting physicians for office-based research.
OBJECTIVES: Research conducted in community outpatient offices can provide insight into the common experiences of patients and physicians. However, recruiting physicians to participate in office-based research is challenging and few descriptions of methods that have been used to successfully recruit random samples of physicians are available. This article describes recruitment strategies utilized in a project that achieved high rates of participation from community-based primary care physicians and surgeons. METHODS: Recruitment methods included the use of advisory boards to identify potential barriers to participation, use of respected members of the medical community as recruiters, and obtaining endorsements from physician organizations and prominent members of the medical community. RESULTS: Overall, 81% of physicians contacted from a sample frame agreed to participate in the project. Participating physicians most frequently reported that they participated because the project could provide them with feedback about their interviewing style. CONCLUSIONS: The recruitment methods described here can be generalized to other types of investigations.
Colorado↗
Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons.
OBJECTIVE: To identify specific communication behaviors associated with malpractice history in primary care physicians and surgeons. DESIGN: Comparison of communication behaviors of "claims" vs "no-claims" physicians using audiotapes of 10 routine office visits per physician. SETTINGS: One hundred twenty-four physician offices in Oregon and Colorado. PARTICIPANTS: Fifty-nine primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons and their patients. Physicians were classified into no-claims or claims (> or =2 lifetime claims) groups based on insurance company records and were stratified by years in practice and specialty. MAIN OUTCOME MEASURES: Audiotape analysis using the Roter Interaction Analysis System. RESULTS: Significant differences in communication behaviors of no-claims and claims physicians were identified in primary care physicians but not in surgeons. Compared with claims primary care physicians, no-claims primary care physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, and tended to use more facilitation (soliciting patients' opinions, checking understanding, and encouraging patients to talk). No-claims primary care physicians spent longer in routine visits than claims primary care physicians (mean, 18.3 vs 15.0 minutes), and the length of the visit had an independent effect in predicting claims status. The multivariable model for primary care improved the prediction of claims status by 57% above chance (90% confidence interval, 33%-73%). Multivariable models did not significantly improve prediction of claims status for surgeons. CONCLUSIONS: Routine physician-patient communication differs in primary care physicians with vs without prior malpractice claims. In contrast, the study did not find communication behaviors to distinguish between claims vs no-claims surgeons. The study identifies specific and teachable communication behaviors associated with fewer malpractice claims for primary care physicians. Physicians can use these findings as they seek to improve communication and decrease malpractice risk. Malpractice insurers can use this information to guide malpractice risk prevention and education for primary care physicians but should not assume that it is appropriate to teach similar behaviors to other specialty groups.
Colorado↗
Ethnography: a stepwise approach for primary care researchers.
Ethnography is a research method borrowed from cultural anthropology and a disciplined method for understanding human conduct. It is a valid alternative to quantitative methods for primary care researchers. This article reviews the defining principles of ethnographic research, which uses principally observational methods to study actions and events that exist in natural situations. It is the job of ethnographic researchers to establish and frame their observations from the point of view of the people under observation. We present five steps fundamental to the development of an ethnographic research plan and a research case study that demonstrates the use of ethnography by a family physician.
Anthropology, Cultural↗
The doctor-patient relationship and malpractice. Lessons from plaintiff depositions.
BACKGROUND: The current literature does not provide an answer to the question, "What prompts patients to sue doctors or hospitals?" Not all adverse outcomes result in suits, and threatened suits do not always involve adverse outcomes. The exploration of other factors has been hampered by the lack of a methodology to contact plaintiffs and elicit their views about their experience in delivered health care. This study employed the transcripts of discovery depositions of plaintiffs as a source of insight into the issues that prompted individuals to file a malpractice claim. METHODS: This study is a descriptive series review of a convenience sample of 45 plaintiffs' depositions selected randomly from 67 depositions made available from settled malpractice suits filed between 1985 and 1987 against a large metropolitan medical center. Information extracted from each deposition included the alleged injury; the presence of the question, "Why are you suing?" and, if present, the answer; the presence of problematic relationship issues between providers and patients and/or families and, if present, the discourse supporting it; the presence of the question, "Did a health professional suggest maloccurrence?" and, if yes, who. Using a process of consensual validation, relationship issues were organized into groups of more generalized categories suggested by the data. Answers to the questions, "Why are you suing?" and "Who suggested maloccurrence?" are described. RESULTS: Problematic relationship issues were identified in 71% of the depositions with an interrater reliability of 93.3%. Four themes emerged from the descriptive review of the 3787 pages of transcript: deserting the patient (32%), devaluing patient and/or family views (29%), delivering information poorly (26%), and failing to understand the patient and/or family perspective (13%). Thirty-one plaintiffs were asked if health professionals suggested maloccurrence. Fifty-four percent (n = 17) responded affirmatively. The postoutcome-consulting specialist was named in 71% (n = 12) of the depositions in which maloccurrence was allegedly suggested. CONCLUSIONS: In our sample, the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of health care. The issues identified included perceived unavailability, discounting patient and/or family concerns, poor delivery of information, and lack of understanding the patient and/or family perspective. Particular attention should be paid to the postadverse-event consultant-patient interaction.
Adult↗
The use of videotape in internal medicine training.
By paying attention to the power of the medium and the method of feedback, videotaping programs can be a remarkably successful teaching and research tool. Learners can view their performance, review feedback on their own behavior, knowledge, and displayed attitudes, and develop plans to change behavior that can be followed up on subsequent tappings. In addition, trainees can share important experiences with each other and valued teachers. Interviewing skills can be documented and preserved, creating a video library that allows trainees to actually visualize improvements in their own performances over time. An archive of many such performances allows trainees, faculty, and researchers alike comparative access to the complex challenges of the medical interview.
Decision Making↗
Detection of the new tuberculosis: ocular examination as a diagnostic imperative.
BACKGROUND: Until recently, tuberculosis in the U.S. had been considered a public health concern of the past, largely conquered by therapy devised in the 1950s. However, in the past several years, the incidence of tuberculosis has increased steeply and unexpectedly, owing to a conspiracy of new factors. These include: the epidemic of acquired immune deficiency, the emergence of drug-resistant strains, the confinement of susceptibles in crowded shelters, and the premature demolition of public health programs. METHODS: A dynamic interplay exists between the tubercle bacillus and the declining immune system in AIDS patients. Because of this, many atypical, clinical presentations of tuberculosis have emerged. RESULTS: The detection of ocular manifestations of tuberculosis has thus assumed increased importance. It can allow not only for an earlier diagnosis of TB, but an earlier diagnosis of AIDS, preventing spread of both diseases within the population. CONCLUSIONS: Evaluation of ocular signs of tuberculosis should now be a diagnostic imperative.
AIDS-Related Opportunistic Infections↗
The effect of physician behavior on the collection of data.
Determining the patient's major reasons for seeking care is of critical importance in a successful medical encounter. To study the physician's role in soliciting and developing the patient's concerns at the outset of a clinical encounter, 74 office visits were recorded. In only 17 (23%) of the visits was the patient provided the opportunity to complete his or her opening statement of concerns. In 51 (69%) of the visits the physician interrupted the patient's statement and directed questions toward a specific concern; in only 1 of these 51 visits was the patient afforded the opportunity to complete the opening statement. In six (8%) return visits, no solicitation whatever was made. Physicians play an active role in regulating the quantity of information elicited at the beginning of the clinical encounter, and use closed-ended questioning to control the discourse. The consequence of this controlled style is the premature interruption of patients, resulting in the potential loss of relevant information.
Communication Barriers↗
T cell subsets and cellular immunity in end-stage renal disease.
The T lymphocyte population was studied by immunofluorescent staining with monoclonal antibodies and laser flow cytometry in the blood of 50 patients with end-stage renal disease undergoing long-term maintenance intermittent hemodialysis. The absolute number of T cells was lower in patients receiving dialysis for more than one year (p less than 0.001), as was the absolute count of helper T cells (p less than 0.005). In patients under 30 years of age, the absolute number of helper T cells was markedly reduced, whereas the number of suppressor/cytotoxic T lymphocytes was not changed. In patients between the ages of 30 and 60 years, both helper and suppressor cells were significantly reduced. In patients over 60 years of age, only the number of helper T cells was reduced. The in vitro response of patients' lymphocytes was reduced both in the mixed lymphocyte reaction (p less than 0.01) and after phytohemagglutinin stimulation (p less than 0.001). Natural killer cytotoxicity of patients' peripheral blood mononuclear cells, however, was unaffected.
Adolescent↗
The meaning of symptoms in 10 women with somatization disorder and a history of childhood abuse.
OBJECTIVE: To understand the associated experiences and illness behavior in patients with somatization disorder and a history of childhood abuse. DESIGN: In-depth interviews were conducted with patients who had somatization disorder and a history of childhood abuse; qualitative content analysis was then performed. SETTING: Patients were recruited from 2 primary care teaching practices. PARTICIPANTS: Physicians were asked to refer patients suspected of having both conditions, yielding 21 potential participants. Eight declined, and 3 did not meet standardized screening questionnaire criteria, yielding 10 women who participated in the study. Participants and nonparticipants had a similar range of socioeconomic variables. RESULTS: An analysis of the interviews yielded 22 themes. Seven themes relevant to understanding the link between illness behavior and abuse were the abuse experiences, emotional and behavioral reactions to the abuse, relationship of abuse to somatoform symptoms, relationship of abuse to health care use, attempts to tell about the abuse, relationships with physicians, and physician behavior. Childhood attempts to tell adults about the abuse resulted in threats of punishment, contributing to lifelong patterns of secrecy, even with physicians. Six women reported having childhood physicians who were family members, friends, or the abuser's physician, reinforcing their subsequent secrecy. The women reported that their current physicians denied their physical pain as adults, just as the abusers denied their emotional and physical pain in childhood. Seven women reported decreased health care use once they associated symptoms with abuse experiences. Nine women reported spousal abuse. CONCLUSIONS: Somatization and childhood abuse may involve a paradoxical pattern of hiding feelings and reality, while seeking acknowledgment of suffering. Patient insight may decrease health care use. Therefore, the exploration of patient experiences may be useful for women with somatization disorder and a history of childhood abuse. The risks of spousal abuse and denial and rejection in the physician-patient relationship could also be important.
Adolescent↗
Evaluating the quality of qualitative research: a proposal pro tem.
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Quality Control↗
Getting the most out of the clinical encounter: the four habits model.
Medical interviewing is the foundation of medical care and is the clinician's most important activity. A growing body of evidence suggests that clinicians use distinctive, describable behaviors to conduct medical interviews. This article describes four patterns of behavior that we term Habits and reviews the research evidence that links each Habit with both biomedical and functional outcomes of care. The Four Habits are: Invest in the Beginning, Elicit the Patient's Perspective, Demonstrate Empathy, and Invest in the End. Each Habit refers to a family of skills. In addition, the Habits bear a sequential relationship to one another and are thus interdependent. The Four Habits approach offers an efficient and practical framework for organizing the flow of medical visits. It is unique because it concentrates on families of interviewing skills and on their inter-relationships.
Empathy↗