Biomedical subjects
Publications and source records attributed to Richard M Frankel.
Effective communication is necessary for achieving important outcomes in veterinary practice, including patient health, accuracy, efficiency, and economic viability. Communication is a series of learned skills. Daily practice, feedback, and refinement are the ingredients for continued practice success.
BACKGROUND: Women experiencing domestic violence (DV) frequent health care settings, but DV is rarely identified. METHODS: We conducted a randomized controlled trial to determine the effect of computer screening on health care provider-patient DV communication at 2 socioeconomically diverse emergency departments (EDs). Consenting nonemergent female patients, aged 18 to 65 years, were randomized to self-administered computer-based health risk assessment, with a prompt for the health care provider, or to "usual care"; all visits were audiotaped. Outcome measures were rates of DV discussion, disclosure, and services. RESULTS: Of 2169 eligible patients, 1281 (59%) consented; 871 (68%) were successfully audiotaped, and 903 (71%) completed an exit questionnaire. Rates of current DV risk on exit questionnaire were 26% in the urban ED and 21% in the suburban ED. In the urban ED, the computer prompt increased rates of DV discussion (147/262 [56%] vs 123/275 [45%]; P = .004), disclosure (37/262 [14%] vs 23/275 [8%]; P = .07), and services provided (21 [8%] vs 10 [4%]; P = .04). Women at the suburban site and those with private insurance or higher education were much less likely to be asked about experiences with abuse. Only 48% of encounters with a health care provider prompt regarding potential DV risk led to discussions. Both inquiries about and disclosures of abuse were associated with higher patient satisfaction with care. CONCLUSIONS: Computer screening for DV increased but did not guarantee that DV would be addressed during ED encounters. Nonetheless, it is likely that low-cost interventions that allow patients the opportunity to self-disclose can be used to improve detection of DV.
BACKGROUND: Effective health care depends on multidisciplinary collaboration and teamwork, yet little is known about how well medical students and nurses interact in the hospital environment, where physicians-in-training acquire their first experiences as members of the health care team. The objective of this study was to evaluate the quality of interaction between third-year medical students and nurses during clinical rotations. METHODS: We surveyed 268 Indiana University medical students and 175 nurses who worked at Indiana University Hospital, the School's chief clinical training site. The students had just completed their third year of training. The survey instrument consisted of 7 items that measured "relational coordination" among members of the health care team, and 9 items that measured psychological distress. RESULTS: Sixty-eight medical students (25.4%) and 99 nurses (56.6%) completed the survey. The relational coordination score (ranked 1 to 5, low to high), which provides an overall measure of interaction quality, showed that medical students interacted with residents the best (4.16) and with nurses the worst (2.98; p < 0.01). Conversely, nurses interacted with other nurses the best (4.36) and with medical students the worst (2.68; p < 0.01). Regarding measures of psychological distress (ranked 0 to 4, low to high), the interpersonal sensitivity score of medical students (1.56) was significantly greater than that of nurses (1.03; p < 0.01), whereas the hostility score of nurses (0.59) was significantly greater than that of medical students (0.39; p < 0.01). CONCLUSION: The quality of interaction between medical students and nurses during third-year clinical rotations is poor, which suggests that medical students are not receiving the sorts of educational experiences that promote optimal physician-nurse collaboration. Medical students and nurses experience different levels of psychological distress, which may adversely impact the quality of their interaction.
The authors use the concept of "samaritan medicine" to tie together papers by Klitzman, by Wear and colleagues, and by Branch appearing in this issue of Academic Medicine on the physician-patient relationship. Practicing physicians and trainees alike must confront the challenge of acknowledging and connecting to otherness or difference in patients and in themselves, and practice based in "samaritan medicine" can help to bridge the gaps between self and other. The authors present three vignettes that highlight physicians' and patients' differing perspectives on the stories in which they are mutually involved. The authors then suggest three approaches that operate at the organization as well as the individual level and that speak to establishing and sustaining health-supporting relationships between patients and doctors: video review and replay, Appreciative Inquiry, and self-disclosure. The aim of such approaches is that physicians and physician-trainees be able to ask-and answer-questions about the "narratives" they are enacting, such as "In this story, where am I? Where is the other? Where is the common good? What, then, should I do?" in order that they may develop a robust appreciation of patient interactions and understanding of self that fosters the practice of "samaritan medicine."
PURPOSE: Humanistic care is regarded as important by patients and professional accrediting agencies, but little is known about how attitudes and behaviors in this domain are taught in clinical settings. To answer this question, the authors studied how excellent clinical teachers impart the behaviors and attitudes consistent with humanistic care to their learners. METHOD: Using an observational, qualitative methodology, the authors studied 12 clinical faculty identified by the medical residents enrolled from 2003 to 2004 as excellent teachers of humanistic care on the inpatient medical services at four medical universities in the United States (University of Minnesota Medical School, Emory University, University of Rochester School of Medicine, and Baylor College of Medicine). Observations were conducted by the authors using standardized field notes. After each encounter, the authors debriefed patients, learners (residents and medical students), and the teaching physicians in semistructured interviews. RESULTS: Clinical teachers taught primarily by role modeling. Although they were highly aware of their significance as role models, they did not typically address the human dimensions of care overtly. Despite the common themes of role modeling identified, each clinical teacher exhibited unique teaching strategies. These clinical teachers identified self-reflection as the primary method by which they developed and refined their teaching strategies. CONCLUSIONS: Role modeling is the primary method by which excellent clinical teachers try to teach medical residents humanistic aspects of medical care. Although clinical teachers develop unique teaching styles and strategies, common themes are shared and could be used for the future development of clinical faculty.
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Relationship-centered care reflects both knowing and feeling: the knowledge that physician and patient bring from their respective domains of expertise, and the physician's and patient's experience, expression, and perception of emotions during the medical encounter. These processes are conveyed and reciprocated in the care process through verbal and nonverbal communication. We suggest that the emotional context of care is especially related to nonverbal communication and that emotion-related communication skills, including sending and receiving nonverbal messages and emotional self-awareness, are critical elements of high-quality care. Although nonverbal behavior has received far less study than other care processes, the current review argues that it holds significance for the therapeutic relationship and influences important outcomes including satisfaction, adherence, and clinical outcomes of care.
BACKGROUND: Low rates of partner violence inquiry and detection are reported in the medical setting. PURPOSE: To determine if a teaching module with a mnemonic improves interviewing skills. METHOD: Prospective randomized trial. A total of 43 medical students were assigned to either the intervention group (teaching module with guided discussion and practice highlighting use of a mnemonic) or the control group (general discussion and provision of the mnemonic at the end of the session). These students subsequently interviewed simulated patients. RESULTS: A total of 75% of the intervention group and 62% of the control group reported the mnemonic was helpful. A total of 68% of the intervention group and 45% of the control group asked a direct question about partner violence. Students who obtained a history of abuse consistently asked direct, nonjudgmental question(s). CONCLUSIONS: Students learn to perform desired interviewing skills more frequently when they have the benefit of guided discussion, practice, and memory aids.
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OBJECTIVES: Physicians experience feelings of caring and sometimes frustration toward patients during routine visits. To date, no studies have explored surgeons' feelings toward patients. Our objectives were: (1) to examine how much surgeons like their patients and (2) to assess the relationship of surgeons' liking to patient and surgeon characteristics and to patient satisfaction. METHODS: Participants included 66 surgeons (orthopaedic and general surgeons) in community practice in Colorado and Oregon, and 701 of their patients. Exit questionnaires asked surgeons how much they liked the patient on a 1-5 scale ranging from "not at all" to "very much". Patients scored satisfaction with the visit on a 1-5 scale. Logistic regression was conducted with surgeon liking and patient satisfaction as dependent variables. RESULTS: Surgeons' ratings of liking ranged across all five categories. Patient characteristics including age over 65 years, higher education and income, and better health were associated with higher liking scores. Surgeon characteristics hours worked per week, practice setting and surgeons' self-rating of their own health were associated with liking. Patient satisfaction were associated with "liking". CONCLUSION AND PRACTICE IMPLICATIONS: These findings shed light on a rarely addressed issue-surgeons' feelings toward their patients. We found that surgeons do not like their patients equally. Their feelings are associated with surgeon and patient characteristics, and with patient satisfaction. Our findings have important implications for surgeons seeking to improve care striving to enhance or maintain their own career satisfaction.
OBJECTIVES: When a physician believes that the troubles of caring for a patient outweigh the rewards, he or she can move--"turf", the unwanted patient from his or her own to another physician's territory. Physicians receiving such patients can feel burdened by, and resentful about, caring for those who are "turfed" to them by other physicians, yet little is known about the effects such "turf battles" have on patient care. This study aims to discover if "turfed" patients (TPs) experience their hospitalizations differently from patients whose admissions are perceived more favorably by their physicians. DESIGN: Semi-structured, in-depth interviews. POPULATION: Twenty Six English-speaking patients on a medical service in a tertiary care university hospital. OUTCOMES: Hospitalization experiences based on qualitative thematic analysis of interview audiotapes and transcripts. RESULTS: The experience of patients perceived as "turfs" differed from patients deemed more appropriately admitted in two areas: mode of admission and tone of interview themes. TPs were admitted via the emergency department or intra-hospital transfer; unlike the "appropriate" patients (APs), none came from outside hospitals. Although patients in both groups voiced many similar themes, nearly all TP interview themes were unfavorable. AP interviewees, by comparison expressed both favorable and unfavorable themes. TPs were direct and explicit about their anger and frustration, while APs mixed humor with complaints. CONCLUSIONS: "Turfed" patients may have different care experiences from those of patients deemed appropriate for a medical service. Inter-specialty barriers to collegiality and relationship-centered care shape physicians' perceptions of patient appropriateness and desirability and merit further large-scale exploration.
OBJECTIVE: This article describes the approach taken over the past 16 years by one large healthcare organization, Kaiser Permanente (KP), to enhance the clinical communication and relationship skills of their clinicians. METHODS: The centerpiece of KP's approach has been the creation and dissemination of a unifying clinician-patient communication (CPC) framework for teaching and research called the Four Habits Model. RESULTS: The Model has served as the foundation for a diverse array of KP programs. Sustained improvement in patient satisfaction scores has been demonstrated. Clinician-patient communication training has become a well-established component of professional development in KP. DISCUSSION: Enhancing clinicians' communication with patients is a complex task requiring planning and organizational commitment. Factors that have contributed to the success and lessons learned from incorporating clinician communication skills across the organization are described. CONCLUSION: The KP experience attests to the feasibility of bringing the vital skills of effective communication to large numbers of busy clinicians. PRACTICE IMPLICATIONS: Healthcare practices wishing to enhance clinician-patient communication skills should consider using a consistent teaching model, ensuring strong sponsorship from leaders, and emphasizing clinician satisfaction in the design of programs.
Despite repeated calls for greater patient autonomy, shared decision making, and exploration of patient preferences, relatively little is known about how patients actually experience care as a face-to-face interactional process. A selected review of the literature in this area suggests that important asymmetries exist. Key among them is the tendency to report experiences from the point of view of only one member of the doctor-patient dyad. Thus, patients might report on their experiences of the system gone awry or professionals might attempt to understand the root cause(s) of an error by describing the conditions under which it occurred. Either way, information about the experience of care tends to be reported as a "my side" telling. Optimal healing environments are defined as health care contexts that are based upon mutual respect and build positive, resilient relationships among participants, using the qualities and resources of those relationships to enhance health. Understanding optimal healing environments also requires a knowledge of how doctors and patients share time and space together in the consultation (an etic or outsider perspective) and also a knowledge of the participants' experience of their time together (an emic or insider perspective). After reviewing its methodological roots, the IMPACT approach (Interactive Methodology for Preserving and Analyzing Clinical Transactions) using videotaped encounters along with independent commentaries by participants is described and applied in two different types of analyses: one in which the doctor-patient dyad is the unit of measure; the second in which physicians are stratified by having historically high or low satisfaction scores. In the latter approach, doctors' and patients' comments are compared across strata. At the dyadic level, and despite large gaps in income and social status, doctors and patients exhibit a strong tendency to cluster in terms of where they comment, so much so that in a pilot study using the approach, each stopped and commented on the videotapes at the "same" location (within an utterance of one another) 60% of the time. This finding flies in the face of traditional sociological thought, which holds that the greater the social distance between actors (doctors and patients), the more difficult it should be to communicate. With respect to being stratified by historical satisfaction scores, doctors with high historical satisfaction were found to comment more often, make fewer assumptions, take longer with their patients, and be more vigilant than doctors with historically low satisfaction scores. We conclude that videotape review is a parsimonious way of integrating face-to-face communication with the participants' lived experience of the care process, a necessary ingredient in creating optimal healing environments.
Handoffs involve the transfer of rights, duties, and obligations from one person or team to another. In many high-precision, high-risk contexts such as a relay race or handling air traffic, handoff skills are practiced repetitively to optimize precision and anticipate errors. In medicine, wide variation exists in handoffs of hospitalized patients from one physician or team to another. Effective information transfer requires a solid foundation in communication skills. While these skills have received much attention in the medical literature, scholarship has focused on physician-to-patient, not physician-to-physician, communication. Little formal attention or education is available to reinforce this vital link in the continuity of patient care. The authors reviewed the literature on patient handoffs and evaluated the patient handoff process at Indiana University School of Medicine's internal medicine residency. House officers there rotate through four hospitals with three different computer systems. Two of the hospitals employ a computer-assisted patient handoff system; the other two utilize the standard pen-to-paper method. Considerable variation was observed in the quality and content of handoffs across these settings. Four major barriers to effective handoffs were identified: (1) the physical setting, (2) the social setting, (3) language barriers, and 4) communication barriers. The authors conclude that irrespective of local context, precise, unambiguous, face-to-face communication is the best way to ensure effective handoffs of hospitalized patients. They also maintain that the handoff process must be standardized and that students and residents must be taught the most effective, safe, satisfying, and efficient ways to perform handoffs.
BACKGROUND: We conducted a longitudinal faculty development programme for medical school faculty, focused on enhancing learner-centred teaching skills, by integrating traditional elements of education, focusing on knowledge, skills and attitudes, with the non-traditional process elements of community building, self-awareness and relationship formation. METHODS: This year-long programme enrolled faculty from a range of clinical departments at a single institution. The participants gathered for day-long sessions in each of 9 months and also met at lunchtime once a month for "booster" meetings. Sessions were organised according to content areas identified as relevant to enhancing teaching skills. In addition to each content area, a variety of experiential and process learning methods were incorporated and modelled in each session. The impact of the programme was assessed using self-report data after each session, and together with paired interviews at the completion of the programme. EVALUATION: Programme attendance was 97%. Qualitative thematic and content analysis showed that faculty reported renewed energy and enthusiasm for teaching, as well as skills mastery. Faculty also reported significant improvements in self-awareness and habits of lifelong learning. Many faculty members felt that a singular benefit of the programme was developing and nurturing personal as opposed to instrumental relationships. CONCLUSIONS: It is feasible to successfully convene clinical faculty from different departments in the same faculty development programme with little or no concern for competition and conflict. The key to success is integrating content and process dimensions into a framework of community building and collective engagement. From the participants' perspective, skills and confidence, which by self-report increased for all participants, was less consequential than the opportunity to learn about themselves and their relationships to others in a safe environment. We have conducted this programme for 5 successive years.
OBJECTIVES: To pilot and assess the role of videoconferencing in clinicians' medical decision-making and their interactions with nursing home residents (NHRs). DESIGN: Paired virtual and bedside examinations. Face-to-face (FTF) examination of NHRs by off-site clinicians immediately followed videoconferencing between the same clinician-NHR pair. SETTING: A 240-bed, county-managed, urban nursing home. PARTICIPANTS: NHRs (n=35) and clinicians (n=3) receiving or providing routine care between 2002 and 2003. MEASUREMENTS: Orders generated by clinicians, clinicians' ratings of videoconferencing, and coded review of video encounters. After both examinations, clinicians rated the encounters and generated orders necessary for NHRs. Orders were categorized and counted according to timing (before or after the FTF visit). Clinician-NHR interactions were assessed using coding videos with a 31-item instrument. RESULTS: For 71% of the encounters, clinicians stated that videoconferencing facilitated their assessment. Difficulties included sound quality (19%) and participants' familiarity with videoconferencing (7%). Although NHRs were alert in 50% of encounters, 62% of alert NHRs did not indicate understanding of the recommended treatment. CONCLUSION: FTF examination was superior for most assessments, but videoconferencing was judged to be valuable, especially for wound care. Even when NHRs were alert, informed medical decision-making by NHRs with their clinicians was limited. Enhancing videoconferencing quality and providing more training about informed decision-making using videoconferencing might improve the effectiveness of the technology.
The social environment or "informal" curriculum of a medical school profoundly influences students' values and professional identities. The Indiana University School of Medicine is seeking to foster a social environment that consistently embodies and reinforces the values of its formal competency-based curriculum. Using an appreciative narrative-based approach, we have been encouraging students, residents, and faculty to be more mindful of relationship dynamics throughout the school. As participants discover how much relational capacity already exists and how widespread is the desire for a more collaborative environment, their perceptions of the school seem to shift, evoking behavior change and hopeful expectations for the future.
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