No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Humor During Clinical Practice: Analysis of Recorded Clinical Encounters
Abstract
Objective:
Little is known about humor's use in clinical encounters, despite its many potential benefits. We aimed to describe humor during clinical encounters.
Design:
We analyzed 112 recorded clinical encounters. Two reviewers working independently identified instances of humor, as well as information surrounding the logistics of its use.
Results:
Of the 112 encounters, 66 (59%) contained 131 instances of humor. Humor was similarly frequent in primary care (36/61, 59%) and in specialty care (30/51, 59%), was more common in gender-concordant interactions (43/63, 68%), and was most common during counseling (81/112, 62%). Patients and clinicians introduced humor similarly (63 vs 66 instances). Typically, humor was about the patient's medical condition (40/131, 31%).
Discussion and conclusion:
Humor is used commonly during counseling to discuss the patient's medical condition and to relate to general life events bringing warmth to the medical encounter. The timing and topic of humor and its use by all parties suggests humor plays a role in the social connection between patients and physicians and allows easier discussion of difficult topics. Further research is necessary to establish its impact on clinicians, patients, and outcomes.
... Laughter is well recognised as being helpful for managing sensitive situations and maintaining interpersonal relationships in both ordinary and medical contexts [23][24][25][26][27][28][29][30][31][32][33]. In an everyday context, when a speaker laughs first, the laughter often targets the self, e.g. ...
... A handful of studies on laughter in medical interactions in various linguistic contexts indicate that doctors laugh less frequently than patients and do not usually reciprocate patient laughter [24,26,27,29,[37][38][39]. Patients laugh when dealing with sensitive situations such as responding to the doctor's criticisms [27], pointing out problems in the doctor's recommendations, rejecting the doctor's understanding of their health issues [24], and remedying their own misunderstandings [29]. ...
... A handful of studies on laughter in medical interactions in various linguistic contexts indicate that doctors laugh less frequently than patients and do not usually reciprocate patient laughter [24,26,27,29,[37][38][39]. Patients laugh when dealing with sensitive situations such as responding to the doctor's criticisms [27], pointing out problems in the doctor's recommendations, rejecting the doctor's understanding of their health issues [24], and remedying their own misunderstandings [29]. While existing studies do not offer detailed analyses of doctor laughter, there is a belief that sharing laughter and humour has the potential to reduce social distance and build social connection between doctors and patients [26,38]. The only relevant empirical study to this current work, is one that examines nurses' laughter during consultations regarding prenatal screening [28]. ...
Objective:
This study investigates laughter by General Practitioners (GPs) in response to patient laughter in lifestyle behaviour consultations.
Method:
We examined video-recorded consultations involving 44 patients of four GPs in Australia. After identifying 33 cases of patient laughter, we examined whether GPs laughed in response. We used Conversation Analysis to explore the appropriateness of GP laughter and non-laughter by investigating the talk before and after the occurrence of patient laughter.
Results:
GP reciprocal laughter was found in thirteen occasions when patients unsolicitedly mentioned their behaviours, laughed and displayed their evaluative stances (whether the behaviours were positive or negative). On twenty occasions, patients laughed in response to GP enquiries, which worked to problematise particular behaviours. In this context, patient laughter was not usually reciprocated (19/20 cases) because reciprocal laughter may risk being interpreted as laughing at the patient, as evidenced by one deviant case.
Conclusion:
GP reciprocal laughter may be problematic when the behaviour issues are raised by GPs and patients' evaluative stances regarding their behaviour have not yet been revealed.
Practice implications:
To decide when it is appropriate to reciprocate laughter, GPs should consider the contexts that lead to patient laughter and patients' evaluative stances.
... Regarding the use of humor in clinical interaction, different definitions and identification criteria have been adopted in studies analyzing recorded clinical consultation. For example, laughter has been used as a marker of humor (Sala et al., 2002) and has not been included in the analysis when it was not accompanied to an amusing statement (Schöpf et al., 2017;Phillips et al., 2018). However, laughs and jokes can occur together or be produced independently (Holt, 2011) and both are stereotypically connected with amusement even if they both can have different underlying interactional meanings (Haakana, 2001;Beach and Prickett, 2017;Schöpf et al., 2017). ...
... The quantitative findings showed that laughs and jokes were registered in the vast majority (96%) of the visits and were largely used during the interaction, with an average rate of 17 utterances per encounter. This finding is only partially consistent with the literature related to other settings as 94% of diabetes visits contained amusing comment (Schöpf et al., 2017), while only 60% of primary care and specialty care visits contained reciprocated and shared amusement (Phillips et al., 2018). These studies reported lower frequencies of target events per visit, ranging from two instances (Phillips et al., 2018) to six (Sala et al., 2002;Schöpf et al., 2017). ...
... This finding is only partially consistent with the literature related to other settings as 94% of diabetes visits contained amusing comment (Schöpf et al., 2017), while only 60% of primary care and specialty care visits contained reciprocated and shared amusement (Phillips et al., 2018). These studies reported lower frequencies of target events per visit, ranging from two instances (Phillips et al., 2018) to six (Sala et al., 2002;Schöpf et al., 2017). One explanation could be the different definition and inclusion criteria, however, it could be hypothesized that the high frequency of laughs and jokes is due to the different setting analyzed: ART treatments are long and complex and infertility is a stressful and burdensome issue, therefore laughs and jokes might be used to strengthen the relationship between participants (Martin et al., 2003), create a partnership and to produce a more relaxed atmosphere (Joshua et al., 2005). ...
Purpose: To explore the characteristics of the use of laughs and jokes during doctor-couple assisted reproductive technology (ART) visits.
Methods: 75 videotaped doctor-couple ART visits were analyzed and transcribed in order to: (1) quantify laugh and jokes, describing the contribution of doctors and couples and identifying the timing of appearance; (2) explore the topic of laughs and jokes with qualitative thematic analysis.
Results: On average, each visit contained 17.1 utterances of laughs and jokes. Patients contributed for 64.7% of utterances recorded. Doctor (40.6%) and women (40%) introduced the majority of laughs and jokes. Visits with female physicians had significantly more laughs and jokes than visits with male doctors; no differences were found considering physicians’ age and years of experience, cause of infertility, and prognosis. Laughs and jokes were mainly recorded during history taking and information giving. Four core themes were identified, regarding the topic of laughs and jokes: health status, infertility treatment, organizational aspects, and doctor-patient interaction.
Conclusion: Laughs and jokes are common in doctor-couple ART visits and are frequently used during the dialogue, covering a wide range of topics. Results seem to show that laughs and jokes are related to doctor’s personal characteristics (like gender), while are not associated with infertility aspects. Given the complexity of this communicative category, further studies are needed to explore the functions and the effects of laugh and jokes.
... It may not be an unwarranted suggestion therefore that sharing therapeutic humour (defined below) with a counsellor could be equally beneficial. This assumption is supported by evidence from Phillips et al. (2018) who found that positive interactions between a clinician and their patient helped to build the relationship, enhance trust and also led to better health outcomes. Also, in relation to counselling specifically, Gupta et al. (2018) found that clients evaluated their therapy experience more positively when reflective laughter had occurred in their counselling sessions. ...
... Finally, most, if not all, authors who discuss therapeutic humour offer a variety of caveats for its role in counselling, including being aware of cultural (e.g., Maples et al., 2001) and gender differences (e.g., Phillips et al., 2018) between counsellor and client, and maintaining appropriate boundaries when humour arises (Maples et al., 2001). Interestingly, only one participant mentioned cultural differences, and none mentioned gender, meaning these were not emergent themes within the data; however, the importance of appropriateness of the humour and following the client's lead were emphasised by all participants. ...
Based on a substantial amount of evidence suggesting that humour can have a great amount of therapeutic benefit, three trainee and three qualified counsellors took part in semi‐structured interviews to discuss their experiences of humour within their work with their clients, and a variety of experiences were disclosed. Interpretative phenomenological analysis was utilised to generate themes that reflect participants' experiences. The findings suggest that humour can be a natural part of the therapeutic relationship; there are key moments of humour that can shape the counselling process such as moments of real catharsis, and client use of defensive humour; clients can use humour in creative ways; and there are important risk factors that counsellors must be mindful of when humour is present in the therapy room, including the need to be aware of clients using gallows humour. Implications for training and practice are discussed, and potential areas for further research are suggested. A common suggestion put forward by participants was that therapeutic humour can be effectively and appropriately utilised even early in a counsellor's career, but that this is never mentioned in training courses, which they felt should be rectified.
... The physician questionnaire was selfadministered, and patient questionnaire was administered by a trained research assistant. A mean of 16.7 questionnaires was completed per physician (range [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. The physicians reported having used some humor in only 95 encounters (38%), whereas almost 60% of patients agreed with the statement, "The doctor used some humor during the visit". ...
... Phillips & al. (17) emphasized that little is known about humor's use in clinical encounters, despite its many potential benefits. The aim was to describe humor during clinical encounters. ...
Humor is a complex phenomenon, incorporating cognitive, emotional, behavioral, physiological and social aspects. Humor is one of the innate abilities that an individual develops whilst growing up and which is affected by his/her experiences in life.
What is the neuropsychology of humor? What are the characteristics of humor? How do children percept humor? What are the features of humor in the older individuals? How does humor is related to the medical practice? What is the effect of humor on human health? What are the clinical presentations? How can the clinical cases be managed?
In the present research, the Biblical verses are described. Therefore, this research deals with various medical aspects of the humor.
This Research shows that the awareness of the humor has accompanied human during the long years of our existence.
... The use of humour is arguably one of the easiest ways to induce positive affect in others. Humour is defined by Phillips et al. [44] as "a statement made with the intent to make others in the room laugh or react positively and to which a positive response is elicited" (p. 271). ...
... Use of humour by healthcare professionals is found to assist both staff and patients in coping during unpleasant medical procedures and has been found to increase staff coping, emotional resilience, and perceptions of the work environment [58,59]. In a study by Philips et al. [44], use of physician humour was present in 59% of medical encounters with patients and was found to facilitate conversation and coping during difficult or uncomfortable situations. In research exploring characteristics of physicians about malpractice claims, the use of humour was found to be a significant factor for those doctors without any claims [23]. ...
A growing shortfall exists between the number of older individuals who require healthcare support and the number of qualified healthcare professionals who can provide this. Robots offer the potential to provide healthcare support to patients both at home and in healthcare settings. However, in order for robots to be successfully implemented in these environments, they need to behave in ways that are appropriate and acceptable to human users. One way to identify appropriate social behaviours for healthcare robots is to model their behaviour on interactions between healthcare professionals and patients. This literature review aimed to inform healthcare robotics research by highlighting communication behaviours that are important within the context of healthcare. The review focussed on relevant research in human clinical interactions, followed by a review of similar factors in social robotics research. Three databases were searched for terms relating to healthcare professional communication behaviours associated with patient outcomes. The results identified key communication behaviours that can convey clinical empathy, including humour, self-disclosure, facial expressions, eye gaze, body posture, and gestures. A further search was conducted to identify research examining these key behaviours within the context of social and healthcare robotics. Research into these factors in human–robot interaction in healthcare is limited to date, and this review provides a useful guide for future research.
... one another, engage in face saving correction, and draw attention to or introduce a difficult message (Phillips et al., 2018;Schöpf et al., 2017). While the outcomes of humor run the gamut between positive and negative, healthcare humor scholarship demonstrates that humor is both frequent and useful for providers and patients alike. ...
In response to a case study entitled, "Your Doctor is Right," this chapter examines how humor, including dark humor, is used to manage medical uncertainty and advance narrative medicine. The chapter culminates in recommendations for practice when using humor that is dark, managing uncertainty, and advancing narrative medicine.
... Evolving from strangers to co-agents and avoiding threats to one another's identities helped the interactants reduce power imbalances and avoid creating animosity in the relationship, which "paint[ed] a larger picture" of trust and empathy over time. All of these factors were instrumental in facilitating the collaborative and serious talk necessary to complete the task while finding greater satisfaction in their relationships (Phillips et al., 2018). ...
Cases on Applied and Therapeutic Humor focuses on humor in medical care and will discuss issues in humor research, assessment of the effectiveness of humor in medical settings, and examples of medical care in specific health settings. The chapters will explore how propriety, effectiveness, perception, and cultural variables play a role in using humor as therapy and will also provide practical case studies from medical/healthcare professionals in which they personally employed humor in medical practice. This book is ideal for medical students, therapists, researchers interested in health, humor, and medical care; healthcare professionals; humor researchers; along with practitioners, academicians, and students looking for a deeper understanding of the role humor can play as well as guidance as to the effective and meaningful use of humor in medical/healthcare settings.
... Humor in healthcare settings is well appreciated by patients [26] and may facilitate a social connection between doctors and patients to allow easier discussions of difficult topics [27]. ...
Massage is one of the most commonly used complementary therapies worldwide. Besides helping to reduce stress and manage pain, massage can also promote tissue healing and enhance immunity. It is widely utilized in diverse populations ranging from infants to older adults, not only for wellness and disease prevention purposes, but also for treatment of specific conditions such as chronic pain and cancer.
As the saying goes, “laughter is the best medicine.” Even though empirical studies to support the use of humor and laughter as an intervention for specific conditions remain scarce, with limited adverse effects and easy prescription, humor should be a part of any wellness
program to promote joy and its healing effects.
Music itself is potentially healing. The application of music therapy as an adjunct to address many conditions such as dementia and depression is promising. Providing music to patients suffering from medical conditions can be a cost-effective and feasible strategy to improve unpleasant symptoms. Music can be more widely applied to enhance the health and wellness of patients.
... And humorously, we will end with an article that humors our hearts. 15 Joking aside, humor is common in office visits and introduced by patients and doctors of all types. In our offices, we feel that it makes the visit more pleasurable and sometimes more effective in leading to outcomes. ...
This issue includes several excellent observational studies prompted by physicians' clinical questions. Many people use lots of menthol cough drops-does the menthol overall lengthen the cough duration? When should we intensify treatment of older individuals with diabetes? Do occipital nerve blocks work for acute migraine headaches? Did you know that the plantar fascia can rupture? What happens to those patients with chest pain but low pretest probability for serious cardiac disease who are admitted to the hospital? Acupuncture can work well-for the patients-but how can we incorporate it into the usual pace of the family medicine office? Is it a win-lose situation when medical assistant roles are expanded? How many practice sites do physicians have and does that make a difference in the number or type of health personnel shortage areas? What would you guess on the presence of humor in the medical office-more or less than half of the visits; introduced by doctors or patients; primary care or specialty doctors?
The present work studies how community health workers (CHWs) perform the role of educator and how this relates to the implementation of other CHW roles, skills, and qualities. Prior studies on this topic have relied on interviews or focus groups rather than analysis of CHW interactions. We conducted a thematic analysis of 24 transcripts of conversations occurring between CHWs and participants during home visits as part of the Mexican American Trial of Community Health Workers, a randomized controlled trial that improved clinical outcomes among low-income Mexican American adults with type 2 diabetes. Three themes describing interactions related to diabetes self-management education accounted for about half of encounter content. The other half of encounter content was dedicated to interactions not explicitly related to diabetes described by 4 subthemes. In a successful CHW intervention, focused educational content was balanced with other interactions. Interactions not explicitly related to diabetes may have provided space for the implementation of core CHW roles, skills, and qualities other than educator, particularly those related to relationship building. It is important that interventions provide CHWs with sufficient time and flexibility to develop strong relationships with participants.
Despite medical guidelines delineating respect towards patients, many encounters between patients and clinicians are problematic, in which patients feel disrespected, unheard, shamed or abused. This article uses an anthropological lens to focus on the imbrication of humour and humiliation as forms of shame and obstetric violence within obstetric encounters. Humour as a form of speech play creates a substrate for the occurrence of humiliation and shaming of obstetric patients. Humour enhances patients' feelings of shame, making them vulnerable to verbal and physical forms of obstetric violence. Ethnographic methods of observation and interviews were performed in two hospitals in the Mexican city of Puebla to uncover clinicians' perceptions and narratives about their patients as problematic others. Narratives about patient worth underscored interactions. Humour and humiliation were centrally present within these interactions. Ultimately, both humour and humiliation functioned as shaming mechanisms that increased the presence of obstetric violence in these encounters. The article examines whether an understanding of shame can improve clinical practice and concludes with implications to clinical practice.
Osteoporosis Choice, an encounter decision aid, can engage patients and clinicians in shared decision making about osteoporosis treatment. Its effectiveness compared to the routine provision to clinicians of the patient's estimated risk of fracture using the FRAX calculator is unknown.
Patient-level, randomized, three-arm trial enrolling women over 50 with osteopenia or osteoporosis eligible for treatment with bisphosphonates, where the use of Osteoporosis Choice was compared to FRAX only and to usual care to determine impact on patient knowledge, decisional conflict, involvement in the decision-making process, decision to start and adherence to bisphosphonates.
We enrolled 79 women in the three arms. Because FRAX estimation alone and usual care produced similar results, we grouped them for analysis. Compared to these, use of Osteoporosis Choice increased patient knowledge (median score 6 vs. 4, p = .01), improved understanding of fracture risk and risk reduction with bisphosphonates (p = .01 and p<.0001, respectively), had no effect on decision conflict, and increased patient engagement in the decision making process (OPTION scores 57% vs. 43%, p = .001). Encounters with the decision aid were 0.8 minutes longer (range: 33 minutes shorter to 3.0 minutes longer). There were twice as many patients receiving and filling prescriptions in the decision aid arm (83% vs. 40%, p = .07); medication adherence at 6 months was no different across arms.
Supporting both patients and clinicians during the clinical encounter with the Osteoporosis Choice decision aid efficiently improves treatment decision making when compared to usual care with or without clinical decision support with FRAX results.
clinical trials.gov NCT00949611.
As Coser (1962) demonstrated in her landmark hospital study, a humor is one of the great tools of reassurance on the hospital ward. After all, if something is ridiculous, how can it be threatening? In this study, the authors examine the role of humor in medical interactions, with an eye toward greater understanding of the means by which people manage the emotions of others. Through face to face interviews with 22 providers in a large hospital, this study garners empirical support for a previously developed definition of humor as interpersonal emotion management. In addition, the study uncovers the particular roles played by the contextual factors of humor, including actor, setting, and timing. These factors are critical in determining whether humor is appropriate and successful in achieving desired emotional change, or whether it will fail or even backfire, causing emotional and interactional harm. The study draws implications for the potential study of harmful coping and social support.
Effective doctor-patient communication is a central clinical function in building a therapeutic doctor-patient relationship, which is the heart and art of medicine. This is important in the delivery of high-quality health care. Much patient dissatisfaction and many complaints are due to breakdown in the doctor-patient relationship. However, many doctors tend to overestimate their ability in communication. Over the years, much has been published in the literature on this important topic. We review the literature on doctor-patient communication.
The purpose of this study was the development of a rating instrument to assess the use of humor in physician- patient interactions, and to compare humor use as a function of patients' socioeconomic status. The 46-item Physician-Patient Humor Rating Scale (PPHRS) was used to rate 246 audiotaped primary care interactions. Four subscales were reliable and valid, demonstrating correlations with patient satisfaction and reports of physician humor, with physician satisfaction and with separate affective communication ratings. There was a significant difference in use of humor as a function of patient socioeconomic status, such that there was greater mutual trust between physicians and high versus low income patients.
Patient involvement in the choice of antihyperglycemic agents could improve adherence and optimize glycemic control in patients with type 2 diabetes mellitus.
We conducted a pilot, cluster randomized trial of Diabetes Medication Choice, a decision aid that describes 5 antihyperglycemic drugs, their treatment burden (adverse effects, administration, and self-monitoring demands), and impact on hemoglobin A(1c) (HbA(1c)) levels. Twenty-one clinicians were randomized to use the decision aid during the clinical encounter and 19 to dispense usual care and an educational pamphlet. We used surveys and video analysis to assess postvisit decisional outcomes, and medical and pharmacy records to assess 6-month medication adherence and HbA(1c) levels.
Compared with usual care patients (n = 37), patients receiving the decision aid (n = 48) found the tool more helpful (clustered-adjusted mean difference [AMD] in a 7-point scale, 0.38; 95% confidence interval [CI], 0.04-0.72); had improved knowledge (AMD, 1.10 of 10 questions; 95% CI, 0.11-2.09); and had more involvement in making decisions about diabetes medications (AMD, 21.8 of 100; 95% CI, 13.0-30.5). At 6-month follow-up, both groups had nearly perfect medication use (median, 100% of days covered), with better adherence (AMD, 9% more days covered; 95% CI, 4%-14%) and persistence (AMD, 12 more days covered; 95% CI, 3-21 days) in the usual care group, and no significant impact on HbA(1c) levels (AMD, 0.01; 95% CI, -0.49 to 0.50).
An innovative decision aid effectively involved patients with type 2 diabetes mellitus in decisions about their medications but did not improve adherence or HbA(1c) levels. Trial Registration clinicaltrials.gov Identifier: NCT00388050.
To identify specific communication behaviors associated with malpractice history in primary care physicians and surgeons.
Comparison of communication behaviors of "claims" vs "no-claims" physicians using audiotapes of 10 routine office visits per physician.
One hundred twenty-four physician offices in Oregon and Colorado.
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.
Audiotape analysis using the Roter Interaction Analysis System.
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.
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.
Context:
The best treatment option for patients with Graves Disease (GD) depends on each person's situation and how the differences between the treatment options matter to them in bringing resolution to their illness. Our objective was to develop and test an encounter decision tool (GD Choice) for patients and clinicians to engage in shared decision making about the treatment of GD Methods: GD Choice was developed using an iterative process based on the principles of interaction design and participatory action research. To evaluate the impact of the tool we conducted a controlled before-and-after study assessing the use of GD Choice vs. usual care (UC).
Results:
We enrolled 68 patients, 37 to UC and 31 to GD Choice. At baseline, the groups were similar. Treatment discussion length was similar in both arms. After their visit, patients in both groups had similar knowledge about the options, except for GD Choice patients knowing significantly more about the complications of treatment (correctly answered by 83% vs. 55%, p=0.04). Compared to UC, patients in the GD Choice arm had greater involvement in decision making observed on video recordings of clinical encounters (mean OPTION scale score, 35% vs. 30%, p=.02), but reported similar levels of decisional comfort and participation in shared decision making.
Conclusions:
GD Choice increases engagement in the decision-making process and knowledge regarding intervention complications without increasing the length of consultation. These promising results support the conduct of a randomized trial of GD choice vs. UC in a large multicenter trial.
Clinical trial registration:
URL: https://clinicaltrials.gov. Unique identifier: NCT02107794.
Importance:
For antidepressants, the translation of evidence of comparative effectiveness into practice is suboptimal. This deficit directly affects outcomes and quality of care for patients with depression. To overcome this problem, we developed the Depression Medication Choice (DMC) encounter decision aid, designed to help patients and clinicians consider the available antidepressants and the extent to which they improved depression and other issues important to patients.
Objective:
Estimate the effect of DMC on quality of the decision-making process and depression outcomes.
Design, setting, and participants:
We conducted a cluster randomized trial of adults with moderate to severe depression considering treatment with an antidepressant. Primary care practices in 10 rural, suburban, and urban primary care practices across Minnesota and Wisconsin were randomly allocated to treatment of depression with or without use of the DMC decision aid.
Intervention:
Depression Medication Choice, a series of cards, each highlighting the effect of the available options on an issue of importance to patients for use during face-to-face consultations.
Main outcomes and measures:
Decision-making quality as judged by patient knowledge and involvement in decision making, patient and clinician decisional comfort (Decisional Conflict Scale) and satisfaction, encounter duration, medication adherence, depression symptoms, and the Patient Health Questionnaire for depression (PHQ-9).
Results:
We enrolled 117 clinicians and 301 patients (67% women; mean [SD] age, 44 [15] years; mean [SD] PHQ-9 score, 15 [4]) into the trial. Compared with usual care (UC), use of DMC significantly improved patients' decisional comfort (DMC, 80% vs UC, 75%; P = .02), knowledge (DMC, 65% vs UC, 56%; P = .03), satisfaction (risk ratio [RR], from 1.25 [P = .81] to RR, 2.4 [P = .002] depending on satisfaction domain), and involvement (DMC, 47% vs UC, 33%; P<.001). It also improved clinicians' decisional comfort (DMC, 80% vs UC, 68%; P < .001) and satisfaction (RR, 1.64; P = .02). There were no differences in encounter duration, medication adherence, or improvement of depression control between arms.
Conclusions and relevance:
The DMC decision aid helped primary care clinicians and patients with moderate to severe depression select antidepressants together, improving the decision-making process without extending the visit. On the other hand, DMC had no discernible effect on medication adherence or depression outcomes. By translating comparative effectiveness into patient-centered care, use of DMC improved the quality of primary care for patients with depression.
Trial registration:
clinicaltrials.gov Identifier: NCT01502891.
The current study investigated the extent to which various types of humor are associated with high- and low-satisfaction doctor visits and whether male and female physicians and patients differ in their use of humor. A humor coding scheme, capable of distinguishing three categories (negative, positive, and general) and ten sub-types of humor, was validated against 92 audiotaped physician-patient primary care visits, half rated high and half rated low in satisfaction. Results revealed that physicians and patients used more light humor, more humor that relieves tension, more self-effacing humor, and more positive-function humor in high satisfaction than in low-satisfaction visits. In addition, the patients of female physicians used more humor than the patients of male physicians across levels of satisfaction. The results indicate a strong association between humor and satisfaction, and suggest ways in which humor and laughter help to maintain rapportin the physician-patient relationship.
Objectives:
Effective patient-provider communication is a critical aspect of the delivery of high-quality patient care; however, research regarding the conversational dynamics of an overall emergency department (ED) visit remains unexplored. Identifying both patterns and relative frequency of utterances within these interactions will help guide future efforts to improve the communication between patients and providers within the ED setting. The objective of this study was to analyze complete audio recordings of ED visits to characterize these conversations and to determine the proportion of the conversation spent on different functional categories of communication.
Methods:
Patients at an urban academic ED with four diagnoses (ankle sprain, back pain, head injury, and laceration) were recruited to have their ED visits audio recorded from the time of room placement until discharge. Patients were excluded if they were age < 18 years, were non-English-speaking, had significant history of psychiatric disease or cognitive impairment, or were medically unstable. Audio editing was performed to remove all silent downtime and non-patient-provider conversations. Audiotapes were analyzed using the Roter Interaction Analysis System (RIAS). RIAS is the most widely used medical interaction analysis system; coders assign each "utterance" (or complete thought) spoken by the patient or provider to one of 41 mutually exclusive and exhaustive categories. Descriptive statistics were calculated for all 41 categories and then grouped according to RIAS standards for "functional groupings." The percentage of total utterances in each functional grouping is reported.
Results:
Twenty-six audio recordings were analyzed. Patient participants had a mean (±SD) age of 38.8 (±16.0) years, and 30.8% were male. Intercoder reliability was good, with mean intercoder correlations of 0.76 and 0.67 for all categories of provider and patient talk, respectively. Providers accounted for the majority of the conversation in the tapes (median = 239 utterances, interquartile range [IQR] = 168 to 308) compared to patients (median = 145 utterances, IQR = 80 to 198). Providers' utterances focused most on patient education and counseling (34%), followed by patient facilitation and activation (e.g., orienting the patient to the next steps in the ED or asking if the patient understood; 30%). Approximately 15% of the provider talk was spent on data gathering, with the majority (86%) focusing on biomedical topics rather than psychosocial topics (14%). Building a relationship with the patient (e.g., social talk, jokes/laughter, showing approval, or empathetic statements) constituted 22% of providers' talk. Patients' conversation was mainly focused in two areas: information giving (47% of patient utterances: 83% biomedical, 17% psychosocial) and building a relationship (45% of patient utterances). Only 5% of patients' utterances were devoted to question asking. Patient-centeredness scores were low.
Conclusions:
In this sample, both providers and patients spent a significant portion of their talk time providing information to one another, as might be expected in the fast-paced ED setting. Less expected was the result that a large percentage of both provider and patient utterances focused on relationship building, despite the lack of traditional, longitudinal provider-patient relationships.
Objective: To describe patient-obstetrician communication during the first prenatal visit and its relationship to physician gender and patient satisfaction. Methods: The first prenatal visit of 87 women with 21 obstetricians (11 male and ten female) was audiotaped and analyzed using the Roter Interaction Analysis System. Patient satisfaction was measured by postvisit questionnaire. Results: Communication during first prenatal visits was largely biomedical, with little psychosocial or social discussion. Male physicians conducted longer visits than females (26 minutes versus 21.9 minutes, P <.05) and engaged in more facilitative Communication tie, making sure they were understood and providing direction and orientation) and explicit statements of concern and partnership (z > 1.96, P <.05). Female physicians devoted more communication to agreements, disagreements, and laughter than males fz > 1.96, P <.05]. Satisfaction with physicians' emotional responsiveness and informational partnership was related to female physician gender and a variety of task-focused and affective communication variables. Conclusion: Communication and satisfaction between women and obstetricians during initial prenatal visits is related to physician gender and patient satisfaction Male physicians conducted longer visits but women were more satisfied with female physicians. (C) 1999 by The American College of Obstetricians and Gynecologists.
To assess the relationship between observable patient and doctor verbal and non-verbal behaviors and the degree of enablement in consultations according to the Patient Enablement Instrument (PEI) (a patient-reported consultation outcome measure).
We analyzed 88 recorded routine primary care consultations. Verbal and non-verbal communications were analyzed using the Roter Interaction Analysis System (RIAS) and the Medical Interaction Process System, respectively. Consultations were categorized as patient- or doctor-centered and by whether the patient or doctor was verbally dominant using the RIAS categorizations.
Consultations that were regarded as patient-centered or verbally dominated by the patient on RIAS coding were considered enabling. Socio-emotional interchange (agreements, approvals, laughter, legitimization) was associated with enablement. These features, together with task-related behavior explain up to 33% of the variance of enablement, leaving 67% unexplained. Thus, enablement appears to include aspects beyond those expressed as observable behavior.
For enablement consultations should be patient-centered and doctors should facilitate socio-emotional interchange. Observable behavior included in communication skills training probably contributes to only about a third of the factors that engender enablement in consultations.
To support patient enablement in consultations, clinicians should focus on agreements, approvals and legitimization whilst attending to patient agendas.
Poor adherence to therapy, perhaps related to unaddressed patient preferences, limits the effectiveness of osteoporosis treatment in at-risk women. A parallel patient-level randomized trial in primary care practices was performed.
Eligible postmenopausal women with bone mineral density T-scores less than -1.0 and not receiving bisphosphonate therapy were included. In addition to usual primary care, intervention patients received a decision aid (a tailored pictographic 10-year fracture risk estimate, absolute risk reduction with bisphosphonates, side effects, and out-of-pocket cost), and control patients received a standard brochure. Knowledge transfer, patient involvement in decision-making, and rates of bisphosphonate start and adherence were studied. Data came from medical records, post-visit written and 6-month phone surveys, video recordings of clinical encounters, and pharmacy prescription profiles.
A total of 100 patients (range of 10-year fracture risk, 6%-60%) were allocated randomly to receive the decision aid (n=52) or usual care (n=48). Patients receiving the decision aid were 1.8 times more likely to correctly identify their 10-year fracture risk (49% vs 28%; 95% confidence interval [CI], 1.03-3.2) and 2.7 times more likely to identify their estimated risk reduction with bisphosphonates (43% vs 16%; 95% CI, 1.3-5.7). Patient involvement improved with the decision aid by 23% (95% CI, 13.6-31.4). Bisphosphonates were started by 44% of patients receiving the decision aid and 40% of patients receiving usual care. Adherence at 6 months was similarly high across both groups, but the proportion with more than 80% adherence was higher with the decision aid (n=23 [100%] vs n=14 [74%]; P = .009).
A decision aid improved the quality of clinical decisions about bisphosphonate therapy in at-risk postmenopausal women, did not affect start rates, and may have improved adherence.
Incl. app., bibliographical notes and references, frequently asked questions: pp. 105-138, index
In recent years, there has been significant interest and investment in conducting comparative effectiveness research (CER) of medical treatments to improve the quality of care and reduce costs. The Agency for Healthcare Research and Quality (AHRQ) has been leading this effort and has invested a significant amount of resources to advance CER. However, little is known about translating the findings from CER into routine practice such that it provides value to the patients, clinicians, and the healthcare system.
We present the role of shared decision making for patient-centered CER translation and its application to diabetes medications. CER of oral diabetes medications suggests that all medications are similar in their effects on glycemic control, but there is variability in side-effects, which may affect medication adherence and treatment intensification. Shared decision making, facilitated by tools such as decision aids, may enhance the quality of diabetes care by activating patients, enhancing the patient-clinician communication, and improving uptake and adherence to the medication that is determined to be consistent with patients' goals, values, and preferences. We describe the iterative, multidisciplinary process for developing and testing a diabetes medication decision aid, and examine the implications for CER translation.
In our pilot study we found the decision aid to be acceptable to patients and providers and effective for knowledge translation; however, it did not impact short-term outcomes.
Our pilot trial found that decision aids enhanced the discussion about diabetes medications without any adverse effects on the outcomes. Further issues related to the use of decision aids to translate CER need to be addressed in larger trials to understand the effectiveness and efficiency of translating evidence into routine practice in unique contexts of patients, providers, and healthcare systems.
To assess the impact of a decision aid on perceived risk of heart attacks and medication adherence among urban primary care patients with diabetes.
We randomly allocated 150 patients with diabetes to participate in a usual primary care visit either with or without the Statin Choice tool. Participants completed a questionnaire at baseline and telephone follow-up at 3 and 6 months.
Intervention patients were more likely to accurately perceive their underlying risk for a heart attack without taking a statin (OR: 1.9, CI: 1.0-3.8) and with taking a statin (OR: 1.4, CI: 0.7-2.8); a decline in risk overestimation among patients receiving the decision aid accounts for this finding. There was no difference in statin adherence at 3 or 6 months.
A decision aid about using statins to reduce coronary risk among patients with diabetes improved risk communication, beliefs, and decisional conflict, but did not improve adherence to statins.
Decision aid enhanced communication about the risks and benefits of statins improved patient risk perceptions but did not alter adherence among patients with diabetes.
Research electronic data capture (REDCap) is a novel workflow methodology and software solution designed for rapid development and deployment of electronic data capture tools to support clinical and translational research. We present: (1) a brief description of the REDCap metadata-driven software toolset; (2) detail concerning the capture and use of study-related metadata from scientific research teams; (3) measures of impact for REDCap; (4) details concerning a consortium network of domestic and international institutions collaborating on the project; and (5) strengths and limitations of the REDCap system. REDCap is currently supporting 286 translational research projects in a growing collaborative network including 27 active partner institutions.
Barriers frequently develop in physician-patient encounters. If they go unrecognized, they can severely limit the therapeutic potential of the doctor-patient relationship. Because barriers are not always explicit, a strategy is presented for recognizing implicit signs such as verbal-nonverbal mismatch, cognitive dissonance, unexpected resistance, and physician discomfort. Once a potential barrier is identified, its source can be defined and explored using standard clinical reasoning techniques such as hypothesis generation and testing. Patients can often share in the process of generating hypotheses about the nature and sources of barriers. Once defined and understood, most barriers can be lessened and sometimes resolved using the basic communication skills of acknowledgment, exploration, empathy, and legitimation. When conflict exists, common interests and differences must be clarified. Conflict might involve disagreement about the presence of a barrier, its nature or source, its relevance to the physician-patient relationship, or about strategies for approaching it. Negotiation need not be limited to the initial positions, but can include creative solutions whereby both parties gain. The decision to confront a barrier depends on both doctor and patient readiness, as well as how critical the barrier is to the therapeutic process, and how amenable it is to change. By effectively uncovering and addressing barriers, the physician can often turn roadblocks to effective communication into means for enhancing the therapeutic relationship.
To ascertain whether the quality of physician-patient communication makes a significant difference to patient health outcomes.
The MEDLINE database was searched for articles published from 1983 to 1993 using "physician-patient relations" as the primary medical subject heading. Several bibliographies and conference proceedings were also reviewed.
Randomized controlled trials (RCTs) and analytic studies of physician-patient communication in which patient health was an outcome variable.
The following information was recorded about each study: sample size, patient characteristics, clinical setting, elements of communication assessed, patient outcomes measured, and direction and significance of any association found between aspects of communication and patient outcomes.
Of the 21 studies that met the final criteria for review, 16 reported positive results, 4 reported negative (i.e., nonsignificant) results, and 1 was inconclusive. The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control.
Most of the studies reviewed demonstrated a correlation between effective physician-patient communication and improved patient health outcomes. The components of effective communication identified by these studies can be used as the basis both for curriculum development in medical education and for patient education programs. Future research should focus on evaluating such educational programs.
There has been extensive research on the factors associated with patient satisfaction with communication during medical encounters, however, little attention has been paid to satisfaction among subgroups of patients, including the elderly. It is inappropriate to assume that all patients have the same physician-patient relationship needs, and thus, they will all be satisfied with the same communication approaches during medical visits. In this study, we examine the interactional correlates of older patient satisfaction with an initial visit with a general internist. A multidisciplinary team composed of social scientists and physicians used the Multi-dimensional Interaction Analysis system to code audiotapes. Patients and physicians completed post-visit satisfaction questionnaires. Older patient satisfaction was positively correlated with the following variables: physician questioning and supportiveness on patient-raised topics; patient information-giving on patient-raised topics; the length of the visit; the physician's use of questions worded in the negative; shared laughter between the physician and the patient; and physician satisfaction. These findings suggest that older patients prefer encounters in which: (1) there is physician supportiveness and shared laughter; (2) they are questioned about and given an opportunity to provide information on their own agenda items; and (3) physicians provide some structure for the first meeting through their use of questions worded in the negative. The authors caution that although this sample of older patients appears to be satisfied with a communication style usually considered characteristic of the traditional model of the physician-patient relationship (i.e. a warm interpersonal style and physician-generated structure for the visit), older patients in other settings and future cohorts of elderly patients may prefer other communication approaches. It is also suggested that aspects of communication which provide satisfaction to patients in first visits may be different than aspects of communication associated with patient satisfaction in follow-up visits.
The role of humor in medicine is becoming increasingly apparent. Humor helps individuals narrow interpersonal and cultural gaps, communicate difficult messages, express frustration and anger, and cope with anxiety. Primary care providers need to be able to interpret humor used by patients and can learn to use humor to create a healing environment. This article reviews the roles played by humor in the doctor-patient relationship and provides a brief guide to using one's sense of humor to improve and enrich patient care.
Humor has been identified as an intrinsic social phenomenon occurring in all groups throughout human history. It is among the most prevalent forms of human social behavior yet one of the least understood or defined. Although researchers in a number of disciplines have studied the effects of humor on patients, limited work has focused on end-of-life care. The present study investigated social interactions involving humor in hospice settings using nonparticipant observation. Results revealed that humor was present in 85 percent of 132 observed nurse-based hospice visits. Of these, hospice patients initiated humor 70 percent of the time. These findings were consistent regardless of hospice setting. Humor was spontaneous and frequent, and instances of humorous interactions were a prevalent part of everyday hospice work.
Beginning in July 2002, all residencies were required to show that their residents were obtaining competency in six core areas defined by the Accreditation Council for Graduate Medical Education (ACGME).
In 2003, we surveyed all 444 family medicine program directors regarding the ACGME Core Competencies and how programs evaluated them.
A total of 287/444 (64.6%) responded. Almost all (279/287) had heard of the ACGME Core Competencies, and most (257/287) had begun to implement evaluation programs. Of program directors responding, 67.6% identified patient care as the most important competency. Evaluation methods most frequently used were active precepting (76.0%), record review (72.8%), and procedure logs (63.8%). The least commonly used tools were OSCE (9.1%), audit of computer utilization and knowledge (10.5%), and simulations (11.1%). Respondents identified time (74.3 %) and faculty development (13.0%) as primary implementation barriers.
Program directors believe that patient care is the most important competency. Some programs are not yet attempting to address the competencies, and some were unaware of the accreditation implications of noncompliance with the Outcome Project. Time was identified as the major barrier to implementing core competency evaluation methods.
Describe the content and of mode of patient-physician-nurse interactions during ward-rounds in Internal Medicine.
In 267/448 patients, 13 nurses, and 8 physicians from two wards in General Internal Medicine 448 interactions on ward rounds were tape recorded by observers. After exclusion of interactions with more than three participants (N=150), a random sample of 90 interactions was drawn. Data were analysed with a modified RIAS version that allowed for the registration of a third contributor and for the assessment of the direction of a communicative action (e.g.: nurse-->patient, etc.). Furthermore, time spent per individual patient was registered with a stop-watch.
A total of 12,078 utterances (144 per ward round) were recorded. Due to problems with the comprehensibility of some interactions the final data set contains 71 ward round interactions with 10,713 utterances (151 per ward round interaction). The average time allotted to an individual patient during ward-rounds was 7.5 min (range: 3-16 min). The exchange of medical information is the main topic in physicians (39%) and nurses (25%), second common topic in patients (28%), in whom communicative actions like agreement or checking are more common (30% patients/25% physicians/22% nurses). Physicians and patients use a substantial number of communicative actions (1397/5531 physicians; 1119/3733 patients). Patients receive about 20 bits of medical or therapeutic information per contact during ward-rounds.
If ward rounds serve as the central marketplace of information nurses' knowledge is under-represented. Further research should try to determine whether the quality of patient care is related to a well balanced exchange of information, to which nurses, physicians, and patients contribute their specific knowledge.
Given the fact that in-patients in Interna Medicine usually present complex problems, the exchange of factual information, expectations, and concepts is of paramount importance. We hope that this paper is going to direct the attention of the scientific community to the characteristics of ward-rounds because they will remain the central marketplace of communication in hospital.