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Impact of Prognostic Discussions on the Patient-Physician Relationship: Prospective Cohort Study.

ABSTRACT: Purpose Some research has suggested that discussion of prognosis can disrupt the patient-physician relationship. This study assessed whether physician discussion of prognosis is associated with detrimental changes in measures of the strength of the patient-physician relationship. Methods This was a longitudinal cohort study of 265 adult patients with advanced cancer who visited 38 oncologists within community- and hospital-based cancer clinics in Western New York and Northern California. Prognostic discussion was assessed by coding transcribed audio-recorded visits using the Prognostic and Treatment Choices (PTCC) scale and by patient survey at 3 months after the clinic visit. Changes in the strength of the patient-physician relationship were computed as differences in patient responses to The Human Connection and the Perceived Efficacy in Patient-Physician Interactions scales from baseline to 2 to 7 days and 3 months after the clinic visit. Results Prognostic discussion was not associated with a temporal decline in either measure. Indeed, a one-unit increase in PTCC during the audio-recorded visit was associated with improvement in The Human Connection scale at 2 to 7 days after the visit (parameter estimate, 0.10; 95% CI, -0.02 to 0.23) and 3 months after the visit (parameter estimate, 0.18; 95% CI, 0.02 to 0.35) relative to baseline. Standardized effect sizes (SES) associated with an increase of two standard deviations in the PTCC at each time point were consistent with small beneficial effects (SES, 0.14 [95% CI, -0.02 to 0.29] at 2 to 7 days; SES, 0.24 [95% CI, 0.02 to 0.45] at 3 months), and lower bounds of CIs indicated that substantial detrimental effects of prognostic discussion were unlikely. Conclusion Prognostic discussion is not intrinsically harmful to the patient-physician relationship and may even strengthen the therapeutic alliance between patients and oncologists.

SUBMITTER: Fenton JJ

PROVIDER: S-EPMC5773842 | biostudies-literature | 2018 Jan

REPOSITORIES: biostudies-literature

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Impact of Prognostic Discussions on the Patient-Physician Relationship: Prospective Cohort Study.

Fenton Joshua J JJ Duberstein Paul R PR Kravitz Richard L RL Xing Guibo G Tancredi Daniel J DJ Fiscella Kevin K Mohile Supriya S Epstein Ronald M RM

Journal of clinical oncology : official journal of the American Society of Clinical Oncology 20171117 3

Purpose Some research has suggested that discussion of prognosis can disrupt the patient-physician relationship. This study assessed whether physician discussion of prognosis is associated with detrimental changes in measures of the strength of the patient-physician relationship. Methods This was a longitudinal cohort study of 265 adult patients with advanced cancer who visited 38 oncologists within community- and hospital-based cancer clinics in Western New York and Northern California. Prognos ...[more]

PMID: 29148892

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Project description:BACKGROUND:The quality of patient-physician discussions about chronic kidney disease (CKD) in primary care has not been studied previously. STUDY DESIGN:Cross-sectional study. SETTINGS & PARTICIPANTS:We audiotaped encounters between 236 patients with hypertension and their primary care physicians (n = 40). PREDICTORS:Patient, physician, and encounter characteristics. OUTCOMES & MEASUREMENTS:We described the occurrence and characteristics (content, use of technical terms, and physician assessment of patient comprehension of new concepts) of CKD discussions. We assessed patient and physician characteristics associated with CKD discussion occurrence. RESULTS:Many patients (mean age, 59 years) had uncontrolled hypertension (51%), diabetes (44%), and/or 3 or more comorbid conditions (51%). Most primary care physicians practiced (52%) fewer than 10 years. CKD discussions occurred in few (26%; n = 61) encounters, with content focused on laboratory assessment (89%), risk-factor treatment (28%), and causes (26%) of CKD. In encounters that included a CKD discussion, physicians used technical terms (28%; n = 17) and rarely assessed patients' comprehension (2%; n = 1). CKD discussions were statistically significantly less common in visits of patients with some (vs no) college education (OR, 0.23; 95% CI, 0.09-0.56), with 3 or more (vs fewer) comorbid conditions (OR, 0.49; 95% CI, 0.25-0.96), and who saw physicians with more (vs fewer) than 10 years of practice experience (OR, 0.41; 95% CI, 0.21-0.80). CKD discussions were more common during longer encounters (OR, 1.31; 95% CI, 1.04-1.65) and encounters in which diabetes was (vs was not) discussed (OR, 2.87; 95% CI, 1.22-6.77). LIMITATIONS:Generalizability of our findings may be limited. CONCLUSIONS:Patient-physician discussions about CKD in high-risk primary care patients were infrequent. Physicians used technical terms and infrequently assessed patients' understanding of new CKD concepts. Efforts to improve the frequency and content of patient-physician CKD discussions in primary care could improve patients' clinical outcomes.

Project description:BACKGROUND:Little is known about agreement between patients and physicians on content and outcomes of clinical discussions. A common perception of content and outcomes may be desirable to optimize decision making and clinical care. OBJECTIVE:To determine patient-physician agreement on content and outcomes of coronary heart disease (CHD) prevention discussions. DESIGN:Cross-sectional survey nested within a randomized CHD prevention study. SETTING AND PARTICIPANTS:University internal medicine clinic; 24 physicians and 157 patients. METHODS:Following one clinic visit, we surveyed patients and physicians on discussion content, decision making and final decisions about CHD prevention. For comparison, we audio-recorded, transcribed and coded 20 patient-physician visits. We calculated percent agreement between patient/physician reports, patient/transcription reports and physician/transcription reports. We calculated Cohen's kappas to compare patient/physician perspectives. RESULTS:Patients and physicians agreed on whether CHD was discussed in 130 visits (83%; kappa = 0.55; 95% CI 0.40-0.70). When discussions occurred, they agreed about discussion content (pros versus cons) in 53% of visits (kappa = 0.15; 95% CI -0.01-0.30) and physicians' recommendations in 73% (kappa = 0.44; 95% CI 0.28-0.66). Patients and physicians agreed on final decisions to take medication in 78% (kappa = 0.58; 95% CI 0.45-0.71) and change lifestyle in 69% (kappa = 0.38; 95% CI 0.24-0.53). They agreed less often, 43% (kappa = 0.13; 95% CI -0.11-0.37) about degree of involvement in decision making. Audio-recorded results were similar, but showed very low agreement between transcripts and patients' and physicians' self-report on discussion content and decision making. CONCLUSIONS:Disagreements about clinical discussions and decision making may be common. Future work is needed to determine: how widespread such agreements are; whether they impact clinical outcomes; and the relative importance of the subjective experience versus objective steps of shared decision making.

Project description:BackgroundElectronic health record (EHR) use can impede or augment patient-physician communication. However, little research explores the use of an educational comic to improve patient-physician-EHR interactions.ObjectiveTo evaluate the impact of an educational comic on patient EHR self-advocacy behaviors to promote patient engagement with the EHR during clinic visits.MethodsWe conducted a prospective observational study with adult patients and parents of pediatric patients at the University of Chicago General Internal Medicine (GIM) and Pediatric Primary Care (PPC) clinics. We developed an educational comic highlighting EHR self-advocacy behaviors and distributed it to study participants during check-in for their primary care visits between May 2017 and May 2018. Participants completed a survey immediately after their visit, which included a question on whether they would be interested in a follow-up telephone interview. Of those who expressed interest, 50 participants each from the adult and pediatric parent cohorts were selected at random for follow-up telephone interviews 8 months (range 3-12 months) post visit.ResultsOverall, 71.0% (115/162) of adult patients and 71.6% (224/313) of pediatric parents agreed the comic encouraged EHR involvement. African American and Hispanic participants were more likely to ask to see the screen and become involved in EHR use due to the comic (adult P=.01, P=.01; parent P=.02, P=.006, respectively). Lower educational attainment was associated with an increase in parents asking to see the screen and to be involved (ρ=-0.18, P=.003; ρ=-0.19, P<.001, respectively) and in adults calling for physician attention (ρ=-0.17, P=.04), which was confirmed in multivariate analyses. Female GIM patients were more likely than males to ask to be involved (median 4 vs 3, P=.003). During follow-up phone interviews, 90% (45/50) of adult patients and all pediatric parents (50/50) remembered the comic. Almost half of all participants (GIM 23/50, 46%; PPC 21/50, 42%) recalled at least one best-practice behavior. At subsequent visits, adult patients reported increases in asking to see the screen (median 3 vs 4, P=.006), and pediatric parents reported increases in asking to see the screen and calling for physician attention (median 3 vs 4, Ps<.001 for both). Pediatric parents also felt that the comic had encouraged them to speak up and get more involved with physician computer use since the index visit (median 4 vs 4, P=.02) and that it made them feel more empowered to get involved with computer use at future visits (median 3 vs 4, P<.001).ConclusionsOur study found that an educational comic may improve patient advocacy for enhanced patient-physician-EHR engagement, with higher impacts on African American and Hispanic patients and patients with low educational attainment.

Project description:INTRODUCTION:Little is known about whether patients and physicians perceive lung cancer screening (LCS) as a teachable moment to promote smoking cessation or the degree to which physicians in "real world" settings link LCS discussions with smoking cessation counseling. We sought to characterize patient and physician perspectives of discussions about smoking cessation during LCS. METHODS:We conducted a qualitative study (interviews and focus groups) with 21 physicians and 28 smokers screened in four diverse hospitals. Transcripts were analyzed for characteristics of communication about smoking cessation and LCS, the perceived effect on motivation to quit smoking, the degree to which physicians leverage LCS as a teachable moment to promote smoking cessation, and suggestions to improve patient-physician communication about smoking cessation in the context of LCS. RESULTS:Patients reported that LCS made them more cognizant of the health consequences of smoking, priming them for a teachable moment. While physicians and patients both acknowledged that smoking cessation counseling was frequent, they described little connection between their discussions regarding LCS and smoking cessation counseling. Physicians identified several barriers to integrating discussions on smoking cessation and LCS. They volunteered communication strategies by which LCS could be leveraged to promote smoking cessation. CONCLUSIONS:LCS highlights the harms of smoking to patients who are chronic, heavy smokers and thus may serve as a teachable moment for promoting smoking cessation. However, this opportunity is typically missed in clinical practice. IMPLICATIONS:LCS highlights the harms of smoking to heavily addicted smokers. Yet both physicians and patients reported little connection between LCS and tobacco treatment discussions due to multiple barriers. On-site tobacco treatment programs and post-screening messaging tailored to the LCS results are needed to maximize the health outcomes of LCS, including smoking quit rates and longer-term smoking-related morbidity and mortality.

Dataset Information

Impact of Prognostic Discussions on the Patient-Physician Relationship: Prospective Cohort Study.

Publications

Impact of Prognostic Discussions on the Patient-Physician Relationship: Prospective Cohort Study.

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