BMC Family Practice - Latest Comments

No evidence that skills have been developed through experience.

Christopher Weatherburn — 2012-10-01T11:05:39Z

Interesting study however I do disagree with how the article has ended:

"Our results indicate that the GPs seem to recognise immediately both problems and persons, hence the quintessence of the expert skill of the GP as developed through experience. "

This is an assumption that these relatively senior GPs studied have developed expert skill through experience. There is no control group of less experienced GPs doing the same task. There is a possibility that less senior GPs could have performed better if also studied.

References in tables

Andrew Riordan — 2012-03-03T22:00:49Z

The reference numbers in Tables 2 and 3 do not correlate with the reference list in the article.
Is it possible to correct this.

Author error

Sarah Redsell — 2011-07-27T12:08:19Z

The authors would like to point out that there is an error in Table 2. Under Gender Male 19 it should read (16.4%).

Grant Acknowledgment

Christopher P. Morley — 2011-06-17T12:26:35Z

This project was partially supported by HRSA grant D54HP05462 (Andrea T. Manyon, PI).

Patient-Physician Communication: How to Address Hidden Agendas of "Asymptomatic" Patients Who Visit a Doctor for Periodic Health Examinations

Christian T. K.-H. Stadtländer — 2011-05-17T14:20:58Z

Hunziker et al. [1] discussed an important issue that relates to patient-physician communication and, in turn, to the development of a trusting relationship. The authors conducted a follow-up study of 66 patients who visited an outpatient clinic for a general, preventive check-up (i.e., a periodic health examination [PHE]), and who initially declared to be "asymptomatic." The authors observed that the majority of the patients had actually "hidden agendas," which means, they mentioned during the consultation specific symptoms, health concerns, or psychosocial problems. It is believed that these initially undisclosed issues were the primary reasons for the patients' requests for routine check-ups.

Communication is an important part for a successful relationship, including the patient-doctor relationship. Treece [2] pointed out that the word "communication" comes from the Latin word "communis" and means "common." Thus, in communication, we attempt to establish a commonness by sharing information, attitudes, ideas, and understanding. Interpersonal communication can take on different forms: for example, verbal or nonverbal; on a one-to-one basis or in group interactions. We can only say that the communication was successful when 1. The message was understood (i.e., the patient and the doctor recognize its true meaning); 2. The message accomplished its purpose (i.e.,the patient gets proper medical treatment for his concerns); and 3. The sender and the receiver (patient and doctor) of the message maintain a favorable relationship [2].

Hunziker et al. [1] videotaped all consultations and analyzed the interactions for cues (verbal and nonverbal hints) that might provide relevant information about hidden agendas. Although I believe patient "interview" videotapes can be helpful for the portrait of the patient and the reconstruction of the patient-doctor dialogue, I wonder if patients reacted "naturally" when being videotaped. Visual and audio recording of a person can cause in some great anxiety (e.g., a feeling of being documented, perhaps even of being "caught on camera"); this can have an influence on the interpretation of the data. Furthermore, it would be interesting to know what the observer(s)' frame of mind was. Investigators generally enter their research projects with certain preconceptions, assumptions about the subjects, and the setting they are studying. Bogdan and Biklen [3] summed it up as follows: "Like everyone else, qualitative researchers have opinions, beliefs, attitudes, and prejudices, and they try to reveal these in their notes by reflecting on their own way of thinking."

There is another, closely related issue. Hunziker et al. [1] provided a list of baseline patient characteristics (gender and age; marital-, employment-, and disability-status; and nationality). These data are important as they indicate that the patients came from different backgrounds. For example, patients had different nationalities: Swiss, German, Italian, Turkish, and other. Since each nationality typically relates to a certain type of culture (i.e., "a learned set of shared interpretations about beliefs, values, and norms, which affect behavior" [4]), it would be interesting to know from what culture(s) the researchers came and what factors (e.g., intercultural differences; anxiety levels; cultural biases; cultural differences in persuasion, etc.) might have influenced the cross-cultural communication between the patient and the physician. There is always a risk that improper cross-cultural communication leads to misunderstanding caused by misperception, misinterpretation, and misevaluation [5].

In conclusion, the study by Hunziker et al. [1] provides valuable information about the "hidden agendas" patients seem to have when visiting a doctor for PHE. I fully agree with the authors that recognizing and identifying hidden agendas is not easy and that paying attention to behavioral and verbal cues can lead to successful communication and proper medical treatment. Along the same line, Larsen, Risor, and Putnam [6] developed an interesting nine-step model (called P-R-A-C-T-I-C-A-L), starting with how the patient has prepared for the visit (Prior to consultation: the patient's story) and ending with time for reflection (Leave from consultation: did I remember everything?). The authors believe that using this model can help determine the real content of the patient's visit by balancing the patient's views of an illness ("voice of the lifeworld") with the physician's views ("voice of medicine"), thus making the consultation a more productive and enjoyable process for both. I think this model can be quite useful for addressing both, open and hidden agendas.

References

1. Hunziker S, Schlaepfer M, Langewitz W, Kaufmann G, Nuesch R, Battegay E, Zimmerli LU: Open and hidden agendas of "asymptomatic" patients who request check-up exams. BMC Family Practice 2011, 12:22.

2. Treece M: Successful Communication for Business and the Professions. 6th edition. Needham Heights, Massachusetts: Allyn and Bacon; 1994.

3. Bodgan RC, Biklen SK: Qualitative Research for Education: An Introduction to Theories and Methods. 5th edition. Boston, Massachusetts: Pearson Education; 2007.

4. Lustig MW, Koester J: Intercultural Competence: Interpersonal Communication across Cultures. 3rd edition. New York, New York: Addison Wesley Longman; 1999.

5. Adler NJ: International Dimensions of Organizational Behavior. 4th edition. Cincinnati, Ohio: South-Western; 2002.

6. Larsen J-H, Risor O, Putnam S: P-R-A-C-T-I-C-A-L: a step-by-step model for conducting the consultation in general practice. Family Practice 1997, 14(4):295-301.

Does provision of free medication represent usual care?

Oliver Frank — 2011-03-28T14:53:46Z

This is an important study and a well-designed trial overall, and I look forwards to seeing the findings. I would like to comment on the issue of aiming to have a 'usual care' control group.

The investigators say: "Practices will be allocated to one of three groups 1) Quit with Practice Nurse 2) Quitline Referral 3) usual care control group", but later state: "For patients in all three groups who are on low incomes and therefore eligible for subsidised medicines under the Australian Government Pharmaceutical Benefit Scheme (PBS) the project will fund access to nicotine patches."

The investigators justify this with: "This targeted subsidy will not disrupt the ecological validity of the study as a test of the different modes of cessation support as it will be offered equally across all three arms of the study".

The third group of practices will not be offering usual care, but instead will be offering free medication plus whatever other care the doctors and nurses choose to give. I would be happier to see the treatment to be provided by the third group described in these or similar terms.

Since the protocol was published, nicotine patches have been made available in Australia on the Pharmaceutical Benefits Scheme, which has greatly reduced the price that low income earners have to pay for them, but the principle remains the same. Provision of medication that would normally cost the patient something cannot be represented as usual care.

Would it help to have a fourth group of practices that are in fact free to provide whatever care they usually would?

Urgent need to get all health care workers certified in palliative care

Michael Hahn — 2010-09-21T16:46:24Z

Regarding the statement that "...actual and potential delivery of palliative care by general practitioners and community based nurses has been sorely neglected." The same scenario is true throughout the world.

Although many claim that palliative care is increasing more available in many health care settings, the service is often weak (poorly funded and staffed) and under-utilized.

All health care workers should be required to become certified in palliative care (similar to how advanced life support is trained) so that this vital service can be provided by any clinician in any health care setting. To find out about this, visit the website for the American Society for the Advancement of Palliative Care (ASAP Care) at http://www.asap-care.org .

Early diagnosis of CFS/ME has been shown to lead to a better prognosis

Tom Kindlon — 2010-04-06T08:17:10Z

It was interesting to see the various views expressed by GPs in this paper[1]. However I think a couple of useful points could have been added.

There is much discussion in the paper about whether a label of CFS/ME is useful or not. The authors refer to NICE guidelines which "emphasise the importance of a definitive diagnosis"[2]. However, I think it would have been useful to add some direct evidence on this issue. For example, research published by the Centres for Disease Control and Prevention (CDC) which found that an earlier diagnosis led to a better prognosis[3]. This prompted the CDC to launch a two-pronged awareness drive aimed at both health professionals and the general public - the tag line for the latter was, "Get informed. Get diagnosed. Get help."[4]. A UK study found that the longer the interval between a patient falling ill and getting a diagnosis, the greater the likelihood that they would become severely affected. [5]

The authors mention the issue of CFS/ME being managed in primary care. It is important for GPs to know that GPs encouraging patients to do a graded exercise programme is associated with a higher rate of adverse reactions. For example, a survey which asked patients about their experiences of treatments over the previous three years found that 45% reported being made worse by a graded exercise therapy (GET) programme overseen by their GP, compared to 31% who reported being made worse by a GET under a NHS specialist and 29% of those who did a GET in other circumstances[6]. The NICE guidelines do not recommend that a GP oversee such an approach[2].

References

[1] Chew-Graham C, Dowrick C, Wearden A, Richardson V, Peters S. Making the diagnosis of Chronic Fatigue Syndrome/Myalgic Encephalitis in primary care: a qualitative study. BMC Fam Pract. 2010 Feb 23;11:16.

[2] NICE CG 53 Chronic fatigue syndrome/Myalgic encephalomyelitis (or encephalopathy) guideline.

[3] Nisenbaum R, Jones JF, Unger ER, Reyes M and Reeves WC. A population-based study of the clinical course of chronic fatigue syndrome. Health and Quality of Life Outcomes 2003;1:49-58.

[4] CDC Chronic Fatigue Syndrome Awareness Campaign. http://cdc.gov/cfs/awareness.htm [Last accessed: 31 March, 2010]

[5] Pheby D and Saffron L. Biology and Medicine (2009); 1 (4):50-74. http://biolmedonline.com/Articles/vol1_4_50-74.pdf [Last accessed: 31 March, 2010]

[6] Action for M.E. and AYME Survey 2008 Results http://afme.wordpress.com/5-treatments-and-symptoms/ [Last accessed: 31 March, 2010]

Burnout and quality of interpersonal care

Ronald Epstein — 2009-10-15T09:13:01Z

To the editors,

We take a different interpretation of the findings reported by Zantinge, et al.1 in their recent article documenting a positive cross-sectional association between greater psychosocial orientation observed during clinical interviews and higher levels on two of the three facets of burnout. Their study and analyses were designed with a model of implicit causality, suggesting that burnout would reduce physicians’ psychological availability to patients. Instead, they found that more psychosocially-oriented physicians were also more burned out. An unfortunate conclusion of their negative findings might be that physician burnout increases physicians’ sensitivity to patients’ needs and that attempts to reduce burnout might compromise the quality of interpersonal care.

However, as the authors imply briefly, by reversing dependent and independent variables, a different conclusion would be reached – physicians who are more sensitive to and willing to engage with patients’ emotional concerns (by training or by temperament) might be more vulnerable to burnout, perhaps because they try to achieve more for their patients. A corollary to this alternative theory is that such physicians would need to develop psychological resilience to allow them to tolerate the additional “emotional labor”2 of empathic engagement with patients and benefit from the interpersonal richness of knowing their patients more intimately.3 Some evidence for the alternative hypothesis comes from our recently-published trial of an educational program in “mindful communication” in a group of primary care physicians with high baseline levels of burnout.4 With an intensive intervention to improve self-awareness, communication and resilience, we noted improvements in burnout, which were associated with improvements in empathy and psychosocial orientation to care. These changes were mediated by increased mindfulness, providing further rationale that psychological resilience to support a more biopsychosocial approach to care is not only desirable but also possible to achieve.

We also have become aware of a factor that may confound the interpretation of “psychosocial talk.” This category can sometimes include physician self-disclosures that have little relevance to patients’ concerns.5 The authors’ (and our) concern that distressed physicians might need to self-disclose information about themselves to patients at the expense of time spent on patients’ worries could be easily explored through content-oriented sequential analyses. These further analyses might help explain the lack of association of increased psychosocial talk with improved depression care.

Sincerely yours,

Ronald M. Epstein, MD
Michael S. Krasner, MD
Howard Beckman, MD
Benjamin Chapman, PhD
Anthony L. Suchman, MD, MA
Christopher J. Mooney, MA
Timothy E. Quill, MD
Kevin Fiscella, MD, MPH

Reference List

1. Zantinge E, Verhaak P, de Bakker D, van der Meer K, Bensing J. Does burnout among doctors affect their involvement in patients' mental health problems? A study of videotaped consultations. BMC Family Practice 2009;10(1):60.
2. Larson EB, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. Jama 2005;293(9):1100-1106.
3. Horowitz CR, Suchman AL, Branch WT, Jr., Frankel RM. What do doctors find meaningful about their work? Ann Intern Med 2003;138(9):772-775.
4. Krasner MS, Epstein RM, Beckman H et al. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA: The Journal of the American Medical Association 2009;302(12):1284-1293.
5. McDaniel SH, Beckman HB, Morse DS, Silberman J, Seaburn DB, Epstein RM. Physician self-disclosure in primary care visits: enough about you, what about me? Archives of Internal Medicine 2007;167(12):1321-1326.

Industry sponsorship is associated with a lower probability of publishing data required to calculate trial characteristics

Ronan Conroy — 2009-07-20T11:58:23Z

In table 5, Jones and colleagues present odds ratios for the impact of various types of trial funding on the probability that the trial will report the data required to determine the number of patients needed to be screened in order to randomize one participant, a key indicator of the external validity of any study.

However, the associated statistical analysis contrasts each of five funding sources with funding by charities. This has two disadvantages: by disaggregating their data into small groups, the authors' power to detect significant effects is diminished. But, more important, there is no a priori reason to compare each source of funding with charitable funding - why should charities be different?

On the other hand, there are compelling reasons to explore the effect of industry sponsorship on disclosure of the data required to assess external validity. Fifteen trials were sponsored by the pharmaceutical industry, of which eight (53%) provided data. Of the remaining trials with identifiable sources of funding (charities, governing body, government) 68 of 86 (79%) provided such data.

The relative risk of data disclosure associated with industry sponsorship is therefore 0.67 (P=0.0.033).

This is perhaps a lesson that for hypothesis tests to be meaningful there has to be a meaningful hypothesis being tested.