Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study.

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.

Health information technology and physician-patient interactions: impact of computers on communication during outpatient primary care visits.

Objective: The aim of this study was to evaluate the impact of introducing health information technology (HIT) on physician-patient interactions during outpatient visits.

Design: This was a longitudinal pre-post study: two months before and one and seven months after introduction of examination room computers. Patient questionnaires (n = 313) after primary care visits with physicians (n = 8) within an integrated delivery system.

A Mendelian locus on chromosome 16 determines susceptibility to doxorubicin nephropathy in the mouse.

The development of kidney disease is influenced by both genetic and environmental factors. Searching for models of glomerulopathy that display strong gene-environment interaction, we examined the determinants of anthracycline-induced nephropathy, a classic, strain-dependent experimental model applied to rodents in the past four decades. We produced three crosses derived from mice with contrasting susceptibility to doxorubicin (DOX) nephropathy and, surprisingly, we found that this widely studied model segregates as a single-gene defect with recessive inheritance.

Humanising medical education through faculty development: linking self-awareness and teaching skills.

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.

Precepting humanism: strategies for fostering the human dimensions of care in ambulatory settings.

Humanistic medical care is an important element of quality health care, and teaching humanism is increasingly recognized as an integral component of medical education. The goal of this article is to illustrate a series of tools that are effective in fostering both the provision and teaching of humanistic medical care in the ambulatory setting. Through a series of discussions, workshops, literature review, and practice, the authors have identified critical elements that promote the teaching of humanistic care.

Can patients tell when they are unwanted? "Turfing" in residency training.

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.

Spatiotemporal distribution of marine magnetotactic bacteria in a seasonally stratified coastal salt pond.

The occurrence and distribution of magnetotactic bacteria (MB) were studied as a function of the physical and chemical conditions in meromictic Salt Pond, Falmouth, Mass., throughout summer 2002. Three dominant MB morphotypes were observed to occur within the chemocline.

Patient reports of preventable problems and harms in primary health care.

Background: Despite recent attention given to medical errors, little is known about the kinds and importance of medical errors in primary care. The principal aims of this study were to develop patient-focused typologies of medical errors and harms in primary care settings and to discern which medical errors and harms seem to be the most important.

Methods: Thirty-eight in-depth anonymous interviews of adults from rural, suburban, and urban locales in Virginia and Ohio were conducted to solicit stories of preventable problems with primary health care that led to physical or psychological harm.

What do physicians tell patients about themselves? A qualitative analysis of physician self-disclosure.

Objective: Physician self-disclosure (PSD) has been alternatively described as a boundary violation or a means to foster trust and rapport with patients. We analyzed a series of physician self-disclosure statements to inform the current controversy.

Design: Qualitative analysis of all PSD statements identified using the Roter Interaction Analysis System (RIAS) during 1,265 audiotaped office visits.

Is physician self-disclosure related to patient evaluation of office visits?

Context: Physician self-disclosure has been viewed either positively or negatively, but little is known about how patients respond to physician self-disclosure.

Objective: To explore the possible relationship of physician self-disclosure to patient satisfaction.

Design: Routine office visits were audiotaped and coded for physician self-disclosure using the Roter Interaction Analysis System (RIAS).

Resuscitating the physician-patient relationship: emergency department communication in an academic medical center.

Study Objective: We characterize communication in an urban, academic medical center emergency department (ED) with regard to the timing and nature of the medical history survey and physical examination and discharge instructions.

Methods: Audiotaping and coding of 93 ED encounters (62 medical history surveys and physical examinations, 31 discharges) with a convenience sample of 24 emergency medicine residents, 8 nurses, and 93 nonemergency adult patients.

Results: Patients were 68% women and 84% black, with a mean age of 45 years.

Listening for feelings: identifying and coding empathic and potential empathic opportunities in medical dialogues.

The objective of the study was to validate the model of empathic opportunity (EO) and potential empathic opportunity (PEO) using the Roter Interaction Analysis System (RIAS) in a sample of cancer patients. Thirty-nine audio taped consultations at an outpatient oncology clinic performed by four oncologists were previously coded with the Roter Interaction Analysis System for another purpose. These consultations were also coded by two raters with the empathic and potential empathic opportunity method (E-PE-O method).

Assessing competence in communication and interpersonal skills: the Kalamazoo II report.

Accreditation of residency programs and certification of physicians requires assessment of competence in communication and interpersonal skills. Residency and continuing medical education program directors seek ways to teach and evaluate these competencies. This report summarizes the methods and tools used by educators, evaluators, and researchers in the field of physician-patient communication as determined by the participants in the "Kalamazoo II" conference held in April 2002.

Toward an informal curriculum that teaches professionalism. Transforming the social environment of a medical school.

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.

Mapping a locus for susceptibility to HIV-1-associated nephropathy to mouse chromosome 3.

HIV-1-associated nephropathy (HIVAN) is a major complication of HIV-1 infection with distinct pathologic features. Introduction of the HIV-1 genome into mice results in a renal disease with all of the histologic and clinical hallmarks of HIVAN on the FVB/N genetic background (TgFVB). We assessed the influence of genetic background on the development or progression of HIVAN by making F1 hybrids of TgFVB with five other inbred strains (CBA, DBA/2, CAST/Ei, C3H/He, BALB/c) and determining phenotypes relevant to renal failure among transgenic offspring (histology, blood urea nitrogen, proteinuria, serum albumin, and serum cholesterol).

Study design in qualitative research--2: Sampling and data collection strategies.

In two prior papers in our series on qualitative research [Frankel & Devers (2000a, 2000b) Qualitative research: a consumer's guide, Education for Health, 13, 113-123; Frankel & Devers (2000) Study design in qualitative research-1: developing research questions and assessing research needs, Education for Health, 13, 251-261], we examine two critical issues in qualitative research design: sampling, including identifying and negotiating access to research sites and subjects, and data collection and management. We describe these two key steps in the qualitative research design process, discuss challenges that often emerge when pursuing these steps, and provide guidelines for addressing them. Qualitative research most often uses "purposive," rather than random, sampling strategies.

Study design in qualitative research--1: Developing questions and assessing resource needs.

This is the second in a series of four papers on understanding and doing qualitative research [Frankel & Devers (2000) Qualitative research: a consumer's guide, Education for Health, 13, 113-123; Devers & Frankel (2000) Study design in qualitative research--2: sampling and data collection strategies, Education for Health, 13, 263-271]. Here, we focus on problems of study design, including question development, literature review, identifying a target audience and resource needs assessment. We provide a step-by-step description of major issues and choice points in the process.

Getting qualitative research published.

Translating research findings in health education into a publishable manuscript is challenging regardless of whether qualitative or quantitative methods are used. In this paper, we offer practical advice about how to successfully prepare and guide manuscripts based on qualitative research methods, in particular through the peer-reviewed journal publication process. Researchers trying to publish qualitative findings may face some unique challenges, given the field's current knowledge of qualitative methods, evaluation criteria, and conventional manuscript styles and length.

One year's experience with a program to facilitate personal and professional development in medical students using reflection groups.

Purpose: (1) to integrate sociobehavioral science concepts into the early curriculum through a continuity ambulatory clinical experience in primary care, and (2) to expose students to a learning environment in which self-awareness and emotional development are nurtured in the context of dealing with the stresses of an early clinical experience.

Methods: Second-year students spent half a day twice monthly in a primary care community practice, kept a journal of their experiences, and attended biweekly 60-minute Reflection Groups designed to foster personal awareness and empathic witnessing. Analysis of journal entries and Reflection Group field notes identified stressors occurring during the students' clinical encounters.

Qualitative research: a consumer's guide.

Qualitative research is best characterized as a family of approaches whose goal is understanding the lived experience of persons who share time, space and culture. Although they are often judged as a single entity, the approaches actually vary in their theoretical assumptions and canons of evidence. Four qualitative research domains that are currently used in studying education for health are reviewed here.

Improving the adverse changes in cardiac autonomic nervous control during laparoscopic surgery, using an intermittent sequential pneumatic compression device.

Background: The creation of positive pressure pneumoperitoneum (PP) may lead to adverse cardiovascular effects during laparoscopic operations. It can also lead to increased sympathetic cardiac activity, that might have serious consequences. We hypothesized that by reversing the hemodynamic effects, the use of intermittent sequential pneumatic compression device (Lympha-press) on the lower extremities would lead to improved cardiac autonomic control.

Magnetotactic bacteria on Earth and on Mars.

Continued interest in the possibility of evidence for life in the ALH84001 Martian meteorite has focused on the magnetite crystals. This review is structured around three related questions: is the magnetite in ALH84001 of biological or non-biological origin, or a mixture of both? does magnetite on Earth provide insight to the plausibility of biogenic magnetite on Mars? could magnetotaxis have developed on Mars? There are credible arguments for both the biological and non-biological origin of the magnetite in ALH84001, and we suggest that more studies of ALH84001, extensive laboratory simulations of non-biological magnetite formation, as well as further studies of magnetotactic bacteria on Earth will be required to further address this question. Magnetite grains produced by bacteria could provide one of the few inorganic traces of past bacterial life on Mars that could be recovered from surface soils and sediments.

Making the case for a qualitative study of medical errors in primary care.

In the interest of publicizing examples of funded qualitative health research, the authors share a proposal to the Agency for Healthcare Research and Quality in Washington, D.C., in which they sought to elicit patient stories of preventable problems in their primary health care that were associated with psychological or physical harms.