Good Bedside Manner Research Articles

(137) MULTIDISCIPLINARY PERSPECTIVES ON FEMALE SEXUAL HEALTH: HOW CAN WE DO BETTER?

Abstract Introduction Sexual dysfunction is a pervasive yet overlooked concern in the care of women with chronic urological conditions. Objective The purpose of this study is to evaluate the challenges and opportunities that urologists and sex therapists encounter when treating and referring female patients with chronic urological conditions and sexual health concerns. Methods All participants were recruited by email to participate in semi-structured interviews about their current practices, perceived barriers and facilitators, and preferences for further training. The interviews were recorded, transcribed, and inductively coded by two independent researchers. Excerpts were then analyzed using qualitative description to identify themes. Results We conducted 22 interviews involving 6 urologic oncologists, 7 urogynecologists, and 9 sex therapists, and determined themes affecting care for women with chronic urological conditions and sexual concerns: (Table 1). Lack of Training All participants indicated lack of education on the association between female sexual dysfunction and chronic urological conditions. Urologists were hesitant to discuss sexual health, citing a lack of counseling skills and treatment familiarity. Sex therapists, particularly those unaffiliated with academic centers, either did not inquire about or could not identify urological conditions in patients. Participants universally supported more focused training. Insufficient Communication Urologists were unlikely to proactively initiate the conversation about sexual health concerns with patients, primarily due to lack of time, need to focus on primary urological issues, older patient age, or the patient's low priority of sexual health. They saw merit, however, in using standardized questionnaires to facilitate discussions. Urogynecologists avoided treating sexual dysfunction to maintain a balanced surgical and clinical caseload. Sex therapists faced communication challenges with patients who normalized their symptoms or were overwhelmed by the chronicity of their condition. Integrated Care All participants considered multi-disciplinary collaboration with one another, and with gynecologists and pelvic floor physical therapists to be beneficial. Referral Dynamics All participants identified cost, insurance coverage, lack of understanding of each profession's capabilities, and patient reluctance as barriers to referral. Urologists were motivated to refer to sex therapists when they exhausted treatment options, when patients expressed interest in seeing a sex therapist, or when urologists had a trusted list of sex therapists for referrals. Sex therapists were more inclined to refer if they knew the urologist was collaborative, possessed a good bedside manner, showed interest in female sexual medicine, and had good marketing. Conclusions Participants faced personal, professional, and patient-centered obstacles when addressing the sexual concerns of women with chronic urological conditions. Future interventions should aim to mitigate these factors and promote cross-disciplinary partnership to enhance the overall quality of sexual health care. Disclosure No.

What Makes a 5-Star Orthopaedic Sports Medicine Surgeon? An Analysis of Positive Online Patient Reviews.

The increased focus on patient satisfaction has led to growth in the use of physician rating websites. To analyze the factors associated with online 5-star patient reviews for orthopaedic sports medicine surgeons. Cross-sectional study. A total of 70 orthopaedic sports medicine surgeons were randomly selected from the AOSSM website. A search was performed for these surgeons on Yelp.com. All reviews other than 5 stars (of a possible 5 stars) were excluded from the study. Each review was categorized as referring to a surgical or nonsurgical aspect of care, and each comment within the review was categorized as being clinically or nonclinically related. Comments were further subcategorized by specific features such as bedside manner, clinical outcomes, and patient education. Categorical variables were analyzed using the chi-square test. Overall, 400 five-star reviews were included in the study, comprising 1225 total positive comments. Of the 400 five-star reviews, 200 (50%) were from surgically treated patients, and 200 (50%) were from nonsurgically treated patients. Of the 1225 positive comments, 505 (41%) were clinically related, and 720 (59%) were nonclinical. The most common positive clinical comments were for clear treatment plans (191 reviews [48%]), good outcomes (173 reviews [43%]), and providing alternative treatment plans (55 reviews [14%]). The most common positive nonclinical comments were for good physician bedside manner (287 reviews [72%]), friendly/professional staff (194 reviews [49%]), and ease of scheduling (68 reviews [17%]). The majority of 5-star patient reviews left positive comments regarding nonclinical aspects of care such as physician bedside manner and friendly staff. The most common positive comments regarding clinical aspects concerned good outcomes and clear treatment plans. The overall most common positive comment, in both surgically and nonsurgically treated patients, referred to good bedside manner.

“Shoot from the Hip”: What Patients with Cancer Want from Communication About Serious Illness During COVID-19 (S526)

Outcomes1. Describe what patients with cancer and caregivers value in communication about serious illness2. Examine strategies that model these valuesOriginal Research BackgroundWhen asked to share recommendations for providers and health systems to foster high-quality care during COVID-19, patients with cancer and their caregivers recommended providers to “communicate proactively and effectively” about serious illness.Research ObjectiveIn this secondary analysis of participant responses, we aimed to identify patient and caregiver perspectives on what it means to “communicate proactively and effectively” about serious illness.MethodsContent analysis of communication-related output from 15 semistructured interviews of diverse patients with cancer and caregivers of patients with serious illness.ResultsTheme 1: Transparency: Clinicians share the medical rationale for recommendations: “If what's explained to me is that my chance of recovery … is minimal, and I'm just going to increase my suffering, well, then that feels like a chance for acceptance.”Theme 2: Proactivity: Clinicians facilitate conversations about care preferences in advance: “Right now, you guys have this incredible opportunity to have these conversations. To enable—you know, oncologists to have these conversations with their patients while they're as an outpatient, before they get COVID?”Theme 3: Coordination: Clinicians integrate with the interdisciplinary palliative care team to communicate serious news: “I would ask that [what] be done a little bit better is the integration of the social worker with the doctor, especially in the palliative and hospice care. We know that not every doctor has got a good bedside manner… it's hard to tell someone you're going to die.”Theme 4: Respect for autonomy: Patients and caregivers feel empowered by clinicians to make informed decisions: “You're still in control of your decision-making, given the parameters, even though you're not in control of the parameters.”ConclusionPatients with serious illness and caregivers of patients with serious illness value transparent, proactive, and coordinated communication that respects their autonomy.Implications for Research, Policy, or PracticeEfforts to make serious illness communication more patient-centered during COVID-19 will target these areas that align with established patient-centered communication theories.

P6. A BIG DATA APPROACH TO UNDERSTANDING PATIENT SATISFACTION WITH MASTOPEXY SURGERY

PURPOSE: A physician’s online footprint is becoming increasingly important in the age of social media. Therefore, understanding what drives patient satisfaction and behavior on social media is paramount to increasing patient satisfaction and maintaining a pristine online image. This study utilizes data obtained from Realself.com, a social media platform that allows patients to leave reviews of their plastic surgery experiences, to further elucidate the drivers behind patient satisfaction. METHODS: Patient reviews from the ‘Mastopexy’ category of Realself.com were collected using Scrapy, a python web crawling software that collects textual data from websites. Patient review data includes star ratings 1-5 in overall rating and various subcategories, as well as a free text entry, and cost data. Each entry was manually reviewed and categorized. Additionally, multiple regression was performed to assess independent predictors of overall satisfaction on the overall experience. RESULTS: A total of 968 mastopexy reviews were collected, 85.6% positive and 14.4% negative. The most common reasons for positive experience were aesthetic appearance (66.5%) and good physician bedside manner (21.7%). Similarly, negative reviews also most frequently cited appearance(58.3%) and bedside manner (26.6%). Several independent predictors of overall satisfaction were identified. Physician bedside manner (p<0.001), after-care follow up(p<0.001), staff professionalism and courtesy(p=0.016) and wait times (p=0.011) were independently associated with a positive overall review. CONCLUSION: We found that physician bedside manner, after-care follow up, staff professionalism and courtesy and wait times are independent predictors of overall patient satisfaction. Understanding the importance of these factors will increase rates of patient satisfaction and improve their overall online footprint.

Using Sentiment Analysis to Understand What Patients Are Saying About Hand Surgeons Online.

Physician review websites have influence on a patient's selection of a provider. Written reviews are subjective and difficult to quantitatively analyze. Sentiment analysis of writing can quantitatively assess surgeon reviews to provide actionable feedback for surgeons to improve practice. The objective of this study is to quantitatively analyze large subset of written reviews of hand surgeons using sentiment analysis and report unbiased trends in words used to describe the reviewed surgeons and biases associated with surgeon demographic factors. Online written and star-rating reviews of hand surgeons were obtained from healthgrades.com and webmd.com. A sentiment analysis package was used to calculate compound scores of all reviews. Mann-Whitney U tests were performed to determine the relationship between demographic variables and average sentiment score of written reviews. Positive and negative word and word-pair frequency analysis was also performed. A total of 786 hand surgeons' reviews were analyzed. Analysis showed a significant relationship between the sentiment scores and overall average star-rated reviews (r2 = 0.604, P ≤ .01). There was no significant difference in review sentiment by provider sex; however, surgeons aged 50 years and younger had more positive reviews than older (P < .01). The most frequently used bigrams used to describe top-rated surgeons were associated with good bedside manner and efficient pain management, whereas those with the worst reviews are often characterized as rude and unable to relieve pain. This study provides insight into both demographic and behavioral factors contributing to positive reviews and reinforces the importance of pain expectation management.

Creepy, but Persuasive: In a Virtual Consultation, Physician Bedside Manner, Rather than the Uncanny Valley, Predicts Adherence

Care for chronic disease requires patient adherence to treatment advice. Nonadherence worsens health outcomes and increases healthcare costs. When healthcare professionals are in short supply, a virtual physician could serve as a persuasive technology to promote adherence. However, acceptance of advice may be hampered by the uncanny valley effect—a feeling of eeriness elicited by human simulations. In a hypothetical virtual doctor consultation, 441 participants assumed the patient’s role. Variables from the stereotype content model and the heuristic–systematic model were used to predict adherence intention and behavior change. This 2 × 5 between-groups experiment manipulated the doctor’s bedside manner—either good or poor—and virtual depiction at five levels of realism. These independent variables were designed to manipulate the doctor’s level of warmth and eeriness. In hypothesis testing, depiction had a nonsignificant effect on adherence intention and diet and exercise change, even though the 3-D computer-animated versions of the doctor (i.e., animation, swapped, and bigeye) were perceived as eerier than the others (i.e., real and cartoon). The low-warmth, high-eeriness doctor prompted heuristic processing of information, while the high-warmth doctor prompted systematic processing. This pattern contradicts evidence reported in the persuasion literature. For the stereotype content model, a path analysis found that good bedside manner increased the doctor’s perceived warmth significantly, which indirectly increased physical activity. For the heuristic–systematic model, the doctor’s eeriness, measured in a pretest, had no significant effect on adherence intention and physical activity, while good bedside manner increased both significantly. Surprisingly, cognitive perspective-taking was a stronger predictor of change in physical activity than adherence intention. Although virtual characters can elicit the uncanny valley effect, their effect on adherence intention and physical activity was comparable to a video of a real person. This finding supports the development of virtual consultations.

668 Qualitative assessment of patient values in decision making for alopecia areata: Preliminary results

Alopecia areata (AA) is a common disease of hair loss with no FDA-approved therapies. While many treatments are available to patients, each have their own benefits and risks. Clarifying patient values is an important step to help patients choose the treatment that best fits their unique needs. A qualitative study using semi-structured interviews was conducted with 10 patients recruited from Brigham and Women’s Hospital dermatology clinic. Interviews were split and independently coded among two pairs of researchers. Codes were determined by consensus. Coding reliability and frequency were determined using NVIVO software. Interrater reliability ratings were κ =.77 (% agreement: 99%) and κ=.69 (% agreement: 98%) for the two coding teams, indicating good-excellent agreement. Key themes emerged: 100% of patients considered treatment efficacy, safety profile, and convenience of use when choosing an AA treatment. 90% of patients reported barriers to receiving appropriate treatment for various reasons, such as lack of local experts in hair loss, other time commitments, and health insurance coverage. The majority of patients considered physician recommendations (80%) and information found on the internet (70%) when choosing a treatment. 60% of patients sought dermatologists with qualifications such as affiliations with teaching hospitals and specialization in hair loss. Patients preferred physicians that reviewed treatment options comprehensively with good bedside manner (50%). Understanding patient values and barriers to treatment is important in the shared-decision making process. This study demonstrates that patients highly value information on treatment risks and benefits, which they obtain from multiple sources including physicians and online-based materials. These findings are important to discuss to help patients make higher quality decisions that align with their treatment preferences.

Assessment of Knowledge and Awareness about Consent among Medical Practitioners in a Tertiary Care Hospital – A Questionnaire based Study

Introduction: The medicine being a moral profession, the relationship of doctor and patient entailsthe highest conceivable degree of trust and fidelity. Good bedside manner, technical competency andcommunication skills are the physician’s behaviors most strongly associated with patient trust. The changingmedical practice of the 20th century has given place to patient’s autonomy and informed consent. Consentis not mere submission of the patient to a particular treatment, but a process of communication requiringthe fulfilment of certain established elements like competence, sufficient disclosure, understanding andvolunteering. However, less attention has been paid to the implications of obtaining informed consent, fromthe physicians’ perspective. Considering the above fact, the study was undertaken to assess the knowledgeand awareness about informed consent among medical practitioners in a tertiary care hospital.Materials and Methods: A prospective, cross-sectional, questionnaire-based study was undertaken in 100medical practitioners during May 2020 to July 2020.Results: It was observed that most of the participants were aware and had sufficient knowledge aboutinformed consent, but the law related to consent and other inner details of informed consent in medicalpractice were lacking.Conclusion: We concluded that medical institutions, various medical associations and medico-legal bodiesmust conduct regular medico legal training programmes, continuum medical education programmes,seminars and workshops and must be made mandatory to participate actively for all medical practitioners toupdate their knowledge related to consent in medical practice and law related to medical practice.

Human Rights of Users of Humanlike Care Automata

Care is more than dispensing pills or cleaning beds. It is about responding to the entire patient. What is called “bedside manner” in medical personnel is a quality of treating the patient not as a mechanism but as a being—much like the caregiver—with desires, ideas, dreams, aspirations, and the gamut of mental and emotional character. As automata, answering an increasing functional need in care, are designed to enact care, the pressure is on their becoming more humanlike to carry out the function more effectively. The question becomes not merely whether the care automaton can effect good bedside manner but whether the patient’s response is not feeling deceived by the humanlikeness. It seems the device must be designed either to effect explicit mere human-“likeness,” thus likely undermining its bedside-manner potential, or to fool the patient completely. Neither option is attractive. This article examines the social problems of designing maximally humanlike care automata and how problems may start to erode the human rights of users/patients. The article then investigates the alternatives for dealing with this problem, whether by industrial and professional self-regulation or public-policy initiatives. It then frames the problem in the broader historical perspective in terms of previous bans, moratoria, and other means of control of hazardous and potentially rights-violating techniques and materials.

21: Characterizing anxiety at the first encounter in women presenting to the urogynecology clinic: the Café Study

Anxiety can be measured in various ways. State anxiety is temporary and is sensitive to change, while trait anxiety is a generalized propensity to be anxious. Our objective is to characterize the reasons for anxiety in women presenting for their initial urogynecologic consultation, to measure the change in participant anxiety after the visit, and to correlate the degree of anxiety improvement with visit satisfaction. All new patients presenting to our tertiary Urogynecology clinic were invited to participate in this IRB approved study. Following consent, participants completed pre- and post-visit questionnaires. The pre-visit questionnaires included the Pelvic Floor Distress Inventory (PFDI), Generalized Anxiety Disorder-7 (GAD), and the Spielberg State Trait Anxiety Inventory (STAI) Y6. Participants were also asked to list their pre-visit anxieties. The provider was blinded to any of the pre and post-visit questionnaire responses. The post-visit questionnaires consisted of the STAI-Y6, patient global impression of improvement (PGI-I) of participant anxiety, patient satisfaction, and the participant’s perception of how their anxiety was address during the visit. The anxieties listed by participants were reviewed independently by 2 authors (TP and YC) and categorized. A third-party panel arbitrated when there were disagreements among anxiety categories. A total of 50 women, primarily white (66%), with an average age of 53 years (range 21-86) completed the study. The visit diagnoses included: POP (20%), UUI (46%), SUI (54%), recurrent UTI (12%), and myofascial pain (28%). 22% of participants had a history of anxiety diagnosis. The average pre-visit STAI score was 42.9 (SD=11.98) which decreased by 12.60 points post-visit (Figure 1). Post-visit decreased anxiety was associated with improvements in the PGI-I scores and with the perception that participant anxiety was completely addressed. The most reported causes for consultation-related anxiety were: lack of knowledge of diagnosis and ramifications, fear of no solution/persistent suffering, and fear of pelvic exam. Participants reported the following reasons why their anxiety improved: patient education, reassurance, good bedside manner, and clear diagnosis with an acceptable treatment plan. Participants reporting complete satisfaction demonstrated a greater decrease in post-visit STAI scores compared to participants not reporting complete satisfaction. Changes in the STAI score were not associated with the PFDI or GAD scores. Women with the highest satisfaction following their initial Urogynecology visit also demonstrate the largest decreases in anxiety following the visit. Changes in anxiety scores were not correlated with the PFDI or with measures of generalized anxiety (GAD-7).

The doctor's digital double: how warmth, competence, and animation promote adherence intention.

BackgroundEach year, patient nonadherence to treatment advice costs the US healthcare system more than $300 billion and results in 250,000 deaths. Developing virtual consultations to promote adherence could improve public health while cutting healthcare costs and usage. However, inconsistencies in the realism of computer-animated humans may cause them to appear eerie, a phenomenon termed the uncanny valley. Eeriness could reduce a virtual doctor’s credibility and patients’ adherence.MethodsIn a 2 × 2 × 2 between-groups posttest-only experiment, 738 participants played the role of a patient in a hypothetical virtual consultation with a doctor. The consultation varied in the doctor’s Character (good or poor bedside manner), Outcome (received a fellowship or sued for malpractice), and Depiction (a recorded video of a real human actor or of his 3D computer-animated double). Character, Outcome, and Depiction were designed to manipulate the doctor’s level of warmth, competence, and realism, respectively.ResultsWarmth and competence increased adherence intention and consultation enjoyment, but realism did not. On the contrary, the computer-animated doctor increased adherence intention and consultation enjoyment significantly more than the doctor portrayed by a human actor. We propose that enjoyment of the animated consultation caused the doctor to appear warmer and more real, compensating for his realism inconsistency. Expressed as a path model, this explanation fit the data.DiscussionThe acceptance and effectiveness of the animation should encourage the development of virtual consultations, which have advantages over creating content with human actors including ease of scenario revision, internationalization, localization, personalization, and web distribution.

Online Physician Reviews in Female Pelvic Medicine and Reconstructive Surgery: What Do Patients Really Want?

This study aimed to qualitatively analyze online reviews of Female Pelvic Medicine and Reconstructive Surgery (FPMRS) specialists to better understand patients' experiences and improve patient satisfaction. Fifty urologists and urogynecologists were randomly sampled from the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction membership website. We evaluated patient ratings and reviews of physicians from 4 websites: Yelp, Healthgrades, Vitals, and UCompareHealthCare. Qualitative data analysis was performed using grounded theory methodology, as described by Charmaz (Constructing Grounded Theory, 2014). Across the four websites, the mean number of stars per physician ranged from 3.6 to 4.1 and the mean number of reviews per physician ranged from 1.3 to 7.6. Qualitative analysis revealed several preliminary themes: patient-physician experience, medical and surgical treatment, office staff, and analysis of worth. Physicians who developed strong connections with patients through empathetic communication were likely to receive a positive review, regardless of wait times. Bedside manner was found to be multidimensional and included physician competence and understanding patients' concerns. Failure to meet several expectations led to dissatisfaction of care and negative patient reviews. Patients' perspectives of quality of care in FPMRS are weighted heavily toward establishing personal connections with physicians. Accurate diagnosis and effective management of urological conditions, especially after negative experiences with previous providers, were associated with satisfaction of care. It seems that the concept of good bedside manner is multifactorial and requires the provider to demonstrate not one but several different sets of communication skills.

Navigating the social synapse: the neurobiology of bedside manner.

This paper seeks to explore the application of neurobiology to further understanding the importance of developing, refining and modelling good bedside manner in psychiatry. The concept of a social synapse is used as a framework to understand the impact of verbal and non-verbal information that crosses between two attuned individuals. Research shows that widely distributed cortical and subcortical networks are involved in processing of social information and the perception of safety. Good bedside manner is proposed as the ability of a clinician to navigate the social synapse and make a patient feel at ease. Findings from neurobiology suggest that good bedside manner needs to be a more considered component of effective psychiatric health care.

Examiner and simulated patient ratings of empathy in medical student final year clinical examination: are they useful?

BackgroundMany medical schools state that empathy is important and have curricular learning outcomes covering its teaching. It is thought to be useful in team-working, good bedside manner, patient perspective taking, and improved patient care. Given this, one might expect it to be measured in assessment processes. Despite this, there is relatively little literature exploring how measures of empathy in final clinical examinations in medical school map onto other examination scores. Little is known about simulated patient (actors) rating of empathy in examinations in terms of inter-rater reliability compared with clinical assessors or correlation with overall examination results.MethodsExaminers in final year clinical assessments in one UK medical school rated 133 students on five constructs in Objective Structured Long Examination Record (OSLER) with real patients: gathering information, physical examination, problem solving, managing the diagnosis, and relationship with the patient. Scores were based on a standardized well-established penalty point system. In separate Objective Structured Clinical Examination (OSCE) stations, different examiners used the same penalty point system to score performance in both interactional and procedural stations. In the four interaction-based OSCE stations, examiners and simulated patient actors also independently rated empathy of the students.ResultsThe OSLER score, based on penalty points, had a correlation of −0.38 with independent ratings of empathy from the interactional OSCE stations. The intra-class correlation (a measure of inter-rater reliability) between the observing clinical tutor and ratings from simulated patients was 0.645 with very similar means. There was a significant difference between the empathy scores of the 94 students passing the first part of the sequential examination, based on combined OSCE and OSLER scores (which did not include the empathy scores), and 39 students with sufficient penalty points to trigger attendance for the second part (Cohen’s d = 0.81).ConclusionsThese findings suggest that empathy ratings are related to clinical performance as measured by independent examiners. Simulated patient actors are able to give clinically meaningful assessment scores. This gives preliminary evidence that such empathy ratings could be useful for formative learning, and bolsters the call for more research to test whether they are robust enough to be used summatively.

Diagnosis, Bedside Manner and Comment Style are Predictive Factors in Online Ratings of Urologists

IntroductionWe assess how urologists are rated online by patients and which factors influence these ratings. MethodsWe created an anonymous database of urologists’ ratings from Ontario, Canada using a popular rating website (RateMDs.com). Comments were assessed for mention of diagnosis, bedside manner and nonlinguistic emphasis devices, and the impact of these variables was analyzed. ResultsA total of 3,288 ratings were identified for 224 urologists (median 15 ratings per urologist, range 1 to 35), representing 75.4% of practicing urologists in the province. Mean rating was 3.96/5 (median 4.75, range 1 to 5). Overall 2,215 ratings (67.4%) were 4/5 or greater. Comment on good bedside manner was associated with higher ratings (mean 4.74 vs 3.92, p <0.001) and comment on poor bedside manner was associated with lower ratings (mean 2.45 vs 4.01, p <0.001). Patients mentioning surgery rated urologists higher than those who did not (4.28 vs 3.85, p <0.001). A specific diagnosis was mentioned in 1,056 cases (32.1%). Mean rating was highest for kidney cancer (4.67) and lowest for vasectomy (3.77, p <0.001). Comments with at least 1 word in full capital letters and those with a word or phrase in quotation marks were accompanied by lower ratings (mean 3.11 vs 4.03 and 3.13 vs 4.02, respectively, p <0.001). Longer comments were also associated with lower ratings (word count 1 to 50—mean rating 4.24, word count 51 to 100—mean rating 3.88, word count greater than 100—mean rating 3.29; p <0.001). ConclusionsUrologists are reviewed favorably online. Patients who note surgery, a cancer diagnosis or good bedside manner rate urologists highly, while longer comments, the use of all caps or quotation marks, or mention of a poor bedside manner are associated with lower ratings.

Neurological perspectives on person-centered medicine

The doctor-patient relationship has developed from unspecified good bedside manner to patient-centered medicine with an increasing focus upon the recognition of patients’ ethical and legal rights. In any given clinical situation, our medical decisions are made in the balance between the physician’s knowledge and experience, and the patient and his relatives’ values and preferences. Shared decision-making is a part of each specialty, but it will be modified according to the clinical problems specific for that specialty.

The consultation and physical examination

Since Michael Balint in the 1950s much reflection and comment has occurred on the concept of the consultation.1 Now cohort after cohort of medical students benefit from ever greater exposure to communication ideas leaving their more qualified colleagues running to catch up. Little, though, has been said about the physical examination. This is remarkable. The physical examination forms part of our earliest clinical experience but has had little focus in my professional development since then. I believe that the evolution in our communication skills has more to contribute to the physical examination of our patients and the physical examination has more to contribute to the consultation than is commonly identified. Balint said ‘Our patients are trained from childhood to expect a more or less thorough physical examination.’1 Patients intermingle telling their story and the doctor's examination, and see these as two parts of a whole. I examine sometimes to meet patient expectation. Although there are patients who prepare for a physical examination (going home to wash) and I only identify this as I am closing the consultation, how many others will have left without this expectation being understood and met? But a physical examination does more than address patient expectation. The acknowledged significance of physical examination is in finding physical signs. There are decades of medical undergraduate education committed to this. Although the ‘thorough physical examination’ was a 20th century phenomenon, before that, ‘the physician's job was not hands on: what counted were book learning, experience, memory, judgement and a good bedside manner’.2 In the diagrammatic representation of the Cambridge Calgary model3 of the consultation, …

Communication skills teaching comes of age

The doctor–patient relationship (a good bedside manner) has always been recognised as central to medicine. However, the systematic teaching of communication skills and assessment of students communicating with their patients is a relatively new element in medical education. It is only recently that we have moved from the belief that entrants to medical school, by virtue of their intelligence, are innately effective and sensitive communicators, and that any who aren’t can pick up the skills by osmosis and good intentions. Now, communication skills teaching to undergraduates has come of age. Building on pioneering work introducing the use of simulated patients (e.g. Barrows in North America and Whitehouse and colleagues in the UK), communication skills education has now developed to the point where, for example, medical students in the UK are expected to learn core skills in all components of the medical interview, such as information gathering, and explanation and planning, as well as those required in challenging communication situations such as the breaking of bad news, and to be assessed in their performance of these tasks before they can qualify. However, there is evidence of considerable variability in course content, timing, duration and methods of assessment, which means that students at different schools may have very different experiences.

Communication with Patients who have Low Vision

Vision rehabilitation is a clinical discipline in which there is a great deal of discussion with patients--reviewing patients' goals; educating patients about their ocular condition; outlining rehabilitation options; and often conveying news, such as the assessment that a patient can no longer drive or that it is anticipated that a patient's vision will never improve. This article reviews two published models of physician-patient communication and addresses how each may apply to health care professionals in vision rehabilitation who communicate with patients, such as discussing the need to stop driving with patients who have age-related macular degeneration (AMD). Communication with patients is a core clinical skill for all health care professionals that can be evaluated, taught, and improved. Medical schools historically taught this skill informally and referred to physicians as having or not having a good bedside manner. Today, more emphasis is placed on communication as a teachable skill in the health care setting, with a shift toward communication skills being more explicitly taught and evaluated. In the United States, the Accreditation Council for Graduate Medical Education requires that residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates (Hutul, Carpenter, Tarpley, & Lomis, 2006, p. 401). One can consider how clinicians communicate with patients who have AMD by considering how one would approach a discussion in the following hypothetical scenario: Mr. B is a spry 80 year old who lives alone. He was diagnosed with AMD three years ago and has had photodynamic treatment in one eye and antivascular endothelial growth factor intravitreal treatment to his left eye. Mr. B's acuity is now 20/100 OD and 20/200 OS. His contrast sensitivity is markedly reduced, and he has large scotomas in the left eye and scotomas encircling the central retina in the right eye. His wife recently died, and he moved to a neighboring city to be closer to his two daughters. Mr. B drives only during the day. He reported that he is depressed, having fallen recently and experiencing the symptom of seeing people and faces that he knows are not there. He set his car keys on the desk beside him when the interview started and cried twice during the interview. How does a clinician approach a patient who needs to be told that he cannot continue to drive? How does a clinician approach a patient who begins to cry during the interview? This scenario presents many issues for a vision rehabilitation clinician to discuss with Mr. B. THE SPIKES STRATEGY Robert Buchman is an oncologist who wrote both a text, How to Break Bad News: A Guide for Health Care Professionals (Buchman, 1992), and an article entitled, Breaking Bad News: The SPIKES Strategy (Buchman, 2005). He defined bad news as any news that is contrary to a patient's expectations. It is the patient's perception of the situation that determines how bad the news is, not the clinician's perception of the significance of the discussion. The SPIKES protocol is a strategy, not a scripted language, for approaching discussions with a patient. It recommends that health care professionals consider the sequential steps outlined by Buchman: setting, perception, invitation, knowledge, empathy, and strategy and summary. The SPIKES protocol first recommends that clinicians attend to the setting, so that significant news is discussed at a time when privacy is assured, the appropriate individuals are present, the clinician can be comfortably seated at the same level as the patient, and the clinician can be attentive and not rushed. In the second step, perception, the clinician asks before he or she tells. As Buchman (1992, p. 140) noted, Before you break bad news to your patients, you should glean a fairly accurate picture of their perception of the medical situation--in particular, how they view the seriousness of the condition. …

Medical Informed Consent

Until the mid-twentieth century, rarely would a patient question a doctor's diagnosis or proposed treatment. The "good bedside manner" was used to describe a doctor who made the effort to explain medical procedures to his patients. Recently, however, the legal profession has begun questioning medical practitioners about treatments that have gone wrong. In this paper, the writers trace the concept of medical informed consent and explore whether the laws serve to protect and inform the public or whether they merely confuse the issues.