Patient-centered Attitudes Research Articles

Nonverbal Sensitivity in Medical Students: Implications for Clinical Interactions

Clinicians' accuracy in perceiving nonverbal cues has potentially important consequences, but has received insufficient research. To examine the relation of medical students' nonverbal sensitivity to their gender and personal traits, as well as to their communication and impressions made during a standardized patient (SP) visit. Psychometric testing, questionnaire, and observation. One US medical school. Two-hundred seventy-five third-year medical students. Nonverbal sensitivity and attitudes were measured using standard instruments. Communication during the SP visit was measured using trained coders and analogue patients who viewed the videotapes and rated the favorability of their impressions of the student. Nonverbal sensitivity was higher in female than male students (P < 0.001) and was positively correlated with self-reported patient-centered attitudes (P < 0.01) and ability to name one's own emotions (P < 0.05). It was also associated with less distressed (P < 0.05), more dominant (P < 0.001), and more engaged (P < 0.01) behavior by the SP, and with more liking of the medical student (P < 0.05) and higher ratings of compassion (P < 0.05) by the analogue patients. Correlations between nonverbal sensitivity and other variables were generally stronger and different for male than female students, but nonverbal sensitivity predicted analogue patients' impressions similarly for male and female students. Medical students' nonverbal sensitivity was related to clinically relevant attitudes and behavioral style in a clinical simulation.

Can Changes in the Principal Clinical Year Prevent the Erosion of Studentsʼ Patient-Centered Beliefs?

The third year of medical school, in which students traditionally receive their first immersion into hospital-based clinical medicine, often results in a degradation of attitudes toward medicine and patient care. The authors present data collected in the 2005-2006 academic year from a pilot program aimed at enhancing this experience, thereby enabling students to resist these negative influences. Thirty-two Harvard Medical School students, who spent their entire principal clinical experience (PCE) at one of three clinical sites (PCE group), completed the Patient-Practitioner Orientation Scale (PPOS), a measure of patient-centered attitudes, at the beginning of the year. They completed the PPOS again at year's end as well as the Community, Curriculum, and Culture (C3) hidden curriculum measure of patient-centered clinical experiences. Their responses on these measures were compared with those of a traditional-rotation control group that moved from site to site. At the beginning of the year, no PPOS differences were found within PCE groups or between PCE and control students. Traditional students' attitudes became significantly less patient-centered at year's end, whereas PCE students' attitudes did not change. PCE students reported more support for their patient-centered behaviors, and, across all students, C3 scores and changes in PPOS scores were significantly correlated. Innovations in clinical education may help inoculate medical students against the degradation of attitudes. Although this research was a test of a small pilot program, the consistent pattern of findings across those clinical sites and educational models studied provides suggestive evidence that the oft-cited negative impacts of the principal clinical year are not inevitable.

Longitudinal Pedagogy: A Successful Response to the Fragmentation of the Third-Year Medical Student Clerkship Experience

A longitudinal clerkship was designed at Harvard Medical School (HMS) in 2004-2005 to emphasize continuity, empathy, learner-centeredness, and patient-centered care. In 2005-2006, the curriculum was piloted with eight students who voluntarily enrolled in the third-year curriculum, which focused on longitudinal mentorship and feedback, interdisciplinary care, integration of clinical and basic science, and humanism in patient care. Eighteen traditional curriculum (TC) students at HMS who were comparable at baseline served as a comparison group. SHELF exams and OSCE performance, monthly and end-of-year surveys, and focus groups provided comparisons between pilot and TC students on their performance, perceptions, attitudes, and satisfaction. Pilot students performed as well as or better than their peers in standardized measures of clinical aptitude. They demonstrated statistically significant greater preservation of patient-centered attitudes compared with declining values for TC students. Pilot students rated the atmosphere of learning, effective integration of basic and clinical sciences, mentorship, feedback, clerkship satisfaction, and end-of-year patient-care preparedness significantly higher than TC students. The authors conclude that implementation of a longitudinal third-year curriculum, with only modest alterations in existing clinical training frameworks, is feasible and effective in meeting its stated goals. "Exposing" the hidden curriculum through specific longitudinal activities may prevent degradation of student attitudes about patient-centered care. Minimizing the disjointed nature of clinical training during a critical time in students' training by providing a cohesive longitudinal curriculum in parallel to clinical clerkships, led by faculty with consistent contact with students, can have positive effects on both professional performance and satisfaction.

Medicina centrada no paciente e ensino médico: a importância do cuidado com a pessoa e o poder médico

Este artigo apresenta uma revisão da medicina centrada no paciente e da importância de ensiná-la nas escolas médicas, em virtude das repercussões para o exercício da medicina advindas da mudança na nosologia prevalente e da maior disponibilidade de informações sobre saúde e doenças para os leigos. Também discute o uso de escalas para avaliação de atitudes a respeito da relação médico-paciente, particularmente da escala Patient-practitioner orientation scale (PPOS), em que escores mais elevados estão associados a atitudes mais centradas no paciente. Apresenta os resultados da aplicação dessa escala em 738 estudantes de seis diferentes períodos do curso de Medicina da Faculdade de Medicina da Universidade Federal de Minas Gerais, comparando-os com os obtidos com estudantes norte-americanos com uso da mesma escala. Os escores foram mais elevados entre estudantes brasileiros, com atitudes mais centradas no paciente do que os estudantes norte-americanos. A análise das subescalas de poder e cuidado mostra que há uma valorização do cuidado. Entretanto, houve uma tendência à concentração de poder no médico.

Doctors' responses to patients with medically unexplained symptoms who seek emotional support: criticism or confrontation?

Objective Consultations about medically unexplained symptoms (MUSs) can resemble contests over the legitimacy of patients' demands. To understand doctors' motivations for speech appearing to be critical of patients with MUSs, we tested predictions that its frequency would be related to patients' demands for emotional support and doctors' patient-centered attitudes as well as adult attachment style. Methods Twenty-four general practitioners identified 249 consecutive patients presenting with MUSs and indicated their own patient-centered attitudes as well as adult attachment style (positive models of self and others). Before consultation, patients self-reported their desire for emotional support. Consultations were audio recorded and coded utterance by utterance. The number of utterances coded as criticism was the response variable in the multilevel regression analyses. Results Frequency of criticism was positively related to patients' demands for emotional support, to doctors' belief in sharing responsibility with patients and to doctors' positive model of themselves. It was inversely associated with doctors' belief that patients' feelings were legitimate business for consultation and was unrelated to their model of others. Conclusions From the perspective of doctors, speech that appears to be critical probably reflects therapeutic intent and might therefore be better described as “confrontation.” Understanding doctors' motivations for what they say to patients with MUSs will allow for more effective interventions to improve the quality of consultations.

Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees

Disclosing errors to patients is an important part of patient care, but the prevalence of disclosure, and factors affecting it, are poorly understood. To survey physicians and trainees about their practices and attitudes regarding error disclosure to patients. Survey of faculty physicians, resident physicians, and medical students in Midwest, Mid-Atlantic, and Northeast regions of the United States. Actual error disclosure; hypothetical error disclosure; attitudes toward disclosure; demographic factors. Responses were received from 538 participants (response rate = 77%). Almost all faculty and residents responded that they would disclose a hypothetical error resulting in minor (97%) or major (93%) harm to a patient. However, only 41% of faculty and residents had disclosed an actual minor error (resulting in prolonged treatment or discomfort), and only 5% had disclosed an actual major error (resulting in disability or death). Moreover, 19% acknowledged not disclosing an actual minor error and 4% acknowledged not disclosing an actual major error. Experience with malpractice litigation was not associated with less actual or hypothetical error disclosure. Faculty were more likely than residents and students to disclose a hypothetical error and less concerned about possible negative consequences of disclosure. Several attitudes were associated with greater likelihood of hypothetical disclosure, including the belief that disclosure is right even if it comes at a significant personal cost. There appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation.

The effect of professional skills training on patient-centredness and confidence in communicating with patients

The effect of introducing professional skills training on students' patient-centred attitudes and perceptions of ability to communicate was examined. The professional skills training included weekly training in communication skills, ethics and law, and clinical skills. Consecutive cohorts of medical students receiving a traditional pre-clinical curriculum (n = 199) and a new curriculum including professional skills training (n = 255) were compared. Students completed the Doctor-Patient Scale to assess patient-centred attitudes and an 11-item scale to assess confidence in their ability to communicate with patients. Students completed the measures at the start of Year 1 and the end of Year 2. Students receiving the professional skills training showed increased confidence in communicating with patients and increases in 2 dimensions of patient-centredness ('holistic care' and 'patient decision making'). Students receiving the traditional curriculum showed increased nervousness in talking to patients. Gender and ethnic differences were found in patient-centredness and confidence in communicating, which were maintained over time. The introduction of professional skills training was successful in improving students' confidence in their ability to perform specific communicative behaviours and increasing patient-centredness relative to a traditional curriculum.

Medical students' attitudes toward patient-centred care: a longitudinal survey

Patient-centredness should be at the heart of medical education. This longitudinal study aimed to assess possible attitude changes towards patient-centredness in a medical students' cohort as they progressed through the clinical curriculum. It also investigated the possible impact of socio-demographic factors on students' attitudes. The same student cohort was tested on 2 occasions: during their initial exposure to clinical curricula (year 4) and after 2 years, at the end of the clerkship (year 6). Students completed a questionnaire including demographics and the 18-item Patient-Practitioner Orientation Scale (PPOS). PPOS differentiates between patient-centred versus doctor-centred or disease-centred orientation, measuring attitudes along 2 dimensions: 'sharing' and 'caring'. A total of 483 fully completed questionnaires was returned (response rate 83%). The cohort's attitudes were significantly more doctor-centred at the end of their studies compared to the beginning of their clinical curricula (P < 0.001). However, regarding the caring part of their relationship with patients, they maintained a satisfactory level of patient-centredness. Concerning sharing information, female students were significantly more patient-centred at year 4, with their mean score decreasing at the end of their clerkship. Furthermore, among only female students, having a looser relationship with religion was associated with more patient-centred attitudes. Increased authoritarianism in graduating students' attitudes emphasises clearly the need for future research and redesigning communication curricula. Furthermore, the influence of gender and relationship with religion on attitudes towards the doctor-patient relationship should be explored further, in order to eliminate disparities in the provision of patient-centred medical care.

Does Equal Education Generate Equal Attitudes? Gender Differences in Medical Students' Attitudes Toward the Ideal Physician

Developing a patient-centered attitude is an important objective of medical education. Gender differences in students' patient-centered attitudes are also reported.Our study aims to measure (a) do gender differences and age differences exist in 1st- and 6th-year students' attitudes toward the ideal physician? and (b) what happens to gender differences in attitudes as students pass the medical curriculum?In 2004, attitudes of 1st-year and 6th-year medical students of the Radboud University Nijmegen Medical Centre are measured with the Ideal Physician Scale. Scores between groups are compared with t tests and univariate analysis of variance tests.Although both male and female students' attitudes become more care-oriented as they pass through the curriculum, gender differences are still apparent.Medical education does not differentially influence male and female students. Nevertheless, existing gender differences are reproduced. Equal education does not lead to equal attitudes.

Brazilian medical students’ attitudes towards patient-centered care

Background: The doctor-patient relationship is essencial to medical care (Engel 1980; Balint 1984), however, medical schools focus mainly on biomedical subjects and don’t give the necessary attention to communication skills, humanistic attitudes, and professional values (Haidet et al. 2001, 2002).Methods: Attitudes of medical students towards the doctor-patient relationship have been examined and the Patient-Practitioner Orientation Scale (PPOS) has been used to measure students’ and practitioners’ patient-centered beliefs, first in USA (Haidet et al. 2002), and then in several other countries (Choi & Moon 2005; Tsimtsiou et al. 2005; Shankar et al. 2006).This study aimed to examine the attitudes of Brazilian medical students towards the doctor-patient relationship by using the PPOS.The scale was translated into Portuguese and was administered to approximately 800 students in their first, fifth, seventh, ninth, tenth and twelfth semesters of medical school along with a socio-demographic questionnaire.Results: A total of 738 students (>90%) completed data collection. For the entire cohort, female gender (p < 0.000), later semester in medical school (p < 0.000), primary-care specialty choice (p < 0.02) and lower familial income (p < 0.03) were significantly associated with more patient-centered attitudes. Sharing sub-scores, measuring beliefs about power and information between physician and patient, were significantly more patient-centered for twelfth semester male students than for first semester males (p < 0.000), but not for female students. Caring sub-scores, which measure beliefs about attending to patient's emotions and lifestyle, did not change with the years of school. In general, Caring scores were considerably higher than Sharing scores. Total PPOS scores in Brazil are comparable to those found among medical students in the United States, however they are considerably higher than PPOS total scores in Nepal, Greece, and Korea.Conclusions: Communication skills and patient care needs to be critically examined by Brazilian teachers and students aiming to change attitudes toward the doctor-patient relationship to be more patient-centered attitudes.

The interpersonal experience of health care through the eyes of patients with diabetes

Patients with chronic illness often face challenges navigating the US health care system because of the system's lack of coordination and continuity. Patients with more difficulty relying on others and with reluctance in engaging frequently or in-depth with providers, face even greater challenges obtaining optimal health care in this system. Using a self-report measure of attachment style, we selected patients with varying degrees of comfort and trust in relationships. We conducted qualitative semi-structured interviews with a purposive sample of 27 patients with type 2 diabetes attending the University of Washington Diabetes Care Center in Seattle to explore issues of trust and collaboration in the health care setting. We used a constant comparative approach in which contemporaneous data collection and analysis took place. A subset of patients with fearful and dismissing attachment style reported having low levels of trust and an inability to collaborate with others of longstanding duration. Many aspects of the current health care system, such as its rushed, impersonal nature and a perceived “wall” between providers and patients were frustrating for most study patients. Patients with fearful and dismissing attachment style reported that these aspects of the health care system often interfered with their ability to partner with providers but also reported that patient-centered attitudes and behaviors by providers could improve their trust and ability to engage in the health care system. Implications of using a conceptual model of attachment theory to improve patient-centered care and customer service are discussed.

Medical student attitudes towards HIV

The aim of the study was to determine medical student attitudes towards HIV-related issues, to examine if the following student factors can affect attitudes: gender, perception of HIV infectivity, exposure to an HIV+ individual, career intent and attending a clinical attachment. A self-administered questionnaire was given to students at the beginning and end of a clinical attachment. Of the 240 questionnaires handed out at the beginning of the attachment, 183 (76%) were completed. Students generally expressed positive attitudes towards people with HIV. Female students and individuals who had considered working in a related specialty or had met an HIV+ person expressed more patient-centred attitudes in some of their responses. Following the course, 72 questionnaires were returned. Responses to several of the attitudinal statements had changed significantly. Medical students generally have enlightened attitudes towards HIV-related issues, which may be affected by student factors and attending a clinical attachment.

Follow the patient: process and outcome evaluation of medical students' educational experiences accompanying outpatients

To instill patient-centred attitudes in medical students, several medical schools in Japan have recently started to offer educational experiences in which medical students accompany outpatients throughout entire visits to hospitals. To evaluate the processes and outcomes of the educational experience of Year 5 medical students accompanying outpatients at Nagoya University Hospital. An integrated, multimethod approach was adopted using a written survey with open-ended questions for students, focus groups with students, and a written evaluation survey for patients. In all, 99 students completed the survey, 19 students participated in 3 focus groups, and 46 patients participated in the evaluation. Many students were sceptical about the objectives of the exercise. We were able to gain insight into student perceptions about facets of the exercise such as the ratio of students to patients and whether or not students should wear white coats. In particular, there was consensus among students about the importance of the debriefing session after the experience. Students achieved different learning outcomes depending on their particular individual experiences. In the student survey, 49% were satisfied with this experience, 6% were dissatisfied, and 43% were neither. In contrast, patients were highly satisfied with the experience (mean score 4.2 out of 5.0 on a Likert scale). Some students expressed concern about being a burden to patients, while many patients reported feeling emotionally supported by being accompanied by students. An integrated approach to programme evaluation, using quantitative and qualitative methods, was useful in the process and outcome evaluation of this new educational experience. The results have been taken into consideration for quality improvement of this curricular element.

The moral nature of patient-centeredness: Is it “just the right thing to do”?

Objective Patient-centeredness is regarded as an important feature of high quality patient care, but little effort has been devoted to grounding patient-centeredness as an explicitly moral concept. We sought to describe the moral commitments that underlie patient-centered care. Methods We analyzed the key ideas that are commonly described in the literature on patient-centeredness in the context of three major schools of ethical thought. Results Consequentialist moral theories focus on the positive outcomes of providing patient-centered care. Deontological theories emphasize how patient-centered care reflects the ethical norms inherent in medicine, such as respect for persons and shared decision-making. Virtue-based theories highlight the importance of developing patient-centered attitudes and traits, which in turn influence physicians’ behaviors toward their patients. Conclusion Different ethical theories concentrate on different features of patient-centered care, but all can agree that patient-centeredness is morally valuable. Practice implications In order to sustain patient-centeredness as a moral concept, practitioners and students ought to examine these ideas to determine what their own personal reasons are for or against adopting a patient-centered approach.

Promoting a biopsychosocial orientation in family practice: effect of two teaching programs on the knowledge and attitudes of practising primary care physicians

The bio-psychosocial (BPS) approach to patient care has gained acceptance in medical education. However, reported teaching programs rarely describe the efficacy of alternative approaches to continuing medical education aimed at promoting a BPS approach. The objective was to describe and evaluate the effect of two teaching programs on learners’ BPS knowledge, management intentions, patient-centered attitudes, professional self-esteem, burnout, work related strain and mental workload. The learners were Israeli general practitioners. The first (“didactic”) program consisted of problem-based reading assignments, lectures and discussions. The second (“interactive”) program consisted of reading assignments, lectures and discussions, in addition to role-playing exercises, Balint groups and one-to-one counseling by a facilitator. One month before and six months after the teaching interventions, we used structured questionnaires to test for knowledge, management intentions (responses to questions, such as “what would you tell a patient with …”) and attitudes. Both programs led to measurable improvement in knowledge, intentions, patient-centered attitudes and self-esteem. The interactive teaching approach improved significantly more the learners’ professional self-esteem and intentions than the didactic approach. Self-reported burnout significantly increased after the program. It is concluded that teaching intervention enhanced a BPS orientation and led to changes in knowledge, intentions, self-esteem and attitudes. An interactive method of instruction was more effective in achieving some of these objectives than a didactic one. The observed increase in burnout was unexpected and requires further study and confirmation.

Patient-Centered Attitudes and Communication Skills in Medical Students after Clerkship

Purpose: Patient-centered communication is known to improve patient satisfaction, compliance, doctor-patient relationship, and health outcomes. The aim of this study is to evaluate patient-centered communication skills and attitudes in medical students after their clerkship. Method: To evaluate their communication skills, OSCE was performed on 114 fourth-year medical students who had completed their clerkship. After OSCE, we used structured questionnaires to survey the subjects in assessing attitudes toward communication skill learning and patient-centeredness. Results: The accomplished frequency of patient-centered communication items were as follows: allow patient’s narrative thread (), open-to-closed-ended questions (), discuss psychosocial and emotional factors (), elicit patient’s concerns and perspectives (), discuss how health problem affects patient’s daily life (), express empathy (), negotiate plan of action with patient (), and ask whether patient has further issues to discuss (). The students who did [medical service as extracurricular activity??????????] and were confident with their communication skills performed better patient-centered interviews. There was no significant relationship between medical students’ patient-centered attitudes and patient-centered OSCE scores. Conclusion: Having completed their clerkship, medical students were still unable to perform a good patient-centered interview. Current medical curriculum should teach medical students how to communicate in a patient-centered manner. The education method should focus on behavior change initiatives.

Psychiatrists' attitudes to maintenance medication for patients with schizophrenia.

Maintenance antipsychotic medication is the mainstay of relapse prevention in patients with schizophrenia. Long acting depot antipsychotics were developed to promote treatment adherence and yet their utilization is variable, perhaps due to negative attitudes of both patients and psychiatrists. Recently, a shift away from depots has occurred, in favour of the newer atypical oral antipsychotics. This study investigated the current attitudes and knowledge concerning depots, with a newly designed questionnaire, in a cross-sectional postal survey of qualified psychiatrists working in south-east England. A substantial minority of psychiatrists believe that depots are old fashioned (40%), stigmatizing (48%) and are associated with more side-effects than typical oral antipsychotics (38%). Many believe that depots are as efficacious as oral medication (91%) but are less acceptable to patients (69%) and relatives (66%). A large majority consider depots enhance patient compliance (81%) and prevent relapse (94%). Psychiatrists would be persuaded to prescribe depots if they were associated with fewer side-effects, in patients where compliance is an issue, and if atypical depot antipsychotics were available, presumably because they would have a lower incidence of side-effects. Additionally, psychiatrists' knowledge about depots was positively associated with attitudes. More favourable patient-centred attitudes were reported by psychiatrists with higher depot use. Practising psychiatrists have several strongly endorsed attitudes towards depot medication that are associated with knowledge and prescribing habits. By updating psychiatrists' knowledge about depots, in turn their attitudes may become more positive and prescribing practices may subsequently change.

Medical student attitudes toward the doctor-patient relationship

Medical educators have emphasized the importance of teaching patient-centred care. To describe and quantify the attitudes of medical students towards patient-centred care and to examine: (a) the differences in these attitudes between students in early and later years of medical school; and (b) factors associated with patient-centred attitudes. We surveyed 673 students in the first, third, and fourth years of medical school. Our survey utilized the Patient-Practitioner Orientation Scale (PPOS), a validated instrument designed to measure individual preferences towards various aspects of the doctor-patient relationship. Total PPOS scores can range from patient-centred (egalitarian, whole person oriented) to disease- or doctor-centred (paternalistic, less attuned to psychosocial issues). Additional demographic data including gender, age, ethnicity, undergraduate coursework, family medical background and specialty choice were collected from the fourth year class. A total of 510 students (76%) completed data collection. Female gender (P < 0.001) and earlier year of medical school (P = 0.03) were significantly associated with patient-centred attitudes. Among fourth year students (n = 89), characteristics associated with more patient-centred attitudes included female gender, European-American ethnicity, and primary-care career choice (P < 0.05 for each comparison). Despite emphasis on the need for curricula that foster patient-centred attitudes among medical students, our data suggest that students in later years of medical school have attitudes that are more doctor-centred or paternalistic compared to students in earlier years. Given the emphasis placed on patient satisfaction and patient-centred care in the current medical environment, our results warrant further research and dialogue to explore the dynamics in medical education that may foster or inhibit student attitudes toward patient-centred care.

Cohort, gender and practice organization: examining the bounds of collaborative medicine among newly established female and male family physicians in Ontario.

This paper analyzes data from a 1993 survey of 395 newly established female and male family physicians in Ontario, Canada, to examine the relationship between practice organization and gender. Previous research suggests that younger physicians, particularly women, tend to enter group practice. Compared to solo practice, groups may offer more predictable incomes, more manageable workloads, peer collaboration and review, and economies of scale. Further, female physicians in groups may develop distinctive styles of collaborative medicine. The results show that a majority of physicians in our cohort are in private community-based group practice. However, while many groups share premises, staff and expenses, and many have common charts and practice guidelines, only a minority incorporate regular meetings to discuss business or patient care, have shared care of hospitalized patients, or audits of physicians' practices. Few gender differences are observed in private group practice: although women physicians attract larger proportions of female patients than do their male colleagues, women and men organize their groups in similar ways and have similarity strong patient-centered attitudes.

Disease-Centred Versus Patient-Centred Attitudes: Comparison of General Practitioners in Belgium, Britain and The Netherlands

The attitudes of general practitioners in Belgium, Britain and the Netherlands have been sought to determine if they are patient-centred or disease-centred (that is, doctor-centred). The results indicated that many of the doctors held disease-centred attitudes, which in previous studies in the Netherlands and Belgium had correlated with increased prescribing of symptomatic medication, shorter consultation time, inadequate patient records and poorer standards of care within the consultation. Doctors in Belgium had the highest level of disease-centred attitudes, Dutch doctors the lowest. Possible explanations for these differences include differences in the doctor-patient relationship that exist between these countries. Although the results must be interpreted with some care, they should form a basis for discussions about doctor-patient relations and medical education in each country.