Patient-practitioner Interaction Research Articles

Book Review: Patient Practitioner Interaction: An Experiential Manual for Developing the Art of Health Care

Book Review: Patient Practitioner Interaction: An Experiential Manual for Developing the Art of Health Care

The gap between results from sham-controlled trials and trials using other controls in acupuncture research—The influence of context

In chronic pain studies involving acupuncture treatments, the size of the effect between acupuncture and a sham acupuncture control is usually small. By contrast, when acupuncture is compared to an active control group (usual care or standard treatment), the size of the effect is generally moderate and clinically relevant. Factors such as treatment setting, the expectations of patient and practitioner, and the interaction between patient and practitioner differ for different treatments and may influence the study outcome. In acupuncture, these factors seem to play a role. Acupuncture research is helpful in stimulating placebo research and illuminates a variety of aspects that influence the placebo response. The influence of different types of patient-practitioner interaction and their underlying mechanisms seem to be a clinically relevant area for future research, but should be researched in less complex placebo models than sham acupuncture.

Whole-Systems Research in Integrative Inpatient Treatment

In the last years, medicine has seen a shift from a depersonalized towards a patient-centered individualized medicine. This, on the one hand, is based on the achievements in the field of genetics and molecular science fostering an individually designed drug therapy and treatment tailoring [1]. On the other hand, research on patient-practitioner interaction, psychosocial and behavioral conditions of chronic diseases, and a patient-centered treatment approach has revealed that nonpharmacological factors such as empathy might be essential parameters for the outcome of the patient [2]. Moreover, complementary therapies as traditional whole-medical systems (Ayurveda, traditional Chinese medicine a.o.) or homeopathy, which according to their definition are individualized, have attained increasing interest for improving the patient care, for example, in the treatment of chronic diseases and pains syndromes. More recently, the combination of conventional medicine, complementary medicine, and patient-centered approaches has been put into the conceptional frame of “integrative medicine” which covers these topics adequately [3]. The most common and comprehensive definition up to now has been given by the Consortium of Integrative Medicine in 2005. It describes integrative medicine as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing” [4]. It therefore joins the latest scientific advances with the profound insights of traditional healing systems and individualized patient care in complementary medicine to regain and preserve health and to enhance self-efficacy and patient's own capacities to recover from illness and to maintain health. In the last decades, several hospitals have adopted this concept of integrative medicine for the treatment of chronic and acute states of illnesses in an inpatient treatment. For instance, Sendelbach et al. (2003) describe the development of an inpatient integrative therapies program in a cardiovascular tertiary care center [5]. Ernst and Ferrer (2009) also reflect on the implementation of a 7-year integrative hospital program in a cardiac hospital center from the viewpoint of the nursing staff [6]. In almost all cases, these hospitals have integrated one or more complementary disciplines as naturopathy, anthroposophical medicine, homeopathy, or traditional Chinese medicine. While, in the USA integrative medicine has emerged towards a marker for innovative quality patient care within the last two decades, other countries have a longer tradition in this field [7]. In Germany, for instance, the amendment to the German Drug Law in 1976 has recognized anthroposophic medicine, homeopathy, and phytotherapy as “Specific Therapeutic Systems” [8]. As a consequence, inpatient treatment opportunities for integrative medicine increased, and specialized hospitals and hospital departments started to evaluate their programs also with respect to comparative cost scenarios [9] which are nowadays still seen as a major goal [10]. Thus, several approaches have already entered the platform of in-patient care in integrative medicine. A current study of Kligler et al. (2011) found a decrease in the use of medications resulting in substantial cost savings in the care of oncology patients treated with an integrative in-patient approach including yoga therapy, holistic nursing, and healing environment [11]. Unfortunately, due to heterogeneity of the approaches and evaluations, the meta-analyses and systematic reviews of such evaluations in most cases suffer from a lack of comparability of outcome parameters within these evaluations so far. Of note, whole-systems evaluation of integrative in-patient treatment might also benefit from a systematic analysis of the patient characteristics of clinical pathways and flow processes between in- and outpatient treatments, which has been described [12]. Finally, concepts of combining education, teaching, and in-patient integrative treatment can be seen as an important milestone for the development of integrative medicine. If only students are able to discover and get some first insight into the potential different perspectives of medicine and healing, they might be able to argue open-mindedly about the best fitting therapeutic strategy for the individual patient to regain his optimal health [13]. Despite these current achievements, evaluations of the approach of integrative medicine as a whole system and its interactions with other services of patient care have only been seen marginally. Thus, the cutting edge for the future development of integrative medicine now is to close the “evidence gap” [4] and to summarize and communicate these findings of research to the public, the stakeholders, and policy makers of healthcare authorities [14]. This special issue tries to step into this direction by bringing together evidence from different perspectives. Apart from whole-systems evaluations of hospital programs, cost studies, and findings on educational aspects of integrative medicine, this issue also covers historical aspects of the development of integrative medicine and presents the meta-analyses of integrative approaches. Hopefully, science-driven implementation of integrative medicine into hospitals and patient care can improve the 21st century medicine. Thomas Ostermann Andre-Michael Beer Vassya Bankova Andreas Michalsen

Sickness certification as a complex professional and collaborative activity - a qualitative study

BackgroundPhysicians have an important but problematic task to issue sickness certifications. A manifold of studies have identified a wide spectrum of medical and insurance-related problems in sickness certification. Despite educational efforts aiming to improve physicians’ knowledge of social insurance medicine there are no signs of reduction of these problems. We hypothesised that the quality deficits is not only due to lack of knowledge among issuing physicians. The aim of the study was to explore physicians’ challenges when handling sickness certification in relation to their professional roles as physicians and to their interaction with different stakeholders.MethodsOne hundred seventy-seven physicians in Stockholm County, Sweden, participated in a sick-listing audit program. Participants identified challenges in handling sick-leave issues and formulated action plans for improvement. Challenges and responsible stakeholders were identified in the action plans. To deepen the understanding facilitators of the program were interviewed. A qualitative content analysis was performed exploring challenge categories and categories of stakeholders with responsibility to initiate actions to improve the quality of the sick-listing process. The challenge categories were then related by their content to professional competence roles in accord with the Canadian Medical Education Directions for Specialists (CanMEDS) framework and to the stakeholder categories.ResultsSeven categories of challenges were identified. Practitioner patient interaction, Work capacity assessment, Interaction with the Social Insurance Administration, The patient’s workplace and the labour market, Sick-listing practice, Collaboration and resource allocation within the Health Care System, Leadership and routines at the Health Care Unit. The challenges were related to all seven CanMEDS roles. Five categories of stakeholders were identified and several stakeholders were involved in each challenge category.ConclusionsPhysicians performing sickness certification tasks experience a complex variety of challenges. From physician perspective actions to handle these need to be initiated in interaction with both medical and non-medical stakeholders. The relation between the challenges and a well-established professional competence framework revealed a complex pattern. Thus, from a public health perspective, educational activities aimed to improve the sick-listing process should address all physician competences including identification and interaction with stakeholders, and not just knowledge of social insurance medicine.

Towards non-reductionistic medical anthropology, medical education and practitioner–patient-interaction: The example of Anthroposophic Medicine

ObjectiveTo develop the hypothesis that reductionism in medical anthropology, professional education and health care influences empathy development, communication and patient satisfaction. MethodWe identified relevant literature and reviewed the material in a structured essay. We reflected our hypothesis by applying it to Anthroposophic Medicine (AM), an example of holistic theory and practice. ResultsReductionism in medical anthropology such as in conventional medicine seems to lead to a less empathetic and less communicative health care culture than holism such as in CAM disciplines. However, reductionism can be transformed into a systemic, multi-perspective holistic view, when the emergent properties of the physical, living, psychic, spiritual and social levels of human existence and the causal relations between them are more carefully accounted for in epistemology, medical anthropology and professional education. This is shown by the example of AM and its possible benefits for communication with and satisfaction of patients. ConclusionA non-reductionistic understanding of the human being may improve communication with patients and enhance patient benefit and satisfaction. Practice implicationsInterdisciplinary qualitative and quantitative studies are warranted to test this hypothesis and to understand the complex relations between epistemology, medical anthropology, education, health care delivery and benefit for patients.

Designing for healthy living: Supporting reflectivity on interactions in healthcare

The design of an efficient and effective healthcare services is part of the design for healthy living. Contemporary models of health rely on a deeper involvement of the patient in the decision-making through the steps of the health journey. In these methods, the quality of practitioner–patient interaction is central to the successful processes and patient participation. The quality of these interactions and the ability of both medical practitioners and patients to reflect on each session is part of the design strategies for healthy living. Interactions rely on extensive, effective and empowering communication between practitioner and patient. The purpose of this work is to address the recognition of this importance, evidenced from the broad and diverse communication training for practitioners, by enabling the capture of information about the quality of these interactions. Captured information has to be encoded in a way that enables computer reasoning with it, as well as delivered to patients and practitioners in ways that allow quick interpretation from respective sides. We present the mechanics of the development of a visual language and analysis system enabling visual reasoning about the quality of interactions. The visual knowledge representation is designed based on aspects of human movement. Such design is justified from the fact that human possess implicit knowledge about human movement. The paper presents KIA (Kinetic Inter-Acting) encoding system that is the foundation of the visual language and respective visual analysis method. KIA enables both humans and machines to utilise information about how interactions unfold, which is necessary for practitioner–patient interaction. The paper concludes with discussion of KIA approach and technology in terms of the implications for designing for healthy living.

Exploratory Review of Placebo Characteristics Reported in Randomised Placebo Controlled Antidepressant Drug Trials

Systematic reviews of randomised placebo controlled trials of antidepressants have found small and decreasing differences in outcome between pharmacological and placebo arms. Increased knowledge of placebo characteristics may provide greater understanding of antidepressant pharmacological effect. We conducted a systematic review to identify the presence of key placebo characteristics in a sample of antidepressant clinical trials. 82 randomised placebo controlled trials of antidepressants, selected in 2 previous systematic reviews (Walsh et al. 2002; NICE 2009), were examined. Presence of placebo characteristics documented using detailed standardised form, with 5 domains: health care environment, practitioner characteristics, patient characteristics, practitioner-patient interaction, and non-pharmaceutical drug characteristics. First authors contacted where possible, and further clarification sought on placebo characteristics within trials. Percentage of trials reporting placebo characteristics within the 5 domains: health care setting 100%, environment 5%; practitioner profession 18%, status 0%, incentives 0%, gender 10%, age 4%, beliefs 6%; patient age 85%, gender 91%, ethnicity 41%, diagnosis and severity 100%, recruitment 16%, incentives 12%, co-morbidity 12%, expectation 0%, beliefs 0%; patient-practitioner interaction type of care 10%, number of visits 94%, empathy and congruence 2%; drug form 45% and frequency 57%. Placebo characteristics represent confounding variables which, if not adequately controlled for, could distort findings and conclusions about efficacy. The lack of systematic recording of many placebo characteristics in antidepressant drug trials is a cause for concern. To reduce imprecision and increase generalisability, future antidepressant clinical trials should consider the impact of key placebo characteristics and record their presence when disseminating findings.

Perception of empathy in the therapeutic encounter: Effects on the common cold

ObjectiveTo evaluate the effects of patient–practitioner interaction on the severity and duration of the common cold. MethodsWe conducted a randomized controlled trial of 719 patients with new cold onset. Participants were randomized to three groups: no patient–practitioner interaction, “standard” interaction or an “enhanced” interaction. Cold severity was assessed twice daily. Patients randomized to practitioner visits used the Consultation and Relational Empathy (CARE) measure to rate clinician empathy. Interleukin-8 (IL-8) and neutrophil counts were obtained from nasal wash at baseline and 48h later. ResultsPatients’ perceptions of the clinical encounter were associated with reduced cold severity and duration. Encounters rated perfect on the CARE score had reduced severity (perfect: 223, sub-perfect: 271, p=0.04) and duration (perfect: 5.89 days, sub-perfect: 7.00 days, p=0.003). CARE scores were also associated with a more significant change in IL-8 (perfect: mean IL-8 change 1586, sub-perfect: 72, p=0.02) and neutrophil count (perfect: 49, sub-perfect: 12, p=0.09). ConclusionsWhen patients perceive clinicians as empathetic, rating them perfect on the CARE tool, the severity, duration and objective measures (IL-8 and neutrophils) of the common cold significantly change. Practice implicationsThis study helps us to understand the importance of the perception of empathy in a therapeutic encounter.

Teaching patient care to students: A blended learning approach in radiography education

Understanding the complexity of the patient–practitioner interaction is a challenging area for radiography students early in their programmes. A small scale research project was undertaken to develop blended learning resources for the teaching of patient care to radiography students. Its purpose was to utilise experiences gathered from interviews with ex-patients to produce video clips of patient–practitioner interactions so that students might gain some insight into the reality of the clinical setting, thus enabling them to link theory with practice. A total of eight interviews with ex-patients were carried out and the transcripts used to generate scripts which were enacted and filmed by a professional acting company. Thematic analysis of the study data initiated the generation of scenarios, which formed the basis of the videos. Twelve scenes showing patient–practitioner interactions in various parts of a medical imaging department and four ‘talking heads’ clips were produced. These were loaded onto the university’s virtual learning environment and made available for viewing together with self-test and evaluation questionnaires. A pilot study was carried out; evaluation of the videos by second year student radiographers was positive. The main study was carried out using first year students with similarly positive findings and the videos are now publically available for teaching purposes. Further work in this promising area of e-learning could further utilise patients’ experiences, and using the same technology, might offer students of other professions the opportunity to gain vicarious experience prior to their first encounters with patients and the general public. In conclusion, research leading to the production of simulations of real-life patient–practitioner interactions delivered using blended learning is a useful pedagogical tool in the education of radiography students.

Patient perception of nursing service quality; an applied model of Donabedian’s structure‐process‐outcome approach theory

Nursing is a labour-intensive field, and an extensive amount of latent information exists to aid in evaluating the quality of nursing service, with patients' experiences, the primary focus of such evaluations. To effect further improvement in nursing as well as medical care, Donabedian's structure-process-outcome approach has been applied. To classify and confirm patients' specific experiences with regard to nursing service based on Donabedian's structure-process-outcomes model for improving the quality of nursing care. Items were compiled from existing scales and assigned to structure, process or outcomes in Donabedian's model through discussion among expert nurses and pilot data collection. With regard to comfort, surroundings were classified as structure (e.g. accessibility to nurses, disturbance); with regard to patient-practitioner interaction, patient participation was classified as a process (e.g. expertise and skill, patient decision-making); and with regard to changes in patients, satisfaction was classified as an outcome (e.g. information support, overall satisfaction). Patient inquiry was carried out using the finalized questionnaire at general wards in Japanese hospitals in 2005-2006. Reliability and validity were tested using psychometric methods. Data from 1,810 patients (mean age: 59.7 years; mean length of stay: 23.7 days) were analysed. Internal consistency reliability was supported (α = 0.69-0.96), with factor analysis items of structure aggregated to one factor and overall satisfaction under outcome aggregated to one. The remaining items of outcome and process were distributed together in two factors. Inter-scale correlation (r = 0.442-0.807) supported the construct validity of each structure-process-outcome approach. All structure items were represented as negative-worded examples, as they dealt with basic conditions under Japanese universal health care system, and were regarded as representative related to concepts of dissatisfaction and no dissatisfaction. Patients' experiences with nursing service were confirmed using Donabedian's approach and can therefore be applied to improve quality of nursing practice by practitioners, managers and policy makers.

Patient–practitioner interaction and placebo response

Patient–practitioner interaction and placebo response

Medical students’ views of power in doctor-patient interactions: the value of teacher-learner relationships

This paper aims to contribute to the important, and relatively underexplored, area of medical education research that seeks to illuminate the value and meaning of relationships in the undergraduate education of doctors. Here I present new empirical material in which I ground my reflections on some ways in which teacher-learner relationships can help address medical students' often uncritical views of professional practice. The views I illustrate are of particular significance as they contrast sharply with the participative models of practice promoted by current policy, professional and educational discourses. My reflections stem from the analysis of data I generated for a larger, broadly ethnographic study exploring students' approaches to their future role as practitioners in one UK medical school. I draw upon this larger body of data and focus here on two examples in particular of the more general uncritical readings of medical professionalism I encountered at Sundown Medical School (an invented name), namely: students' often reductive views of medical power, and their simplistic formulations of patient education. I argue for the need to foster richer and more critical understandings of professional power and knowledge among students and educators, and suggest here that teacher-learner interactions could have an important role in fostering such richer understandings. I argue that teacher-learner relationships can model some of the dynamics of the practitioner-patient interaction and thus provide useful opportunities for closer and more critical analysis of power, education and knowledge in the medical school classroom as well as in the consultation room. I suggest that effective integration of participative and critical pedagogical strategies in medical curricula and more structured involvement of patients in the role of teachers may represent valuable strategies for the development of learning relationships that better promote reflexive and collaborative forms of professionalism.

Patient and Practitioner Influences on the Placebo Effect in Irritable Bowel Syndrome

To determine whether placebo responses can be explained by characteristics of the patient, the practitioner, or their interpersonal interaction. We performed an analysis of videotape and psychometric data from a clinical trial of patients with irritable bowel syndrome who were treated with placebo acupuncture in either a warm empathic interaction (Augmented, n = 96), a neutral interaction (Limited, n = 97), or a waitlist control (Waitlist, n = 96). We examined the relationships between the placebo response and a) patient personality and demographics; b) treating practitioner; and c) the patient-practitioner interaction as captured on videotape and rated by the Psychotherapy Process Q-Set. Patient extraversion, agreeableness, openness to experience, and female gender were associated with placebo response, but these effects held only in the augmented group. Regression analyses controlling for all other independent variables suggest that only extraversion is an independent predictor of placebo response. There were significant differences between practitioners in outcomes; this effect was twice as large as the effect attributable to treatment group assignment. Videotape analysis indicated that the augmented group fostered a treatment relationship similar to a prototype of an ideal healthcare interaction. Personality and gender influenced the placebo response, but only in the warm, empathic, augmented group. This suggests that, to the degree a placebo effect is evoked by the patient-practitioner relationship, personality characteristics of the patient will be associated with the placebo response. In addition, practitioners differed markedly in effectiveness, despite standardized interactions. We propose that the quality of the patient-practitioner interaction accounts for the significant difference between the groups in placebo response.

A questionnaire to measure health practitioners’ attitudes to partnership in medicine taking: LATCon II

To revise and improve an existing scale to measure health practitioners' attitudes to partnership in medicine taking and to ascertain the views of medical students, nursing students and pre-registration pharmacists on concordance. The traditional model of the practitioner-patient interaction incorporates a practitioner-centred approach, focusing on the disease rather than the patient. The philosophy of 'concordance' (or 'partnership in medicine-taking') puts the patient at the centre of the interaction, with the patient interacting reciprocally with the practitioner. The Leeds Attitude to Concordance (LATCon) scale was developed in 2001 to assess practitioners' and patients' attitudes to concordance. However, thinking on concordance has developed since then and the present study aimed to revise the scale to ensure that it reflected current thinking and also to increase its reliability and validity. A pool of potential items was developed and sent to three subject experts for opinion. An attitudinal Likert scale of 31 items was developed. Its completion was followed by statistical item reduction to 20 items. The shorter scale was completed by the same participants 4-6 weeks later. The study was set in a university in the UK. Participants were 183 medical students, nursing students, and pre-registration pharmacists. The study derived a 20 item scale, including five negatively-worded items, with good levels of internal and test-retest reliability. Factor analysis suggested five main factors. A statistically significant difference in attitudes was found between student nurses and medical students, and student nurses and pre-registration pharmacists, with student nurses being more in agreement with the concordant approach. Overall, participants were in agreement with the concordant approach to medicine taking. The UK National Health Service advocates partnership in medical care and is encouraging both practitioners and patients to work to introduce this. There is increased awareness of the patients' perspective by practitioners, but its impact on their practice remains unclear. Education and skills teaching must continue for the benefits of a concordant approach to be seen. The LATCon scale could play a useful role in education and training, and in research assessing the movement towards the new approach.

Patient‐based evaluations of primary care for cardiovascular diseases: a comparison between conventional and complementary medicine

Patients with chronic diseases, including cardiovascular conditions, increasingly rely on complementary and alternative medical (CAM) therapies. The Swiss Program for Complementary Medicine Evaluation offers a unique opportunity to analyse cardiovascular patients' satisfaction with CAM and conventional medical (COM) therapies. The treatment choices of doctors certified in conventional as well as complementary therapies also could be studied. A national observational evaluation on treatment satisfaction of patients consulting COM or CAM doctors. Out of this evaluation project, data related to patients with cardiovascular diseases were specifically analysed for patient satisfaction with treatment and outcome when treated by COM or CAM doctors. Of 199 included doctors (78 COM, 121 CAM) treating cardiovascular patients, COM doctors treated twice as many cardiovascular patients per doctor than CAM doctors. CAM doctors treated less than 1/3 of their cardiovascular patients solely by CAM, while they treated 42% exclusively by COM therapies. Patients seeing a CAM doctor had a significantly longer consultation and were more likely to be highly satisfied with overall treatment outcome and patient-practitioner communication. Moreover, patients seeing a CAM doctor and being treated solely by a CAM therapy more often report 'complete fulfilment of outcome expectation' and 'high overall satisfaction with treatment', although their symptoms less often disappear totally than those of COM therapy-treated patients. CAM therapies are not the first treatment choice for cardiovascular diseases. However, even though CAM doctors preferentially apply COM therapies, cardiovascular patients treated by CAM doctors are more likely to be satisfied with the overall treatment outcome, possibly because of the longer and better patient-practitioner interaction.

Patient Practitioner Interaction: An Experiential Manual for Developing the Art of Health Care, ed 4

Davis CM. Thorofare, NJ 08086, Slack Inc, 2006, paperback, 304 pp, illus, ISBN: 1-55642-720-4, $42.95. The first edition of this book was published in 1988 as an attempt to fill a void in many health care curricula: the teaching of professional roles beyond hands-on care. Professionalism is now a standard element in health care curricula, but anyone who has tried to teach professionalism knows that it is easier said than done. Hence, there is a continuing need for this book. This fourth edition has expanded and evolved, but remains true to its original goal—guiding students toward developing the “art of health care.” This includes learning about ethics, values, and communication and acknowledging the emotional needs of patients. This book is clearly geared to beginning students with limited experience in patient interaction. Written in …

Is homeopathy possible?

As a therapeutic intervention, homeopathy is the target of increased scepticism because in the main, its remedies are diluted and succussed (potentized) out of material existence. This puts homeopathy seemingly at odds with the paradigm of conventional science, in particular, that atoms and molecules are the fundamental building blocks of all matter. Accordingly, homeopathy cannot work, so that any reported beneficial effects must, at best, be due to the placebo effect. The purpose of this article is to challenge that conclusion and to suggest that there may well be conventional science-based explanations of how homeopathy could be possible. Homeopathy's key principles are first described. Then the double-blind randomized controlled trial (RCT), the chief means by which homeopathic remedies and prescribing are tested, is shown to be based on a linear reductionism that is too blunt an instrument with which to test the efficacy of complex interventions such as homeopathy The memory of water hypothesis, as a mechanism for how potentized remedies might work, is reviewed, along with some evidence for its existence. A possible rationale for the water memory effect is proposed in terms of a dynamic 'ordering' of water's constantly switching network of intermolecular hydrogen bonds, induced by the manufacturing process of homeopathic remedies. This could lead to a long-range molecular 'coherence' between trillions of mobile water molecules. However, the water memory effect is an essentially pharmacological explanation of homeopathy's putative efficacy. It is pointed out that healing also entails an interaction between consenting beings. From this point of view, an explanation of any therapeutic procedure should include an attempt to describe the nature of the patient-practitioner interaction. From this perspective, a quantum theoretical treatment of the therapeutic process, involving a form of macro-entanglement between patient, practitioner and remedy (PPR), is advanced as another possible explanation of the homeopathy's efficacy. This shows that the reason double-blind RCTs deliver at best only equivocal results on homeopathy's efficacy is because it effectively breaks the PPR entangled state. A comparison is made between the entanglement-breaking effect of double-blind RCTs and the wave-function 'collapsing' effect of observation in orthodox quantum theory. The article concludes by suggesting that the memory of water and PPR entanglement are not competing but most likely complementary hypotheses, and that both are probably required in order to provide a complete description of the homeopathic process. While awaiting experimental evidence of these hypotheses, it is suggested that observations of clinical outcomes would be superior to RCTs for further testing homeopathy's efficacy.

Psychological approaches for the nursing management of chronic pain: part 2

The aim of this article was to present the ways that nurses can integrate psychological approaches into their management of chronic pain conditions using a biopsychosocial framework. Communication, the importance of the patient-practitioner interaction, the role of education and provision of information, reassurance and reduction of anxiety and the use of coping strategies training in the management of chronic pain are reviewed alongside the key skills of nursing. This is the second part of a two-part article. Part 1 was a discussion of psychosocial factors associated with chronic pain conditions and the psychological approaches used in the management of these conditions. It is identified that key nursing skills often equate to the requirements of the psychological approaches, therefore specific techniques from a cognitive-behavioural framework can be readily applied, integrated and used by nurses in the management of chronic pain conditions. Commonly utilized nursing skills are similar to those required for cognitive-behavioural therapy. It is reasonable to assume therefore that nurses can and should be involved in effectively managing the psychological aspects associated with chronic pain conditions.

Interactive Guided ImagerySMTherapy with Medical Patients: Predictors of Health Outcomes

To assess whether Interactive Guided Imagery (IGI) is helpful to medical patients and to identify factors that contribute to positive outcomes. A prospective cohort study of 323 medical patients who received 6 IGI sessions on a weekly basis. Patients and practitioners completed questionnaires at the beginning, middle, and end of the 6 IGI sessions. The questionnaires assessed the patients' ability to do IGI, the quality of the practitioner-patient interaction, possible confounding variables, and enabling factors. The hypothesis was that measures of the process of doing IGI and the practitioner-patient relationship would predict outcomes. The subjects were all patients seeking treatment at California Pacific Medical Center in San Francisco, and Marin General Hospital in Greenbrae, CA. Using IGI interactively is a cognitive-behavioral intervention designed to help patients relax by using mental images to discover and cultivate healing intentions, and to reflect on the meaning of these images. The individual measures to assess the patients' ability to do IGI and measures of the practitioner-patient relationship were factor-analyzed to use as predictor variables in a multiple regression. Similarly, the questionnaire items measuring cognitive, emotional, behavioral, and spiritual benefits of IGI were factor-analyzed into factors representing "insight" and "all other" benefits. The multiple regression shows that both process and practitioner-patient interaction factors significantly contributed to a combined 40% of the variance in patients' ratings of insight into the nature of their problem and to becoming aware of an aspect of self, F(4,56) = 9.4, p < 0.005. The same process and interaction factors were less strongly related to the other outcomes, r2 = 0.14, F(4,56) = 2.3, p = 0.06. None of the demographic, confounding, or enabling factors was related to the outcome measures. The process of doing IGI and the relationship with the practitioner were both independently associated with the patients' insight into their health problems.

The role of the Internet in patient-practitioner relationships: findings from a qualitative research study.

Background Studies suggest that there has been an increase in the use of the Internet by patients in many Western societies. However, despite the many texts available on health and the Internet, not much is known about how much patients actually use the Internet to look up health information in their daily lives. We know little about what meaning this activity has for their experience of health and illness, and for their relationship with health-care practitioners.Objective To explore patients' and practitioners' use of the Internet and to consider whether use of the Internet is changing relationships between patients and health-care practitioners.Method The study used qualitative interviews and observations of patient–practitioner interaction. Our purposive sample of 47 patients (32 women and 15 men) had all had contact with the health services for information/treatment in relation to hormone replacement therapy (HRT)/menopause and Viagra/erectile dysfunction. The setting for the research was in general practitioners' surgeries, specialist clinics and patients' homes in the United Kingdom. Participants reflected a wide range of socio-economic groups, but most were white and British born, which, given the ethnic make-up of the town in which we conducted the research, was not surprising. In addition to patients, we interviewed 10 health-care practitioners (4 consultant doctors, 3 GPs, 2 specialist nurses, and a psychologist) about their own health information seeking practices (HISPs) and those of their patients.Results Use of the Internet can increase patients' knowledge about their health conditions, although patients in our study were often too overwhelmed by the information available on the Internet to make an informed decision about their own care. Patients have a great deal of trust in their health-care practitioners. Health-care practitioners need to improve their own skills in Internet use. Hype around Internet use by patients appears to exceed the reality of Internet use.Conclusions Our qualitative study suggests that use of the Internet is contributing to subtle changes in the relationship between health-care practitioners and their patients, rather than effecting the dramatic transformation some people envisage for it.