What you "see" is how you communicate: Medical students' meaning making of a patient's vignette.

OBJECTIVES: To examine how medical students notice issues in a vignette and construct their meaning, and how this construction influences their plan to communicate with the patient. METHODS: Following a breaking bad news course for 112 senior medical students, we qualitatively analyzed the participants' written descriptions of the issues they noticed as requiring special attention, using an Immersion/Crystallization iterative consensus process. RESULTS: Different students noticed different issues, but no-one noticed all 19 planted issues (Mean of issues noticed by students = 6.77; SD = 2.29). The students wrote about the issues in 46 different ways, representing the diverse meanings they ascribed, ranging from identifying, through inferring, to interpreting while jumping to conclusions. Moreover, for some issues, some students focused on the patient whereas others focused on the physician or the physician-patient relationship. Noticing issues led to preparing for communication with the patient. CONCLUSIONS: Noticing the issues and the subsequent meaning-making process facilitated the preparation to address them in the envisioned encounter. PRACTICE IMPLICATIONS: When teaching communication skills, it would be helpful to focus on increasing students' awareness of the issues they notice or fail to notice and their personal meaning-making process. This might reduce bias and enhance their preparation for effective patient-centered communication.

[Psychological and familial aspects of the familial breast and ovarian cancer genetic counseling process].

Breast cancer is the most prevalent malignancy among women, whilst ovarian cancer is less common but carries a graver prognosis. Carriers of the BRCA mutations have a few-fold higher risk for those diseases. Genetic counseling for the families at risk has been available for almost two decades, since the definition of the mutation. The existence of the deleterious mutation has implications beyond the individual level and touches the lives and future of many other family members. Being part of a BRCA family has medical as well as psychosocial implications. Various barriers and facilitators must be dealt with during the process of sharing the information with kins. Most families cope well with those issues, while some require the guidance of professionals. Special subpopulations, i.e. non-carrier women in BRCA families, young carriers and men who are under minimal personal threat but might transfer the mutation to their off springs, have special needs which should be addressed. The desired outcome of the counseling process is achievement of normal adaptation which balances life in the shadow of uncertainty and threat with the ability to lead a normal life. The process of counseling is multidisciplinary, and along with the advances in scientific and medical aspects, the ethical, legal and social implications (ELSI) have also been developed. The professional personnel escorting those families need to develop and maintain specific skills.

Current knowledge and future directions about the disclosure of dementia: a systematic review of the first decade of the 21st century.

BACKGROUND: The disclosure of Alzheimer's disease presents a great challenge because it entails emotionally charged communication about a life-threatening, incurable, and stigmatized disease. Although a broad consensus has evolved regarding the potential benefits of early disclosure of the diagnosis, little is known about how these recommendations are actually implemented, and there is limited published research about the process issues of the disclosure. PURPOSE: (1) To systematically obtain and evaluate the relevant literature on disclosing a diagnosis of dementia, with special attention to process issues, and (2) to summarize current research findings and draw conclusions for future research and clinical care in this area. METHODS: A systematic review of the literature on disclosure of dementia during the first decade of the 21st century was conducted. RESULTS: From 265 articles retrieved, 47 were included in the review. Although the studies published in the first years of the decade were concerned with assessing attitudes and preferences of those involved in the process of disclosing the diagnosis, those of the last years have focused more on communication and other process issues. CONCLUSIONS: A conceptual development over time in the area is observed in which in the first years, thought processes begin as an ethical debate among clinicians and researchers about the topic of "truth telling" and dementia, continue as a search of the opinions of those involved in the process of disclosure about truth telling, and evolve (observed more recently) into an examination of how this truth telling is delivered.

Are you talking to me?! An exploration of the triadic physician-patient-companion communication within memory clinics encounters.

OBJECTIVE: To explore and gain further insight into the nature of the triadic interaction among patients, companions and physicians in first-time diagnostic disclosure encounters of Alzheimer's disease in memory-clinic visits. METHODS: Twenty-five real-time observations of actual triadic encounters by six different physicians were analyzed. The analysis was accomplished through an innovative combination of grounded theory text analysis and graphics to illustrate the communicational exchanges. RESULTS: The "triadic" communication was actually a series of alternating dyadic exchanges where the third person tries, with inconsistent degrees of success, to become actively involved. During the initial introduction (phase 1) and summation/disclosure (phase 3), the core dyad shifts from physician-patient to physician-companion. CONCLUSION: The focus of communication shifts within these encounters: from talking with the patient to talking about him or ignoring him. These shifts may signify an emotionally loaded role transformation from companion to caregiver. PRACTICE IMPLICATIONS: Effective and empathic management of a triadic communication that avoids unnecessary interruptions and frustrations requires specific communication skills (e.g., explaining the rules and order of the conversation). Professionals need to facilitate the emotionally difficult shift from companion to caregiver and the adjustment of companion and demented patient to this shift.

Expectations, experiences, and tensions in the memory clinic: the process of diagnosis disclosure of dementia within a triad.

BACKGROUND: Health communication studies emphasize the importance of addressing the needs and expectations of patients and families with the disclosure of grave medical conditions. However, little attention has focused on their expectations and experiences of the clinical encounters in diagnosis disclosure of dementia. METHODS: In-depth post-encounter interviews with ten patients and 17 companions from two memory clinics in Israel were analyzed using grounded theory. The analysis focused on identifying their expectations, their experiences, and their perceptions of the process and outcomes. RESULTS: Major differences exist between patients' and companions' expectations. Patients' expectations were an expression of the lack of knowledge/understanding of the visit's purpose and of insight into the memory deterioration. Companions had more clear-cut expectations: some desired confirmation of the legitimacy and pertinence of their concerns about their relatives' memory problem, whereas others hoped to allay their concerns. Patients' dissatisfaction stemmed mostly from their perceptions of the process, communication, and outcome. Companions' dissatisfaction stemmed from lack of information or of tailored follow-up processes for implementing recommendations provided by the clinic. CONCLUSIONS: Our findings expose two main issues challenging fulfillment of the different and frequently opposing expectations of patients and companions. The first is a consequence of the multi-participant nature of the encounter and the second relates to the character and severity of the disease itself. The discordance between the expectations of the two participants generates conflicts that interfere with meeting their diverse needs within the encounters - with consequent disappointment. The implications of these issues merit consideration in the planning of dementia management.

The impact of senior medical students' personal difficulties on their communication patterns in breaking bad news.

PURPOSE: To evaluate the possible influence of personal difficulties and barriers that are within the news bearer and his or her self-awareness (SA) of them, on the patterns of communication during encounters involving breaking bad news (BBN). METHOD: Following an intensive BBN course in 2004, 103 senior medical students at the Sackler School of Medicine, Tel Aviv University, were evaluated for BBN competencies by the analysis of their written descriptions of how they visualized their manner of delivering bad news to a patient described in a challenging vignette. The students were further asked to reflect on their own difficulties and barriers that surfaced in response to reading the narrative presented in the vignette and in delivering the bad news. Using an immersion crystallization narrative analysis method, the authors analyzed the relationship between the students' BBN strategies and their self-perceived barriers and difficulties. RESULTS: Four types of communicators were identified and related to 45 different personal and professional barriers that the students, through self-reflection, found in themselves. These perceived barriers as well as the ability to self-reflect on them influenced their patterns of communication in their envisioned and written-down encounters, including the level of emotional connectedness, information provided, and the chosen focus-of-care paradigm (physician-centered, patient-centered, or relationship-centered). CONCLUSIONS: These findings empirically demonstrate that intrapersonal difficulties within the communicator and his or her level of SA about them influenced the manner and content of the communication during the encounter. This finding suggests that enhancing SA and addressing personal and professional difficulties could help physicians' capability to cope with challenging communication tasks. The authors propose a working tool (the Preparatory SPIKES) to facilitate the integration of self-reflection (by identifying personal difficulties) into day-by-day planning and delivery of bad news.

Written notification of test results: meanings, comprehension and implication on patients' health behavior.

OBJECTIVE: Mailing test results are frequently used to provide patients with information about their medical condition and enhancing their participation in subsequent management. This study explores patients' experiences of the written notification process and its implications. METHODS: Telephone interviews were conducted with 128 patients who had undergone endoscopic examinations in two gastroenterology clinics after the received of their mailed biopsies results. The interviews (open and closed questions) focused on patients' perceptions and emotions while waiting, and after reading the reports. RESULTS: The findings are divided to emotions experienced, comprehension and behavioral implications. The reports arrived 6-33 days later than promised. Many patients were dissatisfied but most did nothing to hasten the process. Over half of them were unable to understand the information in the letters and the future steps needed to be taken. Explanatory covering letters, sent by the hospital clinic, enhanced comprehension and diminished confusion. CONCLUSIONS: Mailed biopsy reports frequently failed to enhance patient understanding and participation in decisions. Incomprehensibility of written information, and unmet expectations, evoked negative emotional responses. PRACTICE IMPLICATIONS: Improving readability with simple, non-technical information; and verification of understanding and fulfillment of recommendations using a follow-up call are critical for accomplishing the goals of mailed biopsy reports.

Factors in the doctor-patient relationship that accentuate physicians' hurt feelings when patients terminate the relationship with them.

OBJECTIVE: The present study explores the emotional effect of the injury experienced by physician's, as a consequence of a patient's termination of their relationship. METHODS: A vignette study using different scenarios describing a patient who switched to another doctor was distributed to 119 family physicians. A three-way ANCOVA analysis was employed. Additionally, physicians' answered an open question asking of situations that elicited negative emotions. RESULTS: The quantitative results indicated that termination of the relationship by a "high status" patient and/or after a long duration is more emotionally hurtful than termination by a "lower status" patient after a brief relationship. The results of the open question provided an additional insight into the emotional impact of the doctor's hurt feelings on the doctor-patient relationship. CONCLUSIONS: The severity and consequences of the emotional injury experienced by physicians when patients decide to transfer to another physician are influenced by factors related to the patient, physician and the relationship between them. PRACTICE IMPLICATIONS: We discuss the implications of our results on the understanding of the emotional injury and consequent impaired function and possible "burn-out" in physicians and explore the possibility of educating doctors to heightened awareness and consequently enhanced ability to cope with such situations.

Dilemmas in the (un)veiling of the diagnosis of Alzheimer's disease: walking an ethical and professional tight rope.

OBJECTIVE: To enhance the understanding and effect of physician's difficulties, attitudes and communication styles on the disclosure of the diagnosis of AD in practice. METHODS: Qualitative, phenomenological study, combining pre-encounter interviews with physicians, observations of actual encounters of diagnosis disclosure of AD, and post-encounter interviews. RESULTS: There were various ways or tactics to (un)veil the bad news that may be perceived as different ways of dulling the impact and avoiding full and therefore problematic statements. In the actual encounters this was accomplished by keeping encounters short, avoiding elaboration, confirmation of comprehension and explicit terminology and using fractured sentences. CONCLUSION: The present study's findings highlight the difficulties encountered in breaking the news about AD, in the way it is actually done, and the problems that may arise from this way of un/veiling the news. The main problem is that the reluctance to make a candid disclosure of the diagnosis as was demonstrated in this study may violate basic moral and legal rights and may also deprive patients and caregivers of some of the benefits of early disclosure of diagnosis. PRACTICE IMPLICATIONS: There is a need for assisting physicians to cope with their personal difficulties, problems and pitfalls in breaking the news.

Comparisons of American, Israeli, Italian and Mexican physicians and nurses on the total and factor scores of the Jefferson scale of attitudes toward physician-nurse collaborative relationships.

This cross-cultural study was designed to compare the attitudes of physicians and nurses toward physician-nurse collaboration in the United States, Israel, Italy and Mexico. Total participants were 2522 physicians and nurses who completed the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration (15 Likert-type items, (Hojat et al., Evaluation and the Health Professions 22 (1999a) 208; Nursing Research 50 (2001) 123). They were compared on the total scores and four factors of the Jefferson Scale (shared education and team work, caring as opposed to curing, nurses, autonomy, physicians' dominance). Results showed inter- and intra-cultural similarities and differences among the study groups providing support for the social role theory (Hardy and Conway, Role Theory: Perspectives for Health Professionals, Appelton-Century-Crofts, New York, 1978) and the principle of least interest (Waller and Hill, The Family: A Dynamic Interpretation, Dryden, New York, 1951) in inter-professional relationships. Implications for promoting physician-nurse education and inter-professional collaboration are discussed.

Maternal mosaicism for a second mutational event--a novel deletion--in a familial adenomatous polyposis family harboring a new germ-line mutation in the alternatively spliced-exon 9 region of APC.

Familial Adenomatous Polyposis (FAP) is an autosomal dominant heritable disorder caused by germ-line mutations in the APC gene. To date, more than 300 germ-line mutations within this gene have been described. Using PCR, SSCP and DNA sequencing, we have identified a new mutation in the alternatively spliced region of exon 9 (1042C-->T), which results in a stop signal. This mutation manifested an aggressive form of FAP with onset of symptoms in one proband at age 17. Our results differ from reported exon 9 mutations in the spliced-out portion of the gene manifesting an attentuated form of FAP (AAPC) [Varesco et al 1994; van der Luijt et al. 1995; Curia et al. 1998; Young et al. 1998]. When analyzing this family, we encountered a mutant FAP gene which had undergone a second mutational event, a deletion. In addition to linkage analysis, both the occurrence of the two exon 9 mutation-carrier siblings, of which one is affected, harboring the same novel deletion in one generation of this family, and its absence in both parents indicates the existence of maternal germ-line mosaicism for cells bearing the latter second mutational event. Our study is only the second report of parental mosaicism in the APC gene.

The education and training of gastroenterologists for the 21st century: a paradigm for the education of medical specialists in technology-intensive fields - an international and Israeli perspective.

Gastroenterology in the developed world as a paradigm for technologically intensive medical specialties has undergone dramatic changes during the last half-century with expansion, proliferation and affluence followed by serious reactions on the part of cost-conscious and demanding governments, insurers and consumers. A review of events in several regions within the developed world reveals tremendous technological progress but inadequate attention to professional, economic and ethical issues, which are crucial for the education of a model gastroenterologist who will embody the qualities that will enable him/her to function well clinically, technologically, scientifically, professionally and ethically and thus enable him/her to cope with the increasingly complex challenges that are likely to arise during the next decades. The possibility and need for defining a specific ethic for technology-intensive medical specialists is discussed.