A Nephrology Fellows' Communication Skills Course: An Educational Quality Improvement Report.

BACKGROUND: Nephrology fellows need expertise navigating challenging conversations with patients throughout the course of advanced kidney disease. However, evidence shows that nephrologists receive inadequate training in this area. This study assessed the effectiveness of an educational quality improvement intervention designed to enhance fellows' communication with patients who have advanced kidney disease. STUDY DESIGN: Quality improvement project. SETTING & PARTICIPANTS: Full-day annual workshops (2013-2014) using didactics, discussion, and practice with simulated patients. Content focused on delivering bad news, acknowledging emotion, discussing care goals in dialysis decision making when prognosis is uncertain, and addressing dialysis therapy withdrawal and end of life. Participants were first-year nephrology fellows from 2 Harvard-affiliated training programs (N=26). QUALITY IMPROVEMENT PLAN: Study assessed the effectiveness of an intervention designed to enhance fellows' communication skills. OUTCOMES: Primary outcomes were changes in self-reported patient communication skills, attitudes, and behaviors related to discussing disease progression, prognostic uncertainty, dialysis therapy withdrawal, treatments not indicated, and end of life; responding to emotion; eliciting patient goals and values; and incorporating patient goals into recommendations. MEASUREMENTS: Surveys measured prior training, pre- and postcourse perceived changes in skills and values, and reported longer term (3-month) changes in communication behaviors, using both closed- and open-ended items. RESULTS: Response rates were 100% (pre- and postsurveys) and 68% (follow-up). Participants reported improvement in all domains, with an overall mean increase of 1.1 (summed average scores: precourse, 2.8; postcourse, 3.9 [1-5 scale; 5 = "extremely well prepared"]; P<0.001), with improvement sustained at 3 months. Participants reported meaningful changes integrating into practice specific skills taught, such as "Ask-Tell-Ask" and using open-ended questions. LIMITATIONS: Self-reported data may overestimate actual changes; small sample size and the programs' affiliation with a single medical school may limit generalizability. CONCLUSIONS: A day-long course addressing nephrology fellows' communication competencies across the full course of patients' illness experience can enhance fellows' self-reported skills and practices.

Clinically relevant correlates of accurate perception of patients' thoughts and feelings.

The goal was to explore the clinical relevance of accurate understanding of patients' thoughts and feelings. Between 2010 and 2012, four groups of participants (nursing students, medical students, internal medicine residents, and undergraduate students) took a test of accuracy in understanding the thoughts and feelings of patients who were videorecorded during their actual medical visits and who afterward reviewed their video to identify their thoughts and feelings as they occurred (Test of Accurate Perception of Patients' Affect, or TAPPA). Participants' accuracy scores were then correlated with participants' attitudes toward patient-centered care, clinical course background, recall of clinical conversation, evaluations of clinical performance made by preceptors, evaluations of interpersonal skill made by standardized patients in clinical encounters, and independent coding of behavior in a clinical encounter. Accuracy in understanding patients' thoughts and feelings was significantly correlated with nursing students' clinical course experience, clinicians' favorable attitudes to psychosocial discussion, standardized patients' evaluations of medical students' interpersonal skill, independent coding of medical students' patient-centered behavior while taking a social history, and undergraduates' more accurate recall of what an actor-physician said on video. Accuracy in perceiving patients' thoughts and feelings can be objectively measured and is a skill relevant to clinical performance.

The Test of Accurate Perception of Patients' Affect (TAPPA): an ecologically valid tool for assessing interpersonal perception accuracy in clinicians.

OBJECTIVE: A clinician's ability to infer patients' thoughts and feelings is a critical component of high quality care. The goal of this article is to present a new test to measure this ability in clinicians, called the Test of Accurate Perception of Patients' Affect (TAPPA). METHODS: Audiovisual clips were taken from patients' actual medical visits. The patients reviewed the videotape after the visit to identify their thoughts and feelings during the visit. This information was used to extract short audiovisual clips for which the correct answer was the patient's report of the thought or feeling associated with that clip. The TAPPA contains 48 audiovisual clips, each responded to in a multiple choice format. RESULTS: The TAPPA showed good psychometric properties (optimal mean and good variance, adequate internal consistency, and strong re-test reliability) and convergent validity with other tests of emotion recognition. In addition, the test showed predicted better performance by female than male participants. CONCLUSION: The TAPPA promises to be a valuable tool for research and education on provider-patient relationships and quality of care. PRACTICE IMPLICATIONS: A tool for testing clinicians' understanding of patients' thoughts and feelings may contribute to better quality of care and to improved selection and training.

Abnormal uterine bleeding.

Disorders of the menstrual cycle are common problems in ambulatory medicine. Abnormal uterine bleeding describes bleeding that is excessive or outside the normal menstrual cycle. In the premenopausal woman, the differential diagnosis is broad, and pregnancy must always be considered. Determining whether the bleeding is ovulatory or anovulatory is a central part of the evaluation, as anovulation is one of the most common causes of abnormal uterine bleeding. In patients with anovulatory bleeding, the goal of treatment is to minimize blood loss and prevent complications from chronic unopposed estrogen. In women with oligomenorrhea or amenorrhea, after establishing the etiology, it is necessary to maintain adequate estrogen to support bone health. In the peri- and postmenopausal population, because the incidence of endometrial hyperplasia and malignancy rises, it is important to have a low threshold for endometrial assessment.

Lessons from a patient partnership intervention to prevent adverse drug events.

BACKGROUND: Patient safety 'best practices' that call for patient participation to prevent adverse drug events have not been rigorously evaluated. OBJECTIVE: To consider lessons learned from a patient partnership intervention to prevent adverse drug events among medical in-patients. DESIGN: Prospective randomized, controlled pilot trial. SETTING: Boston teaching hospital. Patients. Two hundred and nine adult in-patients on a general medicine unit. INTERVENTION: Intervention patients (n = 107) received drug safety information and their medication list; controls (n = 102) received drug safety information only. Measurements. Adverse drug events and close-call drug errors were identified using chart review and incident reports from nurses, pharmacists, and physicians. Patients and clinicians were surveyed about the intervention. RESULTS: In 1053 patient-days at risk, 11 patients experienced 12 adverse drug events and 16 patients experienced 18 close calls. There was a non-significant difference between intervention patients and controls in survey responses and in the adverse drug event rate (8.4% versus 2.9%, P = 0.12) and close-call rate (7.5% versus 9.8%, P = 0.57). Eleven percent of patients were aware of drug-related mistakes during the hospitalization. Among nurse respondents, 29% indicated that at least one medication error was prevented when a patient or family member identified a problem. CONCLUSION: Partnering with in-patients to prevent adverse drug events is a promising strategy but requires further study to document its efficacy.