Patients' intuitive judgments about surveillance endoscopy in Barrett's esophagus: a review and application to models of decision-making.

Adherence to practice guidelines for endoscopic surveillance of Barrett's esophagus is equivocal with evidence of underutilization and overutilization. While physicians report strong agreement with and adherence to recommended surveillance endoscopy (esophagogastroduodenoscopy [EGD]) guidelines, less is known about modifiable barriers and facilitators shaping patients' adherence behaviors. The aim of this study is to conduct a structured literature review of studies exploring patients' perspectives regarding surveillance EGD and to place these results within a conceptual framework. A structured literature review of PubMed, Cochrane, and Google Scholar databases with qualitative thematic analysis was performed. Six studies met eligibility criteria. Analysis of results identified five distinct themes. First, patients' objective cancer risk estimates are consistent with subjective risk perceptions, but neither is associated with EGD surveillance. Second, patients have strong beliefs in the benefits of cancer screening and surveillance and trust in their doctors. Third, anxiety and depression symptoms are related to risk perceptions and outcome expectancies of surveillance. Fourth, endoscopic surveillance itself has affective and physical consequences. Finally, health services and system variables are related to risk perception and EGD surveillance. These themes coherently fit within an integrated model of intuitive decision-making and health behaviors. Studies meeting eligibility criteria were heterogeneous in terms of their study objectives and findings. Quantitative meta-analyses of study findings could not be performed. To improve adherence, endoscopic surveillance programs should consider how patients intuitively frame risks and benefits and patients' emotional reactions to the endoscopy procedure, and focus on how physicians communicate recommendations.

Preconsultation education promoting breast cancer screening: does the choice of media make a difference?

BACKGROUND: Multimedia technology can be a valuable resource for health promotion and patient education initiatives because it allows messages to be presented within an environment that is both sensory-rich and interactive (i.e., the user can explore the information according to his or her particular needs and interests). Using clinic waiting time as an opportunity for breast cancer education, this investigation examined whether an educational intervention promoting breast cancer screening would be more effective when using interactive multimedia than when using written materials. METHODS: Over a five-month period, 108 women (40-70 years of age) from two clinics (a family practice clinic and a free clinic for the poor) participated in the study. Participants initially completed measures assessing perceptions of the personal importance of breast cancer, knowledge, and anxiety about screening procedures. They then were randomly assigned to receive breast cancer education by using an interactive multimedia program or by reading a brochure. Following the intervention, the participants once again completed the perceived importance, knowledge, and anxiety measures, and evaluated the educational materials. RESULTS: These women perceived breast cancer to be a more personally important health issue, learned more, and reported less anxiety about cancer screening following the intervention regardless of method. Younger women learned more from the educational materials than did older women. Although the multimedia program received more favorable evaluations than the brochure, this effect was mediated by the message recipient's age, as younger women responded more favorably to the multimedia materials than did older women. CONCLUSION: Preconsultation education is a valuable but rarely used opportunity to promote breast cancer screening. If well constructed, educational materials using a variety of media can be effective. While preferences for media may in part depend on the audience's age, considerably more research is needed to better understand how the interplay of media, message, and audience characteristics can help accomplish health-promotion objectives.

Patient participation in deciding breast cancer treatment and subsequent quality of life.

This investigation of patients with early breast cancer examined relationships among patient involvement in deciding treatment (i.e., whether to undergo breast removal or breast conservation), perceptions of control over treatment decisions, and subsequent health-related quality of life. It was predicted 1) that patients who more actively participated in consultations to decide treatment would perceive more decision control than would more passive patients and 2) that patients who perceived greater decision control would report better health-related quality of life following treatment than would patients perceiving less decision control. Sixty patients with stage I or II breast cancer allowed their consultations with surgeons to be audiorecorded. Following these visits, patients reported on their involvement in the consultation, optimism for the future, knowledge about treatment, and two aspects of perceived decision control, the perception of having a choice for treatment and the extent to which the doctor or patient was responsible for the decision. Six and 12 months postoperatively, 51 patients (85%) returned a follow-up survey assessing perceived decision control and health-related quality of life. The first prediction received some support. The patients who had more actively participated in their consultations, particularly in terms of offering opinions, assumed more responsibility for treatment decisions during the year following surgery than did less expressive patients. Also, the patients who reported more involvement in their consultations later believed they had had more of a choice for treatment. The second hypothesis was partially supported. Six and 12 months following treatment, the patients who believed they were more responsible for treatment decisions and believed they had more choice of treatment reported higher levels of quality of life than did the patients who perceived themselves to have less decision control. However, perceived control at the time of treatment did not predict later quality of life. Theoretical and clinical implications are discussed.

Increasing patient involvement in choosing treatment for early breast cancer.

BACKGROUND: This investigation examined factors affecting patient involvement in consultations to decide local treatment for early breast cancer and the effectiveness of two methods of preconsultation education aimed at increasing patient participation in these discussions. METHODS: Sixty patients with Stage I or II breast cancer (1) were pretested on their knowledge about breast cancer treatment and optimism for the future, (2) were randomly assigned to one of two methods for preconsultation education: interactive multimedia program or brochure, (3) completed knowledge and optimism measures, (4) consulted with a medical oncologist, radiation oncologist, and general surgeon, and (5) completed self-report measures assessing their involvement in the consultations and control over decision-making. The consultations were audiorecorded and analyzed to identify behavioral indicators of patient involvement (question-asking, opinion-giving, and expressing concern) and physician utterances encouraging patient participation. RESULTS: College-educated patients younger than 65 years of age were more active participants in these consultations than were older, less educated patients. In addition, patients showed more involvement when they interacted with physicians who encouraged and facilitated patient participation. The method of education did not affect patient involvement although patients tended to learn more about breast cancer treatment after using the multimedia program than after reading the brochure. CONCLUSIONS: Although patients vary in their expressiveness, physicians may be able to increase patient participation in deciding treatment by using patient-centered behavior. Also, preconsultation education appears to be an effective clinical strategy for helping patients gain an accurate understanding of their treatment options before meeting with physicians.

Patients' predispositions to discuss health issues affecting quality of life.

BACKGROUND: Many patients are reluctant to talk to family physicians about certain health issues that affect quality of life. This research examines factors that influence a patient's willingness to discuss three aspects of health-related quality of life: overall well-being, physical health, and psychosocial health. METHODS: Prior to their consultations, 254 patients completed questionnaires that assessed their perceptions of health limitations, beliefs about the family physician's job responsibilities, willingness to discuss various topics with the physician, and relational history with the physician (ie, number of previous visits). On the post-visit instrument, patients reported whether certain topics were discussed during the consultation and their satisfaction with the physician. RESULTS: Patients were more willing to discuss all aspects of health-related quality of life when they believed it was the doctor's job to ask about these issues and when they had a longer relational history with the doctor. Patients' health limitations did not predispose patients to talk about certain issues. Patients were more satisfied with care when there was more discussion of the patient's overall well-being and physical health. However, discussions about psychosocial issues were not related to patient satisfaction. CONCLUSIONS: A theoretical model is proposed that may be useful in explaining why patients often vary in their willingness to discuss certain topics, particularly psychosocial issues. Future research should analyze how doctors and patients introduce, manage, and terminate discussions of health-related quality of life.

Using health status surveys in medical consultations.

The goal of this research was to identify patients' preferences for physician inquiry into various aspects of health status and to examine whether the preconsultation availability of health status data (collected from the SF-36 Health Status Questionnaire) influenced the physician's conduct during the consultation. Results from 58 prenatal patient visits yielded the following findings. First, patients expressed strong preferences for physicians to ask about the patient's perceptions of health in general and about physical dimensions of health status such as pain, vitality, and role limitations due to physical functioning. Patients also were more satisfied when doctors were perceived as having asked about these issues. Second, patients varied considerably in their preferences for physician inquiries into psychosocial issues such as social functioning, mental health, and role limitations due to emotional problems. Approximately half the patients wanted these matters discussed, whereas the remainder either did not care or preferred that doctors not ask about these topics. Third, the preconsultation availability of health status information had little effect on the degree to which physicians asked about the patient's health-related quality of life. Clinical implications are discussed.

Provider-patient communication and metabolic control.

OBJECTIVE: To determine whether nurses' and NIDDM patients' communication styles during consultations are related to subsequent metabolic control and to examine factors influencing patterns of communication in these consultations. RESEARCH DESIGN AND METHODS: A total of 47 NIDDM patients participated in the study and completed the following procedures: 1) assessment of baseline HbA1, 2) attended 3.5 days of diabetes education, 3) returned in 1 mo for a follow-up consultation with a nurse, and (4) returned in 9-12 wk for a follow-up HbA1 assessment. The communication variables coded from the consultations were the frequency with which nurses produced controlling, informative, and patient-centered utterances and the frequency with which patients sought information, engaged in decision making, and expressed negative affect. RESULTS: The results were as follows: 1) patients experienced poorer metabolic control after interacting with nurses who were more controlling and directive in their communication with patients (r = 0.39, P < 0.01); 2) the nurses' use of patient-centered responses was directly related to the degree to which patients expressed feelings (r = 0.34, P < 0.01) and exhibited decision-making behavior (r = 0.62, P < 0.01); and 3) several of the nurses' and patients' communicative behaviors were related to patient characteristics such as age, sex, education, and baseline HbA1 levels. CONCLUSIONS: The results suggest that providers' attempts to exert considerable control during consultations with NIDDM patients may be counterproductive and contribute to poorer outcomes. The findings also indicate that patient-centered behaviors (e.g., encouraging the patient's involvement, respecting the patient's opinion, and offering support) facilitate the patient's ability to be an active participant in the consultation.

Microzonation and site amplification of seismic ground motions in the Paducah, Kentucky, area

Site conditions at 37 locations in the Paducah, Kentucky, are have been modeled using seismic refraction and reflection adata to determine site response to hypothetical earthquakes in the New Madrid and southern illinois seismic zones. The seismic data, integrated with local borehole information, indicated that depth to bebrock range from less than 300 ft to more than 500 ft. Shollow subsurface conditions (less than 100 ft) suggest than the study area can be subdivided into three zones : A) An ascient lake bet deposit (underlying the eastern portion of the city), characterized by thick unconsolidated sediments; B) a terrase area (flanking the city), characterized by moderately thick soils; and C) an upland area (south of the city), characterized by thin soil deposits (less than 20 ft) overlying more competent material (AU)

Analyzing communication in medical consultations. Do behavioral measures correspond to patients' perceptions?

When analyzing relationships between physician-patient communication and medical outcomes, researchers typically rely on quantitative measures of behavior (e.g., frequencies or ratios) derived from observer-coding of transcripts, audiotapes, or videotapes. Interestingly, rarely have researchers assessed whether quantitative measures of communication (e.g., the physician's information giving) correspond to patients' perceptions of physicians' communication (e.g., informative). This investigation of 115 pediatric consultations examined this issue and yielded several notable findings. First, less satisfied parents received more directives and proportionally less patient-centered utterances from physicians than did more satisfied parents. Second, findings were mixed regarding the degree to which behavioral measures related to analogue measures of parents' perceptions. For example, the doctors' use of patient-centered statements was predictive of parents' perceptions of physicians' interpersonal sensitivity and partnership building, but the amount of information physicians provided parents was unrelated to judgments of the doctors' informativeness. Third, with some important exceptions, relationships between behavioral measures and parents' evaluations did not vary for parents differing in education and anxiety about the child's health. Finally, behavioral measures in the form of frequencies tended to be better predictors of parents' perceptions than were measures in the form of proportions. Implications are discussed.

Communicative styles and adaptations in physician-parent consultations.

This investigation compares the degree to which personal and interactive factors respectively account for variation in patterns of physician-parent communicative exchange. The analysis of audiorecordings of 115 pediatric consultations revealed several notable findings: (a) individual physicians differed in the degree to which each provided information, issued directives, exhibited positive socioemotional behavior, and engaged in partnership-building, (b) parents who asked more questions and expressed more negative affect (e.g. concerns, frustrations) received more information and directives from physicians, (c) parents who were more affectively expressive elicited a greater number of positive socioemotional comments from doctors, and (d) parents' question-asking and opinion-giving were related to the parents' level of education and the degree to which physicians' engaged in partnership-building. The results of this study suggest that, as are other forms of interpersonal communication, medical consultations are processes of personal and mutual influence that unfold according to the characteristics of the individuals and to interactive processes related to how interactants adapt their communication to one another.

Information-giving in medical consultations: the influence of patients' communicative styles and personal characteristics.

Informing the patient is arguably the physician's most important communicative responsibility. Recognizing this researchers have long been interested in the question of why some patients receive more information from physicians than do others. In this paper, it is argued that the amount of information physicians provide patients during medical consultations may be influenced by two sets of factors, patients' personal characteristics (age, sex, education, and anxiety) and patients' communicative styles (question-asking, opinion-giving, and expression of concern). The analysis of audiovisual recordings of 41 physician-patient consultations in a family practice clinic revealed several notable findings: (a) information regarding diagnosis and health matters was primarily related to the patient's anxiety, education, and question-asking, (b) information regarding treatment was primarily a function of the patient's question-asking and expression of concerns, and (c) patients' assertiveness and expressiveness were strongly influenced by physicians' use of 'partnership-building' utterances that solicited the patient's questions, concerns, and opinions. The data suggest that, when attempting to explicate factors affecting physicians' informativeness, researchers must take into account features of the patients' communicative styles as well as physicians' perceptions of certain groups of patients.

Social and linguistic factors influencing adaptation in children's speech.

The ability to appropriately reciprocate or compensate a partner's communicative response represents an essential element of communicative competence. Previous research indicates that as children grow older, their speech levels reflect greater adaptation relative to their partner's speech. In this study, we argue that patterns of adaptation are related to specific linguistic and pragmatic abilities, such as verbal responsiveness, involvement in the interaction, and the production of relatively complex syntactic structures. Thirty-seven children (3-6 years of age) individually interacted with an adult for 20 to 30 minutes. Adaptation between child and adult was examined among conversational floortime, response latency, and speech rate. Three conclusions were drawn from the results of this investigation. First, by applying time-series analysis to the interactants' speech behaviors within each dyad, individual measures of the child's adaptations to the adult's speech can be generated. Second, consistent with findings in the adult domain, these children generally reciprocated changes in the adult's speech rate and response latency. Third, there were differences in degree and type of adaptation within specific dyads. Chronological age was not useful in accounting for this individual variation, but specific linguistic and social abilities were. Implications of these findings for the development of communicative competence and for the study of normal versus language-delayed speech were discussed.

Earthquake mechanics in the central United States.

Focal mechanism solutions of earthquakes in the central United States suggest that local stress fields are important in determining the type and orientation of faulting. The implied stress system is considerably more complicated than that which would be produced by east-west trending compressive stresses, as previously suggested for this region.