Can All Doctors Be Like This? Seven Stories of Communication Transformation Told by Physicians Rated Highest by Patients.

INTRODUCTION: The top predictors of patient satisfaction with clinical visits are the quality of the physician-patient relationship and the communications contributing to their relationship. How do physicians improve their communication, and what effect does it have on them? This article presents the verbatim stories of seven high-performing physicians describing their transformative change in the areas of communication, connection, and well-being. METHODS: Data for this study are based on interviews from a previous study in which a 6-question set was posed, in semistructured 60-minute interviews, to 77 of the highest-performing Permanente Medical Group physicians in 4 Regions on the "Art of Medicine" patient survey. Transformation stories emerged spontaneously during the interviews, and so it was an incidental finding when some physicians identified that they were not always high performing in their communication with patients. RESULTS: Seven different modes of transformation in communication were described by these physicians: a listening tool, an awareness course, finding new meaning in clinical practice, a technologic tool, a sudden insight, a mentor observation, and a physician-as-patient experience. DISCUSSION: These stories illustrate how communication skills can be learned through various activities and experiences that transform physicians into those who are highly successful communicators. All modes result in a change of state-a new way of seeing, of being-and are not just a new tool or a new practice, but a change in state of mind. This state resulted in a marked change of behavior, and a substantial improvement of communication and relationship.

Upstream discussion provided in the ambulatory setting to assist patients with chronic kidney disease considering dialysis.

OBJECTIVES: Extensive discussion with renal patients about treatment intensity is not systematically integrated into their care and often occurs during an acute hospitalization. We conducted a "test-of-change" pilot study to assess the utility of providing an upstream discussion in the ambulatory setting as an additional nephrology consult to assist patients with chronic kidney disease considering treatment choices. METHODS: We randomly assigned patients with Stage 4 or Stage 5 chronic kidney disease who had not yet begun renal dialysis to 1 of 2 groups. The test group received the additional nephrology consult and met with an interdisciplinary team composed of a nephrologist, social worker, and clinical ethicist, and the control group did not. Qualitative data were collected in 2012 and 2013 via oral questionnaire. Both groups received a 6-month follow-up assessment. RESULTS: Patients who received the nephrology consult reported that they experienced help in forming a treatment plan, felt well understood, and had the opportunity to thoroughly discuss questions. The controls had a 26% increased probability of beginning dialysis and had a statistically significant increase in dialysis and clinic visits (p < 0.10 and p < 0.05). Controls also were likelier than the test group to be admitted to the hospital (0.5 vs 0.2 admissions per patient in the test group), spend more days hospitalized (2.8 vs 0.5 bed days per patient), and visit the emergency room (0.73 vs 0.66 visits per patient) and clinic (6.6 vs 3.6 visits per patient). CONCLUSIONS: An additional nephrology consultation proved helpful both qualitatively and quantitatively.

Living with advanced illness: longitudinal study of patient, family, and caregiver needs.

BACKGROUND AND OBJECTIVES: Inpatient palliative care (IPC) consults are associated with improved quality of care and less intensive utilization. However, little is known about how the needs of patients with advanced illness and the needs of their families and caregivers evolve or how effectively those needs are addressed. The objectives of this study were 1) to summarize findings in the literature about the needs of patients with advanced illness and the needs of their families and caregivers; 2) to identify the primary needs of patients, families, and caregivers across the continuum of care from their vantage point; and 3) to learn how IPC teams affect the care experience. METHODS: We used a longitudinal, video-ethnographic approach to observe and to interview 12 patients and their families before, during, and after an IPC consult at 3 urban medical centers. Additional interviews took place up to 12 months after discharge. RESULTS: Five patient/family/caregiver needs were important to all family units. IPC teams responded effectively to a variety of needs that were not met in the hospital, but some postdischarge needs, beyond the scope of IPC or health care coverage, were not completely met. CONCLUSION: Findings built upon the needs identified in the literature. The longitudinal approach highlighted changes in needs of patients, families, and caregivers in response to emerging medical and nonmedical developments, from their perspective. Areas for improvement include clear, integrated communications in the hospital and coordinated, comprehensive postdischarge support for patients not under hospice care and for their caregivers.

A cognitive-behavioral group for patients with various anxiety disorders.

OBJECTIVE: Cognitive-behavioral therapy (CBT) protocols for each of the anxiety disorders are robust and effective but are best suited for specialty clinics. This study assessed a format more suitable for general clinics: a single protocol based on standard CBT techniques designed to treat patients who have different anxiety disorders in the same group. METHODS: Potential participants in Vancouver, British Columbia, were administered a structured clinical interview to identify those with major anxiety disorders: panic disorder, with or without agoraphobia; obsessive-compulsive disorder; social phobia; generalized anxiety disorder; specific phobia; and posttraumatic stress disorder. Forty-three percent of participants had more than one current anxiety diagnosis. Those with active substance abuse or dependence or with psychosis were excluded. A total of 152 patients were randomly assigned to immediate treatment in the 11-week CBT group or to a wait-list control group. The Beck Anxiety Inventory (BAI) was administered at baseline, at the end of treatment or of the waiting period, and six months later. RESULTS: Reductions in BAI scores for participants in the immediate-treatment groups were greater than those for the control group participants. Patients with panic disorder in particular appeared to benefit. Outcomes for the immediate-treatment group were superior in terms of clinically significant changes, defined as a 20% or 40% improvement. Reductions in BAI scores continued to be present six months later. The improvements correspond to a medium effect size (Cohen's d=.50). CONCLUSIONS: A group CBT protocol for mixed anxiety disorders may make effective treatment more widely available.

Understanding panel management: a comparative study of an emerging approach to population care.

CONTEXT: Panel management is an innovative approach for population care that is tightly linked with primary care. This approach, which is spreading rapidly across Kaiser Permanente, represents an important shift in population-care structure and emphasis, but its potential and implications have not been previously studied. OBJECTIVE: To inform the ongoing spread of panel management by providing an early understanding of its impact on patients, physicians, and staff and to identify barriers and facilitators. DESIGN: Qualitative studies at four sites, including patient focus groups, physician and staff interviews, and direct observation. FINDINGS: Panel management allows primary care physicians to use dedicated time to direct proactive care for their patients, uses staff support to conduct outreach, and leverages new panel-based information technology tools. Patients reported appreciating the panel management outreach, although some also reported coordination issues. Two of four study sites seemed to provide a more coordinated patient experience of care; factors common to these sites included longer maturation of their panel management programs and a more circumscribed role for outreach staff. Some physicians reported tension in the approach's implementation: All believed that panel management improved care for their patients but many also expressed feeling that the approach added more tasks to their already busy days. Challenges yet to be fully addressed include providing program oversight to monitor for safe and reliable coordination of care and incorporation of self-management support. CONCLUSION: Subsequent spread of panel management should be informed by these lessons and findings from early adopters and should include continued monitoring of the impact of this rapidly developing approach on quality, patient satisfaction, primary care sustainability, and cost.