Applying patient perspectives on caring to curriculum development

https://doi.org/10.1016/j.pec.2008.05.020Get rights and content

Abstract

Objective

To report how patient viewpoints on caring inform curriculum development for teaching sessions on delivering bad news, making the transition to palliative care, and communicating about a medical error.

Methods

We conducted focus groups that used patients recruited from the surrounding community to view videotapes of physicians delivering bad news, talking with a patient about palliative care, and communicating about a medical error. We used focus group results, combined with evidence from the medical literature to inform curriculum content for workshops conducted with Internal Medicine and Family Medicine residents at the University of Massachusetts Medical School.

Results

Patient perspectives on caring gathered through focus groups differed in significant ways from the existing medical literature on caring when providers are communicating in the challenging situations that were depicted. Our data pointed out that individual reactions were unique and sometimes contradictory in that one person saw behavior as caring that others thought was uncaring. Participants often used qualifiers in their comments like “appropriate” amounts of information, “measured” empathy, chooses words carefully to reflect the relative nature of caring. “Arranges to meet healthcare needs,” an issue that extends beyond the encounter, was seen as a new component of caring not previously described. Applying these concepts to curriculum required that we not only focus on the behavioral skills involved in these tasks, but also the processes of assessing patient's informational and emotional needs, and then taking steps to meet them, while adjusting behavior in real time to meet patients needs for caring. Workshops delivered were highly evaluated by residents.

Conclusion

Patient perspectives on caring when providers deliver bad news, discuss transitions to palliative care, and communicate about a medical error reinforce that patient expectations for caring are highly contextualized and physician behavior needs to be individualized. We taught residents not only behavioral skills, but also the process skills of anticipating patient reactions, recognizing patient clues, planning and choosing effective strategies on the fly, and assessing one's own performance characteristic of communication expertise.

Practice implications

Teaching caring attitudes with challenging communication tasks requires that learners appreciate and value not only caring behaviors but also learn the process by which they must adjust and titrate their actions to meet patient needs.

Introduction

The secret of the care of the patient is in caring for the patient—Francis Peabody

The physician's caring attitude is essential to the patient's perception of the quality of healthcare. Accrediting bodies call for care that is “compassionate, appropriate, and effective” [1], a sentiment echoed by medical educators [2] and public reporting agencies [3]. There has been a recent focus on developing curricula and training faculty in this area [4], [5], [6]. Yet, current research demonstrates that physicians often miss the opportunity to express caring in their interactions with patients. Levinson, for example, found that both primary care physicians and surgeons failed to positively address emotional clues in their interactions with patients in nearly two thirds of the cases reviewed [7]. Evidence in trainees also suggests that patient-centered attitudes, felt by many to be a proxy for caring, decline as students progress through medical school [8]. Several things may contribute to this. Caring is an elusive concept and lacks clear definition. Recent literature that defines caring behaviors in clinical care [9] and teaching [4] generated perspectives on caring through expert opinion. Patient perspectives on these topics are less common.

While patient perspectives on palliative care [10], [11], [12], communicating about medical error [13] and delivering bad news [14] do exist, teaching and learning about these specific situations that represent challenges to caring also rely chiefly on expert opinion [15], [16]. The literature that details patient perspectives in these areas demonstrates a significant discrepancy between what patients want to talk about and what physicians are ready to discuss. [14], [17], [18]. When a medical error is committed literature suggests that patients desire full disclosure of details, assumption of responsibility, an apology, and detailing next steps to take care of the patient [14], while physicians report that 42% would explicitly state that an error occurred, only 19% would volunteer any information about the error's cause, and 63–92% would not provide specific information about preventing future errors [17], [18]. In a study with standardized patients, surgeons who committed an error apologized in only 47% of encounters [18].

This paper presents the second part of a two-part study that first sought to define caring from the patient's perspective, in situations in which caring is likely to be challenged. The first study demonstrated that (1) patient viewpoints in focus groups differed from trained raters’ views of videotaped encounters in which physicians interviewed standardized patients to help them make transitions to palliative care, hear bad news, and hear about a medical error in their care and (2) individual patient viewpoints were varied and sometimes even contradictory when focus group members viewed videotapes of physicians rated by checklists as particularly caring or uncaring. Opinions of one individual who was thought of as particularly caring were often contradicted by those of others. Contextual features of encounters were found to be critical as demonstrated when participants in the focus groups discussed a relational aspect to caring that they captured in several ways. Participants used qualifiers in some of their comments about providers (gives information in “appropriate” doses; offers measured empathy; carefully crafts empathic statements), describing communication in a way that focused on the process of the interview more than the content, suggesting a give and take or a focus on the relationship between individuals (chooses words carefully and checks for meaning; exhibits a soft but confident tone, slow pace, and comfortable appearance; acts quickly and decisively while preserving patient autonomy), and commented on behavior that extended beyond the encounter (helps the patient move forward with next steps). Thus, rather than being able to define a set of caring behaviors, what emerged is that a key element of caring seemed to be the ability of the provider to anticipate the potential needs of patients, assess and address the individual patient's perspective, reflect on the patient's responses and adjust behaviors based on these patient responses [19]. The purpose of our second study is to translate the research findings into an evidence-based curriculum taught to Internal Medicine and Family Medicine residents at the University of Massachusetts Medical School. In planning our curriculum, we supplemented current literature on delivering bad news, helping patients to make a transition from curative to palliative care, and in disclosing a medical error, with our research findings that incorporated patient perspectives on these three challenging tasks. This report presents the curriculum and residents perception of its value and impact (Table 1).

Section snippets

Methods

We carried out several steps in order to derive curriculum content. Our first study's focus was designed to generate patient viewpoints about caring when providers delivered bad news, helped patients make a transition to palliative care, and communicated about medical error. We used previously developed and rated videotapes depicting physician-standardized patient encounters for the three scenarios. In the first study [19], twelve focus groups viewed videotapes of those physicians deemed most

Application of research findings to curriculum

Focus group data was organized and adapted to aid in the teaching. Major categories of caring were organized by using the mnemonic CARE (see Table 1). We did this to facilitate organization of a teaching framework that would promote learning and retention of the material delivered to Internal Medicine and Family Medicine residents. This overarching framework was supplemented by more specific findings when it was applied to the individual scenarios. Skills in the three scenarios were detailed

Discussion

Gathering patient perspectives on caring through focus groups generated new categories of caring attitudes or behaviors that we applied to our teaching. The category of caring, “Arranges to meet healthcare needs,” suggests that part of caring extends beyond the exam room and what we say to the patient, yet is conveyed through our actions separate from the encounter. Other behaviors that are part of the encounter were seen as highly contextualized by focus group participants, were dependent on

Conflict of interest

The authors of this paper report no financial, personal or other conflicts of interest in relation to this work.

Acknowledgements

We thank Heather-Lyn Haley and Kate Sullivan for their assistance with data collection. We thank Gerry Gleich, M.D., Alexander Bount, Ph.D., and Rick Forster, M.D., for their assistance in the teaching of the workshops.

Role of funding. This work was supported by a grant from the Arthur Vining Davis Foundation. The funding did not have any role in design or conduct of the study, management, collection or analyses of the data, or preparation, review or approval of this manuscript.

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