General practice consultations: is there any point in being positive? Patient-based health status measurement in clinical practice: a study of its impact on epilepsy patients' care An intervention to increase patients' trust in their physicians. Stanford Trust Study Physician Group. Encouraging out-patients to make the most of their first hospital appointment: to what extent can a written prompt help patients get the information they want? A strategy for improving patient satisfaction by the intensive training of residents in psychosocial medicine: a controlled, randomized study Effects of a self-administered previsit questionnaire to enhance awareness of patient’s concerns in primary care Effect of Clinician Communication Skills Training on Patient Satisfaction Assessing patients' expectations in ambulatory medical practice. Does the measurement approach make a difference? Life style intervention in general practice: Effects on psychological well-being and patient satisfaction Increasing patient involvement in choosing treatment for early breast cancer Anxiety among women with mild dyskaryosis: a randomized trial of an educational intervention. Improving patient quality of life with feedback to physicians about functional status Collaborative management to achieve treatment guidelines. Impact on depression in primary care. Effective physician-patient communication and health outcomes: a review. Effects of a physician communication intervention on patient care outcomes A communication skills programme for increasing patients' satisfaction with general practice consultations. Expanding patient involvement in care. Effects on patient outcomes. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. The Effectiveness of Intensive Training for Residents in Interviewing Psychosocial Correlates of Survival in Diabetes Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study The impact of patient-centered care on outcomes. Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention. Bad reporting does not mean bad methods for randomised trials: observational study of randomised controlled trials performed by the Radiation Therapy Oncology Group Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial. Assessing the quality of randomized controlled trials: an annotated bibliography of scales and checklists. Patient participation in the cancer consultation: evaluation of a question prompt sheet. Effectiveness of two preventive interventions for coronary heart disease in primary care. A randomized controlled trial of an intervention designed to improve the care given in general practice to Type II diabetic patients: patient outcomes and professional ability to change behaviour. Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. Active patient orientation. Effect of a general practitioner's consulting style on patients' satisfaction: a controlled study. Promoting patient participation in consultations: a randomised controlled trial to evaluate the effectiveness of three patient-focused interventions. Empowerment of men newly diagnosed with prostate cancer. Framework for design and evaluation of complex interventions to improve health A randomized controlled trial of facilitating information giving to patients with chronic medical conditions: effects on outcomes of care. Assessing the Effects of Physician-Patient Interactions on the Outcomes of Chronic Disease Empowering the patient in the consultation: a pilot study. The consultation and the therapeutic illusion.
A group of 200 patients who presented in general practice with symptoms but no abnormal physical signs and in whom no definite diagnosis was made were r and omly selected for one of four consultations : a consultation conducted in a " positive manner , " with and without treatment , and a consultation conducted in a " non-positive manner , " called a negative consultation , with and without treatment . Two weeks after consultation there was a significant difference in patient satisfaction between the positive and negative groups but not between the treated and untreated groups . Similarly , 64 % of those receiving a positive consultation  got better , compared with 39 % of those who received a negative consultation ( p = 0.001 ) and 53 % of those treated got better compared with 50 % of those not treated ( p = 0.5 ) The objective was to assess the potential benefits of the routine use of the MOS SF-36 Health Survey ( SF-36 ) in the care of ambulatory patients . The design was a longitudinal , prospect i ve , r and omized , controlled study set in the outpatient neurology clinic at the New Engl and Medical Center . There were 163 consecutive patients with epilepsy who had 210 follow-up visits with one of two epileptologists . The patients completed the SF-36 before the patient-physician encounter and the forms were optically scanned . The SF-36 results of the intervention group patients were given to the physicians before the encounter and withheld for control group patients . For intervention group patients , the physicians completed a question naire assessing the impact of the SF-36 on the process of care . After the visit , all patients completed a satisfaction question naire . The main outcome measures were the physicians ' responses to st and ardized questions about the usefulness of the SF-36  for communication with and management of epilepsy patients and the patients ' responses to st and ardized questions about their satisfaction with care . The physicians indicated that the SF-36 provided new information in 63 % of the intervention group encounters . A change in therapy was prompted in 13 % . The physicians rated the SF-36 as at least moderately useful for communication in 14 % of the encounters and to management in 8 % . The lower ( indicating worse health status ) the patients ' SF-36 scale scores , the more useful the SF-36 results were rated by the physicians for communication and management . It was concluded that the routine use of health status measures may enhance patients ' care PURPOSE To investigate the effect of a one-day workshop in which physicians were taught trust-building behaviors on their patients ' levels of trust and on outcomes of care . METHOD In 1994 , the study recruited 20 community-based family physicians and enrolled 412 consecutive adult patients from those physicians ' practice s. Ten of the physicians ( the intervention group ) were r and omly assigned to receive a one-day training course in building and maintaining patients ' trust . Outcomes were patients ' trust in their physicians , patients ' and physicians ' satisfaction with the office visit , continuity in the patient-physician relationship , patients ' adherence to their treatment plans , and the numbers of diagnostic tests and referrals . RESULTS Physicians and patients in the intervention and control groups were similar in demographic and other data . There was no significant difference in any outcome . Although their overall ratings were not statistically significantly different , the patients of physicians in the intervention group reported more positive physician behaviors than did the patients of physicians in the control group . CONCLUSIONS The trust-building workshop had no measurable effect on patients ' trust or on outcomes hypothesized to be related to trust A r and omised controlled study in which a written prompt was sent to new patients to help them make the most of their consultation was conducted amongst patients referred to the dermatology , gynaecology and orthopaedic out- patients clinics at the Royal Free Hospital , London . The impact of the help card on patients ' expectations , preparation for and experience of their out-patient consultation are discussed . A help card and letter were sent to a r and om sample of patients before their appointment to encourage them to prepare and prioritize questions to ask the doctor at the consultation . After their consultation , patients were sent a postal question naire to complete at home . Analysis of the question naires provided quantitative and qualitative data about patients ' information requirements and whether they were fulfilled . The results highlight the difficulties out- patients have in asking questions and discussing topics fully at their initial consultation , even when they have thought of questions in advance . Half the patients who were sent a help card said they got more out of their consultation as a result , yet few statistically significant differences between the help card group and the other patients were found PURPOSE . To use a controlled , r and omized design to assess the effect on patient satisfaction of an  intensive psychosocial training program for residents . METHOD . Twenty-six first-year residents , in two internal medicine and family practice community-based programs affiliated with the Michigan State University College of Human Medicine , were r and omly assigned during 1991 and 1992 to a control group or a one-month intensive training program . Experiential teaching focused on many psychosocial skills required in primary care . A 29-item question naire administered before and after the residents ' training evaluated their patients ' satisfaction regarding patient disclosure , physician empathy , confidence in physician , general satisfaction , and comparison of the physician with other physicians . Analyses of covariance with groups and gender as factors and pre-training patient satisfaction scores as the covariate evaluated the effect of the training . RESULTS . The patients of the trained residents expressed more confidence in their physicians ( p = .01 ) and more general satisfaction ( p = .02 ) than did the patients of controls . The effect of training on patient satisfaction with patient disclosure ( p < .01 ) and physician empathy ( p < .05 ) was greater for female than for male residents . CONCLUSION . The intensive psychosocial training program for residents improved their patients ' satisfaction Objective To determine if a self-administered previsit question naire design ed to increase awareness of patients ’ concerns alters the visit duration , content of the discussion , and patient and physician satisfaction . Design A balanced , two-arm trial in which physicians were r and omized . Setting Two primary -care clinics affiliated , with a university hospital . Patients / Participants Ten physicians and 201 continuitycare patients . Interventions In intervention visits , patients completed a previsit question naire asking about the desire for medical information , psychosocial assistance , therapeutic listening , general health advice , and biomedical treatment . Physicians review ed question naires with patients during the visit . Measurements and main results We used audiotapes of encounters to quantify the duration of the encounter and measured the number and type of diagnoses discussed in the visit , and patient and physician satisfaction with the encounter . Intervention visits were 34 % longer ( increase of 6.8 minutes ; 95 % confidence interval , [ CI ] 0.4 , 13.2 ) than control visits with most of the additional time spent in discussion of biomedical diagnoses ( 3.35 minutes ; 95 % CI 0.00 , 6.72 ) and in the performance of the physical examination ( 2.7 minutes ; 95 % CI 0.5 4.9 ) . The number of diagnoses discussed per visit was 30 % higher in intervention visits ( increase of 1.7 diagnoses per visit ; 95 % CI 0.3 , 3.2 ) , but patients ’ satisfaction with these visits tended to be lower . Conclusions Using a previsit question naire to increase awareness of the patients ’ concerns may entail a trade-off between conflicting goals : trying to respond to patient concerns while not significantly increasing the cost per visit . A future challenge is to develop and refine techniques with sufficient efficacy to justify the expense of implementing the intervention and the longer visit needed to respond adequately to patients ’ concerns In a competitive health care environment , clinicians and health plans are eager to achieve the highest quality of care and the highest levels of patient satisfaction . Studies consistently show that effective communication between clinicians and patients is a critical determinant of patient satisfaction ( 1 - 7 ) . To improve patient satisfaction , many organizations provide communication skills training programs for clinicians  . These programs usually include 4 to 8 hours of instruction and are held during regular office hours ( 8 - 12 ) . Because clinicians may need to be relieved from clinical responsibilities to attend , such programs can be expensive for both the clinicians and their organizations . Despite the substantial time and money invested in these programs , little rigorous research has been done to test their actual effect on patient satisfaction ( 11 , 13 ) . Some studies have measured clinicians ' self-ratings of their communication skills or have included an observation of a small number of visits ( 8 , 12 , 14 - 16 ) . Studies of oncologists have shown improvement in such targeted communication skills as breaking bad news ( 17 , 18 ) , but two recent r and omized trials that involved primary care physicians had conflicting results ( 10 , 19 ) . No r and omized trial has tested the effectiveness of a communication skills program delivered to clinicians of diverse specialties , and no study has directly assessed a program 's actual effect on patient satisfaction ( an outcome of great interest to health care users and sponsors ) . As communication programs proliferate , it is essential to critically evaluate whether they are a worthwhile investment of time and re sources for clinicians and their organizations . We performed a r and omized , controlled trial of a 10-hour communication skills program in a sample of primary care and specialty clinicians . We tested the effect of the program on patients ' satisfaction with providers ' communication during office visits.\E Methods Setting and Intervention The study setting was Kaiser Permanente Northwest Division , a 50-year-old , not-for-profit group-model health maintenance organization ( HMO ) with approximately 420 000 members located in and around Portl and , Oregon . The continuing medical education ( CME ) program we evaluated , titled Thriving in a Busy Practice : Physician-Patient Communication , was developed during numerous sessions with more than 1500 clinicians . Several Kaiser Permanente divisions participated in the program 's development , and the program was popular among clinicians . The program consisted of an initial 4-hour group workshop , 2 hours of subsequent homework , and a 4-hour follow-up workshop . The first workshop focused on skills for building effective relationships with patients , including listening actively ; responding to patients ' feelings ; and communicating concern , underst and ing , and respect . The second workshop focused on skills for successful negotiation , particularly in situations of disagreement ( for example , when a patient requests narcotics for chronic pain and the clinician does not think a prescription is appropriate ) . During a 1-month interval between the two workshops , the clinicians were asked to audiotape a minimum of two of their office visits and listen to the recordings . In addition , an instructor called participants during the interval to inquire about the skills they were trying , to ask whether they had questions , and to encourage them to complete the audiotaping . Both workshops were given by two physicians who were experienced teachers and experts in clinician-patient communication . The program was design ed to incorporate educational elements that had effectively changed clinician performance in other CME programs . The workshops included brief didactic components that were related to clinical needs and role-playing that allowed clinicians to practice communication skills while focusing on situations that they found challenging and relevant ( 20 , 21 ) . Instructors taught interactively , encouraging dialogue with and among participants . Recruitment and R and omization All of the approximately 1000 clinicians who belonged to or were employed by the Permanente Medical Group of the Northwest were eligible to participate . To maximize the external validity of the study , the HMO 's CME office advertised the program and managed the initial recruitment of clinicians by using its regular methods and channels . In addition , clinician leaders encouraged enrollment by direct communication with potential participants and by e-mail . The recruitment messages explained the r and omized trial and offered clinicians equal chances to participate immediately or to participate in a later session of the program . The clinicians who were r and omly assigned to the later session provided our control group . The Figure summarizes the flow of recruitment and r and omization . After clinicians notified the CME department of their interest in the course , we sent them an informed consent form and a self- assessment question naire . When the clinician returned the signed informed consent form , we assigned him or her to one of 16 strata on the basis of sex ( male or female ) , specialty ( primary care , medical specialty , surgical specialty , or allied health ) , and previous mean score ( higher or lower than average ) on the overall satisfaction item from the Art of Medicine survey ( HealthCare Research , Inc. , Denver , Colorado ) , which had been used by the HMO during two 6-month periods before our study took place . Mean scores before the study ranged from 6.84 to 8.91 , with a mean and median of 7.92 ; an SD of 0.47 ; and a quartile distribution of 7.56 , 7.92 , 8.28 , and 8.91 . Figure . Recruitment and r and omization . On a weekly basis , as clinicians registered , we r and omly assigned groups to attend immediate or later sessions of the program . In each stratum , we used a r and om-number table to assign persons to the intervention or control group . We started with the lowest r and om number and alternated assignment in order of ascending r and om number . The study was review ed and approved by the Kaiser Permanente Committee for the Protection of Human Subjects . Measurements Our primary experimental measure was the mean difference in score ( before and after participation in the training program ) on a scale that assessed patients ' ratings of clinicians ' communication skills . We obtained these ratings from the Art of Medicine survey , an anonymous question naire that was mailed to patients by a contractor to the HMO within 10 days after patients had participated in a r and omly selected ambulatory medical care visit . The survey was design ed to obtain 100 completed question naires for each clinician during a 6-month period . We used data from three 6-month survey periods : the last half of 1995 and the first and last halves of 1996 . The Art of Medicine survey elicited ratings on seven aspects of a clinician 's communication behavior or the patient 's reaction to it during a specified ambulatory encounter . In addition , the survey asked patients to rate their overall satisfaction with the service they received from the clinician . A complete list of the survey items is provided in the Appendix Figure . Although the Art of Medicine survey was not chosen by the research teamwe took advantage of the ongoing administration of this survey to conduct our study the items in the survey are similar in content to those in other reliable , vali date d , and widely used clinical communication scales , such as the Patient Satisfaction Question naire ( which was developed by the American Board of Internal Medicine ) ( 22 ) . Appendix Figure . The Art of Medicine survey . Communication skills are the most important determinant of patient satisfaction with care ( 23 - 25 ) , and satisfaction with care is the primary determinant of personal decisions to use health plans and hospitals ( 26 , 27 ) . Communication and satisfaction scales , such as the Art of Medicine survey , have been shown to be correlated with observed and experimentally manipulated differences in communication performance ( 28 ) . Satisfaction with patient-clinician communication also improves adherence to treatment ( 29 , 30 ) and decreases the risk for mal practice lawsuits ( 31 ) . In addition , health plans and clinicians institute or attend communication skills programs mostly to improve scores on such measures as the Art of Medicine survey , in part because they are obligated to determine such scores and make them publicly available to patients ( 32 ) . We prospect ively defined the change in the mean value of all eight survey items as our primary outcome measure . We adopted this approach for several reasons . First , the eight items were highly correlated ( Spearman correlation , 0.69 to 0.84 ) . Second , the mean of the first seven communication items was highly correlated with the overall satisfaction item ( Spearman correlation , 0.92 ) . Third , the Cronbach statistic for reliability of internal consistency was 0.97 for the eight-item survey as a whole , which strongly indicates that all eight questions addressed a single domain . The result ing estimates were therefore highly precise because they were based on many correlated items and on the responses of more than 9500 patients . We obtained secondary measures of study outcomes by mailing a question naire to clinicians in the intervention group both before the course began and 3 months after it ended . The clinician question naire elicited self- assessment of routine communication style , characteristics of unsatisfactory patient visits , and ability to communicate with patients . The follow-up question naire also asked clinicians to assess the effect and value of the communication skills program . All elements of the question naire except for the program assessment were derived from previously vali date d and published measures ( 31 , 33 ) . Hypothesis and Plan for Analysis Before beginning the study , we review ed the results of the Art of Medicine survey as it had been administered in Kaiser Permanente 's Rocky To compare three different approaches to the measurement of patients ' expectations for care , we conducted a r and omized controlled trial . Medical out patients ( n = 318 ) of a small ( six-physician ) , single-specialty ( internal medicine ) , academically affiliated private practice in Sacramento , California , were contacted by telephone the night before a scheduled office visit and enrolled over a 5-month period in early 1994 . Patients were r and omly assigned to receive : ( 1 ) a self-administered , structured , previsit question naire combined with a postvisit question naire ; ( 2 ) an interviewer-administered , semistructured , previsit interview combined with a postvisit question naire ; or ( 3 ) a postvisit question naire only . We assessed the number and content of patients ' expectations by previsit question naire versus interview ; the interaction between sociodemographic characteristics and survey method in predicting number of reported expectations ; the effect of unfulfilled expectations elicited by question naire and interview on visit satisfaction ; and the effect of unfulfilled expectations elicited directly and indirectly on visit satisfaction . Patients reported more expectations by structured question naire than semistructured interview ( median 12 vs 3 , p = .0001 ) . Although there was no main effect of sociodemographic characteristics on expectations , nonwhite patients reported more expectations than white patients by question naire and fewer by interview . The number of interventions desired before the visit but not received ( indirectly reported unfulfilled expectations ) was associated with lower visit satisfaction regardless of whether a question naire or interview was used to elicit previsit expectations ( p value for the interaction between number of expectations and survey method , > .20 ) . Having more indirectly reported unfulfilled expectations was significantly associated with lower visit satisfaction even after controlling for the number of directly reported unfulfilled expectations ( p = .021 ) , but the incremental change in classification accuracy was small ( increase in receiver-operating characteristic curve area , 3 % ) . In conclusion , studies of patients ' expectations for care must content with a substantial " method effect . " In this study from a single group practice , patients checked off more expectations using a structured question naire than they disclosed in a semistructured interview , but both formats predicted visit satisfaction . Asking patients about interventions received in relation to their previsit expectations added little to simply asking them directly about omitted care . The interaction of survey method with ethnicity and other sociodemographic characteristics requires further study The objectives of this study were to : ( 1 ) study if an opportunistic screening of coronary heart disease ( CHD ) risk factors among male attenders in general practice ( GP ) influenced the overall subjective satisfaction with life of persons labelled ‘ high risk ’ compared to other screened persons ; ( 2 ) compare psychological well-being and patient satisfaction in a patient centred and self-directive ( PCSD ) intervention with conventional care ( CC ) ; and ( 3 ) evaluate patient satisfaction and psychological well-being among subjects with high CHD risk during a one year intervention study . Effects of ‘ labelling ’ were evaluated in 115 subjects with high CHD risk in comparison with a low risk reference population . The 22 participating GP centres were r and omly allocated to follow either a PCSD intervention or a CC approach . An overall satisfaction with life question was employed and psychological well-being were measured using the General Health Question naire ( 20 item version ) . Satisfaction measures on health care aspects were also included . No difference of change between the high risk and the reference population was found concerning satisfaction with life after screening . No significant difference of change was found within or between the PCSD and the CC group concerning emotional well-being or overall satisfaction with life during one year intervention . Satisfaction with the care received was significantly better in the CC group as compared with the PCSD group ( p=0.02 ) . Satisfaction with own efforts for improving health was , however , more pronounced in the PCSD group ( p=0.01 ) . A substantial number ( n=61 ) of the participants reported distaste of being reminded of the risk of heart disease and no more than 60 of the participants were satisfied with their own efforts for improving health . Although no significant change of satisfaction with life and emotional well-being due to screening or intervention could be detected , clinicians should be aware that encouraging patients to change life style may lead to patients ' annoyance of being reminded of the risk of disease and dissatisfaction with their own efforts . Increasing patient responsibility and self-determination may improve their satisfaction with their own efforts , but reduce satisfaction with medical care 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 aim ed at increasing patient participation in these discussion BACKGROUND Women with mild dyskaryosis are currently managed by six-month cytological surveillance . While there is good evidence that women suffer psychological distress on receipt of an abnormal test , and that this is amenable to educational intervention , it remains uncertain whether this distress is prolonged and , if so , how it should best be managed . AIM To investigate whether a structured educational intervention containing a risk communication package impacts upon psychological sequelae associated with this surveillance . METHOD A pragmatic cluster-r and omized controlled trial during 14 months in 1995 and 1996 , based in general practice s in Avon and South Glamorgan , that compared the intervention with st and ard care . Follow-up was by postal question naire at six weeks and four months after the screening laboratory had reported the test result . The intervention was an invitation to attend the general practice to consult with a practice nurse trained to deliver the package . The main outcome measures were Spielberger state-anxiety , SF-36 Mental Health dimension , four condition-specific questions regarding concerns about gynaecological health and timing of the repeat smear test , and attendance for the repeat test . RESULTS Of 514 eligible women , 270 were recruited , of whom 240 returned the six-week question naire and 181 returned the four-month question naire . On all but one outcome measure , the differences between the groups were not statistically significant . At six-week follow-up , the proportion who preferred the repeat test to be sooner than six months was statistically significantly higher among controls ( 74 % versus 53 % ; 95 % CI = 9 % to 33 % ) . At the four-month follow-up , the difference was 7 % ( 95 % CI = -7 % to 21 % ) . CONCLUSION There appear to be high levels of anxiety during surveillance for mild dyskaryosis that were not reduced by the intervention . Given that a personally delivered educational intervention design ed to reduce anxiety could be viewed as the best available practice , it is of concern that women in the intervention group demonstrated sustained anxiety over a four-month period . The research agenda therefore seems to return to the fundamental question of whether surveillance should be the management of choice OBJECTIVE : To improve functional status among primary care patients .INTERVENTION : 1 ) Computer-generated feedback to physicians about the patient ’s functional status , the patient ’s self-reported “ chief complaint , ” and problem-specific re source and management suggestions ; and 2 ) two brief interactive educational sessions for physicians . DESIGN : R and omized controlled trial . SETTING : University primary care clinic . PARTICIPANTS : All 73 internal medicine houseofficers and 557 of their new primary care patients . MEASURES : 1 ) Change in patient functional status from enrollment until six months later , using the Functional Status Question naire ( FSQ ) ;  2 )  management plans and additional information about functional status abstract ed from the medical record ; and 3 ) physician attitude about whether internists should address functional status problems . RESULTS : Emotional well-being scores improved significantly for the patients of the experimental group physicians compared with those of the control group physicians ( p<0.03 ) . Limitations in social activities indicated as “ due to health ” decreased among the elderly ( > 70 years of age ) individuals in the experimental group compared with the control group ( p<0.03 ) . The experimental group physicians diagnosed more symptoms of stress or anxiety than did the control group physicians ( p<0.001 ) and took more actions recommended by the feedback form ( p<0.02 ) . CONCLUSIONS : Computer-generated feedback of functional status screening results accompanied by re source and management suggestions can increase physician diagnoses of impaired emotional well-being , can influence physician management of functional status problems , and can assist physicians in improving emotional well-being and social functioning among their patients OBJECTIVE To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of " usual care " by the primary care physician . DESIGN A r and omized controlled trial among primary care patients with major depression or minor depression . PATIENTS Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were r and omized , with 91 patients meeting criteria for major depression and 126 for minor depression . INTERVENTIONS Intervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment ( visits 1 and 3 with a primary care physician , visits 2 and 4 with a psychiatrist ) and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment . Patient education in these visits was supplemented by videotaped and written material s. MAIN OUTCOME MEASURES Primary outcome measures included short-term ( 30-day ) and long-term ( 90-day ) use of antidepressant medication at guideline dosage levels , satisfaction with overall care for depression and antidepressant medication , and reduction in depressive symptoms . RESULTS In patients with major depression , the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more ( 75.5 % vs 50.0 % ; P < .01 ) , were more likely to rate the quality of the care they received for depression as good to excellent ( 93.0 % vs 75.0 % ; P < .03 ) , and were more likely to rate antidepressant medications as helping somewhat to helping a great deal ( 88.1 % vs 63.3 % ; P < .01 ) . Seventy-four percent of intervention patients with major depression showed 50 % or more improvement on the Symptom Checklist-90 Depressive Symptom Scale compared with 43.8 % of controls ( P < .01 ) , and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls ( P < .004 ) . In patients with minor depression , the intervention group had significantly greater adherence than controls to adequate dosage of antidepressant medication for 90 days or more ( 79.7 % vs 40.3 % ; P < .001 ) and more often rated antidepressant medication as helping somewhat to helping a great deal ( 81.8 % vs 61.4 % ; P < .02 ) . However , no significant differences were found between the intervention and control groups in the percentage of patients who were satisfied with the care they received for depression ( 94.4 % vs 89.3 % ) , in the percentage who experienced a 50 % or more decrease in depressive symptoms , or in the decrease of depressive symptoms over time . CONCLUSION A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist , intensive patient education , and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression . It improved satisfaction with care and result ed in more favorable depressive outcomes in patients with major , but not minor , depression OBJECTIVE To ascertain whether the quality of physician-patient communication makes a significant difference to patient health outcomes . DATA SOURCES The MEDLINE data base was search ed for articles published from 1983 to 1993 using " physician-patient relations " as the primary medical subject heading . Several bibliographies and conference proceedings were also review ed . STUDY SELECTION R and omized controlled trials ( RCTs ) and analytic studies of physician-patient communication in which patient health was an outcome variable . DATA EXTRACTION The following information was recorded about each study : sample size , patient characteristics , clinical setting , elements of communication assessed , patient outcomes measured , and direction and significance of any association found between aspects of communication and patient outcomes . DATA SYNTHESIS Of the 21 studies that met the final criteria for review , 16 reported positive results , 4 reported negative ( i.e. , nonsignificant ) results , and 1 was inconclusive . The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes . The outcomes affected were , in descending order of frequency , emotional health , symptom resolution , function , physiologic measures ( i.e. , blood pressure and blood sugar level ) and pain control . CONCLUSIONS Most of the studies review ed demonstrated a correlation between effective physician-patient communication and improved patient health outcomes . The components of effective communication identified by these studies can be used as the basis both for curriculum development in medical education and for patient education programs . Future research should focus on evaluating such educational programs OBJECTIVE : To determine whether an intervention design ed to improve patient-physician communication increases the frequency with which physicians elicit patients ’ concerns , changes other communication behaviors , and improves health care outcomes . DESIGN : Pretest-posttest design with r and om assignment of physicians to intervention or control groups . SETTING : General medicine clinics of a university-affiliated Veterans Affairs Hospital . PATZEWTS/ PARTICIPANTS : Forty-two physicians and 348 continuity care patients taking prescription medications for chronic medical conditions . INTERVENTIONS : Intervention group physicians received 4.5 hours of training on eliciting and responding to patients ’ concerns and requests , and their patients filled out the Patient Requests for Services Question naire prior to a subsequent clinic visit . Control group physicians received 4.5 hours of training in medical decision-making . MEASUREMENTS AND MAIN RESULTS : The frequency with which physicians elicited all of a patient ’s concerns increased in the intervention group as compared with the control group ( p=.032 ) . Patients perceptions of the amount of information received from the physician did increase significantly ( p<.05 ) , but the actual magnitude of change was small . A measure of patient satisfaction with the physicians was high at baseline and also showed no significant change after the intervention . Likewise , the intervention was not associated with changes in patient compliance with medications or appointments , nor were there any effects on outpatient utilization . CONCLUSIONS : A low-intensity intervention changed physician behavior but had no effect on patient outcomes such as satisfaction , compliance , or utilization . Interventions may need to focus on physicians and patients to have the greatest effect The research literature on patient perceptions of general practice consultations shows that , while patients are generally satisfied with the treatment they receive from doctors , they report less satisfaction with the amount and clarity of information they receive and doctors ' expression of caring and respect . In the surgery , inadequate information transmission during the interaction also has the effect of increasing the level of anxiety reported by patients after their consultations . A communication skills programme was developed , incorporating variables from both the emotional and cognitive domains of the consultation . A group of GPs undertook training in this programme . It was hypothesized that patients of the trained doctors would report greater satisfaction and less anxiety , compared with patients of untrained general practitioners . Subsequent r and omized interviews with patients of the trained doctors showed that these patients were significantly more satisfied with their consultations . Patients of the trained doctors also reported less state anxiety immediately following their consultations , as measured using the State-Trait Anxiety Inventory . Attempts by doctors to communicate more effectively in consultations therefore increased patients ' positive feelings and reduced anxiety An intervention was developed to increase patient involvement in care . Using a treatment algorithm as a guide , patients were helped to read their medical record and coached to ask questions and negotiate medical decisions with their physicians during a 20-minute session before their regularly scheduled visit . In a r and omized controlled trial we compared this intervention with a st and ard educational session of equal length in a clinic for patients with ulcer disease . Six to eight weeks after the trial , patients in the experimental group reported fewer limitations in physical and role-related activities ( p less than 0.05 ) , preferred a more active role in medical decision-making , and were as satisfied with their care as the control group . Analysis of audiotapes of physician-patient interactions showed that patients in the experimental group were twice as effective as control patients in obtaining information from physicians ( p less than 0.05 ) . Results of the intervention included increased involvement in the interaction with the physician , fewer limitations imposed by the disease on patients ' functional ability , and increased preference for active involvement in medical decision-making BACKGROUND Although comprehensive geriatric assessment ( CGA ) has been demonstrated to confer health benefits in some setting s , its value in outpatient or office setting s is uncertain . OBJECTIVE To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes . DESIGN A r and omized controlled trial . SETTING Community-based sites . PATIENTS 363 community-dwelling older persons who had failed a screen for at least one of four conditions ( falls , urinary incontinence , depressive symptoms , or functional impairment ) INTERVENTION A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations . MEASUREMENTS Medical Outcomes Study Short Form-36 ( MOS SF-36 ) , restricted activity and bed days , Physical Performance Test , NIA lower-extremity battery . RESULTS In complete case analysis ( excluding the five control group subjects who died during the follow-up period ) , the adjusted difference in change scores ( 4.69 points ) for physical functioning between treatment and control groups indicated a significant benefit of treatment ( P = .021 ) . Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue , social functioning , and physical health summary scales . In analyses assigning scores of 0 to those who died , these benefits were greater , and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being , pain , and mental health summary scales were also demonstrated . CONCLUSIONS A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality -of-life decline among community-dwelling older persons who have specific geriatric conditions Medical interviewing justifiably reigns as the premier skill in medicine [ 1 - 4 ] and is the vehicle for physicianpatient interaction and exchange of information in almost all circumstances [ 3 , 4 ] . The interview alone produces the data required for diagnosis more than three fourths of the time , and it establishes more diagnoses than physical examination and laboratory data combined [ 5 - 8 ] . Interviewing generates most of the data required for treatment and prevention and is the primary means for transmitting information from physician to patient [ 4 , 9 ] . It also defines the physicianpatient relationship , and the quality of the physicianpatient relationship influences the quality of the data exchanged [ 4 , 10 , 11 ] . Against this background , and with the knowledge that most physicians perform more than 200 000 interviews during their careers [ 3 ] , it is a matter of national concern in the United States that the interview often gets short shrift [ 3 ] . Most medical schools teach at least some interviewing skills [ 12 ] , but instruction in interviewing receives scant attention in residencies [ 9 , 13 - 16 ] , despite strong research -based recommendations in favor of such training [ 13 , 17 - 20 ] . Surveys of internal medicine program directors [ 14 , 21 ] showed that formal training in interviewing averaged only 5 to 13 hours per year during residencies . This is far less than the 1 month of full-time training that is often recommended [ 13 , 17 - 2022 , 23 ] , but educators have few empirical data to guide them with respect to what and how to teach residents in intensive interviewing training programs . A recent literature review produced only 12 studies of intensive training programs , and 6 of the 12 had nonexperimental design s [ 13 ] . Of the 6 with quasi-experimental design s , 4 [ 17 - 20 ] specifically addressed interviewing , interpersonal skills , or the physicianpatient relationship and showed positive results , thus supporting a patient-centered approach . The other 2 studies [ 24 , 25 ] did not inform the question [ 13 ] . We developed an intensive training program for primary care residents in interviewing and related psychosocial topics in medicine . Using a r and omized , controlled study design , we tested two hypotheses : 1 ) that trained residents , compared with controls , could gain more knowledge , confidence , and skill in gathering data , building relationships with patients , managing somatizing patients , and educating patients and 2 ) that the patients of trained residents would have greater satisfaction , fewer somatic symptoms , less social dysfunction , less depression and anxiety , and reduced functional disability . Methods Participants We trained 65 medical and family practice residents in postgraduate year 1 and asked them to participate in a study to evaluate the interviewing training program .  Thirty-six men and 27 women accepted ; 2 residents who were trained refused to participate in the evaluation . Each participant was paid $ 100 to participate in the evaluation . Training Program As described elsewhere [ 26 , 27 ] , training was experiential and skills oriented and was guided by competency-based [ 28 ] objectives that were both learner- and teacher-centered [ 29 , 30 ] . To enhance learning of complex new material , we used the four interviewing models described below . Each model described the step-by-step behaviors needed to efficiently conduct a complex interaction with a patient , placed these behaviors in sequence , and prioritized them . Basic Patient-Centered Interviewing and Physician-Patient Relationship Model One of the authors formulated a basic model of the entire interview to serve as an infrastructure that learners could use as a guide [ 4 ] . The model incorporated a rich body of literature , review ed elsewhere [ 4 ] ( a textbook from the American Academy on Physician and Patient is a particularly useful guide for teachers [ 31 ] ) . We restricted our focus to the often unfamiliar patient-centered interviewing process , which places the patient 's needs and the physicianpatient relationship first [ 4 ] , because residents were already relatively skilled with the physician-centered interviewing process aim ed at diagnosing disease . The patient-centered process , which was usually used at the start of the interview , was easily learned and was structured so that , with experience , it usually took no more than 3 to 10 minutes . Other Patient-Centered Interviewing Models Other interviewing models used the basic patient-centered model and integrated it with additional patient-centered skill areas : 1 ) interacting with patients who had chronic somatization by using cognitive-behavioral principles developed by one of the authors [ 32 , 33 ] , 2 ) informing the patient and motivating the patient to take a new course of action ( such as losing weight ) by using a model developed by one of the authors [ 34 ] and others ( [ 4 , 35 - 39 ] ; Vispoel WP , Chen P. Measuring self-efficacy : the state of the art ( Presented paper . Annual Meeting of the American Educational Research Association ; 1990 ; Boston . ) , and 3 ) giving patients bad news by using published approaches [ 4 , 40 ] . Noninterviewing Training Objectives This learning experience encompassed several important objectives apart from interviewing skills . It was intended to help residents develop self-awareness of potentially harmful personal reactions [ 41 - 43 ] ; be able to make accurate neuropsychiatric diagnoses for conditions common in primary care setting s [ 44 - 48 ] ; be skilled with practical psychopharmacology in a medical setting [ 44 ] ; and be skilled in treating anxiety , depression , and chronic somatization in primary care setting s [ 32 , 33 , 44 , 45 , 47 , 49 ] . Training took place during a required , full-time , 4-week block rotation , in which three or four residents matriculated at a time . The rotation had a core seminar component and a core supervisory component . Core seminar sessions of 3 hours each took place three times weekly in a private conference room . A brief discussion of the interviewing model ( or other objective ) was followed by demonstration of and repeated practice with the model through role playing [ 50 ] . The training allowed residents to achieve significant mastery of new , complex , and often counterintuitive interviewing skills before they tried them with actual patients , and it was design ed to foster confidence ( [ 30 , 51 , 52 ] ; Tresolini CP , Stritter FT . Medical students ' development of self-efficacy in conducting patient education for health promotion : an analysis of learning experiences [ Presented paper ] . Annual Meeting of the American Educational Research Association ; 1992 ; San Francisco . ) . Supervisory sessions lasting 3 hours each took place daily and involved inpatient and outpatient interviews that were observed directly or from prerecorded audiotapes . The focus of the seminar and supervisory teaching sessions was efficient data gathering , emotion h and ling , patient education , and management of psychosocial and psychiatric problems common in primary care setting s. Integrated throughout was a strong emphasis on the development of residents ' self-awareness , as detailed elsewhere [ 4 , 41 - 43 ] . We gave residents a syllabus of required readings and other material s ( copies of these documents are available from the authors ) . Experimental Procedure Residents were r and omly assigned to receive training either during the first 6 months of postgraduate year 1 ( training group ) or later in postgraduate year 1 , after they served as controls ( control group ) . An effort to assign equal numbers of men and women to the training and control groups was limited by scheduling constraints . Fifteen women and 16 men ( 16 graduates of international schools and 15 graduates of U.S. schools ) served as trainees , and 12 women and 20 men ( 15 international graduates and 17 U.S. graduates ) served as controls . No international graduates were U.S. citizens . Residents '  interviewing skills were assessed through evaluations of audiotaped recordings of outpatient clinic visits ( for all residents during all 4 years of the study ) and videotaped recordings of simulated patient visits ( for the final 49 residents evaluated during the last 3 years of the study ) . Outpatient interviews were used to assess residents ' skills in information gathering only . Adult patients were approached before clinic visits and were asked to participate in the study after being informed that the visit would be recorded and being told about other data -gathering aspects of the study ; 11 % of patients refused to participate .  Interviews and measurements , described below , were obtained between approximately 4 weeks before and 4 weeks after a resident 's training rotation ( or a similar period for controls ) . Different patients were interviewed by a resident before and after the training period or control period . Six women and 10 men , ranging in age from the early 20s to the early 70s , served as paid trained simulated patients . Twenty-eight simulated patient  scenarios were constructed to assess the three major interviewing models addressed in the training program : gathering data and establishing a relationship , managing somatization , and informing and motivating patients . Each scenario described the patient 's presenting story , social and occupational background , personality , and medical history . Somatization scenarios described patients with physical symptoms for which no organic basis could be found despite thorough and repeated clinical investigations . Informing and motivating scenarios described patients who needed help in reducing a personal health risk , such as smoking . Residents were instructed to interview a simulated patient as they would an actual patient ; before interviewing simulated patients , they were given the patient 's name , age , chief problem , and pertinent history and ( in the case of somatizing patients ) the results of previous clinical evaluations . They received specific instructions about their interviewing task , depending on the type of patient involved . Residents were to gather information as The goal of this research was to quantify therelationships between patient survival and a set of explanatory variables in a r and omly selected sample of community-based patients with non-insulin-dependent diabetes mellitus ( NIDDM ) . The sample included 343 patients with NIDDM initially entered into the study in 1981–1982 and reexamined in 1985–1986 .  Mortality data were collected on reexamination in 1985 and up date d from death-certificate data through 1 January 1986 . The data collected from the patients included demographic and clinical variables , psychosocial variables related to diabetes , measures of physiologic control , hospitalization , and mortality . The Cox proportionalhazards model was used to compute a hazard rate for each individual and to determine risk covariates . The results indicated that the variables most associated with the risk of mortality were patient age , social impact of diabetes , renal function , complexity of diet regimen , and history of smoking . Two of these variables ( social impact and complexity of diet regimen ) were obtained from the Diabetes Educational Profile completed by all patients on entry to the study . The five predictor variables were more closely related to mortality than diabetes control as measured by HbA1 , previous hospital admissions , previous heart attacks , and other physiologic measures frequently used as outcome measures . The only physiologic predictor was renal function OBJECTIVE To assess the effect of additional training of  practice nurses and general practitioners  in patient centred care on the lifestyle and psychological and physiological status of patients with newly diagnosed type 2 diabetes . DESIGN Pragmatic parallel group design , with r and omisation between practice teams to routine care ( comparison group ) or routine care plus additional training ( intervention group ) ; analysis at one year , allowing for practice effects and stratifiers ; self reporting by patients on communication with practitioners , satisfaction with treatment , style of care , and lifestyle . SETTING 41 practice s ( 21 in intervention group , 20 in comparison group ) in a health region in southern Engl and . SUBJECTS 250/360 patients ( aged 30 - 70 years ) diagnosed with type 2 diabetes and completing follow up at one year ( 142 in intervention group , 108 in comparison group ) . INTERVENTION 1.5 days ' group training for the doctors and nurses-introducing evidence for and skills of patient centred care and a patient held booklet encouraging questions . MAIN OUTCOME MEASURES Quality of life , wellbeing , haemoglobin A1c and lipid concentrations , blood pressure , body mass index ( kg/m2 ) . RESULTS Compared with patients in the C group , those in the intervention group reported better communication with the doctors ( odds ratio 2.8 ; 95 % confidence interval 1.8 to 4.3 ) and greater treatment satisfaction ( 1.6 ; 1.1 to 2.5 ) and wellbeing ( difference in means ( d ) 2.8 ; 0.4 to 5.2 ) . However , their body mass index was significantly higher ( d=2.0 ; 0.3 to 3.8 ) , as were triglyceride concentrations ( d=0.4 mmol/l ; 0.07 to 0.73 mmol/l ) , whereas knowledge scores were lower ( d=-2.74 ; -0.23 to -5.25 ) . Differences in lifestyle and glycaemic control were not significant . CONCLUSIONS The findings suggest greater attention to the consultation process than to preventive care among trained practitioners ; those committed to achieving the benefits of patient centred consulting should not lose the focus on disease management Abstract Objective : To determine the relation between exposure to glycaemia over time and the risk of macrovascular or microvascular complications in patients with type 2 diabetes . Design : Prospect i ve observational study . Setting : 23 hospital based clinics in Engl and , Scotl and , and Northern Irel and . Participants : 4585 white , Asian Indian , and Afro-Caribbean UKPDS patients , whether r and omised or not to treatment , were included in analyses of incidence ; of these , 3642 were included in analyses of relative risk . Outcome measures : Primary predefined aggregate clinical outcomes : any end point or deaths related to diabetes and all cause mortality . Secondary aggregate outcomes : myocardial infa rct ion , stroke , amputation ( including death from peripheral vascular disease ) , and microvascular disease ( predominantly retinal photo-coagulation ) . Single end points : non-fatal heart failure and cataract extraction . Risk reduction associated with a 1 % reduction in up date d mean HbA1c adjusted for possible confounders at diagnosis of diabetes . Results : The incidence of clinical complications was significantly associated with glycaemia . Each 1 % reduction in up date d mean HbA1c was associated with reductions in risk of 21 % for any end point related to diabetes ( 95 % confidence interval 17 % to 24 % , P<0.0001 ) , 21 % for deaths related to diabetes ( 15 % to 27 % , P<0.0001 ) , 14 % for myocardial infa rct ion ( 8 % to 21 % , P<0.0001 ) , and 37 % for microvascular complications ( 33 % to 41 % , P<0.0001 ) . No threshold of risk was observed for any end point . Conclusions : In patients with type 2 diabetes the risk of diabetic complications was strongly associated with previous hyperglycaemia . Any reduction in HbA1c is likely to reduce the risk of complications , with the lowest risk being in those with HbA1c values in the normal range ( < 6.0 % ) BACKGROUND We design ed this observational cohort study to assess the association between patient-centered communication in primary care visits and subsequent health and medical care utilization . METHODS We selected 39 family physicians at r and om , and 315 of their patients participated . Office visits were audiotaped and scored for patient-centered communication . In addition , patients were asked for their perceptions of the patient-centeredness of the visit . The outcomes were : ( 1 ) patients ' health , assessed by a visual analogue scale on symptom discomfort and concern ; ( 2 ) self-report of health , using the Medical Outcomes Study Short Form-36 ; and ( 3 ) medical care utilization variables of diagnostic tests , referrals , and visits to the family physician , assessed by chart review . The 2 measures of patient-centeredness were correlated with the outcomes of visits , adjusting for the clustering of patients by physician and controlling for confounding variables . RESULTS Patient-centered communication was correlated with the patients ' perceptions of finding common ground . In addition , positive perceptions ( both the total score and the subscore on finding common ground ) were associated with better recovery from their discomfort and concern , better emotional health 2 months later , and fewer diagnostic tests and referrals . CONCLUSIONS Patient-centered communication influences patients ' health through perceptions that their visit was patient centered , and especially through perceptions that common ground was achieved with the physician . Patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals A brief educational intervention to promote effective communication between physicians , children , and parents during pediatric office visits was design ed and tested . A r and omized clinical trial involving 141 children ( 5- to 15-year-olds ) tested the effectiveness of the intervention to improve the process and outcome of medical care . The intervention was contained in three brief videotapes ( one each for parents , physicians , and patients ) and in accompanying written material s. Material s were design ed to build skills and motivation for increased child competence and participation during pediatric medical visits . Control subjects saw health education videotapes and received material s comparable in length with those of experimental subjects . Postintervention medical visit process was analyzed using videotapes of visits . Visit outcomes , assessed with st and ardized instruments and interviews , included children 's rapport with physicians , children 's anxiety , children 's preference for an active health role , children 's recall of information , parents ' satisfaction with the medical visit , and physician satisfaction . Results indicated that physicians in the intervention group , compared with their counterparts in the control group , more often included children in discussion s of medical recommendations ( 50 % vs 29 % , t = 2.39 , P less than .05 ) ; that children in the intervention group , compared with control children , recalled more medication recommendations ( 77 % vs 47 % , P less than .01 ) and reported greater satisfaction and preference for an active health role ; and that the intervention and control groups did not differ in parent satisfaction , physician satisfaction , or child anxiety . The results suggest that a brief educational intervention administered during waiting room time can positively impact physician-child rapport and children 's preference for an active role in health and their acquisition of medical information Abstract Objective To determine whether poor reporting of methods in r and omised controlled trials reflects on poor methods . Design Observational study . Setting Reports of r and omised controlled trials conducted by the Radiation Therapy Oncology Group since its establishment in 1968 . Participants The Radiation Therapy Oncology Group . Outcome measures Content of reports compared with the design features described in the protocol s for all r and omised controlled trials . Results The method ological quality of 56 r and omised controlled trials was better than reported . Adequate allocation concealment was achieved in all trials but reported in only 42 % of papers . An intention to treat analysis was done in 83 % of trials but reported in only 69 % of papers . The sample size calculation was performed in 76 % of the studies , but reported in only 16 % of papers . End points were clearly defined and α and βerrors were prespecified in 76 % and 74 % of the trials , respectively , but only reported in 10 % of the papers . The one exception was the description of drop outs , where the frequency of reporting was similar to that contained in the original statistical files of the Radiation Therapy Oncology Group . Conclusions The reporting of method ological aspects of r and omised controlled trials does not necessarily reflect the conduct of the trial . Review ing research protocol s and contacting trialists for more information may improve quality assessment BACKGROUND Despite high prevalence , emotional distress among primary care patients often goes unrecognized during routine medical encounters . OBJECTIVE To explore the effect of communication-skills training on the process and outcome of care associated with patients ' emotional distress . METHODS A r and omized , controlled field trial was conducted with 69 primary care physicians and 648 of their patients . Physicians were r and omized to a  no-training control group or one of two communication-skills training courses  design ed to help physicians address patients ' emotional distress . The two training courses addressed communication through problem-defining skills or emotion-h and ling skills . All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Question naire . Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency . Telephone monitoring of distressed patients for utilization of medical services and General Health Question naire scores was conducted 2 weeks , 3 months , and 6 months after their audiotaped office visits . RESULTS Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-h and ling skills than did untrained physicians , without increasing the length of the visit . Trained physicians also reported more psychosocial problems , engaged in more strategies for managing emotional problems with actual patients , and scored higher in clinical proficiency with simulated patients . Patients of trained physicians reported reduction in emotional distress for as long as 6 months . CONCLUSIONS Important changes in physicians ' communication skills were evident after an 8-hour program . The training improved the process and outcome of care without lengthening the visits Assessing the quality of r and omized controlled trials ( RCTs ) is important and relatively new . Quality gives us an estimate of the likelihood that the results are a valid estimate of the truth . We present an annotated bibliography of scales and checklists developed to assess quality . Twenty-five scales and nine checklists have been developed to assess quality . The checklists are most useful in providing investigators with guidelines as to what information should be included in reporting RCTs . The scales give readers a quantitative index of the likelihood that the reported methodology and results are free of bias . There are several shortcomings with these scales . Future scale development is likely to be most beneficial if questions common to all trials are assessed , if the scale is easy to use , and if it is developed with sufficient rigor BACKGROUND Active participation and asking questions are important ways in which patients can ensure they underst and what the doctor has said . This study evaluated a question prompt sheet design ed to encourage patients to ask questions in the cancer consultation . PATIENTS AND METHODS Patients ( n = 142 ) were r and omised to receive ( i ) a question prompt sheet or ( ii ) a general sheet informing patients of services available through the regional Cancer Council . Recall of information was assessed in a structured interview 4 - 20 days after the consultation . Question naires to assess patient satisfaction and adjustment to cancer were sent by mail . RESULTS The question prompt sheet had a significant effect in one content area : prognosis . Thirty-five percent of patients who received the question h and out asked questions about prognosis compared to 16 % of those receiving the information h and out . The prompt sheet did not increase the mean number of questions asked overall . Age , in/out-patient status , gender and involvement preference were predictive of both number and duration of patient questions . CONCLUSIONS A question prompt sheet has a limited but important effect on patient question asking behaviour in the cancer consultation OBJECTIVES 1 . To compare a patient-centred , self-directive intervention with conventional care ; 2 . To evaluate longitudinal within-group changes of coronary heart disease risk . METHODS Risk factor changes were evaluated in 110 men with high coronary heart disease risk attending a one year intervention study in general practice . The 22 participating general practice centres were r and omly allocated to follow either a patient-centred , self-directive intervention or a conventional approach . RESULTS No significant between-group differences were found in any single risk factor or in the combined risk of coronary heart disease . The improvement of total risk from screening time to conclusion of the study corresponded with changes of relative risks of CHD to 0.64 ( 95 % CI : 0.54 - 0.77 ) and 0.65 ( 0.54 - 0.77 ) in the patient-centred , self-directive and the conventional care group respectively ( p < 0.0001 in both groups ) . CONCLUSION Everyday general practice clinical work seems as efficacious as a specific intervention method based on currently advocated behaviour change principles AIM Our objective was to evaluate the effect of training in a patient-centred intervention for GPs and practice nurses on outcomes for patients with Type II diabetes .  METHODS We carried out a r and omized controlled trial within general practice s as the basis for r and omization and a before- and -after design for measures of patient outcome . A parallel process study examined the use of the method by professionals . The study was carried out in 29 general practice s in South Glamorgan who had participated for at least 2 years in a local scheme of audit and CME in relation to Type II diabetes care . The subjects were 252 Type II diabetic patients recruited by 15 experimental and 14 control practice s. The main outcome measures were changes in glycosylated haemoglobin , patient satisfaction with care and treatment , functional health status and professional ability to apply the intervention . RESULTS Professionals adopted the innovative method with enthusiasm , but after 2 years only 19 % continued to apply the method systematic ally . The trial was , therefore , unable to demonstrate significant biochemical or functional improvements . This highlights the need to underst and the factors associated with professional uptake and subsequent ability to sustain changes in behaviour . CONCLUSIONS The efficacy of this behavioural intervention remains unproved , despite its acceptability to professional staff . Detailed and prolonged development and testing of behavioural interventions is an essential first step before embarking on r and omized controlled trials which involve complex behavioural changes in professionals or patients To maximize disease control , patients must participate effectively in their medical care . The authors developed an intervention design ed to increase the involvement of  patients  in medical decision making . In a 20-minute session just before the regular visit to a physician , a clinic assistant review ed the medical record of each experimental patient with him/her , guided by a diabetes algorithm . Using systematic prompts , the assistant encouraged patients to use the information gained to negotiate medical decisions with the doctor . A r and omized trial was conducted in two university hospital clinics to compare this intervention with st and ard educational material s in sessions of equal length . The mean pre-intervention glycosylated hemoglobin ( HbA1 ) values were 10.6 + /- 2.1 % for 33 experimental patients and 10.3 + /- 2.0 % for 26 controls . After the intervention the mean levels were 9.1 + /- 1.9 % in the experimental group ( p less than 0.01 ) and 10.6 + /- 2.22 % for controls . Analysis of audiotapes of the visits to the physician showed the experimental patients were twice as effective as controls in eliciting information from the physician . Experimental patients reported significantly fewer function limitations . The authors conclude that the intervention is feasible and that it changes patient behavior , improves blood sugar control , and decreases functional limitations The successful treatment of chronic ambulatory illness requires that patients be involved actively in the management of their own conditions . How health providers orient services toward patients is likely to affect the quality of patients ' involvement . In the study reported here , three programs of care were evaluated in terms of the extent to which the care provided was oriented toward patients as active participants in the treatment process . Ninety-one hypertensive patients , r and omly assigned among the three programs , rated their care in terms of active patient orientation ( APO ) . On the basis of the structural characteristics of the three programs , it was hypothesized that the contingency-contracting approach would afford a stronger APO than either the educational or routine-care approach . The findings conform to expectation . Observed linkages among structure of care , level of APO reported , and patient participation are discussed in addition to the practice implication OBJECTIVE --To compare the effect of directing and sharing styles of consultation by a general practitioner on patients ' satisfaction with the consultation . DESIGN -- Patients were r and omised to receive a directing or sharing style in the part of the consultation concerned with giving treatment , advice , and prognosis . SETTING --An inner London general practice . PATIENTS --359 R and omly selected patients consulting with one general practitioner . Four patients refused to participate and five were excluded . Thirty failed to complete the initial assessment and 110 failed to complete the assessment a week later , giving response rates of 89 % and 58 % respectively . MAIN OUTCOME MEASURES -- Patients ' satisfaction with the general practitioner 's perceived underst and ing of their problem and the explanation they received and whether they felt that they had been helped immediately after the consultation and one week later . RESULTS -- Patients who had the directing style of consultation reported significantly higher levels of satisfaction on almost all the outcome measures . This was particularly striking for patients with physical problems ( excellent explanation 23/68 ( 34 % ) v 10/65 ( 15 % ) , p less than 0.02 ; excellent underst and ing 25/68 ( 37 % ) v 9/66 ( 14 % ) , p = 0.004 ) , and for patients who received a prescription ( excellent explanation 20/60 ( 33 % ) v 9/59 ( 15 % ) , p less than 0.04 ; excellent underst and ing 27/60 ( 45 % ) v 10/59 ( 17 % ) , p = 0.04 ) . There was no significant difference in the responses to the  directing and sharing styles in longer consultations ( 8/31 ( 26 % ) v 8/31 ( 26 % ) ) , in which the main treatment was advice ( 10/30 ( 33 % ) v 7/36 ( 19 % ) ) , and among patients with psychological ( 6/17 ( 35 % ) v 6/27 ( 22 % ) ) or chronic problems ( 14/28 ( 50 % ) v 8/32 ( 25 % ) ) . CONCLUSIONS --Style of consultation does influence the satisfaction of the patient , but its effect is most noticeable in consultations with patients with physical problems and patients who receive a prescription The aim of this experimental study was to evaluate the effectiveness of three  patient-focused interventions design ed to increase patient question asking in clinical consultations . Patients were r and omly allocated to one of five conditions to receive either one of three interventions or to serve as an attention control group or a control group . The primary outcome measure was question asking by the patient of their physician . Participants in the intervention groups did not ask more questions than participants in the control groups . Immediately after the consultation participants in the intervention groups had higher levels of self-efficacy in asking questions . Three months after the index visit patients in the intervention groups were significantly more likely to be satisfied to some degree than patients in the control group . There was no difference in diabetic control . These results suggest that simple brief patient-focused interventions do not change patient behaviour in medical outpatient consultations The purpose of this study was to explore the hypothesis that assisting men with prostate cancer to obtain information would enable them to assume a more active role in treatment decision making and decrease their levels of anxiety and depression .  Respondents were recruited from one community urology clinic in Winnipeg , Manitoba . Sixty newly diagnosed men were r and omly assigned to receive either a self-efficacy information intervention that consisted of a written information package with discussion , a list of questions they could ask their physician , and an audiotape of the medical consultation ( n = 30 ) , or a written information package alone ( n = 30 ) . Men completed measures of preferred decisional role as the pretest ; anxiety and depression before the intervention , and at 6 weeks post-intervention ; and assumed decisional role at 6 weeks post-intervention . Results demonstrated that men in the intervention group assumed a significantly more active role in treatment decision making , and had lower state anxiety levels at 6 weeks . Levels of depression were similar for both groups at 6 weeks . This group of older men do want to be informed and participate in medical decisions . Further efforts are required to evaluate the efficacy of such an intervention in other community urology clinics R and omised controlled trials are widely accepted as the most reliable method of determining effectiveness , but most trials have evaluated the effects of a single intervention such as a drug . Recognition is increasing that other , non-pharmacological interventions should also be rigorously evaluated.1 - 3 This paper examines the design and execution of research required to address the additional problems result ing from evaluation of complex interventions —that is , those “ made up of various interconnecting parts.”4 The issues dealt with are discussed in a longer Medical Research Council paper ( www.mrc.ac.uk/complex_packages.html ) . We focus on r and omised trials but believe that this approach could be adapted to other design s when they are more appropriate . # # # # Summary points Complex interventions are those that include several components The evaluation of complex interventions is difficult because of problems of developing , identifying , documenting , and reproducing the intervention A phased approach to the development and evaluation of complex interventions is proposed to help research ers define clearly where they are in the research process Evaluation of complex interventions requires use of qualitative and quantitative evidence There are specific difficulties in defining , developing , documenting , and reproducing complex interventions that are subject to more variation than a drug . A typical example would be the design of a trial to evaluate the  benefits of specialist stroke units .  Such a trial would have to consider the expertise of various health professionals as well as investigations , drugs , treatment guidelines , and arrangements for discharge and follow up . Stroke units may also vary in terms of organisation , management , and skill mix . The active components of the stroke unit may be difficult to specify , making it difficult to replicate the intervention . The box gives other examples of complex interventions . # # # # Examples of complex interventions Service delivery and organisation : Stroke units Hospital at home Interventions directed at health professionals ' behaviour : Strategies for implementing guidelines Computerised decision support Community interventions : Community BACKGROUND The purpose of this study was to assess the impact of an intervention to facilitate information giving to patients with chronic medical conditions on outcomes of care . METHODS A consecutive sample of 276 eligible patients with chronic medical conditions at a family medicine clinic was r and omized to control and experimental interventions . A total of 205 completed the study . Experimental group patients received copies of their medical record progress notes , and they completed question lists for physician review , while control group patients received health education sheets and completed suggestion lists for improving clinic care .  Self-reported physical functioning , global health , and patient satisfaction and adherence were measured at enrollment and after the interventions . Visit lengths and patient response to medical record sharing after the interventions were also measured . RESULTS After the intervention , experimental group patients reported 3.7 % better overall physical functioning than did control patients ( mean = 83.6 , st and ard deviation [ SD ] = 17.6 vs mean = 79.9 , SD = 25.3 ; P = .005 after adjusting for covariates ) . The experimental group was more satisfied with their physician 's care ( mean = 31.4 , SD = 4.6 vs mean = 31.3 , SD = 5.2 ; P = .045 after adjusting for covariates ) . They were also more interested in seeing their medical records than were control patients ( mean = 12.0 , SD = 2.8 vs mean = 11.2 , SD = 2.8 ; P = .002 after adjusting for covariates ) . Experimental group patients also reported an 8.3 % improvement in overall health status ( postintervention mean = 3.0 , SD = 1.1 ) compared with their pre-intervention health status ( mean = 2.8 , SD = 1.0 ; P = .001 ) . Visit lengths for patients in the experimental group did not differ from those of the control group . CONCLUSIONS A simple patient-centered intervention to facilitate information giving in the primary health care of patients with chronic medical conditions can improve self-reported health , physical functioning , and satisfaction with care Growing interest in the doctor-patient relationship focuses attention on the specific elements of that relationship that affect patients ' health outcomes . Data are presented for four clinical trials conducted in varied practice setting s among chronically ill patients differing markedly in sociodemographic characteristics . These trials demonstrated that “ better health ” measured physiologically ( blood pressure or blood sugar ) , behaviorally ( functional status ) , or more subjectively ( evaluations of overall health status ) was consistently related to specific aspects of physician-patient communication . We conclude that the physician-patient relationship may be an important influence on patients ' health outcomes and must be taken into account in light of current changes in the health care delivery system that may place this relationship at risk This study examined the efficacy of a brief written intervention for primary care patients , design ed to increase their level of participation in the consultation . Patients given the intervention leaflet ( N = 59 ) were compared with those given a control leaflet ( N = 61 ) on various consultation process and outcome measures . Psychological and sociodemographic data were also obtained to determine whether these influenced the effects of the intervention . The results showed that the intervention group had significantly longer consultations and asked more questions than the controls . Younger patients and those from social classes 1 and 2 were more likely to benefit from the intervention , but locus of control and self-efficacy scores were not particularly helpful in predicting outcomes . No differences in patient satisfaction were found nor were any negative effects on the doctor observed . A number of explanations are explored and some directions for future research are discussed At 45 general- practice surgery sessions  200 patients in whom no definite diagnosis could be made were r and omly selected for one of two procedures . Either they were given a symptomatic diagnosis and medications , or they were told that they had no evidence of disease and therefore they required no treatment . No difference in outcome was found between these two methods as judged by the return or not of the patient within one month and his statement that he did or did not get better
PURPOSE We wanted to identify published r and omized trials of interventions to alter the interaction between patients and practitioners , develop taxonomies of the interventions and outcomes , and assess the evidence that such interventions improve patients ’ health and well-being .