The Issue in Brief

Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity

Richard L. Street, Jr, PhD , and colleagues

Background Are patients more likely to trust a doctor they view as similar to themselves? This study looks at patients' perceptions of concordance (similarity or shared identity) with their doctor based on race and sex. It also looks at whether views of similarity are connected to the patient-doctor relationship and quality of care, including patient participation in the medical visit, trust in the doctor, satisfaction with care, and intent to follow the doctor's advice. The study also tests a new tool to measure perceived similarity based on shared identity.

What This Study Found Patients who believe they are more similar to their doctor in terms of personal beliefs, values, and ways of communicating have more trust in the doctor, more satisfaction with care, and a stronger intention to follow the doctor's recommendations. Patients' perceptions of being similar to the doctor in terms of race and ethnicity are not related to these factors.

Implications

• The patient-doctor relationship is strengthened when patients see themselves as similar to their doctors in terms of personal beliefs, values, and communication.
• Regardless of issues of race and sex, a doctor who is skilled in providing information, showing respect, and supporting patient involvement can establish a connection with the patient that contributes to greater patient satisfaction, trust, and commitment to treatment.
• Future research should examine how similarities and differences in values, beliefs, and behaviors affect the quality of patient-doctor relationships.

Physician Responses to a Community-Level Trial Promoting Judicious Antibiotic Use

Christopher J. Stille, MD, MPH , and colleagues

Background The Centers for Disease Control and Prevention and other organizations have recommended that doctors in the United States reduce inappropriate prescribing of antibiotics. This article reports on the effectiveness of an educational program for doctors about antibiotic prescribing.

What This Study Found The program to promote cautious antibiotic prescribing reached its intended audience and was welcomed by doctors as a tool for parent education. According to participating doctors, the program had little influence on their attitudes and practices, but most report prescribing antibiotics appropriately. Doctors suggest that frequent repetition of brief, consistent messages to parents and doctors, brief handouts, and promotion in the mass media are effective ways to educate the public and the medical profession about antibiotic use.

Implications

• Educational campaigns that repeat brief, consistent reminders to multiple groups may be most effective at assuring appropriate use of antibiotics.

Patients Prefer Pictures to Numbers to Express Cardiovascular Benefit From Treatment

Felicity Goodyear-Smith, MB, ChB, MGP, FRNZCGP , and colleagues

Background The way in which information is presented influences patients' decisions about medical care and treatment. This study compares methods of presenting health risk information to patients with heart disease. In particular, it looks at which methods encourage patients to take preventive medication and which methods they best understand.

What This Study Found Most patients in this study would take a hypothetical medication to reduce risk of heart attack, no matter how the risk information is presented. Even so, patients prefer a graphic format showing risk of heart attack to other methods.

Implications

• Using visual aids may be the best way to present risks and benefits of medical treatment.

Absolute Cardiovascular Disease Risk and Shared Decision Making in Primary Care: A Randomized Controlled Trial

Tanja Krones, MD , and colleagues

Background Decision aids are tools to help patients make decisions about their health care. This study looks at the effectiveness of a decision aid for the prevention of cardiovascular disease that can be used during a visit to the family doctor.

What This Study Found Patients who use the decision aid are more involved in decision making, more satisfied, and have less regret about their health care decisions.

Implications

• This decision aid helps doctors and patients discuss individual concerns and pace information according to patients’ needs.
• Decision aids completed by patients on their own, as well as those used during a visit to the doctor, are important, might be combined, and deserve further study.

The Experience of Pay for Performance in English Family Practice: A Qualitative Study

Stephen M. Campbell, PhD , and colleagues

Background In 2004, the United Kingdom introduced a pay-for-performance plan in which family doctors are financially rewarded for meeting goals pertaining to clinical care, organizational factors, and patients' experiences. This article describes the beliefs and concerns of family doctors and nurses about the pay-for-performance plan.

What This Study Found Participating doctors and nurses believe the pay-for-performance plan motivates them to achieve the program's goals, including improving processes of care for specific diseases, increasing physician income, and capturing medical data. It also leads to unintended effects, however, such as different agendas for patients and doctors, potential loss of skills among doctors as a result of the nurses' increased role, a decline in the ongoing relationship between doctors and patients, resentment by members of the medical team who are not benefiting financially from the plan, and concerns about an ongoing culture of performance monitoring.

Implications

• The new pay-for-performance plan has changed the way doctors and nurses work together and the nature of patient visits.
• Further research will observe the development and effects of the pay for performance plan.

Diabetes Flow Sheet Use Associated With Guideline Adherence

Karissa A. Hahn, MPH , and colleagues

Background Flow sheets (forms in the medical record with information about a patient's specific medical condition and a reminder that care is needed) can improve patient care. This study examines how often flow sheets are used to guide diabetes care and the effectiveness of diabetes flow sheets for improving patient care results.

What This Study Found Diabetes flow sheets were used in 23% of medical records of patients with diabetes. Use of diabetes flow sheets is associated with meeting recommended guidelines of the National Diabetes Education Program for diabetes assessment and treatment, but not for achieving intermediate target results for diabetes patients.

Implications

• Diabetes flow sheets can help meet guideline recommendations for assessing and treating diabetes.
• Additional research is needed to explore factors that influence the relationship between diabetes flow sheets and intermediate outcome targets for people with diabetes.

Age-Related Pulmonary Crackles (Rales) in Asymptomatic Cardiovascular Patients

Hajime Kataoka, MD and Osamu Matsuno, MD

Background Pulmonary crackles (also called rales) are explosive respiratory sounds that occur when breathing in. Although they can be a sign of heart failure, little is known about pulmonary crackles in patients at risk of developing cardiovascular disease. In this study, researchers examine the characteristics of pulmonary crackles in patients who are at high risk for congestive heart failure but have not developed heart disease or symptoms of heart failure.

What This Study Found Elderly patients at high risk for developing heart failure frequently have audible pulmonary crackles, even when there are no signs of cardiac dysfunction or lung disease. In cardiovascular patients with apparently normal heart function, the risk of pulmonary crackles increases 3-fold every 10 years after 45 years of age.

Implications

• It is important to recognize "age-related" crackles so that they are not mistakenly identified as a sign of heart failure deterioration. Other clinical tests should be run to determine whether crackles are related to cardiac dysfunction

Development of a Brief Diabetes Distress Screening Instrument

Lawrence Fisher, PhD , and colleagues

Background Diabetes distress is a condition in which patients with diabetes have concerns about managing their condition, receiving understanding and appropriate support from others, getting needed care, and feeling overwhelmed by the disease. Until now, there has been no time-efficient tool to help doctors screen patients for diabetes distress. This article reports the development of a diabetes distress screening tool.

What This Study Found The DDS2 is a brief, 2-question tool for detecting diabetes distress. For patients who screening test is positive for diabetes distress, a more detailed tool (the DDS17) can be administered. The DDS17 provides more information about the type of distress the patient is experiencing and helps guide treatment of those symptoms.

Implications

• The DDS2 and DDS17 are not substitutes for depression screening. Diabetes patients should be screened for both diabetes distress and depression.
• Future research is needed to determine whether patients with other chronic health conditions have similar types of distress.

Effect of Nonergot Dopamine Agonists on Symptoms of Restless Legs Syndrome

William L. Baker, PharmD, and colleagues

Background People with restless legs syndrome experience unpleasant sensations in the legs and an uncontrollable urge to move to relieve these feelings. A type of drug called nonergot dopamine agonists (NEDAs) is often used to treat restless legs syndrome. This study examines existing research to evaluate the effectiveness of NEDAs in treating restless legs syndrome, the risk of side effects, and the influence of side effects on whether patients continue to take the drugs.

What This Study Found Patients taking NEDAs show significant improvement in symptoms and severity of restless legs syndrome, especially in the early stages of treatment. Many patients discontinue use of the drugs, however, because of side effects, including nausea, dizziness, sleepiness, and fatigue.

Implications

• It is possible that individual NEDA drugs might differ from one another in terms of effectiveness and safety. Future research should directly compare NEDAs with each other in patients with restless legs syndrome and examine the drugs’ long-term effects.

The Unsustainable US Health Care System: A Blueprint for Change

Jennifer E. DeVoe, MD, MPhil

Background Health care in the United States is characterized by unequal distribution of resources and lack of adequate care for growing numbers of American families. In this essay, patients' stories highlight the extent of the problem at different levels of the health care system. The author urges readers to reflect on their own experiences and help bring about change in the health care system.

Today I'm Grieving a Physician Suicide

Jennifer L. Middleton, MD, MPH

Background In the United States, an estimated 250 physicians will commit suicide this year. In this essay, the author shares her grief and guilt over the suicide of a colleague. She reflects on the scale of this largely unacknowledged problem, the stigma that prevents medical professionals from adequately addressing it, and the responsibility of physicians to create an affirming and supportive professional culture.