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Comportment and Communication Score
In 2014, there were more than 40,000 hospitalists in the United States, and approximately 20% were employed by academic medical centers.[1] Hospitalist physicians groups are committed to delivering excellent patient care. However, the published literature is limited with respect to defining optimal care in hospital medicine.
Patient satisfaction surveys, such as Press Ganey (PG)[2] and Hospital Consumer Assessment of Healthcare Providers and Systems,[3] are being used to assess patients' contentment with the quality of care they receive while hospitalized. The Society of Hospital Medicine, the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] There are, however, several problems with the current methods. First, the attribution to specific providers is questionable. Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients' recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Thus, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.
Comportment has been used to describe both the way a person behaves and also the way she carries herself (ie, her general manner).[5] Excellent comportment and communication can serve as the foundation for delivering patient‐centered care.[6, 7, 8] Patient centeredness has been shown to improve the patient experience and clinical outcomes, including compliance with therapeutic plans.[9, 10, 11] Respectful behavior, etiquette‐based medicine, and effective communication also lay the foundation upon which the therapeutic alliance between a doctor and patient can be built.
The goal of this study was to establish a metric that could comprehensively assess a hospitalist provider's comportment and communication skills during an encounter with a hospitalized patient.
METHODS
Study Design and Setting
An observational study of hospitalist physicians was conducted between June 2013 and December 2013 at 5 hospitals in Maryland and Washington DC. Two are academic medical centers (Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center [JHBMC]), and the others are community hospitals (Howard County General Hospital [HCGH], Sibley Memorial Hospital [SMC], and Suburban Hospital). These 5 hospitals, across 2 large cities, have distinct culture and leadership, each serving different populations.
Subjects
In developing a tool to measure communication and comportment, we needed to observe physicianpatient encounters wherein there would be a good deal of variability in performance. During pilot testing, when following a few of the most senior and respected hospitalists, we noted encounters during which they excelled and others where they performed less optimally. Further, in following some less‐experienced providers, their skills were less developed and they were uniformly missing most of the behaviors on the tool that were believed to be associated with optimal communication and comportment. Because of this, we decided to purposively sample the strongest clinicians at each of the 5 hospitals in hopes of seeing a range of scores on the tool.
The chiefs of hospital medicine at the 5 hospitals were contacted and asked to identify their most clinically excellent hospitalists, namely those who they thought were most clinically skilled within their groups. Because our goal was to observe the top tier (approximately 20%) of the hospitalists within each group, we asked each chief to name a specific number of physicians (eg, 3 names for 1 group with 15 hospitalists, and 8 from another group with 40 physicians). No precise definition of most clinically excellent hospitalists was provided to the chiefs. It was believed that they were well positioned to select their best clinicians because of both subjective feedback and objective data that flow to them. This postulate may have been corroborated by the fact that each of them efficiently sent a list of their top choices without any questions being asked.
The 29 hospitalists (named by their chiefs) were in turn emailed and invited to participate in the study. All but 3 hospitalists consented to participate in the study; this resulted in a cohort of 26 who would be observed.
Tool Development
A team was assembled to develop the hospital medicine comportment and communication observation tool (HMCCOT). All team members had extensive clinical experience, several had published articles on clinical excellence, had won clinical awards, and all had been teaching clinical skills for many years. The team's development of the HMCCOT was extensively informed by a review of the literature. Two articles that most heavily influenced the HMCCOT's development were Christmas et al.'s paper describing 7 core domains of excellence, 2 of which are intimately linked to communication and comportment,[12] and Kahn's text that delineates behaviors to be performed upon entering the patient's room, termed etiquette‐based medicine.[6] The team also considered the work from prior timemotion studies in hospital medicine,[7, 13] which led to the inclusion of temporal measurements during the observations. The tool was also presented at academic conferences in the Division of General Internal Medicine at Johns Hopkins and iteratively revised based on the feedback. Feedback was sought from people who have spent their entire career studying physicianpatient relationships and who are members of the American Academy on Communication in Healthcare. These methods established content validity evidence for the tool under development. The goal of the HMCCOT was to assess behaviors believed to be associated with optimal comportment and communication in hospital medicine.
The HMCCOT was pilot tested by observing different JHBMC hospitalists patient encounters and it was iteratively revised. On multiple occasions, 2 authors/emnvestigators spent time observing JHBMC hospitalists together and compared data capture and levels of agreement across all elements. Then, for formal assessment of inter‐rater reliability, 2 authors observed 5 different hospitalists across 25 patient encounters; the coefficient was 0.91 (standard error = 0.04). This step helped to establish internal structure validity evidence for the tool.
The initial version of the HMCCOT contained 36 elements, and it was organized sequentially to allow the observer to document behaviors in the order that they were likely to occur so as to facilitate the process and to minimize oversight. A few examples of the elements were as follows: open‐ended versus a close‐ended statement at the beginning of the encounter, hospitalist introduces himself/herself, and whether the provider smiles at any point during the patient encounter.
Data Collection
One author scheduled a time to observe each hospitalist physician during their routine clinical care of patients when they were not working with medical learners. Hospitalists were naturally aware that they were being observed but were not aware of the specific data elements or behaviors that were being recorded.
The study was approved by the institutional review board at the Johns Hopkins University School of Medicine, and by each of the research review committees at HCGH, SMC, and Suburban hospitals.
Data Analysis
After data collection, all data were deidentified so that the researchers were blinded to the identities of the physicians. Respondent characteristics are presented as proportions and means. Unpaired t test and 2 tests were used to compare demographic information, and stratified by mean HMCCOT score. The survey data were analyzed using Stata statistical software version 12.1 (StataCorp LP, College Station, TX).
Further Validation of the HMCCOT
Upon reviewing the distribution of data after observing the 26 physicians with their patients, we excluded 13 variables from the initial version of the tool that lacked discriminatory value (eg, 100% or 0% of physicians performed the observed behavior during the encounters); this left 23 variables that were judged to be most clinically relevant in the final version of the HMCCOT. Two examples of the variables that were excluded were: uses technology/literature to educate patients (not witnessed in any encounter), and obeys posted contact precautions (done uniformly by all). The HMCCOT score represents the proportion of observed behaviors (out of the 23 behaviors). It was computed for each hospitalist for every patient encounter. Finally, relation to other variables validity evidence would be established by comparing the mean HMCCOT scores of the physicians to their PG scores from the same time period to evaluate the correlation between the 2 scores. This association was assessed using Pearson correlations.
RESULTS
The average clinical experience of the 26 hospitalist physicians studied was 6 years (Table 1). Their mean age was 38 years, 13 (50%) were female, and 16 (62%) were of nonwhite race. Fourteen hospitalists (54%) worked at 1 of the nonacademic hospitals. In terms of clinical workload, most physicians (n = 17, 65%) devoted more than 70% of their time working in direct patient care. Mean time spent observing each physician was 280 minutes. During this time, the 26 physicians were observed for 181 separate clinical encounters; 54% of these patients were new encounters, patients who were not previously known to the physician. The average time each physician spent in a patient room was 10.8 minutes. Mean number of observed patient encounters per hospitalist was 7.
| Total Study Population, n = 26 | HMCCOT Score 60, n = 14 | HMCCOT Score >60, n = 12 | P Value* | |
|---|---|---|---|---|
| ||||
| Age, mean (SD) | 38 (5.6) | 37.9 (5.6) | 38.1 (5.7) | 0.95 |
| Female, n (%) | 13 (50) | 6 (43) | 7 (58) | 0.43 |
| Race, n (%) | ||||
| Caucasian | 10 (38) | 5 (36) | 5 (41) | 0.31 |
| Asian | 13 (50) | 8 (57) | 5 (41) | |
| African/African American | 2 (8) | 0 (0) | 2 (17) | |
| Other | 1 (4) | 1 (7) | 0 (0) | |
| Clinical experience >6 years, n (%) | 12 (46) | 6 (43) | 6 (50) | 0.72 |
| Clinical workload >70% | 17 (65) | 10 (71) | 7 (58) | 0.48 |
| Academic hospitalist, n (%) | 12 (46) | 5 (36) | 7 (58) | 0.25 |
| Hospital | 0.47 | |||
| JHBMC | 8 (31) | 3 (21.4) | 5 (41) | |
| JHH | 4 (15) | 2 (14.3) | 2 (17) | |
| HCGH | 5 (19) | 3 (21.4) | 2 (17) | |
| Suburban | 6 (23) | 3 (21.4) | 3 (25) | |
| SMC | 3 (12) | 3 (21.4) | 0 (0) | |
| Minutes spent observing hospitalist per shift, mean (SD) | 280 (104.5) | 280.4 (115.5) | 281.4 (95.3) | 0.98 |
| Average time spent per patient encounter in minutes, mean (SD) | 10.8 (8.9) | 8.7 (9.1) | 13 (8.1) | 0.001 |
| Proportion of observed patients who were new to provider, % | 97 (53.5) | 37 (39.7) | 60 (68.1) | 0.001 |
The distribution of HMCCOT scores was not statistically significantly different when analyzed by age, gender, race, amount of clinical experience, clinical workload of the hospitalist, hospital, time spent observing the hospitalist (all P > 0.05). The distribution of HMCCOT scores was statistically different in new patient encounters compared to follow‐ups (68.1% vs 39.7%, P 0.001). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes vs 8.7 minutes, P 0.001).
The mean HMCCOT score was 61 (standard deviation [SD] = 10.6), and it was normally distributed (Figure 1). Table 2 shows the data for the 23 behaviors that were objectively assessed as part of the HMCCOT for the 181 patient encounters. The most frequently observed behaviors were physicians washing hands after leaving the patient's room in 170 (94%) of the encounters and smiling (83%). The behaviors that were observed with the least regularity were using an empathic statement (26% of encounters), and employing teach‐back (13% of encounters). A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients' personal histories and their interests.
| Variables | All Visits Combined, n = 181 | HMCCOT Score 60, n = 93 | HMCCOT Score >60, n = 88 | P Value* |
|---|---|---|---|---|
| ||||
| Objective observations, n (%) | ||||
| Washes hands after leaving room | 170 (94) | 83 (89) | 87 (99) | 0.007 |
| Discusses plan for the day | 163 (91) | 78 (84) | 85 (99) | 0.001 |
| Does not interrupt the patient | 159 (88) | 79 (85) | 80 (91) | 0.21 |
| Smiles | 149 (83) | 71 (77) | 78 (89) | 0.04 |
| Washes hands before entering | 139 (77) | 64 (69) | 75 (85) | 0.009 |
| Begins with open‐ended question | 134 (77) | 68 (76) | 66 (78) | 0.74 |
| Knocks before entering the room | 127 (76) | 57 (65) | 70 (89) | 0.001 |
| Introduces him/herself to the patient | 122 (67) | 45 (48) | 77 (88) | 0.001 |
| Explains his/her role | 120 (66) | 44 (47) | 76 (86) | 0.001 |
| Asks about pain | 110 (61) | 45 (49) | 65 (74) | 0.001 |
| Asks permission prior to examining | 106 (61) | 43 (50) | 63 (72) | 0.002 |
| Uncovers body area for the physical exam | 100 (57) | 34 (38) | 66 (77) | 0.001 |
| Discusses discharge plan | 99 (55) | 38 (41) | 61 (71) | 0.001 |
| Sits down in the patient room | 74 (41) | 24 (26) | 50 (57) | 0.001 |
| Asks about patient's feelings | 58 (33) | 17 (19) | 41 (47) | 0.001 |
| Shakes hands with the patient | 57 (32) | 17 (18) | 40 (46) | 0.001 |
| Uses teach‐back | 24 (13) | 4 (4.3) | 20 (24) | 0.001 |
| Subjective observations, n (%) | ||||
| Avoids medical jargon | 160 (89) | 85 (91) | 83 (95) | 0.28 |
| Demonstrates interest in patient as a person | 72 (41) | 16 (18) | 56 (66) | 0.001 |
| Touches appropriately | 62 (34) | 21 (23) | 41 (47) | 0.001 |
| Shows sensitivity to patient modesty | 57 (93) | 15 (79) | 42 (100) | 0.002 |
| Engages in nonmedical conversation | 54 (30) | 10 (11) | 44 (51) | 0.001 |
| Uses empathic statement | 47 (26) | 9 (10) | 38 (43) | 0.001 |
The average composite PG scores for the physician sample was 38.95 (SD=39.64). A moderate correlation was found between the HMCCOT score and PG score (adjusted Pearson correlation: 0.45, P = 0.047).
DISCUSSION
In this study, we followed 26 hospitalist physicians during routine clinical care, and we focused intently on their communication and their comportment with patients at the bedside. Even among clinically respected hospitalists, the results reveal that there is wide variability in comportment and communication practices and behaviors at the bedside. The physicians' HMCCOT scores were associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might translate into enhanced patient satisfaction.
This is the first study that honed in on hospitalist communication and comportment. With validity evidence established for the HMCCOT, some may elect to more explicitly perform these behaviors themselves, and others may wish to watch other hospitalists to give them feedback that is tied to specific behaviors. Beginning with the basics, the hospitalists we studied introduced themselves to their patients at the initial encounter 78% of the time, less frequently than is done by primary care clinicians (89%) but more consistently than do emergency department providers (64%).[7] Other variables that stood out in the HMCCOT was that teach‐back was employed in only 13% of the encounters. Previous studies have shown that teach‐back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization.[14] Further, patients who clearly understand their postdischarge plan are 30% less likely to be readmitted or visit the emergency department.[14] The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States,[15] as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.
Tackett et al. have looked at encounter length and its association with performance of etiquette‐based medicine behaviors.[7] Similar to their study, we found a positive correlation between spending more time with patients and higher HMCCOT scores. We also found that HMCCOT scores were higher when providers were caring for new patients. Patients' complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that information was not conveyed in a clear manner.[16] Such challenges in physicianpatient communication are ubiquitous across clinical settings.[16] When successfully achieved, patient‐centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self‐management of chronic disease.[17, 18, 19, 20, 21, 22, 23, 24, 25, 26] Many of the components of the HMCCOT described in this article are at the heart of patient‐centered care.
Several limitations of the study should be considered. First, physicians may have behaved differently while they were being observed, which is known as the Hawthorne effect. We observed them for many hours and across multiple patient encounters, and the physicians were not aware of the specific types of data that we were collecting. These factors may have limited the biases along such lines. Second, there may be elements of optimal comportment and communication that were not captured by the HMCCOT. Hopefully, there are not big gaps, as we used multiple methods and an iterative process in the refinement of the HMCCOT metric. Third, one investigator did all of the observing, and it is possible that he might have missed certain behaviors. Through extensive pilot testing and comparisons with other raters, the observer became very skilled and facile with such data collection and the tool. Fourth, we did not survey the same patients that were cared for to compare their perspectives to the HMCCOT scores following the clinical encounters. For patient perspectives, we relied only on PG scores. Fifth, quality of care is a broad and multidimensional construct. The HMCCOT focuses exclusively on hospitalists' comportment and communication at the bedside; therefore, it does not comprehensively assess care quality. Sixth, with our goal to optimally validate the HMCCOT, we tested it on the top tier of hospitalists within each group. We may have observed different results had we randomly selected hospitalists from each hospital or had we conducted the study at hospitals in other geographic regions. Finally, all of the doctors observed worked at hospitals in the Mid‐Atlantic region. However, these five distinct hospitals each have their own cultures, and they are led by different administrators. We purposively chose to sample both academic as well as community settings.
In conclusion, this study reports on the development of a comportment and communication tool that was established and validated by following clinically excellent hospitalists at the bedside. Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies will then be needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital.
Disclosures: Dr. Wright is a Miller‐Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine. Susrutha Kotwal, MD, and Waseem Khaliq, MD, contributed equally to this work. The authors report no conflicts of interest.
- 2014 state of hospital medicine report. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/Web/Practice_Management/State_of_HM_Surveys/2014.aspx. Accessed January 10, 2015.
- Press Ganey website. Available at: http://www.pressganey.com/home. Accessed December 15, 2015.
- Hospital Consumer Assessment of Healthcare Providers and Systems website. Available at: http://www.hcahpsonline.org/home.aspx. Accessed February 2, 2016.
- Membership committee guidelines for hospitalists patient satisfaction surveys. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org. Accessed February 2, 2016.
- Definition of comportment. Available at: http://www.vocabulary.com/dictionary/comportment. Accessed December 15, 2015.
- . Etiquette‐based medicine. N Engl J Med. 2008;358(19):1988–1989.
- , , , , . Appraising the practice of etiquette‐based medicine in the inpatient setting. J Gen Intern Med. 2013;28(7):908–913.
- , , . Developing physician communication skills for patient‐centered care. Health Aff (Millwood). 2010;29(7):1310–1318.
- . The impact on patient health outcomes of interventions targeting the patient–physician relationship. Patient. 2009;2(2):77–84.
- , , , , , . Effect on health‐related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med. 2004;2(6):595–608.
- , , , . How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295–301.
- , , , . Clinical excellence in academia: perspectives from masterful academic clinicians. Mayo Clin Proc. 2008;83(9):989–994.
- , , , et al. Where did the day go?—a time‐motion study of hospitalists. J Hosp Med. 2010;5(6):323–328.
- , , , et al. Reducing readmissions using teach‐back: enhancing patient and family education. J Nurs Adm. 2015;45(1):35–42.
- , , . Hand hygiene compliance rates in the United States—a one‐year multicenter collaboration using product/volume usage measurement and feedback. Am J Med Qual. 2009;24(3):205–213.
- , , , et al. Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA. 1994;272(20):1583–1587.
- , . Patient‐Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. NIH publication no. 07–6225. Bethesda, MD: National Cancer Institute; 2007.
- . Interacting with cancer patients: the significance of physicians' communication behavior. Soc Sci Med. 2003;57(5):791–806.
- , , . Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102(4):520–528.
- , . Measuring patient‐centeredness: a comparison of three observation‐based instruments. Patient Educ Couns. 2000;39(1):71–80.
- , , , . Doctor‐patient communication: a review of the literature. Soc Sci Med. 1995;40(7):903–918.
- , , , , , . Linking primary care performance to outcomes of care. J Fam Pract. 1998;47(3):213–220.
- , , , et al. The impact of patient‐centered care on outcomes. J Fam Pract. 2000;49(9):796–804.
- , , , et al. Measuring patient‐centered communication in patient‐physician consultations: theoretical and practical issues. Soc Sci Med. 2005;61(7):1516–1528.
- , . Patient‐centered consultations and outcomes in primary care: a review of the literature. Patient Educ Couns. 2002;48(1):51–61.
- , , . Doctor‐patient communication and satisfaction with care in oncology. Curr Opin Oncol. 2005;17(4):351–354.
In 2014, there were more than 40,000 hospitalists in the United States, and approximately 20% were employed by academic medical centers.[1] Hospitalist physicians groups are committed to delivering excellent patient care. However, the published literature is limited with respect to defining optimal care in hospital medicine.
Patient satisfaction surveys, such as Press Ganey (PG)[2] and Hospital Consumer Assessment of Healthcare Providers and Systems,[3] are being used to assess patients' contentment with the quality of care they receive while hospitalized. The Society of Hospital Medicine, the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] There are, however, several problems with the current methods. First, the attribution to specific providers is questionable. Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients' recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Thus, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.
Comportment has been used to describe both the way a person behaves and also the way she carries herself (ie, her general manner).[5] Excellent comportment and communication can serve as the foundation for delivering patient‐centered care.[6, 7, 8] Patient centeredness has been shown to improve the patient experience and clinical outcomes, including compliance with therapeutic plans.[9, 10, 11] Respectful behavior, etiquette‐based medicine, and effective communication also lay the foundation upon which the therapeutic alliance between a doctor and patient can be built.
The goal of this study was to establish a metric that could comprehensively assess a hospitalist provider's comportment and communication skills during an encounter with a hospitalized patient.
METHODS
Study Design and Setting
An observational study of hospitalist physicians was conducted between June 2013 and December 2013 at 5 hospitals in Maryland and Washington DC. Two are academic medical centers (Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center [JHBMC]), and the others are community hospitals (Howard County General Hospital [HCGH], Sibley Memorial Hospital [SMC], and Suburban Hospital). These 5 hospitals, across 2 large cities, have distinct culture and leadership, each serving different populations.
Subjects
In developing a tool to measure communication and comportment, we needed to observe physicianpatient encounters wherein there would be a good deal of variability in performance. During pilot testing, when following a few of the most senior and respected hospitalists, we noted encounters during which they excelled and others where they performed less optimally. Further, in following some less‐experienced providers, their skills were less developed and they were uniformly missing most of the behaviors on the tool that were believed to be associated with optimal communication and comportment. Because of this, we decided to purposively sample the strongest clinicians at each of the 5 hospitals in hopes of seeing a range of scores on the tool.
The chiefs of hospital medicine at the 5 hospitals were contacted and asked to identify their most clinically excellent hospitalists, namely those who they thought were most clinically skilled within their groups. Because our goal was to observe the top tier (approximately 20%) of the hospitalists within each group, we asked each chief to name a specific number of physicians (eg, 3 names for 1 group with 15 hospitalists, and 8 from another group with 40 physicians). No precise definition of most clinically excellent hospitalists was provided to the chiefs. It was believed that they were well positioned to select their best clinicians because of both subjective feedback and objective data that flow to them. This postulate may have been corroborated by the fact that each of them efficiently sent a list of their top choices without any questions being asked.
The 29 hospitalists (named by their chiefs) were in turn emailed and invited to participate in the study. All but 3 hospitalists consented to participate in the study; this resulted in a cohort of 26 who would be observed.
Tool Development
A team was assembled to develop the hospital medicine comportment and communication observation tool (HMCCOT). All team members had extensive clinical experience, several had published articles on clinical excellence, had won clinical awards, and all had been teaching clinical skills for many years. The team's development of the HMCCOT was extensively informed by a review of the literature. Two articles that most heavily influenced the HMCCOT's development were Christmas et al.'s paper describing 7 core domains of excellence, 2 of which are intimately linked to communication and comportment,[12] and Kahn's text that delineates behaviors to be performed upon entering the patient's room, termed etiquette‐based medicine.[6] The team also considered the work from prior timemotion studies in hospital medicine,[7, 13] which led to the inclusion of temporal measurements during the observations. The tool was also presented at academic conferences in the Division of General Internal Medicine at Johns Hopkins and iteratively revised based on the feedback. Feedback was sought from people who have spent their entire career studying physicianpatient relationships and who are members of the American Academy on Communication in Healthcare. These methods established content validity evidence for the tool under development. The goal of the HMCCOT was to assess behaviors believed to be associated with optimal comportment and communication in hospital medicine.
The HMCCOT was pilot tested by observing different JHBMC hospitalists patient encounters and it was iteratively revised. On multiple occasions, 2 authors/emnvestigators spent time observing JHBMC hospitalists together and compared data capture and levels of agreement across all elements. Then, for formal assessment of inter‐rater reliability, 2 authors observed 5 different hospitalists across 25 patient encounters; the coefficient was 0.91 (standard error = 0.04). This step helped to establish internal structure validity evidence for the tool.
The initial version of the HMCCOT contained 36 elements, and it was organized sequentially to allow the observer to document behaviors in the order that they were likely to occur so as to facilitate the process and to minimize oversight. A few examples of the elements were as follows: open‐ended versus a close‐ended statement at the beginning of the encounter, hospitalist introduces himself/herself, and whether the provider smiles at any point during the patient encounter.
Data Collection
One author scheduled a time to observe each hospitalist physician during their routine clinical care of patients when they were not working with medical learners. Hospitalists were naturally aware that they were being observed but were not aware of the specific data elements or behaviors that were being recorded.
The study was approved by the institutional review board at the Johns Hopkins University School of Medicine, and by each of the research review committees at HCGH, SMC, and Suburban hospitals.
Data Analysis
After data collection, all data were deidentified so that the researchers were blinded to the identities of the physicians. Respondent characteristics are presented as proportions and means. Unpaired t test and 2 tests were used to compare demographic information, and stratified by mean HMCCOT score. The survey data were analyzed using Stata statistical software version 12.1 (StataCorp LP, College Station, TX).
Further Validation of the HMCCOT
Upon reviewing the distribution of data after observing the 26 physicians with their patients, we excluded 13 variables from the initial version of the tool that lacked discriminatory value (eg, 100% or 0% of physicians performed the observed behavior during the encounters); this left 23 variables that were judged to be most clinically relevant in the final version of the HMCCOT. Two examples of the variables that were excluded were: uses technology/literature to educate patients (not witnessed in any encounter), and obeys posted contact precautions (done uniformly by all). The HMCCOT score represents the proportion of observed behaviors (out of the 23 behaviors). It was computed for each hospitalist for every patient encounter. Finally, relation to other variables validity evidence would be established by comparing the mean HMCCOT scores of the physicians to their PG scores from the same time period to evaluate the correlation between the 2 scores. This association was assessed using Pearson correlations.
RESULTS
The average clinical experience of the 26 hospitalist physicians studied was 6 years (Table 1). Their mean age was 38 years, 13 (50%) were female, and 16 (62%) were of nonwhite race. Fourteen hospitalists (54%) worked at 1 of the nonacademic hospitals. In terms of clinical workload, most physicians (n = 17, 65%) devoted more than 70% of their time working in direct patient care. Mean time spent observing each physician was 280 minutes. During this time, the 26 physicians were observed for 181 separate clinical encounters; 54% of these patients were new encounters, patients who were not previously known to the physician. The average time each physician spent in a patient room was 10.8 minutes. Mean number of observed patient encounters per hospitalist was 7.
| Total Study Population, n = 26 | HMCCOT Score 60, n = 14 | HMCCOT Score >60, n = 12 | P Value* | |
|---|---|---|---|---|
| ||||
| Age, mean (SD) | 38 (5.6) | 37.9 (5.6) | 38.1 (5.7) | 0.95 |
| Female, n (%) | 13 (50) | 6 (43) | 7 (58) | 0.43 |
| Race, n (%) | ||||
| Caucasian | 10 (38) | 5 (36) | 5 (41) | 0.31 |
| Asian | 13 (50) | 8 (57) | 5 (41) | |
| African/African American | 2 (8) | 0 (0) | 2 (17) | |
| Other | 1 (4) | 1 (7) | 0 (0) | |
| Clinical experience >6 years, n (%) | 12 (46) | 6 (43) | 6 (50) | 0.72 |
| Clinical workload >70% | 17 (65) | 10 (71) | 7 (58) | 0.48 |
| Academic hospitalist, n (%) | 12 (46) | 5 (36) | 7 (58) | 0.25 |
| Hospital | 0.47 | |||
| JHBMC | 8 (31) | 3 (21.4) | 5 (41) | |
| JHH | 4 (15) | 2 (14.3) | 2 (17) | |
| HCGH | 5 (19) | 3 (21.4) | 2 (17) | |
| Suburban | 6 (23) | 3 (21.4) | 3 (25) | |
| SMC | 3 (12) | 3 (21.4) | 0 (0) | |
| Minutes spent observing hospitalist per shift, mean (SD) | 280 (104.5) | 280.4 (115.5) | 281.4 (95.3) | 0.98 |
| Average time spent per patient encounter in minutes, mean (SD) | 10.8 (8.9) | 8.7 (9.1) | 13 (8.1) | 0.001 |
| Proportion of observed patients who were new to provider, % | 97 (53.5) | 37 (39.7) | 60 (68.1) | 0.001 |
The distribution of HMCCOT scores was not statistically significantly different when analyzed by age, gender, race, amount of clinical experience, clinical workload of the hospitalist, hospital, time spent observing the hospitalist (all P > 0.05). The distribution of HMCCOT scores was statistically different in new patient encounters compared to follow‐ups (68.1% vs 39.7%, P 0.001). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes vs 8.7 minutes, P 0.001).
The mean HMCCOT score was 61 (standard deviation [SD] = 10.6), and it was normally distributed (Figure 1). Table 2 shows the data for the 23 behaviors that were objectively assessed as part of the HMCCOT for the 181 patient encounters. The most frequently observed behaviors were physicians washing hands after leaving the patient's room in 170 (94%) of the encounters and smiling (83%). The behaviors that were observed with the least regularity were using an empathic statement (26% of encounters), and employing teach‐back (13% of encounters). A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients' personal histories and their interests.
| Variables | All Visits Combined, n = 181 | HMCCOT Score 60, n = 93 | HMCCOT Score >60, n = 88 | P Value* |
|---|---|---|---|---|
| ||||
| Objective observations, n (%) | ||||
| Washes hands after leaving room | 170 (94) | 83 (89) | 87 (99) | 0.007 |
| Discusses plan for the day | 163 (91) | 78 (84) | 85 (99) | 0.001 |
| Does not interrupt the patient | 159 (88) | 79 (85) | 80 (91) | 0.21 |
| Smiles | 149 (83) | 71 (77) | 78 (89) | 0.04 |
| Washes hands before entering | 139 (77) | 64 (69) | 75 (85) | 0.009 |
| Begins with open‐ended question | 134 (77) | 68 (76) | 66 (78) | 0.74 |
| Knocks before entering the room | 127 (76) | 57 (65) | 70 (89) | 0.001 |
| Introduces him/herself to the patient | 122 (67) | 45 (48) | 77 (88) | 0.001 |
| Explains his/her role | 120 (66) | 44 (47) | 76 (86) | 0.001 |
| Asks about pain | 110 (61) | 45 (49) | 65 (74) | 0.001 |
| Asks permission prior to examining | 106 (61) | 43 (50) | 63 (72) | 0.002 |
| Uncovers body area for the physical exam | 100 (57) | 34 (38) | 66 (77) | 0.001 |
| Discusses discharge plan | 99 (55) | 38 (41) | 61 (71) | 0.001 |
| Sits down in the patient room | 74 (41) | 24 (26) | 50 (57) | 0.001 |
| Asks about patient's feelings | 58 (33) | 17 (19) | 41 (47) | 0.001 |
| Shakes hands with the patient | 57 (32) | 17 (18) | 40 (46) | 0.001 |
| Uses teach‐back | 24 (13) | 4 (4.3) | 20 (24) | 0.001 |
| Subjective observations, n (%) | ||||
| Avoids medical jargon | 160 (89) | 85 (91) | 83 (95) | 0.28 |
| Demonstrates interest in patient as a person | 72 (41) | 16 (18) | 56 (66) | 0.001 |
| Touches appropriately | 62 (34) | 21 (23) | 41 (47) | 0.001 |
| Shows sensitivity to patient modesty | 57 (93) | 15 (79) | 42 (100) | 0.002 |
| Engages in nonmedical conversation | 54 (30) | 10 (11) | 44 (51) | 0.001 |
| Uses empathic statement | 47 (26) | 9 (10) | 38 (43) | 0.001 |
The average composite PG scores for the physician sample was 38.95 (SD=39.64). A moderate correlation was found between the HMCCOT score and PG score (adjusted Pearson correlation: 0.45, P = 0.047).
DISCUSSION
In this study, we followed 26 hospitalist physicians during routine clinical care, and we focused intently on their communication and their comportment with patients at the bedside. Even among clinically respected hospitalists, the results reveal that there is wide variability in comportment and communication practices and behaviors at the bedside. The physicians' HMCCOT scores were associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might translate into enhanced patient satisfaction.
This is the first study that honed in on hospitalist communication and comportment. With validity evidence established for the HMCCOT, some may elect to more explicitly perform these behaviors themselves, and others may wish to watch other hospitalists to give them feedback that is tied to specific behaviors. Beginning with the basics, the hospitalists we studied introduced themselves to their patients at the initial encounter 78% of the time, less frequently than is done by primary care clinicians (89%) but more consistently than do emergency department providers (64%).[7] Other variables that stood out in the HMCCOT was that teach‐back was employed in only 13% of the encounters. Previous studies have shown that teach‐back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization.[14] Further, patients who clearly understand their postdischarge plan are 30% less likely to be readmitted or visit the emergency department.[14] The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States,[15] as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.
Tackett et al. have looked at encounter length and its association with performance of etiquette‐based medicine behaviors.[7] Similar to their study, we found a positive correlation between spending more time with patients and higher HMCCOT scores. We also found that HMCCOT scores were higher when providers were caring for new patients. Patients' complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that information was not conveyed in a clear manner.[16] Such challenges in physicianpatient communication are ubiquitous across clinical settings.[16] When successfully achieved, patient‐centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self‐management of chronic disease.[17, 18, 19, 20, 21, 22, 23, 24, 25, 26] Many of the components of the HMCCOT described in this article are at the heart of patient‐centered care.
Several limitations of the study should be considered. First, physicians may have behaved differently while they were being observed, which is known as the Hawthorne effect. We observed them for many hours and across multiple patient encounters, and the physicians were not aware of the specific types of data that we were collecting. These factors may have limited the biases along such lines. Second, there may be elements of optimal comportment and communication that were not captured by the HMCCOT. Hopefully, there are not big gaps, as we used multiple methods and an iterative process in the refinement of the HMCCOT metric. Third, one investigator did all of the observing, and it is possible that he might have missed certain behaviors. Through extensive pilot testing and comparisons with other raters, the observer became very skilled and facile with such data collection and the tool. Fourth, we did not survey the same patients that were cared for to compare their perspectives to the HMCCOT scores following the clinical encounters. For patient perspectives, we relied only on PG scores. Fifth, quality of care is a broad and multidimensional construct. The HMCCOT focuses exclusively on hospitalists' comportment and communication at the bedside; therefore, it does not comprehensively assess care quality. Sixth, with our goal to optimally validate the HMCCOT, we tested it on the top tier of hospitalists within each group. We may have observed different results had we randomly selected hospitalists from each hospital or had we conducted the study at hospitals in other geographic regions. Finally, all of the doctors observed worked at hospitals in the Mid‐Atlantic region. However, these five distinct hospitals each have their own cultures, and they are led by different administrators. We purposively chose to sample both academic as well as community settings.
In conclusion, this study reports on the development of a comportment and communication tool that was established and validated by following clinically excellent hospitalists at the bedside. Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies will then be needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital.
Disclosures: Dr. Wright is a Miller‐Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine. Susrutha Kotwal, MD, and Waseem Khaliq, MD, contributed equally to this work. The authors report no conflicts of interest.
In 2014, there were more than 40,000 hospitalists in the United States, and approximately 20% were employed by academic medical centers.[1] Hospitalist physicians groups are committed to delivering excellent patient care. However, the published literature is limited with respect to defining optimal care in hospital medicine.
Patient satisfaction surveys, such as Press Ganey (PG)[2] and Hospital Consumer Assessment of Healthcare Providers and Systems,[3] are being used to assess patients' contentment with the quality of care they receive while hospitalized. The Society of Hospital Medicine, the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] There are, however, several problems with the current methods. First, the attribution to specific providers is questionable. Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients' recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Thus, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.
Comportment has been used to describe both the way a person behaves and also the way she carries herself (ie, her general manner).[5] Excellent comportment and communication can serve as the foundation for delivering patient‐centered care.[6, 7, 8] Patient centeredness has been shown to improve the patient experience and clinical outcomes, including compliance with therapeutic plans.[9, 10, 11] Respectful behavior, etiquette‐based medicine, and effective communication also lay the foundation upon which the therapeutic alliance between a doctor and patient can be built.
The goal of this study was to establish a metric that could comprehensively assess a hospitalist provider's comportment and communication skills during an encounter with a hospitalized patient.
METHODS
Study Design and Setting
An observational study of hospitalist physicians was conducted between June 2013 and December 2013 at 5 hospitals in Maryland and Washington DC. Two are academic medical centers (Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center [JHBMC]), and the others are community hospitals (Howard County General Hospital [HCGH], Sibley Memorial Hospital [SMC], and Suburban Hospital). These 5 hospitals, across 2 large cities, have distinct culture and leadership, each serving different populations.
Subjects
In developing a tool to measure communication and comportment, we needed to observe physicianpatient encounters wherein there would be a good deal of variability in performance. During pilot testing, when following a few of the most senior and respected hospitalists, we noted encounters during which they excelled and others where they performed less optimally. Further, in following some less‐experienced providers, their skills were less developed and they were uniformly missing most of the behaviors on the tool that were believed to be associated with optimal communication and comportment. Because of this, we decided to purposively sample the strongest clinicians at each of the 5 hospitals in hopes of seeing a range of scores on the tool.
The chiefs of hospital medicine at the 5 hospitals were contacted and asked to identify their most clinically excellent hospitalists, namely those who they thought were most clinically skilled within their groups. Because our goal was to observe the top tier (approximately 20%) of the hospitalists within each group, we asked each chief to name a specific number of physicians (eg, 3 names for 1 group with 15 hospitalists, and 8 from another group with 40 physicians). No precise definition of most clinically excellent hospitalists was provided to the chiefs. It was believed that they were well positioned to select their best clinicians because of both subjective feedback and objective data that flow to them. This postulate may have been corroborated by the fact that each of them efficiently sent a list of their top choices without any questions being asked.
The 29 hospitalists (named by their chiefs) were in turn emailed and invited to participate in the study. All but 3 hospitalists consented to participate in the study; this resulted in a cohort of 26 who would be observed.
Tool Development
A team was assembled to develop the hospital medicine comportment and communication observation tool (HMCCOT). All team members had extensive clinical experience, several had published articles on clinical excellence, had won clinical awards, and all had been teaching clinical skills for many years. The team's development of the HMCCOT was extensively informed by a review of the literature. Two articles that most heavily influenced the HMCCOT's development were Christmas et al.'s paper describing 7 core domains of excellence, 2 of which are intimately linked to communication and comportment,[12] and Kahn's text that delineates behaviors to be performed upon entering the patient's room, termed etiquette‐based medicine.[6] The team also considered the work from prior timemotion studies in hospital medicine,[7, 13] which led to the inclusion of temporal measurements during the observations. The tool was also presented at academic conferences in the Division of General Internal Medicine at Johns Hopkins and iteratively revised based on the feedback. Feedback was sought from people who have spent their entire career studying physicianpatient relationships and who are members of the American Academy on Communication in Healthcare. These methods established content validity evidence for the tool under development. The goal of the HMCCOT was to assess behaviors believed to be associated with optimal comportment and communication in hospital medicine.
The HMCCOT was pilot tested by observing different JHBMC hospitalists patient encounters and it was iteratively revised. On multiple occasions, 2 authors/emnvestigators spent time observing JHBMC hospitalists together and compared data capture and levels of agreement across all elements. Then, for formal assessment of inter‐rater reliability, 2 authors observed 5 different hospitalists across 25 patient encounters; the coefficient was 0.91 (standard error = 0.04). This step helped to establish internal structure validity evidence for the tool.
The initial version of the HMCCOT contained 36 elements, and it was organized sequentially to allow the observer to document behaviors in the order that they were likely to occur so as to facilitate the process and to minimize oversight. A few examples of the elements were as follows: open‐ended versus a close‐ended statement at the beginning of the encounter, hospitalist introduces himself/herself, and whether the provider smiles at any point during the patient encounter.
Data Collection
One author scheduled a time to observe each hospitalist physician during their routine clinical care of patients when they were not working with medical learners. Hospitalists were naturally aware that they were being observed but were not aware of the specific data elements or behaviors that were being recorded.
The study was approved by the institutional review board at the Johns Hopkins University School of Medicine, and by each of the research review committees at HCGH, SMC, and Suburban hospitals.
Data Analysis
After data collection, all data were deidentified so that the researchers were blinded to the identities of the physicians. Respondent characteristics are presented as proportions and means. Unpaired t test and 2 tests were used to compare demographic information, and stratified by mean HMCCOT score. The survey data were analyzed using Stata statistical software version 12.1 (StataCorp LP, College Station, TX).
Further Validation of the HMCCOT
Upon reviewing the distribution of data after observing the 26 physicians with their patients, we excluded 13 variables from the initial version of the tool that lacked discriminatory value (eg, 100% or 0% of physicians performed the observed behavior during the encounters); this left 23 variables that were judged to be most clinically relevant in the final version of the HMCCOT. Two examples of the variables that were excluded were: uses technology/literature to educate patients (not witnessed in any encounter), and obeys posted contact precautions (done uniformly by all). The HMCCOT score represents the proportion of observed behaviors (out of the 23 behaviors). It was computed for each hospitalist for every patient encounter. Finally, relation to other variables validity evidence would be established by comparing the mean HMCCOT scores of the physicians to their PG scores from the same time period to evaluate the correlation between the 2 scores. This association was assessed using Pearson correlations.
RESULTS
The average clinical experience of the 26 hospitalist physicians studied was 6 years (Table 1). Their mean age was 38 years, 13 (50%) were female, and 16 (62%) were of nonwhite race. Fourteen hospitalists (54%) worked at 1 of the nonacademic hospitals. In terms of clinical workload, most physicians (n = 17, 65%) devoted more than 70% of their time working in direct patient care. Mean time spent observing each physician was 280 minutes. During this time, the 26 physicians were observed for 181 separate clinical encounters; 54% of these patients were new encounters, patients who were not previously known to the physician. The average time each physician spent in a patient room was 10.8 minutes. Mean number of observed patient encounters per hospitalist was 7.
| Total Study Population, n = 26 | HMCCOT Score 60, n = 14 | HMCCOT Score >60, n = 12 | P Value* | |
|---|---|---|---|---|
| ||||
| Age, mean (SD) | 38 (5.6) | 37.9 (5.6) | 38.1 (5.7) | 0.95 |
| Female, n (%) | 13 (50) | 6 (43) | 7 (58) | 0.43 |
| Race, n (%) | ||||
| Caucasian | 10 (38) | 5 (36) | 5 (41) | 0.31 |
| Asian | 13 (50) | 8 (57) | 5 (41) | |
| African/African American | 2 (8) | 0 (0) | 2 (17) | |
| Other | 1 (4) | 1 (7) | 0 (0) | |
| Clinical experience >6 years, n (%) | 12 (46) | 6 (43) | 6 (50) | 0.72 |
| Clinical workload >70% | 17 (65) | 10 (71) | 7 (58) | 0.48 |
| Academic hospitalist, n (%) | 12 (46) | 5 (36) | 7 (58) | 0.25 |
| Hospital | 0.47 | |||
| JHBMC | 8 (31) | 3 (21.4) | 5 (41) | |
| JHH | 4 (15) | 2 (14.3) | 2 (17) | |
| HCGH | 5 (19) | 3 (21.4) | 2 (17) | |
| Suburban | 6 (23) | 3 (21.4) | 3 (25) | |
| SMC | 3 (12) | 3 (21.4) | 0 (0) | |
| Minutes spent observing hospitalist per shift, mean (SD) | 280 (104.5) | 280.4 (115.5) | 281.4 (95.3) | 0.98 |
| Average time spent per patient encounter in minutes, mean (SD) | 10.8 (8.9) | 8.7 (9.1) | 13 (8.1) | 0.001 |
| Proportion of observed patients who were new to provider, % | 97 (53.5) | 37 (39.7) | 60 (68.1) | 0.001 |
The distribution of HMCCOT scores was not statistically significantly different when analyzed by age, gender, race, amount of clinical experience, clinical workload of the hospitalist, hospital, time spent observing the hospitalist (all P > 0.05). The distribution of HMCCOT scores was statistically different in new patient encounters compared to follow‐ups (68.1% vs 39.7%, P 0.001). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes vs 8.7 minutes, P 0.001).
The mean HMCCOT score was 61 (standard deviation [SD] = 10.6), and it was normally distributed (Figure 1). Table 2 shows the data for the 23 behaviors that were objectively assessed as part of the HMCCOT for the 181 patient encounters. The most frequently observed behaviors were physicians washing hands after leaving the patient's room in 170 (94%) of the encounters and smiling (83%). The behaviors that were observed with the least regularity were using an empathic statement (26% of encounters), and employing teach‐back (13% of encounters). A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients' personal histories and their interests.
| Variables | All Visits Combined, n = 181 | HMCCOT Score 60, n = 93 | HMCCOT Score >60, n = 88 | P Value* |
|---|---|---|---|---|
| ||||
| Objective observations, n (%) | ||||
| Washes hands after leaving room | 170 (94) | 83 (89) | 87 (99) | 0.007 |
| Discusses plan for the day | 163 (91) | 78 (84) | 85 (99) | 0.001 |
| Does not interrupt the patient | 159 (88) | 79 (85) | 80 (91) | 0.21 |
| Smiles | 149 (83) | 71 (77) | 78 (89) | 0.04 |
| Washes hands before entering | 139 (77) | 64 (69) | 75 (85) | 0.009 |
| Begins with open‐ended question | 134 (77) | 68 (76) | 66 (78) | 0.74 |
| Knocks before entering the room | 127 (76) | 57 (65) | 70 (89) | 0.001 |
| Introduces him/herself to the patient | 122 (67) | 45 (48) | 77 (88) | 0.001 |
| Explains his/her role | 120 (66) | 44 (47) | 76 (86) | 0.001 |
| Asks about pain | 110 (61) | 45 (49) | 65 (74) | 0.001 |
| Asks permission prior to examining | 106 (61) | 43 (50) | 63 (72) | 0.002 |
| Uncovers body area for the physical exam | 100 (57) | 34 (38) | 66 (77) | 0.001 |
| Discusses discharge plan | 99 (55) | 38 (41) | 61 (71) | 0.001 |
| Sits down in the patient room | 74 (41) | 24 (26) | 50 (57) | 0.001 |
| Asks about patient's feelings | 58 (33) | 17 (19) | 41 (47) | 0.001 |
| Shakes hands with the patient | 57 (32) | 17 (18) | 40 (46) | 0.001 |
| Uses teach‐back | 24 (13) | 4 (4.3) | 20 (24) | 0.001 |
| Subjective observations, n (%) | ||||
| Avoids medical jargon | 160 (89) | 85 (91) | 83 (95) | 0.28 |
| Demonstrates interest in patient as a person | 72 (41) | 16 (18) | 56 (66) | 0.001 |
| Touches appropriately | 62 (34) | 21 (23) | 41 (47) | 0.001 |
| Shows sensitivity to patient modesty | 57 (93) | 15 (79) | 42 (100) | 0.002 |
| Engages in nonmedical conversation | 54 (30) | 10 (11) | 44 (51) | 0.001 |
| Uses empathic statement | 47 (26) | 9 (10) | 38 (43) | 0.001 |
The average composite PG scores for the physician sample was 38.95 (SD=39.64). A moderate correlation was found between the HMCCOT score and PG score (adjusted Pearson correlation: 0.45, P = 0.047).
DISCUSSION
In this study, we followed 26 hospitalist physicians during routine clinical care, and we focused intently on their communication and their comportment with patients at the bedside. Even among clinically respected hospitalists, the results reveal that there is wide variability in comportment and communication practices and behaviors at the bedside. The physicians' HMCCOT scores were associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might translate into enhanced patient satisfaction.
This is the first study that honed in on hospitalist communication and comportment. With validity evidence established for the HMCCOT, some may elect to more explicitly perform these behaviors themselves, and others may wish to watch other hospitalists to give them feedback that is tied to specific behaviors. Beginning with the basics, the hospitalists we studied introduced themselves to their patients at the initial encounter 78% of the time, less frequently than is done by primary care clinicians (89%) but more consistently than do emergency department providers (64%).[7] Other variables that stood out in the HMCCOT was that teach‐back was employed in only 13% of the encounters. Previous studies have shown that teach‐back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization.[14] Further, patients who clearly understand their postdischarge plan are 30% less likely to be readmitted or visit the emergency department.[14] The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States,[15] as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.
Tackett et al. have looked at encounter length and its association with performance of etiquette‐based medicine behaviors.[7] Similar to their study, we found a positive correlation between spending more time with patients and higher HMCCOT scores. We also found that HMCCOT scores were higher when providers were caring for new patients. Patients' complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that information was not conveyed in a clear manner.[16] Such challenges in physicianpatient communication are ubiquitous across clinical settings.[16] When successfully achieved, patient‐centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self‐management of chronic disease.[17, 18, 19, 20, 21, 22, 23, 24, 25, 26] Many of the components of the HMCCOT described in this article are at the heart of patient‐centered care.
Several limitations of the study should be considered. First, physicians may have behaved differently while they were being observed, which is known as the Hawthorne effect. We observed them for many hours and across multiple patient encounters, and the physicians were not aware of the specific types of data that we were collecting. These factors may have limited the biases along such lines. Second, there may be elements of optimal comportment and communication that were not captured by the HMCCOT. Hopefully, there are not big gaps, as we used multiple methods and an iterative process in the refinement of the HMCCOT metric. Third, one investigator did all of the observing, and it is possible that he might have missed certain behaviors. Through extensive pilot testing and comparisons with other raters, the observer became very skilled and facile with such data collection and the tool. Fourth, we did not survey the same patients that were cared for to compare their perspectives to the HMCCOT scores following the clinical encounters. For patient perspectives, we relied only on PG scores. Fifth, quality of care is a broad and multidimensional construct. The HMCCOT focuses exclusively on hospitalists' comportment and communication at the bedside; therefore, it does not comprehensively assess care quality. Sixth, with our goal to optimally validate the HMCCOT, we tested it on the top tier of hospitalists within each group. We may have observed different results had we randomly selected hospitalists from each hospital or had we conducted the study at hospitals in other geographic regions. Finally, all of the doctors observed worked at hospitals in the Mid‐Atlantic region. However, these five distinct hospitals each have their own cultures, and they are led by different administrators. We purposively chose to sample both academic as well as community settings.
In conclusion, this study reports on the development of a comportment and communication tool that was established and validated by following clinically excellent hospitalists at the bedside. Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies will then be needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital.
Disclosures: Dr. Wright is a Miller‐Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine. Susrutha Kotwal, MD, and Waseem Khaliq, MD, contributed equally to this work. The authors report no conflicts of interest.
- 2014 state of hospital medicine report. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/Web/Practice_Management/State_of_HM_Surveys/2014.aspx. Accessed January 10, 2015.
- Press Ganey website. Available at: http://www.pressganey.com/home. Accessed December 15, 2015.
- Hospital Consumer Assessment of Healthcare Providers and Systems website. Available at: http://www.hcahpsonline.org/home.aspx. Accessed February 2, 2016.
- Membership committee guidelines for hospitalists patient satisfaction surveys. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org. Accessed February 2, 2016.
- Definition of comportment. Available at: http://www.vocabulary.com/dictionary/comportment. Accessed December 15, 2015.
- . Etiquette‐based medicine. N Engl J Med. 2008;358(19):1988–1989.
- , , , , . Appraising the practice of etiquette‐based medicine in the inpatient setting. J Gen Intern Med. 2013;28(7):908–913.
- , , . Developing physician communication skills for patient‐centered care. Health Aff (Millwood). 2010;29(7):1310–1318.
- . The impact on patient health outcomes of interventions targeting the patient–physician relationship. Patient. 2009;2(2):77–84.
- , , , , , . Effect on health‐related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med. 2004;2(6):595–608.
- , , , . How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295–301.
- , , , . Clinical excellence in academia: perspectives from masterful academic clinicians. Mayo Clin Proc. 2008;83(9):989–994.
- , , , et al. Where did the day go?—a time‐motion study of hospitalists. J Hosp Med. 2010;5(6):323–328.
- , , , et al. Reducing readmissions using teach‐back: enhancing patient and family education. J Nurs Adm. 2015;45(1):35–42.
- , , . Hand hygiene compliance rates in the United States—a one‐year multicenter collaboration using product/volume usage measurement and feedback. Am J Med Qual. 2009;24(3):205–213.
- , , , et al. Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA. 1994;272(20):1583–1587.
- , . Patient‐Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. NIH publication no. 07–6225. Bethesda, MD: National Cancer Institute; 2007.
- . Interacting with cancer patients: the significance of physicians' communication behavior. Soc Sci Med. 2003;57(5):791–806.
- , , . Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102(4):520–528.
- , . Measuring patient‐centeredness: a comparison of three observation‐based instruments. Patient Educ Couns. 2000;39(1):71–80.
- , , , . Doctor‐patient communication: a review of the literature. Soc Sci Med. 1995;40(7):903–918.
- , , , , , . Linking primary care performance to outcomes of care. J Fam Pract. 1998;47(3):213–220.
- , , , et al. The impact of patient‐centered care on outcomes. J Fam Pract. 2000;49(9):796–804.
- , , , et al. Measuring patient‐centered communication in patient‐physician consultations: theoretical and practical issues. Soc Sci Med. 2005;61(7):1516–1528.
- , . Patient‐centered consultations and outcomes in primary care: a review of the literature. Patient Educ Couns. 2002;48(1):51–61.
- , , . Doctor‐patient communication and satisfaction with care in oncology. Curr Opin Oncol. 2005;17(4):351–354.
- 2014 state of hospital medicine report. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/Web/Practice_Management/State_of_HM_Surveys/2014.aspx. Accessed January 10, 2015.
- Press Ganey website. Available at: http://www.pressganey.com/home. Accessed December 15, 2015.
- Hospital Consumer Assessment of Healthcare Providers and Systems website. Available at: http://www.hcahpsonline.org/home.aspx. Accessed February 2, 2016.
- Membership committee guidelines for hospitalists patient satisfaction surveys. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org. Accessed February 2, 2016.
- Definition of comportment. Available at: http://www.vocabulary.com/dictionary/comportment. Accessed December 15, 2015.
- . Etiquette‐based medicine. N Engl J Med. 2008;358(19):1988–1989.
- , , , , . Appraising the practice of etiquette‐based medicine in the inpatient setting. J Gen Intern Med. 2013;28(7):908–913.
- , , . Developing physician communication skills for patient‐centered care. Health Aff (Millwood). 2010;29(7):1310–1318.
- . The impact on patient health outcomes of interventions targeting the patient–physician relationship. Patient. 2009;2(2):77–84.
- , , , , , . Effect on health‐related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med. 2004;2(6):595–608.
- , , , . How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295–301.
- , , , . Clinical excellence in academia: perspectives from masterful academic clinicians. Mayo Clin Proc. 2008;83(9):989–994.
- , , , et al. Where did the day go?—a time‐motion study of hospitalists. J Hosp Med. 2010;5(6):323–328.
- , , , et al. Reducing readmissions using teach‐back: enhancing patient and family education. J Nurs Adm. 2015;45(1):35–42.
- , , . Hand hygiene compliance rates in the United States—a one‐year multicenter collaboration using product/volume usage measurement and feedback. Am J Med Qual. 2009;24(3):205–213.
- , , , et al. Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA. 1994;272(20):1583–1587.
- , . Patient‐Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. NIH publication no. 07–6225. Bethesda, MD: National Cancer Institute; 2007.
- . Interacting with cancer patients: the significance of physicians' communication behavior. Soc Sci Med. 2003;57(5):791–806.
- , , . Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102(4):520–528.
- , . Measuring patient‐centeredness: a comparison of three observation‐based instruments. Patient Educ Couns. 2000;39(1):71–80.
- , , , . Doctor‐patient communication: a review of the literature. Soc Sci Med. 1995;40(7):903–918.
- , , , , , . Linking primary care performance to outcomes of care. J Fam Pract. 1998;47(3):213–220.
- , , , et al. The impact of patient‐centered care on outcomes. J Fam Pract. 2000;49(9):796–804.
- , , , et al. Measuring patient‐centered communication in patient‐physician consultations: theoretical and practical issues. Soc Sci Med. 2005;61(7):1516–1528.
- , . Patient‐centered consultations and outcomes in primary care: a review of the literature. Patient Educ Couns. 2002;48(1):51–61.
- , , . Doctor‐patient communication and satisfaction with care in oncology. Curr Opin Oncol. 2005;17(4):351–354.
How Common is Coexisting Epilepsy/PNES?
Researchers examined 1567 patient medical records from the Vanderbilt University Medical Center Adult EMU and found a 5.2% prevalence rate of coexisting epilepsy/psychogenic nonepileptic spells (PNES). Other findings include:
· Epileptic seizures were preceded by a PNES event in 94.4% of epilepsy/PNES patients
· Patients with epilepsy/PNES had a higher presence of epilepsy risk factors
· Abnormal brain MRI and abnormal neurological examination were more common in the epilepsy/PNES group.
Chen-Block S, Abou-Khalil BW, Arain A, et al. Video-EEG results and clinical characteristics in patients with psychogenic nonepileptic spells: the effect of a coexistent epilepsy. Epilepsy Behav. 2016;62:62-65.
Researchers examined 1567 patient medical records from the Vanderbilt University Medical Center Adult EMU and found a 5.2% prevalence rate of coexisting epilepsy/psychogenic nonepileptic spells (PNES). Other findings include:
· Epileptic seizures were preceded by a PNES event in 94.4% of epilepsy/PNES patients
· Patients with epilepsy/PNES had a higher presence of epilepsy risk factors
· Abnormal brain MRI and abnormal neurological examination were more common in the epilepsy/PNES group.
Chen-Block S, Abou-Khalil BW, Arain A, et al. Video-EEG results and clinical characteristics in patients with psychogenic nonepileptic spells: the effect of a coexistent epilepsy. Epilepsy Behav. 2016;62:62-65.
Researchers examined 1567 patient medical records from the Vanderbilt University Medical Center Adult EMU and found a 5.2% prevalence rate of coexisting epilepsy/psychogenic nonepileptic spells (PNES). Other findings include:
· Epileptic seizures were preceded by a PNES event in 94.4% of epilepsy/PNES patients
· Patients with epilepsy/PNES had a higher presence of epilepsy risk factors
· Abnormal brain MRI and abnormal neurological examination were more common in the epilepsy/PNES group.
Chen-Block S, Abou-Khalil BW, Arain A, et al. Video-EEG results and clinical characteristics in patients with psychogenic nonepileptic spells: the effect of a coexistent epilepsy. Epilepsy Behav. 2016;62:62-65.
Hospitalized Patients With Epilepsy at Risk for Specific Safety-Related Adverse Events
People with epilepsy are at an increased risk of specific safety-related adverse events while in the hospital. Researchers found that hospitalized patients with epilepsy were at a greater risk for fall with hip fracture, respiratory failure, sepsis, and preventable postoperative death. The authors also reported that adverse events were associated with a prolonged length of stay, as well as an increase in the odds of inpatient death and an increase in high-level post-acute care.
Mendizabal A, Thibault DP, Willis AW. Patient safety events in hospital care of individuals with epilepsy [published online ahead of print June 28, 2016]. Epilepsia. 2016;doi:10.1111/epi.13440.
People with epilepsy are at an increased risk of specific safety-related adverse events while in the hospital. Researchers found that hospitalized patients with epilepsy were at a greater risk for fall with hip fracture, respiratory failure, sepsis, and preventable postoperative death. The authors also reported that adverse events were associated with a prolonged length of stay, as well as an increase in the odds of inpatient death and an increase in high-level post-acute care.
Mendizabal A, Thibault DP, Willis AW. Patient safety events in hospital care of individuals with epilepsy [published online ahead of print June 28, 2016]. Epilepsia. 2016;doi:10.1111/epi.13440.
People with epilepsy are at an increased risk of specific safety-related adverse events while in the hospital. Researchers found that hospitalized patients with epilepsy were at a greater risk for fall with hip fracture, respiratory failure, sepsis, and preventable postoperative death. The authors also reported that adverse events were associated with a prolonged length of stay, as well as an increase in the odds of inpatient death and an increase in high-level post-acute care.
Mendizabal A, Thibault DP, Willis AW. Patient safety events in hospital care of individuals with epilepsy [published online ahead of print June 28, 2016]. Epilepsia. 2016;doi:10.1111/epi.13440.
Systemic Disease Manifestations of TSC Strongly Associated With Epilepsy
In a study of 1816 patients with tuberous sclerosis complex (TSC), researchers found that specific disease manifestations—cardiac rhabodmyomas, retinal hemartomas, renal cysts, renal angiomyolipipomas, and facial angiofibromas—were associated with a higher likelihood of epilepsy development. The authors posit that this research can help identify patients who will benefit from novel, targeted, preventative treatments.
Jeong A, Wong M. Systemic disease manifestations associated with epilepsy in tuberous sclerosis complex [published online ahead of print July 15, 2016]. Epilepsia. 2016;doi:10.1111/epi.13467.
In a study of 1816 patients with tuberous sclerosis complex (TSC), researchers found that specific disease manifestations—cardiac rhabodmyomas, retinal hemartomas, renal cysts, renal angiomyolipipomas, and facial angiofibromas—were associated with a higher likelihood of epilepsy development. The authors posit that this research can help identify patients who will benefit from novel, targeted, preventative treatments.
Jeong A, Wong M. Systemic disease manifestations associated with epilepsy in tuberous sclerosis complex [published online ahead of print July 15, 2016]. Epilepsia. 2016;doi:10.1111/epi.13467.
In a study of 1816 patients with tuberous sclerosis complex (TSC), researchers found that specific disease manifestations—cardiac rhabodmyomas, retinal hemartomas, renal cysts, renal angiomyolipipomas, and facial angiofibromas—were associated with a higher likelihood of epilepsy development. The authors posit that this research can help identify patients who will benefit from novel, targeted, preventative treatments.
Jeong A, Wong M. Systemic disease manifestations associated with epilepsy in tuberous sclerosis complex [published online ahead of print July 15, 2016]. Epilepsia. 2016;doi:10.1111/epi.13467.
A Second Look at Head MRIs Demonstrates the Value of Re-Review
To determine if patients with epilepsy are appropriate candidates for resective surgery, presurgical conferences are conducted to review magnetic resonance images (MRIs) of the patient’s head. Kenney and associates analyzed repeat reviews of MRIs at presurgical epilepsy conferences to assess their impact on the decision-making process. Among the 233 patients whose charts were re-reviewed, 94 patients (40.3%) had the resective surgery performed, and the analysis revealed that 41 patients (17.6%) had previously undiagnosed findings; 18 of the 41 patients had the surgery. However, among 4 of the 41 patients (9.8%), the re-reviews found abnormalities that did not warrant surgical resection, including autoimmunity and bilateral pathology.
Kenney DL, Kelly-Williams KM, Krecke KN et al. Usefulness of Repeat Review of Head Magnetic Resonance Images During Presurgical Epilepsy Conferences. Epilepsy Res. 2016. In press. http://dx.doi.org/10.1016/j.eplepsyres.2016.06.005.
To determine if patients with epilepsy are appropriate candidates for resective surgery, presurgical conferences are conducted to review magnetic resonance images (MRIs) of the patient’s head. Kenney and associates analyzed repeat reviews of MRIs at presurgical epilepsy conferences to assess their impact on the decision-making process. Among the 233 patients whose charts were re-reviewed, 94 patients (40.3%) had the resective surgery performed, and the analysis revealed that 41 patients (17.6%) had previously undiagnosed findings; 18 of the 41 patients had the surgery. However, among 4 of the 41 patients (9.8%), the re-reviews found abnormalities that did not warrant surgical resection, including autoimmunity and bilateral pathology.
Kenney DL, Kelly-Williams KM, Krecke KN et al. Usefulness of Repeat Review of Head Magnetic Resonance Images During Presurgical Epilepsy Conferences. Epilepsy Res. 2016. In press. http://dx.doi.org/10.1016/j.eplepsyres.2016.06.005.
To determine if patients with epilepsy are appropriate candidates for resective surgery, presurgical conferences are conducted to review magnetic resonance images (MRIs) of the patient’s head. Kenney and associates analyzed repeat reviews of MRIs at presurgical epilepsy conferences to assess their impact on the decision-making process. Among the 233 patients whose charts were re-reviewed, 94 patients (40.3%) had the resective surgery performed, and the analysis revealed that 41 patients (17.6%) had previously undiagnosed findings; 18 of the 41 patients had the surgery. However, among 4 of the 41 patients (9.8%), the re-reviews found abnormalities that did not warrant surgical resection, including autoimmunity and bilateral pathology.
Kenney DL, Kelly-Williams KM, Krecke KN et al. Usefulness of Repeat Review of Head Magnetic Resonance Images During Presurgical Epilepsy Conferences. Epilepsy Res. 2016. In press. http://dx.doi.org/10.1016/j.eplepsyres.2016.06.005.
Stimulation-identified Cortical Naming Sites Pose Unexpected Challenges
Before surgeons perform a resection involving the language-dominant hemisphere of a patient with epilepsy, they may do electrical stimulation mapping to identify a patient’s language-dominant hemisphere. Typically they will ask patients to identify objects to help locate the language cortex and then avoid resection in an area of the brain in which electrical stimulation makes it difficult for patients to name said objects. But because word production involves mechanisms that may be centered in more than one area of the brain, Hamberger et al tested locations that have been identified by stimulation as naming sites to look for disparities. Testing patients with refractory temporal lobe epilepsy who had subdural electrodes implanted, they discovered that stimulating naming sites in the superior temporary lobe was more likely to disrupt phonological processing but did not affect a patient’s ability to process semantic information. Stimulating the inferior temporal naming sites was more likely to impair semantic processing.
Hamberger MJ, Miozzo M, Schevon CA, et al. Functional differences among stimulation-identified cortical naming sites in the temporal region. Epilepsy Behav. 2016;60:124-129.
Before surgeons perform a resection involving the language-dominant hemisphere of a patient with epilepsy, they may do electrical stimulation mapping to identify a patient’s language-dominant hemisphere. Typically they will ask patients to identify objects to help locate the language cortex and then avoid resection in an area of the brain in which electrical stimulation makes it difficult for patients to name said objects. But because word production involves mechanisms that may be centered in more than one area of the brain, Hamberger et al tested locations that have been identified by stimulation as naming sites to look for disparities. Testing patients with refractory temporal lobe epilepsy who had subdural electrodes implanted, they discovered that stimulating naming sites in the superior temporary lobe was more likely to disrupt phonological processing but did not affect a patient’s ability to process semantic information. Stimulating the inferior temporal naming sites was more likely to impair semantic processing.
Hamberger MJ, Miozzo M, Schevon CA, et al. Functional differences among stimulation-identified cortical naming sites in the temporal region. Epilepsy Behav. 2016;60:124-129.
Before surgeons perform a resection involving the language-dominant hemisphere of a patient with epilepsy, they may do electrical stimulation mapping to identify a patient’s language-dominant hemisphere. Typically they will ask patients to identify objects to help locate the language cortex and then avoid resection in an area of the brain in which electrical stimulation makes it difficult for patients to name said objects. But because word production involves mechanisms that may be centered in more than one area of the brain, Hamberger et al tested locations that have been identified by stimulation as naming sites to look for disparities. Testing patients with refractory temporal lobe epilepsy who had subdural electrodes implanted, they discovered that stimulating naming sites in the superior temporary lobe was more likely to disrupt phonological processing but did not affect a patient’s ability to process semantic information. Stimulating the inferior temporal naming sites was more likely to impair semantic processing.
Hamberger MJ, Miozzo M, Schevon CA, et al. Functional differences among stimulation-identified cortical naming sites in the temporal region. Epilepsy Behav. 2016;60:124-129.
Evaluating Alternatives to Open Surgical Resection for Epilepsy
Open surgical resection is still considered the best approach for patients with epilepsy that do not respond well to medical therapy. But despite being considered the gold standard in neurosurgical care, the shortcomings of open surgical resection need to be addressed. McGovern and colleagues do so in a review published in Current Neurology and Neuroscience Reports. They point to the value of stereotactic electroencephalography, which can localize deep epileptic foci. Similarly laser interstitial thermal therapy (LITT) and stereotactic radiosurgery have advantages because they can ablate specific regions of the brain using minimally or non-invasive techniques. In the case of LITT, it can offer clinicians near real-time feedback on its effects. Neurostimulation is also worth consideration in select patients because it can reduce seizure occurrence without the need for ablation or resection
McGovern RA, Banks GP, McKhann GM 2nd. New techniques and progress in epilepsy surgery. Curr Neurol Neurosci Rep. 2016;16(7):65.
Open surgical resection is still considered the best approach for patients with epilepsy that do not respond well to medical therapy. But despite being considered the gold standard in neurosurgical care, the shortcomings of open surgical resection need to be addressed. McGovern and colleagues do so in a review published in Current Neurology and Neuroscience Reports. They point to the value of stereotactic electroencephalography, which can localize deep epileptic foci. Similarly laser interstitial thermal therapy (LITT) and stereotactic radiosurgery have advantages because they can ablate specific regions of the brain using minimally or non-invasive techniques. In the case of LITT, it can offer clinicians near real-time feedback on its effects. Neurostimulation is also worth consideration in select patients because it can reduce seizure occurrence without the need for ablation or resection
McGovern RA, Banks GP, McKhann GM 2nd. New techniques and progress in epilepsy surgery. Curr Neurol Neurosci Rep. 2016;16(7):65.
Open surgical resection is still considered the best approach for patients with epilepsy that do not respond well to medical therapy. But despite being considered the gold standard in neurosurgical care, the shortcomings of open surgical resection need to be addressed. McGovern and colleagues do so in a review published in Current Neurology and Neuroscience Reports. They point to the value of stereotactic electroencephalography, which can localize deep epileptic foci. Similarly laser interstitial thermal therapy (LITT) and stereotactic radiosurgery have advantages because they can ablate specific regions of the brain using minimally or non-invasive techniques. In the case of LITT, it can offer clinicians near real-time feedback on its effects. Neurostimulation is also worth consideration in select patients because it can reduce seizure occurrence without the need for ablation or resection
McGovern RA, Banks GP, McKhann GM 2nd. New techniques and progress in epilepsy surgery. Curr Neurol Neurosci Rep. 2016;16(7):65.
Smartphone app aimed at disrupting first-episode psychosis shows promise
BETHESDA, MD. – What would the world look like for people with first-episode psychosis if they could be identified before they ended up in care? And what if once identified, they could begin receiving treatment immediately?
Those questions are not just hypothetical to Danielle Schlosser, PhD
Using online screening based on proven tools, followed by enrollment in a secured, closed community created through the use of a smartphone app, Dr. Schlosser and her colleagues are delivering remote care to people with first-episode psychosis, rather than making them come to the clinic.
“It’s controversial, but you’re not doing anything meaningful if you don’t stir things up,” Dr. Schlosser said in an interview. “Why do we have to have a one-size-fits-all model?”
Statistics from NIMH show that duration of psychosis before treatment is 1-3 years. People in the early stages of psychosis, typically in their late teens or early 20s, often do not find their way to care until after admittance through an emergency department or a brush with the law, Dr. Schlosser said. Once diagnosed, clinically meaningful improvements in outcomes in this cohort often are impeded by cognitive and motivational impairment, including fear of stigma, or logistical challenges such as finding reliable transportation to a treatment site. According to the World Health Organization, half of all people with schizophrenia globally are not receiving treatment.
“We can do better,” Dr. Schlosser said.
In the PRIME design trials, Dr. Schlosser and her colleagues are evaluating how “user-centered design” might improve treatment delivery. In stage 1 of the study, two design phases, each with a separate group of 10 participants with recent-onset schizophrenia, helped a global design firm called IDEO arrive at a product that Dr. Schlosser and her colleagues described in a study published online as “casual, friendly, and nonstigmatizing, which is in line with the recovery model of psychosis” (JMIR Res Protoc. 2016;5[2]:e77).
The app included short motivational texts from trained therapists, a feature for individualized goal setting in prognostically important psychosocial domains, opportunities for social networking via direct peer-to-peer messaging, and a community “moments feed” aimed at capturing and reinforcing rewarding experiences and achieving goals.
After 12 weeks of using the app, Dr. Schlosser and her coinvestigators found that trial participants, all of whom had been asked to use it at least once a week, had used it an average of once every other day and had actively engaged with its various features with every log-in. Retention and satisfaction was 100% in each group, and levels of engagement from stage 1 to stage 2 increased by what Dr. Schlosser and her coauthors reported as “two- or threefold” in almost each aspect of the platform.
Dr. Schlosser said such impressive results have continued now that the study has entered stage 2, which is being conducted across the United States, Canada, and Mexico. Fifty people have enrolled, Dr. Schlosser said.
“So far, we have a 93% retention in our clinical trial, which is very high for this population,” she said. “We’re also seeing that two-thirds of the population are self-referred. You just don’t see that in early psychosis research.”
She credits those results in part to the study’s online recruitment design, but Dr. Schlosser said the patient-reported outcomes are the most gratifying.
“We got a letter from a mom who said she wished we could have seen her daughter’s face when she saw that everyone in her [online] group looks ‘normal.’ Her daughter was looking for hope, and she found it mirrored back at her,” Dr. Schlosser said. “They are not their illness.”
A prime reason people with recent-onset schizophrenia don’t access formal treatment is the fear they will be stigmatized, Dr. Schlosser said. Furthermore, she said, since most of those affected are young, creative, and “antiestablishment” in their attitudes, they already deal with stigma. The most effective treatment experience needed to be based on those kinds of values, she said.
“They want more control in their lives, and they want to connect with others like them. The idea of seeking care in a traditional setting is a deterrent for these people,” Dr. Schlosser said in the interview. “So, rather than build a new building, we built them a digital platform.”
A few audience members expressed concern that such a treatment model may expose these patients to unnecessary harm. Dr. Schlosser replied in the interview that even in clinical settings, patients prescribed medications still may be noncompliant. “We are not the enforcers of medications. It’s still the patient’s choice. Maybe I am being too provocative, but if people don’t want to take medications, then we try to work with them where they are,” she said.
In addition to the support from the online community, trial participants spend an average of 20 minutes with the coaching staff, making the model a “very low resource” one, according to Dr. Schlosser.
PRIME is expected to complete in the spring 2018, at which time the data collected potentially will be used to refine user-designed apps for use in other mental disorders, Dr. Schlosser said.
“I want to promote a digital system of care so that we can move immediately from when we identify a person is at risk to immediately giving them support. I think we can improve things so that we don’t just have equivalent levels of care but optimal ones,” Dr. Schlosser told the audience. “What we have had as our system of care to date isn’t working.”
Dr. Schlosser did not have any relevant disclosures.
On Twitter @whitneymcknight
One of the most compelling aspects to schizophrenia, the most serious of mental disorders, is its age of onset in late adolescence and early adulthood. Intervening early on has good logic and good sense on its side. Nothing can be more important than giving attention to patients and families early on. However, it still remain unknown what biological processes trigger the disorder, and to date there are no data suggesting that we are able to slow the illness progression. Nevertheless, focusing early will teach us about the illness and set the stage when the next generation of biological treatments emerge.
David Pickar, MD, is a psychiatrist and former (retired) director of intramural research at the National Institute of Mental Health. In addition, Dr. Pickar is adjunct professor of psychiatry at Johns Hopkins University, Baltimore, and at the Uniformed Services University of the Health Sciences, Bethesda, Md.
One of the most compelling aspects to schizophrenia, the most serious of mental disorders, is its age of onset in late adolescence and early adulthood. Intervening early on has good logic and good sense on its side. Nothing can be more important than giving attention to patients and families early on. However, it still remain unknown what biological processes trigger the disorder, and to date there are no data suggesting that we are able to slow the illness progression. Nevertheless, focusing early will teach us about the illness and set the stage when the next generation of biological treatments emerge.
David Pickar, MD, is a psychiatrist and former (retired) director of intramural research at the National Institute of Mental Health. In addition, Dr. Pickar is adjunct professor of psychiatry at Johns Hopkins University, Baltimore, and at the Uniformed Services University of the Health Sciences, Bethesda, Md.
One of the most compelling aspects to schizophrenia, the most serious of mental disorders, is its age of onset in late adolescence and early adulthood. Intervening early on has good logic and good sense on its side. Nothing can be more important than giving attention to patients and families early on. However, it still remain unknown what biological processes trigger the disorder, and to date there are no data suggesting that we are able to slow the illness progression. Nevertheless, focusing early will teach us about the illness and set the stage when the next generation of biological treatments emerge.
David Pickar, MD, is a psychiatrist and former (retired) director of intramural research at the National Institute of Mental Health. In addition, Dr. Pickar is adjunct professor of psychiatry at Johns Hopkins University, Baltimore, and at the Uniformed Services University of the Health Sciences, Bethesda, Md.
BETHESDA, MD. – What would the world look like for people with first-episode psychosis if they could be identified before they ended up in care? And what if once identified, they could begin receiving treatment immediately?
Those questions are not just hypothetical to Danielle Schlosser, PhD
Using online screening based on proven tools, followed by enrollment in a secured, closed community created through the use of a smartphone app, Dr. Schlosser and her colleagues are delivering remote care to people with first-episode psychosis, rather than making them come to the clinic.
“It’s controversial, but you’re not doing anything meaningful if you don’t stir things up,” Dr. Schlosser said in an interview. “Why do we have to have a one-size-fits-all model?”
Statistics from NIMH show that duration of psychosis before treatment is 1-3 years. People in the early stages of psychosis, typically in their late teens or early 20s, often do not find their way to care until after admittance through an emergency department or a brush with the law, Dr. Schlosser said. Once diagnosed, clinically meaningful improvements in outcomes in this cohort often are impeded by cognitive and motivational impairment, including fear of stigma, or logistical challenges such as finding reliable transportation to a treatment site. According to the World Health Organization, half of all people with schizophrenia globally are not receiving treatment.
“We can do better,” Dr. Schlosser said.
In the PRIME design trials, Dr. Schlosser and her colleagues are evaluating how “user-centered design” might improve treatment delivery. In stage 1 of the study, two design phases, each with a separate group of 10 participants with recent-onset schizophrenia, helped a global design firm called IDEO arrive at a product that Dr. Schlosser and her colleagues described in a study published online as “casual, friendly, and nonstigmatizing, which is in line with the recovery model of psychosis” (JMIR Res Protoc. 2016;5[2]:e77).
The app included short motivational texts from trained therapists, a feature for individualized goal setting in prognostically important psychosocial domains, opportunities for social networking via direct peer-to-peer messaging, and a community “moments feed” aimed at capturing and reinforcing rewarding experiences and achieving goals.
After 12 weeks of using the app, Dr. Schlosser and her coinvestigators found that trial participants, all of whom had been asked to use it at least once a week, had used it an average of once every other day and had actively engaged with its various features with every log-in. Retention and satisfaction was 100% in each group, and levels of engagement from stage 1 to stage 2 increased by what Dr. Schlosser and her coauthors reported as “two- or threefold” in almost each aspect of the platform.
Dr. Schlosser said such impressive results have continued now that the study has entered stage 2, which is being conducted across the United States, Canada, and Mexico. Fifty people have enrolled, Dr. Schlosser said.
“So far, we have a 93% retention in our clinical trial, which is very high for this population,” she said. “We’re also seeing that two-thirds of the population are self-referred. You just don’t see that in early psychosis research.”
She credits those results in part to the study’s online recruitment design, but Dr. Schlosser said the patient-reported outcomes are the most gratifying.
“We got a letter from a mom who said she wished we could have seen her daughter’s face when she saw that everyone in her [online] group looks ‘normal.’ Her daughter was looking for hope, and she found it mirrored back at her,” Dr. Schlosser said. “They are not their illness.”
A prime reason people with recent-onset schizophrenia don’t access formal treatment is the fear they will be stigmatized, Dr. Schlosser said. Furthermore, she said, since most of those affected are young, creative, and “antiestablishment” in their attitudes, they already deal with stigma. The most effective treatment experience needed to be based on those kinds of values, she said.
“They want more control in their lives, and they want to connect with others like them. The idea of seeking care in a traditional setting is a deterrent for these people,” Dr. Schlosser said in the interview. “So, rather than build a new building, we built them a digital platform.”
A few audience members expressed concern that such a treatment model may expose these patients to unnecessary harm. Dr. Schlosser replied in the interview that even in clinical settings, patients prescribed medications still may be noncompliant. “We are not the enforcers of medications. It’s still the patient’s choice. Maybe I am being too provocative, but if people don’t want to take medications, then we try to work with them where they are,” she said.
In addition to the support from the online community, trial participants spend an average of 20 minutes with the coaching staff, making the model a “very low resource” one, according to Dr. Schlosser.
PRIME is expected to complete in the spring 2018, at which time the data collected potentially will be used to refine user-designed apps for use in other mental disorders, Dr. Schlosser said.
“I want to promote a digital system of care so that we can move immediately from when we identify a person is at risk to immediately giving them support. I think we can improve things so that we don’t just have equivalent levels of care but optimal ones,” Dr. Schlosser told the audience. “What we have had as our system of care to date isn’t working.”
Dr. Schlosser did not have any relevant disclosures.
On Twitter @whitneymcknight
BETHESDA, MD. – What would the world look like for people with first-episode psychosis if they could be identified before they ended up in care? And what if once identified, they could begin receiving treatment immediately?
Those questions are not just hypothetical to Danielle Schlosser, PhD
Using online screening based on proven tools, followed by enrollment in a secured, closed community created through the use of a smartphone app, Dr. Schlosser and her colleagues are delivering remote care to people with first-episode psychosis, rather than making them come to the clinic.
“It’s controversial, but you’re not doing anything meaningful if you don’t stir things up,” Dr. Schlosser said in an interview. “Why do we have to have a one-size-fits-all model?”
Statistics from NIMH show that duration of psychosis before treatment is 1-3 years. People in the early stages of psychosis, typically in their late teens or early 20s, often do not find their way to care until after admittance through an emergency department or a brush with the law, Dr. Schlosser said. Once diagnosed, clinically meaningful improvements in outcomes in this cohort often are impeded by cognitive and motivational impairment, including fear of stigma, or logistical challenges such as finding reliable transportation to a treatment site. According to the World Health Organization, half of all people with schizophrenia globally are not receiving treatment.
“We can do better,” Dr. Schlosser said.
In the PRIME design trials, Dr. Schlosser and her colleagues are evaluating how “user-centered design” might improve treatment delivery. In stage 1 of the study, two design phases, each with a separate group of 10 participants with recent-onset schizophrenia, helped a global design firm called IDEO arrive at a product that Dr. Schlosser and her colleagues described in a study published online as “casual, friendly, and nonstigmatizing, which is in line with the recovery model of psychosis” (JMIR Res Protoc. 2016;5[2]:e77).
The app included short motivational texts from trained therapists, a feature for individualized goal setting in prognostically important psychosocial domains, opportunities for social networking via direct peer-to-peer messaging, and a community “moments feed” aimed at capturing and reinforcing rewarding experiences and achieving goals.
After 12 weeks of using the app, Dr. Schlosser and her coinvestigators found that trial participants, all of whom had been asked to use it at least once a week, had used it an average of once every other day and had actively engaged with its various features with every log-in. Retention and satisfaction was 100% in each group, and levels of engagement from stage 1 to stage 2 increased by what Dr. Schlosser and her coauthors reported as “two- or threefold” in almost each aspect of the platform.
Dr. Schlosser said such impressive results have continued now that the study has entered stage 2, which is being conducted across the United States, Canada, and Mexico. Fifty people have enrolled, Dr. Schlosser said.
“So far, we have a 93% retention in our clinical trial, which is very high for this population,” she said. “We’re also seeing that two-thirds of the population are self-referred. You just don’t see that in early psychosis research.”
She credits those results in part to the study’s online recruitment design, but Dr. Schlosser said the patient-reported outcomes are the most gratifying.
“We got a letter from a mom who said she wished we could have seen her daughter’s face when she saw that everyone in her [online] group looks ‘normal.’ Her daughter was looking for hope, and she found it mirrored back at her,” Dr. Schlosser said. “They are not their illness.”
A prime reason people with recent-onset schizophrenia don’t access formal treatment is the fear they will be stigmatized, Dr. Schlosser said. Furthermore, she said, since most of those affected are young, creative, and “antiestablishment” in their attitudes, they already deal with stigma. The most effective treatment experience needed to be based on those kinds of values, she said.
“They want more control in their lives, and they want to connect with others like them. The idea of seeking care in a traditional setting is a deterrent for these people,” Dr. Schlosser said in the interview. “So, rather than build a new building, we built them a digital platform.”
A few audience members expressed concern that such a treatment model may expose these patients to unnecessary harm. Dr. Schlosser replied in the interview that even in clinical settings, patients prescribed medications still may be noncompliant. “We are not the enforcers of medications. It’s still the patient’s choice. Maybe I am being too provocative, but if people don’t want to take medications, then we try to work with them where they are,” she said.
In addition to the support from the online community, trial participants spend an average of 20 minutes with the coaching staff, making the model a “very low resource” one, according to Dr. Schlosser.
PRIME is expected to complete in the spring 2018, at which time the data collected potentially will be used to refine user-designed apps for use in other mental disorders, Dr. Schlosser said.
“I want to promote a digital system of care so that we can move immediately from when we identify a person is at risk to immediately giving them support. I think we can improve things so that we don’t just have equivalent levels of care but optimal ones,” Dr. Schlosser told the audience. “What we have had as our system of care to date isn’t working.”
Dr. Schlosser did not have any relevant disclosures.
On Twitter @whitneymcknight
EXPERT ANALYSIS FROM THE 2016 NIMH CONFERENCE ON MENTAL HEALTH SERVICES RESEARCH
Sunscreens safe in babies, children
BOSTON – Despite what some popular online media outlets report, sunscreens are safe in children and can even be used on infants under 6 months of age when sun avoidance – the best approach to protecting babies from the damaging effects of the sun – is not possible, according to Mercedes E. Gonzalez, MD.
A quick Google search reveals numerous, widely-shared articles about the dangers lurking in one’s beach bag, and while many product labels recommend asking a doctor about whether the product is safe for babies under age 6 months, that’s only because most product safety studies didn’t include that age group, Dr. Gonzalez of the University of Miami said at the American Academy of Dermatology summer meeting.
In fact, there is “nothing magical that happens” in infant skin after 6 months that makes sunscreen use safer, she said, explaining that infant skin is structurally and functionally different from adult skin, and that while gradual maturation takes place over time, thereby reducing susceptibility to percutaneous absorption of topically applied products, the risk is minimal even in babies younger than age 6 months.
The skin characteristics that make younger skin more susceptible to percutaneous absorption also make babies and children unusually susceptible to ultraviolet radiation and ultraviolet radiation–induced immunosuppression, for which the consequences are not fully understood, she said.
Among the more commonly cited sunscreen ingredients of concern are oxybenzone, or benzonephenone-3, and nanoparticles, she noted.
However, the overall consensus based on studies of oxybenzone is that aside from causing some cases of allergic and irritant contact dermatitis, the compound is safe; no harmful cause and effect relationship with oxybenzone and systemic side effects in humans have been reported, and periodic reviews by European, Australian and U.S. safety panels all conclude that it is safe.
Numerous studies of nanoparticles – such as nanosized zinc oxide and titanium dioxide – have shown that absorption is confined to the level of stratum corneum – even when skin barrier function has been altered, she said, noting that most are coated with aluminum oxide and SiO2 to minimize contact.
However, the safety of sunscreen shouldn’t be seen as license to ignore sun-exposure recommendations; sunscreen in infants should be considered “the last layer of protection,” used only on exposed areas when adequate clothing and shade are not available, according to a 2011 American Academy of Pediatrics statement (Pediatrics. 2011 Feb. doi: 10.1542/peds.2010-3501).
Efforts should be made to keep babies in the shade when outdoors whenever possible, especially during peak sun hours. Use sun-protective clothing, including hats, sunglasses, and long-sleeved shirts, Dr. Gonzalez advised.
When sunscreen is required, a broad-spectrum water-resistant product with an SPF of more than 30 is preferable.
“But the best sunscreen is the one you and your child will use,” she said.
Mineral-based products are less irritating and thus may be a preferred option for children with atopic dermatitis, she added.
Advise parents to apply sunscreen to all areas not protected by their child’s clothing, paying particular attention to vulnerable areas, including the back of the neck, ears, and dorsal feet. Reapply before going outdoors, and then again every 2 hours, she advised.
“So the overall answer to the parents’ question, ‘Are sunscreens safe?’ ... the overwhelming answer here is yes, and the weight of the evidence shows there is no proven harm from sunscreen use especially when used properly,” she said.
Provide specific guidance for pediatric sunscreen use
In the face of conflicting information about sunscreen safety and efficacy, parents with questions about sunscreen are looking for specific direction, Dr. Gonzalez said.
She said she finds it helpful to teach them about the importance of reading labels. That is, looking at the ingredients, and looking for SPF above 30, broad-spectrum coverage, and water resistance. She also recommends providing a list or images of good options, and circling the specific preferred products.
For babies, she finds stick sunscreens most useful for application.
“I generally don’t recommend sprays, but if they’re going to use a spray – and parents love sprays because they are easy to apply – I recommend the ones that have some zinc oxide in them, so that when they apply them they can see where they’re going on the skin,” Dr. Gonzalez said.
Tell patients to apply sunscreen before leaving the house, she advised, adding that making sunscreen application part of a daily routine helps encourage healthy behaviors, as does allowing children, at the right age, to participate in sunscreen application.
For adolescents, avoid scare tactics such as warning about skin cancer. Rather, focus on benefits of avoiding the sun, help them find a product they like by finding out why they don’t like a particular product and recommending an alternative, then following up on that when they come back in, she suggested.
“I really try to address it at every visit,” Dr. Gonzalez said.
“Finally, the most important message is that sunscreen is really just one part of complete sun protection,” she said, noting that specific information about where to buy sun-protective clothing and hats is also important.
Dr. Gonzalez reported serving as a speaker and/or advisory board member and receiving honoraria from Pierre Fabre Dermatologie, Anacor Pharmaceuticals, Encore Dermatology, and PuraCap Pharmaceutical.
BOSTON – Despite what some popular online media outlets report, sunscreens are safe in children and can even be used on infants under 6 months of age when sun avoidance – the best approach to protecting babies from the damaging effects of the sun – is not possible, according to Mercedes E. Gonzalez, MD.
A quick Google search reveals numerous, widely-shared articles about the dangers lurking in one’s beach bag, and while many product labels recommend asking a doctor about whether the product is safe for babies under age 6 months, that’s only because most product safety studies didn’t include that age group, Dr. Gonzalez of the University of Miami said at the American Academy of Dermatology summer meeting.
In fact, there is “nothing magical that happens” in infant skin after 6 months that makes sunscreen use safer, she said, explaining that infant skin is structurally and functionally different from adult skin, and that while gradual maturation takes place over time, thereby reducing susceptibility to percutaneous absorption of topically applied products, the risk is minimal even in babies younger than age 6 months.
The skin characteristics that make younger skin more susceptible to percutaneous absorption also make babies and children unusually susceptible to ultraviolet radiation and ultraviolet radiation–induced immunosuppression, for which the consequences are not fully understood, she said.
Among the more commonly cited sunscreen ingredients of concern are oxybenzone, or benzonephenone-3, and nanoparticles, she noted.
However, the overall consensus based on studies of oxybenzone is that aside from causing some cases of allergic and irritant contact dermatitis, the compound is safe; no harmful cause and effect relationship with oxybenzone and systemic side effects in humans have been reported, and periodic reviews by European, Australian and U.S. safety panels all conclude that it is safe.
Numerous studies of nanoparticles – such as nanosized zinc oxide and titanium dioxide – have shown that absorption is confined to the level of stratum corneum – even when skin barrier function has been altered, she said, noting that most are coated with aluminum oxide and SiO2 to minimize contact.
However, the safety of sunscreen shouldn’t be seen as license to ignore sun-exposure recommendations; sunscreen in infants should be considered “the last layer of protection,” used only on exposed areas when adequate clothing and shade are not available, according to a 2011 American Academy of Pediatrics statement (Pediatrics. 2011 Feb. doi: 10.1542/peds.2010-3501).
Efforts should be made to keep babies in the shade when outdoors whenever possible, especially during peak sun hours. Use sun-protective clothing, including hats, sunglasses, and long-sleeved shirts, Dr. Gonzalez advised.
When sunscreen is required, a broad-spectrum water-resistant product with an SPF of more than 30 is preferable.
“But the best sunscreen is the one you and your child will use,” she said.
Mineral-based products are less irritating and thus may be a preferred option for children with atopic dermatitis, she added.
Advise parents to apply sunscreen to all areas not protected by their child’s clothing, paying particular attention to vulnerable areas, including the back of the neck, ears, and dorsal feet. Reapply before going outdoors, and then again every 2 hours, she advised.
“So the overall answer to the parents’ question, ‘Are sunscreens safe?’ ... the overwhelming answer here is yes, and the weight of the evidence shows there is no proven harm from sunscreen use especially when used properly,” she said.
Provide specific guidance for pediatric sunscreen use
In the face of conflicting information about sunscreen safety and efficacy, parents with questions about sunscreen are looking for specific direction, Dr. Gonzalez said.
She said she finds it helpful to teach them about the importance of reading labels. That is, looking at the ingredients, and looking for SPF above 30, broad-spectrum coverage, and water resistance. She also recommends providing a list or images of good options, and circling the specific preferred products.
For babies, she finds stick sunscreens most useful for application.
“I generally don’t recommend sprays, but if they’re going to use a spray – and parents love sprays because they are easy to apply – I recommend the ones that have some zinc oxide in them, so that when they apply them they can see where they’re going on the skin,” Dr. Gonzalez said.
Tell patients to apply sunscreen before leaving the house, she advised, adding that making sunscreen application part of a daily routine helps encourage healthy behaviors, as does allowing children, at the right age, to participate in sunscreen application.
For adolescents, avoid scare tactics such as warning about skin cancer. Rather, focus on benefits of avoiding the sun, help them find a product they like by finding out why they don’t like a particular product and recommending an alternative, then following up on that when they come back in, she suggested.
“I really try to address it at every visit,” Dr. Gonzalez said.
“Finally, the most important message is that sunscreen is really just one part of complete sun protection,” she said, noting that specific information about where to buy sun-protective clothing and hats is also important.
Dr. Gonzalez reported serving as a speaker and/or advisory board member and receiving honoraria from Pierre Fabre Dermatologie, Anacor Pharmaceuticals, Encore Dermatology, and PuraCap Pharmaceutical.
BOSTON – Despite what some popular online media outlets report, sunscreens are safe in children and can even be used on infants under 6 months of age when sun avoidance – the best approach to protecting babies from the damaging effects of the sun – is not possible, according to Mercedes E. Gonzalez, MD.
A quick Google search reveals numerous, widely-shared articles about the dangers lurking in one’s beach bag, and while many product labels recommend asking a doctor about whether the product is safe for babies under age 6 months, that’s only because most product safety studies didn’t include that age group, Dr. Gonzalez of the University of Miami said at the American Academy of Dermatology summer meeting.
In fact, there is “nothing magical that happens” in infant skin after 6 months that makes sunscreen use safer, she said, explaining that infant skin is structurally and functionally different from adult skin, and that while gradual maturation takes place over time, thereby reducing susceptibility to percutaneous absorption of topically applied products, the risk is minimal even in babies younger than age 6 months.
The skin characteristics that make younger skin more susceptible to percutaneous absorption also make babies and children unusually susceptible to ultraviolet radiation and ultraviolet radiation–induced immunosuppression, for which the consequences are not fully understood, she said.
Among the more commonly cited sunscreen ingredients of concern are oxybenzone, or benzonephenone-3, and nanoparticles, she noted.
However, the overall consensus based on studies of oxybenzone is that aside from causing some cases of allergic and irritant contact dermatitis, the compound is safe; no harmful cause and effect relationship with oxybenzone and systemic side effects in humans have been reported, and periodic reviews by European, Australian and U.S. safety panels all conclude that it is safe.
Numerous studies of nanoparticles – such as nanosized zinc oxide and titanium dioxide – have shown that absorption is confined to the level of stratum corneum – even when skin barrier function has been altered, she said, noting that most are coated with aluminum oxide and SiO2 to minimize contact.
However, the safety of sunscreen shouldn’t be seen as license to ignore sun-exposure recommendations; sunscreen in infants should be considered “the last layer of protection,” used only on exposed areas when adequate clothing and shade are not available, according to a 2011 American Academy of Pediatrics statement (Pediatrics. 2011 Feb. doi: 10.1542/peds.2010-3501).
Efforts should be made to keep babies in the shade when outdoors whenever possible, especially during peak sun hours. Use sun-protective clothing, including hats, sunglasses, and long-sleeved shirts, Dr. Gonzalez advised.
When sunscreen is required, a broad-spectrum water-resistant product with an SPF of more than 30 is preferable.
“But the best sunscreen is the one you and your child will use,” she said.
Mineral-based products are less irritating and thus may be a preferred option for children with atopic dermatitis, she added.
Advise parents to apply sunscreen to all areas not protected by their child’s clothing, paying particular attention to vulnerable areas, including the back of the neck, ears, and dorsal feet. Reapply before going outdoors, and then again every 2 hours, she advised.
“So the overall answer to the parents’ question, ‘Are sunscreens safe?’ ... the overwhelming answer here is yes, and the weight of the evidence shows there is no proven harm from sunscreen use especially when used properly,” she said.
Provide specific guidance for pediatric sunscreen use
In the face of conflicting information about sunscreen safety and efficacy, parents with questions about sunscreen are looking for specific direction, Dr. Gonzalez said.
She said she finds it helpful to teach them about the importance of reading labels. That is, looking at the ingredients, and looking for SPF above 30, broad-spectrum coverage, and water resistance. She also recommends providing a list or images of good options, and circling the specific preferred products.
For babies, she finds stick sunscreens most useful for application.
“I generally don’t recommend sprays, but if they’re going to use a spray – and parents love sprays because they are easy to apply – I recommend the ones that have some zinc oxide in them, so that when they apply them they can see where they’re going on the skin,” Dr. Gonzalez said.
Tell patients to apply sunscreen before leaving the house, she advised, adding that making sunscreen application part of a daily routine helps encourage healthy behaviors, as does allowing children, at the right age, to participate in sunscreen application.
For adolescents, avoid scare tactics such as warning about skin cancer. Rather, focus on benefits of avoiding the sun, help them find a product they like by finding out why they don’t like a particular product and recommending an alternative, then following up on that when they come back in, she suggested.
“I really try to address it at every visit,” Dr. Gonzalez said.
“Finally, the most important message is that sunscreen is really just one part of complete sun protection,” she said, noting that specific information about where to buy sun-protective clothing and hats is also important.
Dr. Gonzalez reported serving as a speaker and/or advisory board member and receiving honoraria from Pierre Fabre Dermatologie, Anacor Pharmaceuticals, Encore Dermatology, and PuraCap Pharmaceutical.
EXPERT ANALYSIS FROM THE AAD SUMMER ACADEMY 2016
Active surveillance may be feasible for some advanced RCC patients
For metastatic renal cell carcinoma patients with fewer adverse risk factors and fewer metastatic disease sites, initial active surveillance may be a safe and feasible approach to delay the toxicities of systemic therapy, investigators report.
Fifty-two patients with treatment-naive, asymptomatic, metastatic renal-cell carcinoma were enrolled in a prospective phase II trial and radiographically assessed at baseline, every 3 months for year 1, every 4 months for year 2, then every 6 months thereafter. Patients continued on observation until the treating physician and patient made the decision to initiate systemic therapy.
Median follow-up time was 38.1 months and median time on surveillance before treatment initiation – the primary endpoint of the study – was 14.9 months (95% confidence interval, 10.6-25.0), reported Brian Rini, MD, of the Cleveland Clinic Taussig Cancer Institute and his associates (Lancet Oncol. 2016. doi: 10.1016/S1470-2045(16)30196-6).
Forty-three (90%) of the 48 evaluable patients experienced disease progression during the study, median time to progression was 9.4 months, and 22 patients died from renal cell carcinoma. One patient developed brain metastases and died without receiving systemic therapy. In multivariable analysis, only the number of involved organs (P = .0414) and number of International Metastatic Database Consortium risk factors (P = .0403) were independently prognostic.
Using this analysis, Dr. Rini and associates identified two prognostic groups – a favorable group consisting of patients with no or one International Metastatic Database Consortium (IMDC) risk factors and two or fewer organs with metastatic disease, and an unfavorable group consisting of all other patients. The favorable group (n = 22) patients had an estimated median surveillance time of 22.2 months (95% CI, 13.8-33.3), whereas the unfavorable group (n = 19) had an estimated median surveillance time of 8.4 months (3.2-14.1; P = .0056).
Anxiety, depression, and quality of life did not change significantly over the period of surveillance, suggesting that living with untreated cancer did not cause psychological harm to patients in this study.
“Findings from our prospective trial show active surveillance to be a viable initial strategy in some patients with metastatic renal-cell carcinoma. The median surveillance period before start of systematic therapy was greater than 1 year, with no observed adverse effects on quality of life, anxiety and depression,” Dr. Rini and his associates said.
“Appropriate selection of patients and adequate monitoring, which should include CNS surveillance, is crucial in application of this approach,” they added.
This study was unfunded. One investigator reported receiving financial compensation from Pfizer and GlaxoSmithKline. All other investigators reported having no relevant disclosures.
On Twitter @jessnicolecraig
For metastatic renal cell carcinoma patients with fewer adverse risk factors and fewer metastatic disease sites, initial active surveillance may be a safe and feasible approach to delay the toxicities of systemic therapy, investigators report.
Fifty-two patients with treatment-naive, asymptomatic, metastatic renal-cell carcinoma were enrolled in a prospective phase II trial and radiographically assessed at baseline, every 3 months for year 1, every 4 months for year 2, then every 6 months thereafter. Patients continued on observation until the treating physician and patient made the decision to initiate systemic therapy.
Median follow-up time was 38.1 months and median time on surveillance before treatment initiation – the primary endpoint of the study – was 14.9 months (95% confidence interval, 10.6-25.0), reported Brian Rini, MD, of the Cleveland Clinic Taussig Cancer Institute and his associates (Lancet Oncol. 2016. doi: 10.1016/S1470-2045(16)30196-6).
Forty-three (90%) of the 48 evaluable patients experienced disease progression during the study, median time to progression was 9.4 months, and 22 patients died from renal cell carcinoma. One patient developed brain metastases and died without receiving systemic therapy. In multivariable analysis, only the number of involved organs (P = .0414) and number of International Metastatic Database Consortium risk factors (P = .0403) were independently prognostic.
Using this analysis, Dr. Rini and associates identified two prognostic groups – a favorable group consisting of patients with no or one International Metastatic Database Consortium (IMDC) risk factors and two or fewer organs with metastatic disease, and an unfavorable group consisting of all other patients. The favorable group (n = 22) patients had an estimated median surveillance time of 22.2 months (95% CI, 13.8-33.3), whereas the unfavorable group (n = 19) had an estimated median surveillance time of 8.4 months (3.2-14.1; P = .0056).
Anxiety, depression, and quality of life did not change significantly over the period of surveillance, suggesting that living with untreated cancer did not cause psychological harm to patients in this study.
“Findings from our prospective trial show active surveillance to be a viable initial strategy in some patients with metastatic renal-cell carcinoma. The median surveillance period before start of systematic therapy was greater than 1 year, with no observed adverse effects on quality of life, anxiety and depression,” Dr. Rini and his associates said.
“Appropriate selection of patients and adequate monitoring, which should include CNS surveillance, is crucial in application of this approach,” they added.
This study was unfunded. One investigator reported receiving financial compensation from Pfizer and GlaxoSmithKline. All other investigators reported having no relevant disclosures.
On Twitter @jessnicolecraig
For metastatic renal cell carcinoma patients with fewer adverse risk factors and fewer metastatic disease sites, initial active surveillance may be a safe and feasible approach to delay the toxicities of systemic therapy, investigators report.
Fifty-two patients with treatment-naive, asymptomatic, metastatic renal-cell carcinoma were enrolled in a prospective phase II trial and radiographically assessed at baseline, every 3 months for year 1, every 4 months for year 2, then every 6 months thereafter. Patients continued on observation until the treating physician and patient made the decision to initiate systemic therapy.
Median follow-up time was 38.1 months and median time on surveillance before treatment initiation – the primary endpoint of the study – was 14.9 months (95% confidence interval, 10.6-25.0), reported Brian Rini, MD, of the Cleveland Clinic Taussig Cancer Institute and his associates (Lancet Oncol. 2016. doi: 10.1016/S1470-2045(16)30196-6).
Forty-three (90%) of the 48 evaluable patients experienced disease progression during the study, median time to progression was 9.4 months, and 22 patients died from renal cell carcinoma. One patient developed brain metastases and died without receiving systemic therapy. In multivariable analysis, only the number of involved organs (P = .0414) and number of International Metastatic Database Consortium risk factors (P = .0403) were independently prognostic.
Using this analysis, Dr. Rini and associates identified two prognostic groups – a favorable group consisting of patients with no or one International Metastatic Database Consortium (IMDC) risk factors and two or fewer organs with metastatic disease, and an unfavorable group consisting of all other patients. The favorable group (n = 22) patients had an estimated median surveillance time of 22.2 months (95% CI, 13.8-33.3), whereas the unfavorable group (n = 19) had an estimated median surveillance time of 8.4 months (3.2-14.1; P = .0056).
Anxiety, depression, and quality of life did not change significantly over the period of surveillance, suggesting that living with untreated cancer did not cause psychological harm to patients in this study.
“Findings from our prospective trial show active surveillance to be a viable initial strategy in some patients with metastatic renal-cell carcinoma. The median surveillance period before start of systematic therapy was greater than 1 year, with no observed adverse effects on quality of life, anxiety and depression,” Dr. Rini and his associates said.
“Appropriate selection of patients and adequate monitoring, which should include CNS surveillance, is crucial in application of this approach,” they added.
This study was unfunded. One investigator reported receiving financial compensation from Pfizer and GlaxoSmithKline. All other investigators reported having no relevant disclosures.
On Twitter @jessnicolecraig
FROM LANCET ONCOLOGY
Key clinical point: For a subset of patients with metastatic renal cell carcinoma, initial active surveillance of metastasis may be a safe and feasible option.
Major finding: The favorable group (n = 22) patients and had an estimated median surveillance time of 22.2 months (95% CI, 13.8-33.3), whereas the unfavorable group (n = 19) had an estimated median surveillance time of 8.4 months (3.2-14.1; P = .0056)
Data source: A prospective phase II trial involving 52 patients with treatment-naive, metastatic renal cell carcinoma.
Disclosures: This study was unfunded. One investigator reported receiving financial compensation from Pfizer and GlaxoSmithKline. All other investigators reported having no relevant disclosures.
