When it comes to assessing patient-provider communication, a review from the treating physician may not be the best place to turn. After all, these clinicians are likely to report they adhered to communication guidelines even when others may not agree, according to a new study published in JAMA Network Open.
The study, which asked both treating physicians and third-party clinician reviewers to assess transcripts of simulated patient-provider interactions, highlighted some discrepancies between the two sets of reviewers. While physicians said they stuck to key industry guidelines for communications, the third-party reviewers outlined a different picture.
These findings suggest third-party review for patient-provider communication is essential to continuing medical education.
Patient-provider communication, and in particular shared decision-making, is an important aspect of quality patient care. Especially in end-of-life situations, shared decision-making can lead to lower-acuity care that is both less costly and more comfortable for patients in the ICU experiencing deteriorating symptoms.
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But analyzing the quality of that shared decision-making can be challenging. Some medical experts assert that clinicians should self-review in order to truly understand where their communication weaknesses lay.
But that strategy came into question in this latest study.
The researchers tapped 76 ICU doctors to engage in simulated patient-provider interactions. The interactions revolved around the best course of care for a patient who is dying in the ICU. Physicians also interacted with family members during the simulation.
One year later, the physicians reviewed a transcript of their interactions, noting instances where they clearly outlined care choices, offered care focused on comfort, and communicated patient prognosis. The transcripts were also sent to two colleagues for blinded review.
Both sets of analysis revealed stark differences.
Sixty-one doctors said they clearly communicated prognosis, while the two blinded colleagues said 42 clearly communicated prognosis. Conversely, two providers said they themselves did not clearly communicate likelihood of patient death, but the blinded colleagues said they did.
Thirty-three doctors said they offered care focused on comfort, but blinded colleagues said only one did.
Thirty-two clinicians assessed that they gave patients and family members a clear choice in care, with the most common choice being that between offering CPR versus not resuscitating the patient. One patient offered the choice of palliative care.
Clinicians also reported giving their own recommendations during interactions. Thirty-three percent of intensivists recommended patients and families continue the treatment plan or do other things to increase odds of survival. Twenty-seven percent recommended withholding CPR.
“But, if he’s as sick as this and his heart stops, it just wouldn’t make sense to do CPR,” one clinician said during the simulation.
Meanwhile, 24 percent recommended revisiting care recommendations in another day or so.
“The discrepancies between the communication skills self-identified by intensivists and identified by blinded colleagues in reviewing the same transcripts are notable,” the researchers said.
While there is much to be said about the efficacy of self-assessments, this study underscored the pitfalls. A self-review of patient-provider communication and shared decision-making may not have much of a leg to stand on, consider this study’s results, the researchers said.
“Moreover, if the goal of evaluating transcripts of patient-clinician interactions is to quantify what was successfully communicated or understood by patients and their proxies, whether research staff and clinicians are capable of assessing this outcome accurately given their familiarity with the topic area and comparative high health literacy is unclear,” the team said.
The researchers also suggested that asking physicians to self-assess their communication skills runs a similar risk as asking patients to assess — physicians may not see certain decisions as a key decision point and resultantly may not focus on the pertinent areas of the conversation for review.
“Moreover, methods of evaluating physician communication skills that rely on self-report are vulnerable to the Dunning-Kruger effect, in which people who lack a skill also lack the ability to evaluate competence—including their own competence—in that skill,” the research team added. “This effect may also prevent a clinician with underdeveloped communication skills from recognizing when they are not adherent with shared decision-making recommendations.”
These results suggest the healthcare industry may reevaluate how it assesses patient-provider communication. Integrating an area of peer-review may be effective for outlining how providers may improve shared decision-making, particularly in making choices and prognosis clear for patients and families.
“This finding makes routine feedback and continuing education on communication and shared decision-making essential at all levels of practice,” the team concluded. “Without feedback and continuing education, those who would benefit most from supplemental coaching may believe they are already performing recommended skills.”
Source: PatientEngagement HIT