Promoting patient participation in the cancer consultation: evaluation of a prompt sheet and coaching in question-asking. Promoting patient participation in consultations: a randomised controlled trial to evaluate the effectiveness of three patient-focused interventions. Promoting patient participation and shortening cancer consultations: a randomised trial. Empowerment of men newly diagnosed with prostate cancer. Eliciting patients' concerns: a randomised controlled trial of different approaches by the doctor. A randomized trial of psychiatric consultation with distressed high utilizers. Patient-oriented interventions to improve communication in a medical office visit. Cancer consultation preparation package: changing patients but not physicians is not enough. Group therapy in a general practice setting for frequent attenders: a controlled study of mothers with pre-school children. Expanding patient involvement in care. Effects on patient outcomes. Effects of a physician communication intervention on patient care outcomes. A randomized, controlled trial to improve advance care planning among patients undergoing cardiac surgery. Evaluation of a patient education leaflet designed to improve communication in medical consultations. Randomized controlled trial of a telephone intervention by nurses to provide information and support to patients and their partners after elective coronary artery bypass graft surgery: effects of anxiety. Intervention to improve psychological functioning for newly diagnosed patients with cancer. Empowering the patient in the consultation: a pilot study. Long-term efficacy of a checklist to improve patient education in cardiology. Educational workshop improved information-seeking skills, knowledge, attitudes and the search outcome of hospital clinicians: a randomised controlled trial. Involving patients in primary care consultations: assessing preferences using discrete choice experiments. The efficacy and effectiveness of process consultation in improving staff morale and absenteeism. Effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy to treat patients with depression: randomised controlled trial. Increasing patient participation in reproductive health consultations: an evaluation of "Smart Patient" coaching in Indonesia. The effects of patient communication skills training on the discourse of older patients during a primary care interview. Detecting psychological distress: can general practitioners improve their own performance? The effects of a cognitive behavioural intervention in asthmatic patients. Randomised controlled trial of a collaborative care model with psychiatric consultation for persistent medically unexplained symptoms in general practice. Assessing the impact of psychological intervention on family practice clinic visits. Preparing patients for total hip replacement: a randomized controlled trial of a preoperative educational intervention. Preoperative education for total hip and knee replacement patients. Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial.
Active participation in the medical consultation has been demonstrated to benefit aspects of patients' subsequent psychological well-being. We investigated two interventions promoting patient question-asking behaviour. The first was a question prompt sheet provided before the consultation, which was endorsed and worked through by the clinician. The second was a face to face coaching session exploring the benefits of, and barriers to, question-asking, followed by coaching in question-asking behaviour employing rehearsal techniques. Sixty patients with heterogeneous cancers, seeing two medical oncologists for the first time, were randomly assigned to one of three groups: two intervention groups and one control group. Sociodemographic variables and anxiety were assessed prior to the intervention which preceded the consultation. The consultations were audiotaped and subsequently analysed for question-asking behaviour. Anxiety was assessed again immediately following the consultation. Questionnaires to assess patient satisfaction, anxiety and psychological adjustment were sent by mail 2 weeks following the consultation. Presentation and discussion of the prompt sheet significantly increased the total number of questions asked and the number of questions asked regarding tests and treatment. Coaching did not add significantly to the effects of the prompt sheet. Psychological outcomes were not different among the groups. We conclude that a question prompt sheet addressed by the doctor is a simple, inexpensive and effective means of promoting patient question asking in the cancer consultation. The aim of this experimental study was to evaluate the effectiveness of three patient-focused interventions designed to increase patient question asking in clinical consultations. Patients were randomly allocated to one of five conditions to receive either one of three interventions or to serve as an attention control group or a control group. The primary outcome measure was question asking by the patient of their physician. Participants in the intervention groups did not ask more questions than participants in the control groups. Immediately after the consultation participants in the intervention groups had higher levels of self-efficacy in asking questions. Three months after the index visit patients in the intervention groups were significantly more likely to be satisfied to some degree than patients in the control group. There was no difference in diabetic control. These results suggest that simple brief patient-focused interventions do not change patient behaviour in medical outpatient consultations. Patient participation in medical consultations has been demonstrated to benefit their subsequent psychological well being. Question asking is one way in which patients can be active. We investigated 2 means of promoting cancer patient question asking. One was the provision of a question prompt sheet to patients prior to their initial consultation with their oncologist. The second was the active endorsement and systematic review of the question prompt sheet by their oncologist. 318 patients with heterogeneous cancers, seeing one of 5 medical and 4 radiation oncologists for the first time, were randomised to either receive or not receive a question prompt sheet. Doctors were randomised to either proactively address or passively respond to the question prompt sheet in the subsequent consultation. Anxiety was assessed prior to the consultation. Consultations were audiotaped and content analysed. Anxiety was assessed again immediately following the consultation. Within the next 10 days patients completed questionnaires assessing information needs, anxiety and satisfaction and were given a structured telephone interview assessing information recall. Patients provided with a question prompt sheet asked more questions about prognosis compared with controls and oncologists gave significantly more prognostic information to these patients. Provision of the question prompt sheet prolonged consultations and increased patient anxiety; however, when oncologists specifically addressed the prompt sheet, anxiety levels were significantly reduced, consultation duration was decreased and recall was significantly improved. A patient question prompt sheet, used proactively by the doctor, is a powerful addition to the oncology consultation.
                Copyright 2001 Cancer Research Campaign The purpose of this study was to explore the hypothesis that assisting men with prostate cancer to obtain information would enable them to assume a more active role in treatment decision making and decrease their levels of anxiety and depression. Respondents were recruited from one community urology clinic in Winnipeg, Manitoba. Sixty newly diagnosed men were randomly assigned to receive either a self-efficacy information intervention that consisted of a written information package with discussion, a list of questions they could ask their physician, and an audiotape of the medical consultation (n = 30), or a written information package alone (n = 30). Men completed measures of preferred decisional role as the pretest; anxiety and depression before the intervention, and at 6 weeks post-intervention; and assumed decisional role at 6 weeks post-intervention. Results demonstrated that men in the intervention group assumed a significantly more active role in treatment decision making, and had lower state anxiety levels at 6 weeks. Levels of depression were similar for both groups at 6 weeks. This group of older men do want to be informed and participate in medical decisions. Further efforts are required to evaluate the efficacy of such an intervention in other community urology clinics. Although a 'patient-centred' approach to general practice consultation is widely advocated, there is mixed evidence of its benefits.
                To measure the costs and benefits of using a prompt to elicit patients' concerns when they consult for minor illness.
                An open randomised controlled trial.
                Four training semi-rural general practices in the south- east of the United Kingdom.
                Patients identified during the first part of the consultation as having a self-limiting illness were randomised to a second part of the consultation that was conducted 'as usual' or involved a written prompt to elicit the patient's concerns. After each consultation the doctor noted the diagnosis and the consultation length and the patient self-completed a questionnaire containing measures of satisfaction, enablement and anxiety.
                One hundred and ten patients were studied. Patients in the elicitation group reported a small but significant increase in the 'professional care' score of the consultation satisfaction questionnaire (88.2 versus 80.9, mean difference = 7.3, 95% confidence interval = 2.0 to 12.6) but no other benefits were detected. Consultations in the elicitation group, however, were longer by about a minute.
                Given the pressures on consultation time in general practice there must be questions about the practical value of eliciting patients' concerns if the benefit of doing so is small and the cost large. This study reports the results of a randomized trial of a psychiatric consultation intervention with distressed, high utilizing patients of 18 physicians in two primary care clinics. Psychiatric consultation was associated with a significant increase in the use of antidepressants in intervention patients compared with controls in the first 6 months after intervention. Intervention patients were also significantly more likely to continue antidepressant treatment than control patients. The primary care physicians receiving psychiatric consultations increased the rate of prescribing antidepressant medications in their practice from 32 prescriptions filled per 1,000 visits before their participation in four consultations to 44 new prescriptions per 1,000 visits in the 12-month period after. There were no significant differences between intervention patients and controls at 6 and 12 months after randomization in psychiatric distress, functional disability, or utilization of health care (ambulatory visits, radiographic and laboratory testing services, admissions to inpatient medical care). Examined a simple intervention to improve the patient's contribution to communication in a medical office visit. In the first study, women awaiting a medical appointment were randomly assigned either to a group that was asked to list three questions to ask their physician or to a control group. Women who listed questions asked more questions in the visit and reported being less anxious. In the second study, a third group that received a message from their physician encouraging question asking was added. Both experimental groups asked more of the questions they had wished to, had greater feelings of control, and were more satisfied with the visit in general and with the information they received. The two experimental groups did not differ significantly, suggesting that the effect may be attributed either to thinking one's questions out ahead of time or to the perception that one's physician is open to questions. This study evaluated a cancer consultation preparation package (CCPP) designed to facilitate patient involvement in the oncology consultation.
                A total of 164 cancer patients (67% response rate) were randomly assigned to receive the CCPP or a control booklet at least 48 hours before their first oncology appointment. The CCPP included a question prompt sheet, booklets on clinical decision making and patient rights, and an introduction to the clinic. The control booklet contained only the introduction to the clinic. Physicians were blinded to which intervention patients received. Patients completed questionnaires immediately after the consultation and 1 month later. Consultations were audiotaped, transcribed verbatim, and coded.
                All but one patient read the information. Before the consultation, intervention patients were significantly more anxious than were controls (mean, 42 v 38; P = .04); however anxiety was equivalent at follow-up. The CCPP was reported as being significantly more useful to family members than the control booklet (P = .004). Patients receiving the intervention asked significantly more questions (11 v seven questions; P = .005), tended to interrupt the physician more (1.01 v 0.71 interruptions; P = .08), and challenged information significantly more often (twice v once; P = .05). Patients receiving the CCPP were less likely to achieve their preferred decision making style (22%) than were controls (35%; P = .06).
                This CCPP influences patients' consultation behavior and does not increase anxiety in the long-term. However, this intervention, without physician endorsement, reduced the percentage of patients whose preferred involvement in decision making was achieved. The frequent attendance of women suffering from anxiety and depression is a common problem in general practice and the problems are often externalized through the women's children. A small controlled study was carried out in a general practice surgery to see whether demand for medical attention by mothers of pre-school children would decrease after they attended a discussion group. Twenty women who fulfilled the study criteria of more than double the national average consultation rate for their age group and of having at least one pre-school child, were sequentially allocated to a treatment or control group. The group therapy was held over two terms of 10 sessions, each of 90 minutes, and was led by a psychologist and a general practitioner. Consultation rates (including surgery visits, house calls and prescription requests) were recorded for five consecutive six-month periods before and after the intervention. At follow-up six months after the end of the treatment a significant reduction in consultation rate had been achieved and maintained by the treated group compared with the controls (P<0.01). This study shows the value of attending to the cause of frequent consultation as well as to the complaints presented. An intervention was developed to increase patient involvement in care. Using a treatment algorithm as a guide, patients were helped to read their medical record and coached to ask questions and negotiate medical decisions with their physicians during a 20-minute session before their regularly scheduled visit. In a randomized controlled trial we compared this intervention with a standard educational session of equal length in a clinic for patients with ulcer disease. Six to eight weeks after the trial, patients in the experimental group reported fewer limitations in physical and role-related activities (p less than 0.05), preferred a more active role in medical decision-making, and were as satisfied with their care as the control group. Analysis of audiotapes of physician-patient interactions showed that patients in the experimental group were twice as effective as control patients in obtaining information from physicians (p less than 0.05). Results of the intervention included increased involvement in the interaction with the physician, fewer limitations imposed by the disease on patients' functional ability, and increased preference for active involvement in medical decision-making. To determine whether an intervention designed to improve patient-physician communication increases the frequency with which physicians elicit patients' concerns, changes other communication behaviors, and improves health care outcomes.
                Pretest-posttest design with random assignment of physicians to intervention or control groups.
                General medicine clinics of a university-affiliated Veterans Affairs Hospital.
                Forty-two physicians and 348 continuity care patients taking prescription medications for chronic medical conditions.
                Intervention group physicians received 4.5 hours of training on eliciting and responding to patients' concerns and requests, and their patients filled out the Patient Requests for Services Questionnaire prior to a subsequent clinic visit. Control group physicians received 4.5 hours of training in medical decision-making.
                The frequency with which physicians elicited all of a patient's concerns increased in the intervention group as compared with the control group (p = .032). Patients perceptions of the amount of information received from the physician did increase significantly (p < .05), but the actual magnitude of change was small. A measure of patient satisfaction with the physicians was high at baseline and also showed no significant change after the intervention. Likewise, the intervention was not associated with changes in patient compliance with medications or appointments, nor were there any effects on outpatient utilization.
                A low-intensity intervention changed physician behavior but had no effect on patient outcomes such as satisfaction, compliance, or utilization. Interventions may need to focus on physicians and patients to have the greatest effect. Although many healthcare providers and researchers consider it necessary to assist patients with end-stage chronic illnesses to plan for the end of life, they tend to avoid discussing end-of-life issues with patients before major surgery. Consequently, surgical patients and their families generally have insufficient knowledge to make plans in case of life-threatening complications.
                The objective of this study was to evaluate short-term effects of Patient-Centered Advance Care Planning (PC-ACP).
                Thirty-two dyads of patients undergoing cardiac surgery and their surrogates were randomly assigned to receive either the PC-ACP intervention (PC-ACP) or usual care.
                Measures studied were patient-surrogate congruence regarding goals for future medical care, patient and surrogate knowledge of advance care planning and anxiety, and patient decisional conflict. Congruence and anxiety were measured before and after the intervention. Decisional conflict and knowledge of advance care planning were measured after the intervention.
                Compared with the control group, PC-ACP significantly improved patient-surrogate congruence (Delta=1.27, P<0.01) and reduced patients' decisional conflict (Delta=-0.77, P<0.05). Anxiety change (pre/post) did not differ between treatment and control groups. No difference in knowledge of advance care planning was found between the 2 groups.
                The PC-ACP can be an effective approach to advance care planning. Its specificity and relevance to patients' actual medical conditions (as exemplified by its plans for potential complications related to cardiac surgery) can lead to greater patient-surrogate congruence without increasing decisional conflict and anxiety. It is important for patients to provide relevant information to the doctor in consultation and to make their own information requirements known. This requires patients to actively participate in the process, something they appear to be reluctant to do. Earlier patient intervention studies have successfully manipulated patient involvement and question asking, although, the latter has tended to be accompanied by increased tension and negative impact. The present study uses a patient education leaflet which uses a wide definition of patient activation. It emphasizes the role of the 'good' patient as a provider of information extending beyond the recitation of symptoms to include insights to interpretation and meaning. Results showed that patients responded positively to the leaflet and a comparison of doctor ratings of communication quality showed the experimental group performed better than the controls. The findings are considered in terms of improved information exchange and the impact of making the 'rules' of consultation explicit is also discussed. The purpose of this study was to determine the effectiveness of an information and support telephone intervention for reducing anxiety in patients who have undergone coronary artery bypass graft surgery and their partners.
                The study is a randomized controlled trial. Intervention began at discharge; 6 telephone calls were made to patients and partners over 7 weeks. Primary outcome was Beck Anxiety Inventory measured at baseline in hospital, at home on day 3, week 4, and week 8.
                The subjects were 131 patients who have undergone elective coronary artery bypass graft surgery and their partners.
                Patients' anxiety was moderate to severe the day before discharge. It was significantly lower in the treatment group than in the control group at day 2 at home. Partners always had lower anxiety than patients. A more sustained decrease in anxiety in the partner treatment group was found at both day 2 and week 4.
                Intervention effect is in the early period after discharge-- the time most affected by reduced lengths of stay. To test the effects of a computer-based nursing intervention designed to provide patients and family caregivers with concrete, objective information on symptom management; provide education about disease and treatment; coordinate medical resources; and provide emotional support and counseling.
                Two-site, randomized clinical trial.
                A large, urban, midwestern, tertiary-cancer center and a community-based cancer center in a medium-sized midwestern city.
                109 patients newly diagnosed with breast, colon, or lung cancer who were receiving chemotherapy; 54 received standard care, and 55 participated in the intervention group.
                Outcome data were collected via structured telephone interviews at three time points: baseline, midway through the intervention, and one month postintervention. The intervention consisting of nine visits, five in person and four by telephone, was conducted over 18 weeks by advanced practice oncology nurses.
                Psychosocial functioning, anxiety, and depression.
                Patients who received the intervention had significantly less depression between baseline and the midway point, as well as less anxiety and greater improvement in the role-emotional and mental health subscales of the Medical Outcomes Study 36 Short Form.
                Cancer-care nursing interventions can decrease psychosocial morbidity and improve quality of life for newly diagnosed patients with cancer undergoing treatment. Additional research is needed to understand who benefited most from the intervention.
                This nurse-directed intervention resulted in improved mental health for patients; however, physical subscales were not changed. Further work is needed to determine why depression and mental health were affected yet physical health and symptoms did not differ between groups. Results support the important role of nurses in addressing mental health issues in patients and families experiencing cancer. This study examined the efficacy of a brief written intervention for primary care patients, designed to increase their level of participation in the consultation. Patients given the intervention leaflet (N = 59) were compared with those given a control leaflet (N = 61) on various consultation process and outcome measures. Psychological and sociodemographic data were also obtained to determine whether these influenced the effects of the intervention. The results showed that the intervention group had significantly longer consultations and asked more questions than the controls. Younger patients and those from social classes 1 and 2 were more likely to benefit from the intervention, but locus of control and self-efficacy scores were not particularly helpful in predicting outcomes. No differences in patient satisfaction were found nor were any negative effects on the doctor observed. A number of explanations are explored and some directions for future research are discussed. In a randomised controlled trial a Frequently Asked Questions (FAQ) checklist intended to prepare coronary artery disease (CAD) outpatients for a medical check-up visit at the cardiologist was evaluated. The checklist was mailed to patients in preparation to their visits after 1, 4 and 10 months following patients' discharge from hospitalisation for CAD. It was hypothesised that the intervention would result in lower state anxiety, better patient-doctor communication, more knowledge of CAD and greater patient satisfaction, while it would not result in longer visits. Repeated measurements analyses of covariance showed that experimental patients (N = 46) were less anxious before the first visit. This visit was shorter than in the controls, though the third visit was longer. Control patients (N = 59) showed more CAD knowledge than experimental patients at the first and third visit. Experimental patients found the checklist useful, though its value diminished at subsequent visits. Using the checklist thus decreased anxiety prior to the first visit and the duration of that visit, while negatively affecting knowledge. No conclusions about long-term effects could be drawn, due to the likelihood of type II and type III errors. Process evaluation indicated that the approach used is not sufficiently stimulating for patients to use as a preparation to every visit. A double-blind randomised controlled trial was conducted on a group of Hong Kong hospital clinicians. The objective was to test if a three-hour educational workshop (with supervised hands-on practice) is more effective (than no training) to improve clinical question formulation, information-seeking skills, knowledge, attitudes, and search outcomes. The design was a post-test-only control group; recruitment by stratified randomization (by profession), blocked at 800. End-user training was more effective than no training in improving clinical question formulation, in raising awareness, knowledge, confidence and use of databases, but had made no impact on preference for secondary databases. It changed the attitude of clinicians to become more positive towards the use of electronic information services (EIS). Participants had higher search performance and outcomes (satisfaction with information obtained (NNT = 3), EIS satisfaction (NNT = 3) and success in problem solving (NNT = 4)). The workshop improved knowledge and skills in evidence-based searching, but this effect gradually eroded with time. Search logs confirmed that follow-up is required if effects are to be sustained. Longer effects on search behaviours appear to be positive. A randomised controlled trial is valuable in identifying cause-and-effect relations and to quantify the magnitude of the effects for management decision-making. Shared decision making (SDM) involves patients and doctors contributing as partners to treatment decisions. It is not known whether or to what extent SDM contributes to the welfare arising from a consultation, and how important this contribution is relative to other attributes of a consultation.
                To identify patient preferences for SDM relative to other utility bearing attributes of a consultation.
                In parallel with a randomised trial in training GPs in SDM competencies and risk communication skills, a discrete choice experiment exercise was conducted to assess patients' utilities.
                Twenty general practices in South Wales, UK.
                Five hundred and eighty-four responders from 747 patients attending the randomised trial (response rate = 78%). All patients had one of four conditions (atrial fibrillation, menorrhagia, menopausal symptoms or prostatism) and attended a consultation with a doctor in their own practice. Patients were randomised to attend a consultation either with a doctor who had received no training in the study or risk communication training alone or SDM training alone, or both combined.
                Five key utility bearing attributes of a consultation were identified. All significantly influenced patient's choice of preferred consultation style (P<0.001). Larger increases in utility were associated with changes on "doctor listens" attribute, followed by easily understood information, a shared treatment decision, more information and longer consultation. Utilities were influenced by whether the doctor had received risk communication training alone or SDM training alone, or both combined, prior to the consultations. The randomised trial itself had identified that the communication processes of these consultations changed significantly, with greater patient involvement in decision making, after the training interventions.
                Shared treatment decisions were valued less than some other attributes of a consultation. However, patient utilities for such involvement appeared responsive to changes in experiences of consultations. This suggests that SDM may gain greater value among patients once they have experienced it. The purpose of this randomized controlled trial was to test the efficacy and effectiveness of process consultation consisting of a series of nurse manager-consultant problem-solving meetings for leadership development that would lead to their staff's improved morale, quality of care, and reduced absenteeism.
                Thirteen consenting clinical inpatient units were stratified for four variables known to affect outcome and were then randomly assigned to treatment and control conditions. The nurse managers from the seven experimental units were paired with outside nurse consultants from the McMaster University School of Nursing (Hamilton, Ontario, Canada) in a cooperative form of retraining in problem-solving through process consultation. Morale was determined through measures of perceptions of the work environment, an attitude scale concerning work (alienation), a personality measure (hardiness), and one of each scale for work satisfaction and for sources of satisfaction and dissatisfaction. Demographic data and information regarding family life responsibilities were collected as well. Assessment of quality of care was determined by the frequency and type of incident reports and by patients' perception of their satisfaction. A ratio of absence hours to total paid hours of work was used to compare experimental and control units' absenteeism rates.
                Experimental subjects reported a statistically significant improvement in the characteristics of their work setting and in the quality of working relationships. The consultation process facilitated a perceived change in the organizational context of the experimental hospital units with less centralization of authority and more clarity about expectation. These organizational changes were accompanied by improved working relationships and less alienation from work. There was no statistically significant difference in absenteeism. However, a subanalysis of the units by "dose" of the intervention identified those who benefited from the effects of the consultation. Subjects whose nurse managers participated more actively in the consultation process accounted for the changes in working relationships and perceived organizational changes. The "low-dose" experimental subjects were more like the control subjects, with the exception of absenteeism, for which they had higher rates.
                The findings of this study suggest that process consultation can alter the staff's perceptions of the characteristics of the work setting, can reverse negative attitudes (alienation), and can create a more positive and supportive working environment (improved working relationship). However, the results suggest the need to target this type of intervention to managers who have the personal resources to engage in self-evaluation and personal development and thus to participate in the consultative process. To assess the effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy.
                Parallel group, cluster randomised, controlled trial of an educational package on cognitive behaviour therapy.
                General practices in north London.
                84 general practitioner principals and 272 patients attending their practices who scored above the threshold for psychological distress on the hospital anxiety and depression scale. Intervention: A training package of four half days on brief cognitive behaviour therapy. Main outcome measures: Scores on the depression attitude questionnaire (general practitioners) and the Beck depression inventory (patients).
                Doctors' knowledge of depression and attitudes towards its treatment showed no major difference between intervention and control groups after 6 months. The training had no discernible impact on patients' outcomes.
                General practitioners may require more training and support than a basic educational package on brief cognitive behaviour therapy to acquire skills to help patients with depression. Paternalistic models of health care, social distance between patients and providers, and cultural norms discourage patients from playing an active role in health consultations. This study tested whether individual coaching can give family planning patients the confidence and communication skills to talk more openly and more vigorously with providers. Educators met with 384 Indonesian women in clinic waiting rooms and coached them on asking questions, expressing concerns, and seeking clarification. An analysis of audiotaped consultations found that patients who received coaching articulated significantly more questions and concerns than others. Coaching narrowed differentials in active communication by patient type, age, and assertiveness, but it widened differentials by patient education and socioeconomic class. The discontinuation rate at 8 months was lower in the intervention than the control condition, but the difference was only marginally significant. To test the effects of a communication skills training intervention on older patients' discourse during a primary care interview.
                A quasi-experimental design involving two intervention conditions.
                The Family Practice Center of a university-based clinic.
                Thirty-three patients averaging age 72 and 9 family practice physicians.
                A communication skills training booklet received approximately 3 days before the scheduled appointment and a 30-minute face-to-face follow-up session before seeing the physician.
                Patients' seeking, providing, and verifying of information were coded from transcripts of the 33 interviews.
                Trained patients engaged in significantly more seeking and providing of information than untrained patients. Additionally, trained patients obtained significantly more information from physicians than did untrained patients, both in terms of the number of total information units and the number of units per question asked.
                Patient communication skills training appears to be an effective means of enhancing patients' participation in the medical interview without increasing the overall length of the interview. Many studies have suggested that general practitioners fail to detect a substantial minority of their patients who are psychologically distressed, and there is concern about the possible sequelae of this. Individual patients may suffer unresolved problems, and there are potential costs to the health service in consequent recurrent consultations, inappropriate referrals or treatment. Educational interventions based on small groups led by facilitators have been shown to alter the consultation behaviours of general practitioners that are known to be related to accurate detection of psychological distress.
                This controlled study aimed to show that, by utilizing a brief self-directed educational intervention focusing on detection of psychological distress, general practitioners can improve their performance significantly. For this purpose, a new educational intervention was designed: the second aim of the study was thus to assess the effectiveness of this specific intervention.
                An educational intervention was designed which focused on skills relevant to detecting psychological distress, using the principles of reflection on general practitioner performance and consultation skill work. It was designed to be used by individual general practitioners without outside support, using a combination of written background material, feedback on performance and analysis of video material. The effectiveness of the intervention was tested by comparing a trial and control cohort of general practitioners, using detection rates as an outcome measure.
                The detection rate of the general practitioners who underwent the intervention improved significantly compared with their performance before intervention and with that of the control group.
                General practitioners can improve their ability to detect psychological distress in their patients utilizing this self-directed educational approach. There is evidence that educational programmes may improve patient's compliance with asthma treatment and control symptoms. Whilst medical parameters have been thoroughly studied, few data are available concerning psychological intervention. The aim of our open pilot study was to verify whether any difference in perceived illness and response style to asthma existed in the patients enrolled in an Asthma Rehabilitation Group (ARG) and in a Control Group (CG). Forty consecutive asthmatics were randomly enrolled, all of whom were diagnosed, treated and followed-up according to the International Guidelines. Both groups underwent a psychological assessment at baseline and after one year. A battery of questionnaires was used to obtain data relating to baseline characteristics (anxiety, depression, psychophysiological disorders), emotional reactions to asthma attacks (panic-fear, etc,) and cognitive variables (external control, psychological stigma, internal beliefs, external chance, etc.) involved in the perceived illness. In addition, the Asthma Rehabilitation Group patients underwent an educational programme and a cognitive-behavioural intervention. In both groups, a reduction of anxiety and depression scores was observed, as well as a significant improvement of the medical parameters evaluated. Only the Asthma Rehabilitation Group reported lower scores on the Psychophysiological Questionnaire and on the External Control Subscale after 1 year. The Control Group reported higher score on the External Chance Scale. The data of our study seem to confirm the effectiveness of psychological intervention on the cognitive skills involved in the perception and management of asthma. Larger scale studies on this topic are suggested. Patients with persistent medically unexplained symptoms often exhibit general dysfunction and psychiatric comorbidity and frequently resist psychiatric referral. The aim of this study was to evaluate the efficacy of a collaborative care model including training for general practitioners (GPs) and a psychiatric consultation model for patients with persistent medically unexplained symptoms in general practice.
                Randomised controlled trial. Cluster randomisation at GP practices and multilevel analysis were performed. A total of 81 patients from 36 general practices completed the study. A collaborative care model of training and psychiatric consultation in general practice in the presence of the GP was compared with training plus care as usual by the GP. Outcome assessment on the patients' well-being, functioning and utilisation of health care services was performed 6 weeks and 6 months later.
                All the patients had somatoform disorders (Whitely Index 7.46), and 86% had comorbid psychiatric disorders. In the intervention group, the severity of the main medically unexplained symptoms decreased by 58%. The patients' social functioning improved. The utilization of health care was lower than in the care as usual group.
                A collaborative care model combining training with psychiatric consultation in the general practice setting is an effective intervention in the treatment of persistent medically unexplained symptoms. Anxiety and depressive disorders are highly comorbid in this group. The findings warrant a larger study. The effects of brief psychological intervention on rates of medical utilization were investigated in a family practice clinic. Patients referred to the psychology service served as experimental subjects. These subjects underwent psychological assessment and treatment from supervised clinical psychology externs in joint working arrangements with family practice residents. Control subjects were other family practice patients, matching the experimental group in age, sex, and race. The number of medical visits to the family practice clinic, specialty clinics, and the emergency room were the dependent measures. The study period was two years. Results indicated that the experimental subjects were more likely than control subjects to decrease medical utilization of the family practice clinic. The findings are consistent with earlier work showing an association between brief psychosocial intervention and decreases in the frequency of clinic visits. However, this study suggests that preinternship-level clinical psychology trainees can be equally as effective in providing this intervention as mental health professionals who have completed their training. Previous research indicates that giving appropriate information to patients before surgery yields many benefits. This randomized controlled trial evaluated a pre admission and postadmission intervention comprising a video, booklet and plastic models for patients undergoing total hip replacement. Seventy-eight patients participated in the study and were randomized into control and intervention groups. The intervention was implemented one month before surgery. Over the operative period, patients completed questionnaires including the Hospital Anxiety and Depression Scale, Nottingham Health Profile and Stress Arousal Checklist. Results showed no significant differences between control and intervention groups for the Hospital Anxiety and Depression Scale, Nottingham Health Profile and Stress Arousal Checklist. However, patients from the intervention group were more likely to know as much as they wanted to know before admission (p <.001) and felt less confronted by information on arrival for the hospital stay. In an era when patient satisfaction is of paramount importance, this preoperative intervention has applications in many settings. Psychoeducational preparation is known to improve postoperative outcome. We tested two common psychoeducational procedures in elderly orthopedic patients, examining how best to match interventions to patients by psychological type.
                Two hundred twenty-two elderly patients undergoing total hip or knee replacement were randomly assigned to 1) a slide-tape with information on the postoperative, in-hospital rehabilitation experience, or 2) training in Benson's Relaxation Response with a bedside audiotape, in a 2 x 2 factorial design.
                The relaxation response did not influence postoperative outcomes. The educational intervention reduced length of stay and pain medication use for patients who exhibited most denial (tendency to avoid thinking about unpleasant events), and reduced postoperative anxiety and cognitive errors on the Mini-Mental State Exam for patients with most baseline anxiety. There was no effect on postoperative pain.
                The importance of attending to the patient's psychological state and level of preparation before orthopedic surgery is reinforced. Patients who exhibit most denial and highest anxiety may benefit from educational interventions, but patients' directly expressing desire for information may be a poor guide in deciding which patients would benefit, compared with more formal psychological testing for denial and anxiety. Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters.
                To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress.
                A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion-handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits.
                Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months.
                Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits.
Interventions before consultations designed to help patients address their information needs within consultations produce limited benefits to patients. Further research could explore whether the quality of questions is increased, whether anxiety before consultations is reduced, the effects on other outcomes and the impact of training and the timing of interventions. More studies need to consider the timing of interventions and possibly the type of training provided to clinicians.