•Clinicians frequently encounter epistemic uncertainty, yet communication about uncertainty is often ineffective.•Mindfulness may address reduce barriers to discussing uncertainty, such as ...defensiveness, avoidance and cognitive rigidity.•Shared mind may improve shared understanding, affective attunement, advance care planning and treatment decision-making.
Epistemic uncertainty refers to situations in which available evidence is insufficient or unreliable, often accompanied by complexity due to novel contexts, multifactorial causation, and emerging options (the “unknowable unknown”). It stands in contrast to aleatory uncertainty where probabilities are known, and potential benefits and harms can be calculated and presented graphically (the “knowable unknown”).
Epistemic uncertainty is common, and encompasses uncertainty about the nature of the illness, whom to entrust with one’s care, and one’s ability to adapt and cope. Communication about the “unknowable unknown” occurs infrequently and ineffectively, and there is little research on improving communication in the face of epistemic and complex uncertainty. Terror Management Theory (TMT) predicts that in encountering serious illness, people engage in “worldview defense” – suppressing death-related thoughts, affiliating with like-minded others, and developing cognitive rigidity and intolerance of information that challenges their worldview. Mindfulness is associated with diminished defensive worldview reactions and cognitive rigidity, and greater tolerance of ambiguity. Shared mind encompasses shared understanding and affective attunement.
For clinicians and seriously ill patients facing epistemic uncertainty, psychologically-informed interventions that promote mindfulness and shared mind offer promise in promoting open discussions regarding prognostic uncertainty, advance care planning, and treatment decision-making.
Growing enthusiasm about patient-centered medical homes, fueled by the Patient Protection and Affordable Care Act's emphasis on improved primary care, has intensified interest in how to deliver ...patient-centered care. Essential to the delivery of such care are patient-centered communication skills. These skills have a positive impact on patient satisfaction, treatment adherence, and self-management. They can be effectively taught at all levels of medical education and to practicing physicians. Yet most physicians receive limited training in communication skills. Policy makers and stakeholders can leverage training grants, payment incentives, certification requirements, and other mechanisms to develop and reward effective patient-centered communication.
Purpose To provide guidance to oncology clinicians on how to use effective communication to optimize the patient-clinician relationship, patient and clinician well-being, and family well-being. ...Methods ASCO convened a multidisciplinary panel of medical oncology, psychiatry, nursing, hospice and palliative medicine, communication skills, health disparities, and advocacy experts to produce recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. The systematic review focused on guidelines, systematic reviews and meta-analyses, and randomized controlled trials published from 2006 through October 1, 2016. Results The systematic review included 47 publications. With the exception of clinician training in communication skills, evidence for many of the clinical questions was limited. Draft recommendations underwent two rounds of consensus voting before being finalized. Recommendations In addition to providing guidance regarding core communication skills and tasks that apply across the continuum of cancer care, recommendations address specific topics, such as discussion of goals of care and prognosis, treatment selection, end-of-life care, facilitating family involvement in care, and clinician training in communication skills. Recommendations are accompanied by suggested strategies for implementation. Additional information is available at www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki .
Resilience is the capacity to respond to stress in a healthy way such that goals are achieved at minimal psychological and physical cost; resilient individuals "bounce back" after challenges while ...also growing stronger. Resilience is a key to enhancing quality of care, quality of caring, and sustainability of the health care workforce. Yet, ways of identifying and promoting resilience have been elusive. Resilience depends on individual, community, and institutional factors. The study by Zwack and Schweitzer in this issue of Academic Medicine illustrates that individual factors of resilience include the capacity for mindfulness, self-monitoring, limit setting, and attitudes that promote constructive and healthy engagement with (rather than withdrawal from) the often-difficult challenges at work. Cultivating these specific skills, habits, and attitudes that promote resilience is possible for medical students and practicing clinicians alike. Resilience-promoting programs should also strive to build community among clinicians and other members of the health care workforce. Just as patient safety is the responsibility of communities of practice, so is clinician well-being and support. Finally, it is in the self-interest of health care institutions to support the efforts of all members of the health care workforce to enhance their capacity for resilience; it will increase quality of care while reducing errors, burnout, and attrition. Successful organizations outside of medicine offer insight about institutional structures and values that promote individual and collective resilience. This commentary proposes methods for enhancing individuals' resilience while building community, as well as directions for future interventions, research, and institutional involvement.
Abstract Patient-centered care requires different approaches depending on the clinical situation. Motivational interviewing and shared decision making provide practical and well-described methods to ...accomplish patient-centered care in the context of situations where medical evidence supports specific behavior changes and the most appropriate action is dependent on the patient's preferences. Many clinical consultations may require elements of both approaches, however. This article describes these 2 approaches—one to address ambivalence to medically indicated behavior change and the other to support patients in making health care decisions in cases where there is more than one reasonable option—and discusses how clinicians can draw on these approaches alone and in combination to achieve patient-centered care across the range of health care problems.
The COVID-19 pandemic has heightened interest in how physician mental health can be protected and optimised, but uncertainty and misinformation remain about some key issues. In this Review, we ...discuss the current literature, which shows that despite what might be inferred during training, physicians are not immune to mental illness, with between a quarter and a third reporting increased symptoms of mental ill health. Physicians, particularly female physicians, are at an increased risk of suicide. An emerging consensus exists that some aspects of physician training, working conditions, and organisational support are unacceptable. Changes in medical training and health systems, and the additional strain of working through a pandemic, might have amplified these problems. A new evidence-informed framework for how individual and organisational interventions can be used in an integrated manner in medical schools, in health-care settings, and by professional colleagues is proposed. New initiatives are required at each of these levels, with an urgent need for organisational-level interventions, to better protect the mental health and wellbeing of physicians.
The phrase "patient-centered care" is in vogue, but its meaning is poorly understood. This article describes patient-centered care, why it matters, and how policy makers can advance it in practice. ...Ultimately, patient-centered care is determined by the quality of interactions between patients and clinicians. The evidence shows that patient-centered care improves disease outcomes and quality of life, and that it is critical to addressing racial, ethnic, and socioeconomic disparities in health care and health outcomes. Policy makers need to look beyond such areas as health information technology to shape a coordinated and focused national policy in support of patient-centered care. This policy should help health professionals acquire and maintain skills related to patient-centered care, and it should encourage organizations to cultivate a culture of patient-centeredness.
Abstract Objective Although prior research indicates that features of clinician–patient communication can predict health outcomes weeks and months after the consultation, the mechanisms accounting ...for these findings are poorly understood. While talk itself can be therapeutic (e.g., lessening the patient's anxiety, providing comfort), more often clinician–patient communication influences health outcomes via a more indirect route. Proximal outcomes of the interaction include patient understanding, trust, and clinician–patient agreement. These affect intermediate outcomes (e.g., increased adherence, better self-care skills) which, in turn, affect health and well-being. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions. Conclusion Future research should hypothesize pathways connecting communication to health outcomes and select measures specific to that pathway. Practice implications Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual understanding, adherence, social support, self-efficacy) associated with improved health.
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