Communicating decisions about care with patients and companions in emergency department consultations

INTRODUCTION: This paper explores doctor-patient and companion communication about care decisions in a UK emergency department (ED). Doctors interface between patients and healthcare systems and facilitate access to care across a range of encounters, drawing on information and authority to make and communicate clinical care decisions. MATERIALS AND METHODS: We explored characteristics of communication through ethnographic observation of 16 video-recorded case studies of ED consultations (average length: 1 h) collected over 6 months. Companions were present in 10 cases. We conducted a framework analysis to understand the roles of doctors, consultants, patients and companions in relaying ED care decisions. FINDINGS: We present two cases to reflect companion roles and their effect on the consultation. The urgency for care and scarcity of resources means clinicians justify decisions and strategize to move patients along ED pathways. DISCUSSION: Everyday care interactions between patients and doctors are goal-oriented and companions participate by providing case information, querying decisions and advocating for care. Our findings reflect how doctors justify decisions made in communicating the next steps in ways that characterize the clinical encounter. CONCLUSION: By exploring everyday interactions our study contributes to a growing understanding of patient-clinician and companion communication in the ED. PATIENT OR PUBLIC CONTRIBUTION: Patients and caregivers voluntarily participated in data collection and consented to video recordings being conducted of ED consultations between them and junior doctors. There was extensive consultation with all grades of staff about the acceptability of the work and the best way to conduct it to minimize the impact on patients and staff. Through this manuscript, we have demonstrated the presence and important role of companions. On reflection it would have been valuable to have included patients and companions in discussions about the work; however, this project was conducted with very limited funding and no resources were committed to patient and public involvement. Given the setting and scope of the study, it was not feasible to involve patients or members of the public in other stages of the research or preparation of the manuscript. We recognize this as a potential limitation of the work

Development of a tool to assess core cardiorespiratory physiotherapy skills: a Delphi study.

Purpose: This study reports on the development of an outcome measure designed to evaluate pre-registration physiotherapy students’ ability in performing core cardiorespiratory skills. Method: A four round, e-Delphi study using an international panel of expert cardiorespiratory physiotherapists involved in pre-registration student education was undertaken. In round one participants identified what they look for in students competently performing core cardio-respiratory physiotherapy assessment and treatment skills. These items were refined in rounds two and three. Item content validity score (iCVI) of ≥ 0.8 at round four identified consensus. Scale content validity index (SCVI) was calculated. Results: Response rate for round one was 46% (6/13). Additional experts were invited to participate and response rates increased to 71% (round 2), 88% (round 3) and 100% (round 4). Of the 207 items across the seven skills identified in round one, 140 were presented in round four. Of these, consensus was achieved for 128 items, with 12 being excluded. The SCVI was 0.907. Conclusion: This e-Delphi study enabled the development of a draft outcome measure, which aims to assess performance of seven cardiorespiratory physiotherapy skills. This tool will enable rigorous evaluation of different education methods to establish their effectiveness. However, it is first necessary to establish construct validity and assess inter and intra-rater reliability

Anger, Quality of Life and Mood in Multiple Sclerosis

This research was funded by The Multiple Sclerosis Society (UK).Peer reviewedPublisher PD

Surprise! Out-of-network billing for emergency care in the United States

Using insurance claims data capturing 8.9 million emergency episodes, we show that in 22% of cases, patients attended in-network hospitals, but were treated by out-of-network physicians. We find that out-of-network billing is concentrated in a small group of primarily for-profit hospitals. Within 50% of hospitals in our sample, fewer than 5% of patients saw out-of-network physicians. In contrast, at 15% of hospitals, more than 80% of patients saw out-of-network physicians. Out-of-network billing allows physicians to substantially increase their payment rates relative to what they would be paid for treating in-network patients and significantly improve their outside option when bargaining over in-network payments. Because patients cannot avoid out-of-network physicians during an emergency, physicians have an incentive to remain out-of-network and receive higher payment rates. Hospitals incur costs when out-of-network billing occurs within their facilities. We illustrate in a model and confirm empirically via analysis of two leading physician-outsourcing firms that physicians offer transfers to hospitals to offset the hospitals’ costs of allowing out-of-network billing to occur within their facilities. We find that a New York State law that introduced binding arbitration between physicians and insurers to settle surprise bills reduced out-of-network billing rates

Rehabilitation as a disability equality issue: a conceptual shift for disability studies?

Rehabilitation is a controversial subject in disability studies, often discussed in terms of oppression, normalisation, and unwanted intrusion. While there may be good reasons for positioning rehabilitation in this way, this has also meant that, as a lived experience, it is under-researched and neglected in disabilities literature, as we show by surveying leading disability studies journals. With some notable exceptions, rehabilitation research has remained the preserve of the rehabilitation sciences, and such studies have rarely included the voices of disabled people themselves, as we also demonstrate by surveying a cross-section of rehabilitation science literature. Next, drawing on new research, we argue for reframing access to rehabilitation as a disability equality issue. Through in-depth discussion of two case studies, we demonstrate that rehabilitation can be a tool for inclusion and for supporting an equal life. Indeed, we contend that rehabilitation merits disability researchers' sustained engagement, precisely to ensure that a "right-based rehabilitation" policy and practice can be developed, which is not oppressive, but reflects the views and experiences of the disabled people who rehabilitation should serve

Multiple sclerosis, emotion perception and social functioning

Funding Information: This research was supported by a PhD studentship funded by the Economic and Social Research Council through the Scottish Graduate School for Social Sciences, and a grant from the UK MS Society.Peer reviewedPostprin

Effectiveness of high fidelity simulation versus low fidelity simulation on practical/clinical skill development in pre-registration physiotherapy students: a systematic review.

Objective: The objective of this review is to evaluate the effectiveness of high fidelity simulation (HFS) versus low fidelity simulation (LFS) on practical/clinical skill development in pre-registration physiotherapy students. Introduction: Evidence suggests that improved skill development in university can reduce anxiety in practice, improving performance of skills and overall learning at clinical placement for health professions students. However, evidence indicates that the clinical environment is most effective for learning. As a result, there has been increased interest in the use of HFS where students can test knowledge and skills in an increasingly self-directed way. No previous reviews on the effectiveness of HFS on skill development in physiotherapy students were identified. Inclusion criteria: Experimental and quasi-experimental studies comparing HFS (simulated person, manikin, virtual simulation, video case-studies) to LFS (peer role-play, paper-based case-studies) in pre-registration physiotherapy education were included. Primary outcomes were objective measures of skills performance; secondary outcomes were students’ perceptions of the impact of simulation on learning measured using quantitative outcomes. Methods: A three-step search strategy was employed. Following an initial search of MEDLINE and CINAHL and analysis of text words, MEDLINE, CINAHL, ERIC, AMED, EThOS and Google Scholar were searched in November 2017 Reference lists of studies included at critical appraisal stage were hand-searched. Studies published in English from 1978 onwards were included. Title/abstract screening, critical appraisal and data extraction were conducted by two independent reviewers; conflicts were resolved by discussion. Results: Meta-analysis was not possible due to heterogeneity; therefore, results were presented in narrative form. Three randomized controlled trials (RCT) and three quasi-experimental studies (310 participants) were included. They were conducted in the USA and Australia, and evaluated standardized patients (people who take on the role of a real patient), near-peers, computerized manikins and virtual simulation in pre-registration Bachelor of Science (Honors), Master of Science and Doctor of Physiotherapy students. One RCT was considered high quality, with the remainder moderate quality. The findings related to five main areas: i) In terms of motor skill performance, an increased number of safety fails were found with HFS (HFS = 13.5% safety fails, HFS + video feedback = 15.4% safety fails, control [LFS] = 8.1% safety fails); ii) The Assessment of Physiotherapy Practice (APP) tool indicated no significant improvement in mean APP scores at week 6 of clinical placement (HFS mean APP score = 60.7 [9.1], control mean APP score = 58.7 [8.4]; P = 0.35); iii) Only one of two studies showed a statistically significant difference in clinical reasoning with HFS (P = 0.001). This became non-significant once students were on clinical placement (P = 0.328); iv) Students did not perceive a significant difference in their communication skills with HFS (simulation = 9.05 [+/− 1.27]; control 8.75 [+/− 1.2]; P = 0.482); v) Students were significantly more positive about HFS for increasing awareness of safety issues (P = 0.002), patients’ emotional status (P = 0.002), handling skills (P < 0.0001) and ability to provide instructions to patients (P < 0.0001). Conclusions: Currently there is no high quality evidence that HFS improves motor skill performance in pre-registration physiotherapy students. There is a small amount of moderate-quality evidence it may improve students’ perception of their self-efficacy but no evidence that it improves communication skills. However, a lack of studies and variation in outcome measures meant that meta-analysis was not possible. At present, no recommendations can be made regarding the use of HFS to improve skill performance in this population

The effect of high fidelity simulated learning methods on physiotherapy pre-registration education: a systematic review protocol.

The objective of this review is to identify if high fidelity simulated learning methods are effective at enhancing clinical/practical skills compared to usual, low fidelity simulated learning methods in pre-registration physiotherapy education