Physician Communication Skills: Results of a Survey of General/Family Practitioners in Newfoundland

Purpose: To describe the attitudes related to communication skills, confidence in using commnication skills, and use of communication skills during the physician-patient encounter among a population-based sample of family physicians. Procedures: A mailed survey, distributed to all family physicians and general practitioners currently practicing in Newfoundland. The questionnaire was designed to collect data in five general areas participant demographics, physician confidence in using specific communication strategies, perceived adequacy of time spent by physicians with their patients, physician use of specific communication strategies with the adult patients they saw in the prior week, and physician use of specific communication strategies during the closing minutes of the encounters they had with adult patients in the prior week. Main Findings: A total of 160 completed surveys was received from practicing family physicians/general practitioners in Newfoundland, yielding an adjusted response rate of 43.1%. Most of the respondents (83.8%) indicated their communication skills are as important as technical skills in terms of achieving positive patient outcomes. Between one-third and one-half of the respondents, depending on the educational level queried, rated their communications skills training as being inadequate. Fewer than 20% of the respondents rated the communications skills training they received as being excellent. Physicians indicated a need to improve their use of 8 of 13 specific communication strategies during patient encounters, and reported using few communication strategies during the closing minutes of the encounter. Interactions that occurred during a typical encounter tended to focus on biomedical versus psychosocial issues. Conclusions: Family physicians/general practitioners recognize a need to improve their commnications skills. Well-designed communications skills training programs should be implemented at multi-levels of physician training in order to improve patient satisfaction with their encounters with family/general practitioners, and to increase the likelihood of positive patient outcomes

The MASCC/ISOO Mucositis Guidelines: dissemination and clinical impact

This editorial introduces the second set of articles related to the update of the clinical practice guidelines for mucositis, developed by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO)

QOLLTI-F: measuring family carer quality of life

Background: The primary goal of palliative care is to optimize the quality of life (QOL) of people living with a life-threatening illness and that of their families. While there have been important advances in measurement of the QOL of palliative care patients, little attention has been paid to the QOL of their carers (family caregivers). To develop and deliver the most effective services to these carers, their QOL needs to be measured with acceptable and psychometrically sound instruments that have content validity. Methods: This study reports three phases of the development and testing of such a measure: QOLLTI-F, Quality of Life in Life Threatening Illness Á Family Carer Version, simultaneously in English and French. Participants were carers from 12 Canadian palliative care services who were asked to complete QOLLTI-F on three occasions. Results: The final version of QOLLTI-F consists of 16 items. It was deemed acceptable by the vast majority of carers and a longer, 24-item version was completed in a median of 12 min. Content validity was assured by inclusion of all domains reported by carers to be important to their QOL: state of carer, patient wellbeing, quality of care, outlook, environment, finances and relationships. Construct validity was demonstrated, as principal components analysis indicated that the 16 items did indeed reflect these seven domains. Furthermore, the seven domain scores predicted 53% of the variance in global QOL, although the QOLLTI-F Total score predicted less well (43%). The test Áretest reliability for the QOLLTI-F Total score was 0.77 Á0.80 and ranged from 0.50 to 0.79 for the seven domain scores. All QOLLTI-F scores were shown to be significantly different between days the carers considered bad, average and good, demonstrating responsiveness to change, with the exception of the Financial Concerns submeasure, which did not distinguish between average and good days. Conclusions: QOLLTI-F is unique in that in measuring one person's QOL (the carer's) it includes their perception of the condition of another (the patient). This attests to the close relationship between the two. It is also unique in that its content is derived from a qualitative study asking carers what is important to their own QOL, rather than focusing on the changes or burdens related to caregiving. QOLLTI-F also has the advantage of being briefer than other carer QOL measures. It contains measures of seven different domains that are determinants of carer QOL, in addition to a summary score. All these measures are valid, reliable and responsive to change in QOL. Palliative Medicine 2006; 20: 755 Á767 Key words: cancer; carer; end-of-life; family carer; palliative care; quality of life Introduction The goal of palliative care is optimizing quality of life (QOL) in patients and their families by preventing problems, delaying their onset and reducing their severity. QOL is defined as subjective wellbeing, reflecting differences or gaps between hopes and expectations and current experiences. 1 Á 3 QOL must therefore account for expectations as well as objective conditions and ultimately represent the sum of positive and negative factors, rather than simply the presence/absence of QOL detractors. Moreover, the QOL literature in palliative care has primarily focused on patients. 11 The true cost/benefit ratio for society of transferring care to the home, or providing excellent palliative care in an institutional setting, cannot be evaluated without assessing its impact on the QOL of carers. As family members are understandably painfully affected by a lifethreatening illness in a member, they may be viewed as second-order patients in their own right. Domains relevant to QOL of carers of palliative care cancer patients Two past studies focused on defining QOL domains relevant to carers of cancer patients, based on self-report. Weitzner and colleagues developed the content of their Caregiver QOL Index-Cancer (CQOLC) Questionnaire from a qualitative study focused primarily on how the patient's illness impacted the carer's physical, emotional, family and social functioning. 6 As this study did not explore what domains the carers felt were important and the method used presupposed domains, The second study was performed by this investigative group in order to define domains for a new measure of the QOL of carers. Interviews were undertaken with 59 carers of palliative care patients from two large and one small Canadian city, who were caring for loved ones at home or in hospital. The carers were asked to describe what was important to their QOL, with responses reflecting the following seven domains: state of carer, patient wellbeing, quality of care, outlook, environment, finances and relationships. 17 Two instruments, the Caregiver QOL Index (CQLI) and LASAS, were specifically designed for carers of hospice patients and consist of four or five single-item indicators. The 35-item CQOLC, the content of which is based on the qualitative study reviewed above, 6 was tested for reliability and validity in the anticancer treatment setting, where its psychometric properties appeared to be appropriate, 20 These overlap but do not match areas found important to carer QOL in their qualitative study 6 and in our qualitative study, 4,5 as described above. Therefore, while CQOLC has good psychometric qualities, it is probably not sufficiently comprehensive and is lacking in content validity. Although a single summary score representing overall QOL is useful in some situations, for many purposes, more detailed information is required. It is important to 756 R Cohen et al. assess carer status in multiple domains, given the distinct potential for important changes in some domains that would remain unrecognized if only summary scores are used. For example, it is possible to observe significant improvement in some domains (eg, outlook, relationships) and deterioration in others (eg, patient condition, environment) but no change in summary scores. Purpose The purpose of this reported study series was development of an acceptable, psychometrically valid self-report instrument measuring QOL in carers of people with terminal cancer. The content of this instrument, the Quality of Life in Life-Threatening Illness Á Family carer version (QOLLTI-F), was based on a qualitative study wherein carers responded to the question ''What is important to your QOL?'' described previously. 4,5 Phases 1 and 2 developed the initial items and carers judged their importance, comprehensiveness, redundancy and acceptability. This data and frequency distributions were used to refine QOLLTI-F and establish content validity. In Phase 3 the questionnaire was consolidated based on each domain derived from the qualitative work, and subsequently the items and each subscale were tested for validity and reliability to obtain a final psychometrically sound 16-item version. English and French language versions were developed and validated simultaneously. Method Ethics Approval was obtained from the ethics committees of each participating clinical institution, as well as McGill University and the Universities of Saskatchewan, British Columbia and Toronto. All participants gave written informed consent and competent patients gave verbal assent to involve their carer in the study. Sites and settings Participants who were caring for a patient at home or in hospital were recruited in five Canadian cities (Montreal, Quebec City, Saskatoon, Toronto, Vancouver). Services included inpatient palliative care and consultation in tertiary and secondary care hospitals, a free-standing hospice and home care. Participants Primary carers were defined as the person who provided the most care for a person who was followed by a participating service and for whom the primary goal of care was optimization of QOL rather than cure or prolongation of life, and who was not paid to provide care. The carer had to be at least 18 years of age and speak either English or French fluently. No more than one carer per patient participated. They were identified by the patient wherever possible. In cases where the patient was unable to identify the primary carer due to cognitive or physical incapacity, the patient's palliative care doctor or nurse made the identification. Many strategies were implemented to recruit consecutive eligible carers of patients admitted to the participating services. However, due to clinical staff not having the time to determine eligibility for the carer of every patient admitted, the result is a convenience sample. Phase 1 method and results Content development SRC, AL and Terry Bunston, PhD developed a preliminary set of items to represent the seven domains they found to be important to carer QOL in their qualitative study: Environment, State of the Patient, Carer's Own State, Carer Outlook, Relationships, Quality of care and Financial worries. Translation The items were generated in English, then translated into French by a professional translator. As much of the population in Montreal is bilingual, we are able to use palliative care staff to comment on the translations by having them compare both language versions. This was done by five staff members in addition to SRC and AL. A few words were changed. Acceptability and content validity As a preliminary check, six English-speaking and one French-speaking carer were then asked to read over the questionnaires with a research assistant and to indicate whether the instructions or any of the items were unclear. Most were clear and one needed clarification. This item originally read: ''The location of (patient name) was right for me''. It was reworded as ''The place (patient name) was staying was right for me''. Next, 10 carers from each of Montreal, Saskatoon and Toronto (total n 0/30) rated the importance of each of the QOLLTI-F: family carer quality of life 757 40 items to their QOL on a scale from 0 0/not important at all to 100/extremely important. In addition, they were asked to indicate whether any aspect of the questionnaire was unclear, upsetting or unimportant, and whether any questions were redundant or missing. Explanations were gathered each time a part of the questionnaire was unacceptable in any of these ways. A total of 6 palliative care professionals completed the same exercise. Based on the importance ratings and the comments concerning redundancy, relevance and clarity, 10 items were deleted. The 30 items retained had an importance rating from the carers ranging from 7.3 to 9.5. Format QOLLTI-F was designed to be read aloud, in order to allow those with low literacy or physical impairment that precludes them from completing the questionnaire unassisted to participate. The response scales were 11-point numerical rating scales (range of scoring options from 0 through to and including 10), with a descriptive anchor at each end. We chose to use an 11-point scale because we have found it intuitively easier for those with less formal education to understand compared to 7-point scales, eg, they effortlessly realize that 5 is the midpoint. A two-day timeframe was used. Especially near the end of life, situations change rapidly for palliative care patients, and therefore also for the carer. We did not want to use a longer timeframe as this would require the carer to answer by averaging over potentially very different QOL. We feel that the two-day timeframe captures more than the brief snapshot of a single day. In addition, QOLLTI-F was created to be used in conjunction with our McGill Quality of Life Questionnaire that measures patient QOL, which has a two-day time-frame. The 30 carers participating in this phase were asked which of two formats was preferred: one where items were grouped according to domain, and one where items having the same response options (eg, not at all, completely) were grouped together. The carers were asked to look at both versions before carrying out the importance ratings and to choose the one they wanted to use. There was a clear preference for the format with items grouped according to content domain (22/30 0/ 73%) rather than that grouped according to response option. Back-translation The revised 30 ('/2 global)-item questionnaire was then back-translated by two bilingual volunteers, whose first language is English, and who had not seen the English version of the questionnaire. One was a lawyer and the other a professional who had recently been a carer. Both individuals have spent much of their work life communicating in French, and together they brought both precision in language and meaning to the back-translation. The back-translation matched the original English version with one exception. The item reading 'I coped very poorly/well' required clarification to 'I coped with my situation very poorly/well'. Phase 2 method Item reduction and further evidence of acceptability The 30 ('/2 global)-item questionnaire was then completed by a new sample of 60 carers (20 in each of Montreal, Saskatoon and Toronto). In addition, time to complete the questionnaire was noted, and participants were asked whether any items were unclear or upsetting. The distribution of each item was determined, with particular focus on skewness, range of the 0 Á10 scale used and evidence of bimodality. Phase 2 results Participants As intended, approximately half the participants were a family member caring for a patient living at home (28 or 47%) and the other participants were caring for patients who were hospitalized (32 or 53%). The patients had been followed by a palliative care service for between 1 week and 22 months, with the exception of one who was followed for 47 months. Two-thirds of the carers were female and most were the spouse (38 or 63%) or daughter (12 or 20%) of the patient. Carer age was fairly evenly distributed among those over 30: 17 (28%) were aged 31 Á50, 15 (27%) were aged 51Á65 and 23 (38%) were over 65. Only 4 (7%) were aged 18 Á30. The highest level of education was also fairly evenly distributed: 5 (8%) attended only primary school, 21 (35%) attended or completed high school, 14 (23%) attended or completed college or trade school, and 18 (30%) attended or completed university (2 were 'other'). Income was similarly distributed. Most participants lived with a spouse (48 or 80%). Almost one quarter (14 or 23%) had children under 18 living at home. Acceptability Clarity. Asked directly if the instructions were clear, 93% answered 'yes'. Two commented that it was difficult for them to be so precise when choosing a response option on the 11-point scale. While 14/55 (25%) indicated that at least one item was unclear, no item was described as unclear by more than 2/55 people (4%). According to a participant, if it was the first time going through this experience, it was hard to answer questions related to the quality of care as one does not know what kind of care can be expected and what you 758 R Cohen et al. need to know. Another said clarification was required regarding the meaning of 'care for yourself'. Upsetting items. When asked if any questions were upsetting, 6/56 (11%) answered 'yes' for 1Á3 items. No items were listed by more than two people (4%). The items that two people said were upsetting concerned whether the condition of the patient was distressing, whether being ready for the future was a problem and whether they felt financially secure. Time to complete. When asked directly if the questionnaire was too long, only 2 participants (4%) answered 'yes'. The mean time to complete the 30'/2 general items was 21 min (median0/20, range 10 Á35). Content validit

The MASCC/ISOO Mucositis Guidelines: dissemination and clinical impact

This editorial introduces the second set of articles related to the update of the clinical practice guidelines for mucositis, developed by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO)

Perspectives on reach to recovery and CanSurmount: informing the evaluation model

The Canadian Cancer Society requested that the Centre for Behavioural Research and Program Evaluation of the National Cancer Institute of Canada evaluate Reach to Recovery and CanSurmount, 1-on-1 peer-support programs that provide information and support to individuals with cancer and their families. Key informant interviews (with program participants and volunteer visitors) were conducted to gather qualitative data and to help us develop a framework and tools to evaluate these programs. We found that 1) there are program objectives from the perspective of volunteers and participants in addition to those outlined in the program materials; 2) there are variations in how the programs are delivered and how patients or family members are recruited into the program; and 3) there is evidence that Reach to Recovery and CanSurmount volunteers are in a unique position to deliver the programs, either because they have personally experienced cancer or have family members who have had cancer. We describe the key informant exercise developed for this evaluation project and present the results of preliminary data-gathering activities

Post-secondary education and underemployment in a longitudinal study of Ontario baby boomers

We focus first on the changing nature of skill-job mismatch among post-secondary graduates, using longitudinal data to assess the impact of gender, socioeconomic status, field of study, and other factors, on mismatch. Second, we provide a detailed comparison between college and university graduates to determine whether predictors of mismatch are identical for these two groups. Third, we analyse the exposure of post-secondary graduates to alternative education, such as private vocational schools, and assess the relationship between skill-job mismatch and pursuit of further education. In concluding, we argue that the "school-to-work transition" for post-secondary students is becoming more complex. There is little coordination among post-secondary educational offerings and students' choices are often individualized. In order to address the skill-job mismatch problem, greater coordination between suppliers of conventional and extra-institutional forms of post-secondary education is needed

Designing a framework for the delivery of collaborative musculoskeletal care involving chiropractors and physicians in community-based primary care

Abstract Strategies have been proposed to facilitate collaboration between conventional health care providers in primary care. However, little is known if these are transferable to CAM health care providers. We designed a qualitative study to articulate a conceptual model to advance the interprofessional collaboration between physicians and chiropractors within community-based primary care in Ontario, Canada. Data obtained from 16 key informants and eight focus groups, with a range of professionals including chiropractors, physicians and academia as well as patients, informed the development our framework. The framework included processed-based factors that clustered under three categories: communication, practice parameters, and service delivery; presumed necessary to address challenges and optimize benefits of collaboration. The development of this framework may help understand and promote interprofessional collaborative practice and contribute to the understanding of how CAM may participate in mainstream healthcare