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Experts Practice What They Preach
A Descriptive Study of Best and Normative Practices in End-of-Life Discussions
Debra L. Roter, DrPH;
Susan Larson, MS;
Gary S. Fischer, MD;
Robert M. Arnold, MD;
James A. Tulsky, MD
Arch Intern Med. 2000;160:3477-3485.
Background Advance directives (ADs) are widely regarded as the best available mechanism to ensure that patients' wishes about medical treatment at the end of life are respected. However, observational studies suggest that these discussions often fail to meet their stated goals.
Objectives To explore best practices by describing what physicians who are considered expert in the area of end of-life bioethics or medical communication do when discussing ADs with their patients and to explore the ways in which best practices of the expert group might differ in content or style from normative practice derived from primary care physicians' discussions of ADs with their patients collected as part of an earlier study.
Design Nonexperimental, descriptive study of audiotaped discussions.
Setting Outpatient primary care practices in the United States.
Participants Eighteen internists who have published articles in the areas of bioethics or communication and 48 of their patients. Fifty-six academic internists and 56 of their established patients in 5 practice sites in 2 locations—Durham, NC, and Pittsburgh, Pa. Eligible patients were at least 65 years old or suffered from serious medical illness and had not previously discussed ADs with their physician. Expert clinicians had discretion regarding patient selection, while the internists chose patients according to a predetermined protocol.
Measurements Coders applied the Roter Interaction Analysis System (RIAS) to audiotapes of the medical visits to describe communication dynamics. In addition, the audiotapes were scored on 21 items reflecting physician performance in specific skills related to AD discussions.
Results Experts spent close to twice as much time (14.7 vs 8.1 minutes, P<.001) and were less verbally dominant (P<.05) than other physicians during AD discussions. When length of visit was controlled statistically, the expert physicians gave less information about treatment procedures and biomedical issues (P<.05) and asked fewer related questions (P<.05) but tended toward more psychosocial and lifestyle discussion and questions. Experts engaged in more partnership building (P<.05) with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion (P<.001), and more positive talk (P<.05) than patients of community physicians. Expert physicians scored higher on the 21 items reflecting AD-specific skills (P<.001).
Conclusions Best practices as reflected in the performance of expert physicians reflect differences in measures of communication style and in specific AD-related proficiencies. Physician training in ADs must be broad enough to include both of these domains.
From the Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Md (Dr Roter and Ms Larson); the Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Center for Health Law and Bioethics and Center for Research on Health Care, University of Pittsburgh Medical Center, Pittsburgh, Pa (Drs Fischer and Arnold); the Institute for Performance Improvement (Dr Arnold); and the Program on the Medical Encounter and Palliative Care, Durham Veterans Affairs Medical Center, and the Department of Medicine and the Center for the Study of Aging and Human Development, Duke University (Dr Tulsky), Durham, NC.
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