Browsing by Author "Tulsky, James A"

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    Can metaphors and analogies improve communication with seriously ill patients?
    (J Palliat Med, 2010-03) Casarett, David; Pickard, Amy; Fishman, Jessica M; Alexander, Stewart C; Arnold, Robert M; Pollak, Kathryn I; Tulsky, James A
    OBJECTIVE: It is not known how often physicians use metaphors and analogies, or whether they improve patients' perceptions of their physicians' ability to communicate effectively. Therefore, the objective of this study was to determine whether the use of metaphors and analogies in difficult conversations is associated with better patient ratings of their physicians' communication skills. DESIGN: Cross-sectional observational study of audio-recorded conversations between patients and physicians. SETTING: Three outpatient oncology practices. PATIENTS: Ninety-four patients with advanced cancer and 52 physicians. INTERVENTION: None. MAIN OUTCOME MEASURES: Conversations were reviewed and coded for the presence of metaphors and analogies. Patients also completed a 6-item rating of their physician's ability to communicate. RESULTS: In a sample of 101 conversations, coders identified 193 metaphors and 75 analogies. Metaphors appeared in approximately twice as many conversations as analogies did (65/101, 64% versus 31/101, 31%; sign test p < 0.001). Conversations also contained more metaphors than analogies (mean 1.6, range 0-11 versus mean 0.6, range 0-5; sign rank test p < 0.001). Physicians who used more metaphors elicited better patient ratings of communication (rho = 0.27; p = 0.006), as did physicians who used more analogies (Spearman rho = 0.34; p < 0.001). CONCLUSIONS: The use of metaphors and analogies may enhance physicians' ability to communicate.
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    Effective "on-boarding": transitioning from trainee to faculty.
    (J Palliat Med, 2010-10) Gustin, Jillian; Tulsky, James A
    Abstract The transition from trainee to junior faculty member can be both exciting and daunting. However, a paucity of medical literature exists to help guide new faculty in this transition. Therefore, we adapted work from the business management literature on what is referred to as "on-boarding"; effectively integrating and advancing one's position as a new employee. This article outlines strategies for cultivating one's own on-boarding as a junior faculty member at large academic medical centers. These strategies are extrapolated from management practices, culled from the medical literature on developing and retaining junior faculty, and, finally, borrowed from the hard-won knowledge of junior and senior faculty members. They advise new faculty to: (1) start early, (2) define your role--"managing yourself," (3) invest in/secure early wins, (4) manage your manager, (5) identify the "true (or hidden)" organizational culture, (6) reassess your own goals--"look in the rearview mirror and to the horizon," and (7) use your mentors effectively. These strategies provide a roadmap for new faculty members to transition as effectively as possible to their new jobs.
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    Validation of a measure of family experience of patients with serious illness: the QUAL-E (Fam).
    (Journal of pain and symptom management, 2014-12) Steinhauser, Karen E; Voils, Corrine I; Bosworth, Hayden B; Tulsky, James A

    Context

    Family members of seriously ill patients experience significant burden as they advocate with providers and participate in key decisions for loved ones. Most assessments focus on patient experience, yet family members' own quality of experience is central to comprehensive care.

    Objectives

    This study validated a measure of the quality of family experience, the QUAL-E (Fam), in palliative care.

    Methods

    We enrolled family members of terminally ill patients admitted to general medicine services at two hospitals. Items were based on foundational work originally done for the patient instrument, QUAL-E, and interviews of family members of terminally ill patients. Cognitive interviewing was used to refine items, which then underwent formal testing factor analysis. In the first sample, we assessed factor structure. A subsequent sample established predictive validity and test-retest reliability.

    Results

    The initial item pool was reduced to a four-domain, 35-item scale and administered to the validation sample. Further analyses produced a final brief scale comprising 17 items, demonstrating appropriate convergent and divergent validity. Test-retest reliability demonstrated expected levels of stability in a highly changeable population. The scale provides an assessment of family experience and includes subscales assessing relationship with health care provider and completion. Additional scale items assess symptom experience and issues of preparation.

    Conclusion

    The QUAL-E (Fam) is a companion instrument to the patient QUAL-E measure of quality of life at the end of life and is part of a package of assessment tools that can help evaluate the entire patient experience and contribute to quality care.
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    What constitutes quality of family experience at the end of life? Perspectives from family members of patients who died in the hospital.
    (Palliative & supportive care, 2015-08) Steinhauser, Karen E; Voils, Corrine I; Bosworth, Hayden; Tulsky, James A
    Most palliative care efforts focus on assessing and improving the quality of life and quality of care for patients. Palliative care views the family as the unit of care; therefore, excellent comprehensive palliative care should also address the needs of the family and the caregiver(s). While the recent literature has offered detailed descriptions of caregiving needs in the home setting, it is crucial to describe the needs of family members who provide care for patients with advanced illness in an inpatient setting, where family members serve as the key intermediaries and decision makers. Therefore, we sought to define the relevant aspects of quality of experience for families of hospitalized patients.We convened a series of focus groups to identify the domains important for the quality of experience of dying patients' family members. Participants included bereaved family members of patients who had died at a Veterans Administration (VA) or private academic medical center. We conducted four in-depth follow-up interviews to probe for additional details and validate our interpretation of the focus group findings.Participants (n = 14) ranged in age from 46 to 83, with a mean of 62. All were female; 64% were Caucasian, 21% African American, and 14% did not report their ethnicity. Content analysis yielded 64 attributes of quality of family experience constituting eight domains: completion, symptom impact, decision making, preparation, relationship with healthcare providers, affirmation of the whole person, post-death care, and supportive services.Our data have implications for clinical guidance in assisting family members in the inpatient palliative setting, which often includes patient incapacity for communication and decision making. They suggest the importance of developing corresponding methods to assist families with the tasks involved with life completion, being prepared for a crisis and imminent death, and post-death care. Provider communications and relationships are central to the processes of meeting the clinical needs of family members. Our findings should inform the development of measures to assess family experience.