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Awkward Moments in Patient-Physician Communication about HIV Risk

Ronald M. Epstein, MD; Diane S. Morse, MD; Richard M. Frankel, PhD; Lisabeth Frarey, BA; Kathryn Anderson, MA; and Howard B. Beckman, MD
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From Highland Hospital Primary Care Institute, University of Rochester School of Medicine and Dentistry, and Rochester General Hospital, Rochester, New York; and the Institut d'Estudis de la Salut, Barcelona, Spain. Acknowledgments: The authors thank Peter Franks, MD, for statistical consultation; Karen Vane for manuscript preparation; and the physicians and patients who permitted us to examine their discussions about sensitive topics. Grant Support: Dr. Epstein is supported by the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program. Requests for Reprints: Ronald Epstein, MD, Highland Hospital Primary Care Institute, Department of Family Medicine, University of Rochester School of Medicine and Dentistry, 885 South Avenue, Rochester, NY 14620. Current Author Addresses: Dr. Epstein, Ms. Frarey, and Ms. Anderson: Highland Hospital Primary Care Institute, Department of Family Medicine, University of Rochester School of Medicine and Dentistry, 885 South Avenue, Rochester, NY 14620.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;128(6):435-442. doi:10.7326/0003-4819-128-6-199803150-00003
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Background: Physicians frequently encounter patients who are at risk for HIV infection, but they often evaluate risk behaviors ineffectively.

Objective: To describe the barriers to and facilitators of comprehensive HIV risk evaluation in primary care office visits.

Design: Qualitative thematic and sequential analysis of videotaped patient–physician discussions about HIV risk. Tapes were reviewed independently by physician and patient and were coded by the research team.

Setting: Physicians' offices.

Participants: Convenience sample of 17 family physicians and general internists. Twenty-six consenting patients 18 to 45 years of age who indicated concern about or risks for HIV infection on a 10-item questionnaire administered before the physician visit were included.

Measurements: A thematic coding scheme and a five-level description of the depth of HIV-related discussion.

Results: In 73% of the encounters, physicians did not elicit enough information to characterize patients' HIV risk status. The outcome of HIV-related discussions was substantially influenced by the manner in which the physician introduced the topic, handled awkward moments, and dealt with problematic language and the extent to which the physician sought the patient's perspective. Feelings of ineffectiveness and strong emotions interfered with some physicians' ability to assess HIV risk. Physicians easily recognized problematic communication during reviews of their own videotapes.

Conclusions: Comprehensive HIV risk discussions included providing a rationale for discussion, effectively negotiating awkward moments, repairing problematic language, persevering with the topic, eliciting the patient's perspective, responding to fears and expectations, and being empathic. Educational programs should use videotape review and should concentrate on physicians' personal reactions to discussing emotionally charged topics.




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