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A Decalogue for physician-patient communication: how Narrative Medicine produces statistically significant evidences in cardiological visits.

We host, as contribution to the debate on a possible dialog between Evidence-Based Medicine and Narrative Medicine, the presentation of a Decalogue on relationship-wise aspects to not forget in communication physician-patient setting: this work highlights how Narrative Medicine produces statistically significant evidences – in this case – in visits in Cardiology units. Decalogue authors are Massimo Milli (cardiologist at Santa Maria Nuova Hospital, Florence), Stefania Polvani (director of Health Education Structure, coordinator of Narrative Medicine Laboratory of Florence ASL), Piercarlo Ballo (S.C. Cardiology, Santa Maria Annunziata Hospital of Florence), Alfredo Zuppiroli (Cardiology Department, Florence A.S.), Fabrizio Bandini (S.S. Cardiology, Nuovo Ospedale del Mugello, A.S. Florence), Federico Trentanove (anthropologist, project researcher at Florence University, ASL Florence). 

Communication physician-patient: an important tool to improve assistance quality. The proposal of a Decalogue of relationship-wise aspects to not forget.

The communication between physician and patient is a fundamental moment, in hospital and day-surgery setting, to learn important anamnesis information for the diagnosis, to establish a therapeutic relationship and so to protect treatment adherence of patient, and to inform patient and his/her relatives about disease course. Several obstacles impede these aims: the lack of an adequate formation of physician, during his/her study course, about verbal, para-verbal and non-verbal communication principles. The leanings is that of referring to a personal sensibility, that could be more or less present. The continuous pressure about the need of a contraction of hospitalization and waiting times for outpatient services that collides, at least apparently, with the possibility to have satisfying places to talk with patients. The lack of ambiental setting adequate to communicate to the patient and his/her relatives information often emotionally hard about disease.

Still, communicating and acting in the right way in the interests of patient has a fundamental consequence on legal and clinic level. As regarding legal aspects, analyzing claims arrived at the attention of the Azienda Sanitaria of Florence (ASF, Florence HealthCare Company), we could find out that there are, essentially, controversies born on lacking communication problems, and in smaller percentage technical-professional controversies. On the other hand, if is true that physician has to be careful about his/her approach to patient, has to value the listening to patient’s upsets and disease, is also true that the patient has to be prepared to the talk with doctor, and ready to call into question the idea realized about his/her clinical condition. The facility of access to health information via the web, indeed, is an important resource to inform the patient about disease several aspects, but it could cause wrong interpretations that could prevent patient from understanding the problem and the motivations of some therapeutic choices. In conclusion, we must not forget that communication physician-patient, an act that involves two actors, has to consider attention, confidence and respect from both parts.

Since many years, ASF has been sensitive to these problems, and has founded a Narrative Medicine Laboratory which conducted several research projects: in particular, NaMe (Narrative Medicine) project, and NaMe2 project (semi-structured interviews to patients, and analysis of videotaped talks physician-patient), that concentrated in Cardiology, Oncology and Emergency unit. Starting from these experience, we tried to summarize some practical advices concerning the correct communication approach from both doctor and patient. We analyzed, together with a psychologist and sociologist group, videotapes of cardiological visits conducted during NaMe2 project. From this analysis emerged interesting observations that, linked to the clinical everyday experience, induced to draft this Decalogue of aspects not to forget in physician-patient communication.

An innovative aspect of this approach, was that of identifying the same needs for the physician and the patient – needs that must be interpreted in different ways, depending on the subject they refer. The Decalogue is composed by a poster which contains ten points and a brief explanation about the modality of application, a brochure where interested people can find further explanations and an assessment questionnaire.

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The Decalogue adapts its communication style to several subject, trying to interpret reader’s needs, and giving tools to comprehend mutual demands. The Decalogue offers a first “spot” title, easy to understand, that encourages curiosity, and then clarifies, for every item, physician’s and patient’s point of view.

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To validate this tool in clinical practice, we realized a clinical trial based on the comparison of specific assessment questionnaires, filled by patients before and after the visit, in cardiological units where the Decalogue use was inserted, and others where this tool was not applied.

Population. In Santa Maria Nuova, Borgo San Lorenzo and Santa Maria Annunziata hospitals were recruited 149 patients who arrived for a programmed cardiological visit. Patients were divided in two groups:

Sperimental group (n=100, mean age 67,5±15,9 years, 46% women): developed physicians and informed patients via the Decalogue.

Control group (n=49, mean age 70,6±13,5 years, 39% women): not developed physicians and not informed patients via the Decalogue.

Given questionnaires were:

a) POMS 2 (Profile of Mood States): questionnaire amply validated in literature, composed by 65 items, oriented to analyze the patient’s emotional state. POMS 2 value the patient’s emotional state quantifying a total score (Total Mood Disturbance) and single aspects divided in six classes: 1. tension-anxiety, 2. depression-discouragement, 3. aggressiveness-rage, 4. force-activity, 5. tiredness-indolence, 6. confusion-upset.

b) NAME Questionnaire (diagNosis, Agents, lifestyle Modification, lifE; elaborated in our centre): questionnaire composed by four questions relative to comprehension, by patient, of diagnosis, drug therapy, lifestyle modifications and disease and cares potential effect on life.

The analysis of POMS 2 scores highlights a statistically significant difference (p=0.0010) in favor of patients who did visits in centres where the Decalogue was applied, in the score general analysis and in mood single classes.

The Decalogue, then, is a tool born because of practical needs that try, through simple advices, to improve that fundamental stage, in a patient’s health-life, of the talk with doctor. Improving communication and comprehension, the Decalogue wants to move toward a partecipated and adequate care, trying to contribute to the construction of that “bridge” that allow to fix a correct trust relationship between physician and patient: ten simple advices to enhance communication, and so better understand symptoms, everyday difficulties, diagnosis and care strategies. Concluding with Balint: It is not to hope for a “good doctor”, but to strikingly reaffirm that a “capable doctor” must place side by side scientific and relationship-wise expertises.

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