do you speak the other guys language: culture, diversity and the bottom line dr. paul mendis,m.d.,...
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Do You Speak the Other Guy’s Language: Culture, Diversity and
the Bottom Line
Dr. Paul Mendis,M.D., Chief Medical Officer
Neighborhood Health Plan
Boston, MA
Shani A. Dowd, B.A., L.C.S.W.
Dir., Clinical Cultural Competency Training
Harvard Pilgrim Health Care
Boston, MA
© Harvard Pilgrim Health Care, Inc
US Population by Race/Ethnicity2000
White 69.1%
African Amer. 12.3%
Amer. Ind. 0.9%
Asian 3.6%
Pacific Is. 0.1%
Latino 12.5%
Two or More 2.4%
© Harvard Pilgrim Health Care, Inc
Racial and Ethnic Distribution of the Population of the US:
Projected 2030
White, Non-Hisp.60.5%
African American13.1%
Hispanic 18.9%
Asian/ Pacific Is.6.6%
American In./AlaskaNat. 0.8%
Bureau of the Census, Statistical Abstract of the U.S. 1997.
© Harvard Pilgrim Health Care, Inc
Leading Causes of Death, by Race and Ethnic Group, 1996
RankWhite, non-
HispanicAfrican
AmericanLatino
NativeAmerican
AsianAmerican
Cause of
Death
1Heart
DiseaseHeart
DiseaseHeart
DiseaseHeart
DiseaseHeart
Disease
2 Cancer
CVD
Chronic lungDisease
AUI
3
4
5
Cancer Cancer Cancer Cancer
CVD AUI AUI CVD
HIV/AIDS CVD Diabetes AUI
AUI HIV/AIDS CVDPneumonia and
Influenza
AUI =accidents and unintentional injuriesCVD=cerebrovascular disease (stroke, etc.)
Source: DHHS, Health, United States,1998
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Health Care Disparities: Asthma
7% of all children in US have asthma
African American children are:
twice as likely to have asthma
Three times more likely to be hospitalized with asthma
six times more likely to die from asthma
Source: Kaiser Family Foundation www.kff.org
© Harvard Pilgrim Health Care, Inc
Health Care Disparities: AsthmaAmong Latinos, asthma prevalence varies by ethnicity:
Puerto Ricans have the highest rates: 11%
Mexican American children have the lowest rates among Latinos: 3%
Kaiser Family Foundation www.kff.org
© Harvard Pilgrim Health Care, Inc
Health StatusWhile 16% of white Americans self-report indicated that they believed they were in only fair or poor health, :
% of Asians reporting fair or poor health
40% of Vietnamese
29% Korean Americans
11% of Chinese
Kaiser Family Foundation www.kff.org
© Harvard Pilgrim Health Care, Inc
Chronic or Poor Health:
51% of all African Americans have been diagnosed with at least one of the following
within the past 5 years:
Asthma
Cancer
Heart Disease
Diabetes
High Blood Pressure
Obesity
Anxiety/depression
Source: Commonwealth Fund
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Health Care Disparities:HIV/AIDS Treatment
African Americans are twice as likely as whites to NOT receive triple drug antiviral therapies.
African Americans are 1.5 as likely to not get prophylaxis for PCP
Latinos are 1.5 times as likely as whites to NOT get triple drug antiviral therapies
Kaiser Family Foundation www.kff.org
© Harvard Pilgrim Health Care, Inc
Diabetes-Related Death Rate, 1996
11.6
28.8
18.8
8.8
27.8
0
5
10
15
20
25
30
35
White Black Hispanic Al/An Asian/Pl
Racial/Ethnic Disparities in Health: Diabetes Outcomes
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Health Care Disparities: Treatment for Cardiac Care
Among Medicare Beneficiaries:
African Americans are 60% LESS likely than whites to received heart bypass surgery, even when controlled for income, insurance status and place of treatment
Kaiser Family Foundation www.kff.org
© Harvard Pilgrim Health Care, Inc
Racial/Ethnic Disparities in Health:
Cardiovascular Procedures
Differential use based on race of:
Cardiac catherization and angioplasty (Harris et al, Ayanian et al.)
Coronary artery bypass graft (Peterson et al.)
Treatment of chest pain (Johnson et al.)
Referral to cardiology specialist care (Schulman et al.)
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Life Expectancy (in years) at birth and by race and sex, United States, 1998
62
64
66
68
70
72
74
76
78
80
WhiteMales
BlackMales
WhiteFemales
BlackFemales
Life Expectancy inYears
Source: Health United States, 2000. Bureau of Primary Health Care
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10 Health Conditions with Greatest Disparities Between Whites and Members
of Ethnic Communities
COPD
Cancer
Cardiovascular Disease
Infant Mortality Rates
Diabetes
HIV/AIDS
Child and Adult Immunizations
Pneumonia
Stroke
Tuberculosis
© Harvard Pilgrim Health Care, Inc
Percentage of Adults Reporting Problems with Communication with MD
33% of all Latinos
27% of all Asians
23% of all African Americans
16% of all white, non-Latinos
Source: Commonwealth Fund (www.cwf.org)
© Harvard Pilgrim Health Care, Inc
Communication Problems with MD
Of those reporting problems, one or more of the following were reported:
MD did not listen to everything that pt. said
Patient did not fully understand MD
Had questions but did not feel comfortable asking
Source: Commonwealth Fund www.cwf.org
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Latinos Reporting Communication Problems
43% report Spanish as their primary language
26% report English as their primary language.
Source: Commonwealth Fund \\www.cwf.org
© Harvard Pilgrim Health Care, Inc
Patient Satisfaction
Patient satisfaction increases when clinician uses psychosocially-oriented interview
Psychosocially oriented interview was LEAST frequently used
Perception among physician that takes more time
BUT: Study found that psychosocial interview did not significantly increase time of the clinical encounter
Roter,DL, Stewart, M., Putnam, SM, Lipkin, M, Stile, W. & Inui, T (1997) Communication patterns of primary care physicians. Journal of the Amer. Med. Assoc., 277(4):350-56.
© Harvard Pilgrim Health Care, Inc
Malpractice and Physician-Patient Communication
Specific communication problems were identified in a sample of malpractice claims. Physicians with no claims against them were more likely to:
orient patients to the process of the visit
use facilitative statements more, e.g. “Go on, tell me more”
ask patients’ opinions about their medical problems
use humor, indicated warmth and friendliness
Levinson, WL, Roter, DL, Mullooly, JP, et al. (1997) Physician -patient communication: The relationship with malpractice claims among primary care physicians and surgeons. JAMA, 277:553-559.
© Harvard Pilgrim Health Care, Inc
Malpractice and Physician-Patient Communication
Four problematic themes emerged when plaintiffs depositions were reviewed:
Deserting the patient 32%
Devaluing the patient or family views 29%
Delivering information poorly 26%
Failing to understand the patient
and/or family perspective 13%
Beckman, HB, Markakis, KM, Suchman, AL and Frankel, RM. (1994) The Doctor Patient Relationship and malpractice: Lessons from Plaintiff Depositions. Arch. Internal Med., 154: 1365-1370.
© Harvard Pilgrim Health Care, Inc
Malpractice and Physician-Patient Communication
While 1% of hospitalized patients suffer a significant injury due to negligence, fewer than 2% of these patients initiate a malpractice claim.
Patient dissatisfaction is the key element in the decision to initiate a malpractice claim.
Levinson, WL, Roter, DL, Mullooly, JP, et al. (1997) Physician -patient communication: The relationship with malpractice claims among primary care physicians and surgeons. JAMA, 277:553-559.
© Harvard Pilgrim Health Care, Inc
The New Millennium (Health Care Environment)
Health care entities are fewer in number, but larger & more complex in size, product offerings & geography
E-Health will play an increasingly important role in health care industry
Loyalty to skill/profession, work group, colleagues is shifting for many providers
Rapid change (revolutionary)
© Harvard Pilgrim Health Care, Inc
Motivations for Addressing Cultural Issues in Health Care in the United States
Changing demographics
Increasing globalization of US economy
Rising advocacy of health care consumers
Increasing regulatory requirements
Continuing documentation of inequities in access to health care and health care information and in health outcomes
© Harvard Pilgrim Health Care, Inc
Meeting Regulatory and Accreditation Guidelines
NCQA
JCAHO
Office of Minority Health
Department of Medical Assistance
Employer Request for Proposals
Licensure Requirements
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Meeting Regulatory and Accreditation Guidelines
Physicians and hospitals who wish to participate in federally funded medical programs, specific requirements are articulated in the language of the contract relating to cultural issues, such as linguistic access:
• Balanced Budget Act of 1997
• Medicare
• Medicaid
© Harvard Pilgrim Health Care, Inc
Commercial Insurers
Increasingly, large employer groups are finding that their workforces are increasingly diverse in
languages spoken
ethnic cultures
racial groups
religious groups
gender
disabilities
© Harvard Pilgrim Health Care, Inc
What is Cultural Competence?
It is the ability to deliver effective medical care to people from different cultures.
By understanding, valuing and incorporating the cultural differences of America’s diverse population and examining one’s own health-related values and beliefs, health providers deliver more effective and cost-efficient care.
© Harvard Pilgrim Health Care, Inc
What is Cultural Competence?
“…the demonstrated awareness and integration of three population-specific issues:
health-related beliefs and cultural values,
disease incidence and prevalence, and
treatment efficacy.”
Risa Lavisso-Mourey, MD, MBA & Elizabeth Mackenzie, PhD
© Harvard Pilgrim Health Care, Inc
Diversity and Its Stumbling Blocks
•Literacy and Language•Class-related values•Culture related values•Communication•Stereotypes•Racism•Ethnocentricity
Charles, L.T. & Kennedy, D.B. (2000) Social and Cultural Influences on Health. (www.pitt.edu/~super1/lecture)
© Harvard Pilgrim Health Care, Inc
Patient Cultural FactorsThese factors are shown to facilitate immigrants positive adjustment to medical care in the US: A relatively high level of formal education
Greater generational removal from immigrant status
Low degree of encapsulation within an ethnic and family social network
Experiences with medical services that incorporate patient
education
© Harvard Pilgrim Health Care, Inc
Facilitating Cultural Factors (Cont’d)
Previous experience with particular diseases in the immediate family
Immigration to host culture at an early age.
Urban, as opposed to rural origin.
Limited migration back and forth to the home culture.
Harwood, A. (1981) Ethnicity and Medical Care. Cambridge, MA: Harvard Univ. Press.
© Harvard Pilgrim Health Care, Inc
Literacy
40 to 44 million adult Americans are functionally illiterate
50 million have only marginal literacy skills
72 million cannot read technical reports or news magazines
Charles, L.T. & Kennedy, D.B. (2000) Social and Cultural Influences on Health. (www.pitt.edu/~super1/lecture)
© Harvard Pilgrim Health Care, Inc
Literacy
One-half of the adult population of the U.S. has basic literacy deficits:
• 21-23% read no more than 4th grade level
• Unable to read newspaper, follow written instructions
• 25-28% of adult Americans read at about 8th grade level
Greatest number of low-literate adults are native born whites.
Charles, L.T. & Kennedy, D.B. (2000) Social and Cultural Influences on Health. (www.pitt.edu/~super1/lecture)
© Harvard Pilgrim Health Care, Inc
Written Medical Material
Literacy levels vary enormously across class, gender and age.
Bilingual people often have widely different literacy levels in the languages they speak
Literate readers may encounter difficulty translating diagrams which inevitably make use of culturally “normal” visual concepts
© Harvard Pilgrim Health Care, Inc
Literacy and Gender
Among the Sudanese over 15 years of age:
34.6% of all females are literate
57.7% of all males are literate
Among the Congolese, over 15 years of age:
67.2% of all females are literate
83.1% of all males
© Harvard Pilgrim Health Care, Inc
Written Medical Information
Speakers of the same language may vary in idiomatic language use based on gender, age, nationality and class.
How the information is dispersed may signal authenticity in a given culture.
© Harvard Pilgrim Health Care, Inc
Written Medical Material
Literate readers may encounter difficulty translating diagrams which inevitably make use of culturally “normal” abbreviations.
Readers may have cultural barriers to receiving certain kinds of information in writing, or in possessing certain kinds of written information.
© Harvard Pilgrim Health Care, Inc
Developing Written Materials in Languages other than English
Do not assume that highly educated bi-lingual staff, including physicians, are as literate in their firsat language as they are in English.
Do research (focus groups) to determine which dialects should be used.
Use simple language, and where possible, easy to communicate basic concepts.
All literature must be “back translated”.
© Harvard Pilgrim Health Care, Inc
Back Translation
Material is translated from English to target language and target dialect.
Independent translator who speaks target language and target dialect translates document back to English.
Independent translator re-translates document.
Translation errors are corrected and errors in idiomatic expression are corrected.
© Harvard Pilgrim Health Care, Inc
Translation of Clinical Condition: Rheumatoid Arthritis
English:
Rheumatoid arthritis can be acute or chronic. Acute rheumatoid arthritis is more common during adolescence. The cause is believed to be due to an over-sensitive reaction of the joints to the Beta Hemolytic Streptococcus. The most common sites of infection are the throat and tonsil.
English to Chinese to English:
Wet Wind Style Joint inflammation has fast and slow type. The fast type sees more at small year time. The reason for its up believes to be the joint’s over-sensitive reaction to the blood-dissolving chain-ball bacteria. And the affecting path is most frequently the swallow tube and the flat-peach gland.
© Harvard Pilgrim Health Care, Inc
Linguistic Heterogeneity: Chinese
Majority of elderly speak Toisenese; most of them also understand Cantonese.
Mandarin speakers are likely to be students or professionals who probably also speak English (except for the elderly). They tend not to speak Cantonese.
Cantonese-speaking Chinese also speak Mandarin if they are educated.
© Harvard Pilgrim Health Care, Inc
Written Medical Material
Materials providing medical instructions need to be carefully written to avoid dangerous misunderstandings
For Example:
“three times a day”
“insert suppository”
“take with food”
© Harvard Pilgrim Health Care, Inc
Case Example
A fifty-nine year old bilingual Vietnamese immigrant who had been a farmer in Vietnam and was poorly educated prior to immigration, interpreted the direction, “Take with meals,” to mean he should carry the medication in his lunch pail. He did not actually take the medication at the time he ate, as he did not want anyone to know he was ill.
© Harvard Pilgrim Health Care, Inc
The lower the patient satisfaction with the interaction, the greater the
likelihood of non-adherence
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
Perceptions of Time
•How does the patient perceive or organize time?
Patients who are not regularly employed outside the home are usually less “clock-bound” in their perceptions of and organization of time.
Some patients organize time by tasks, rather than by clock time.
In many communities of color, time is organized in a more fluid and phenomenological manner.
© Harvard Pilgrim Health Care, Inc
Perceptions of Time
• Medications requiring rigid dosing by “clock time” must be carefully discussed and reviewed.
• The provider should attempt to determine how the patient understands time.
© Harvard Pilgrim Health Care, Inc
Perceptions of Time
In some cases it may be necessary to tie dosing to an activity or to an event rather than to “clock time”:
e.g. “Take the medication about the time your children would come home from school.”
© Harvard Pilgrim Health Care, Inc
Employ Positive Non-Verbal Behaviors
Lean forward
Silence - LISTEN
Appropriate eye contact
Warm expression
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
The Popularity of
Alternative Medicine More than 4 out of 10 people in the United States visited alternative
medicine practitioners in 1997.
Sharp increase in the number of Americans using it, from 61 million in 1990 to 83 million in 1997, even though many alternative therapies aren’t covered by insurance.
Patients’ spending on alternative therapies nearly doubled from 9.4 billion dollars in 1990 to 17 billion dollars in 1997.
(1998)Trends in Alternative Medicine Use in the United States, 1990-1997, JAMA , 280: 1569-1575.
© Harvard Pilgrim Health Care, Inc
Demographic Profile of People Using Alternative Medicine
In addition to patients from many ethnic groups:
•People who are ages 35 – 49
•Very well-educated
•Incomes of about $50,000 a year
•People who are sick:
In fact, 7 out of 10 cancer patients turn to an alternative therapy
as a means of maximizing their hopes of seeing a cure.
© Harvard Pilgrim Health Care, Inc
Use of Herbal treatments
Most patients tend to think of herbal treatments as “natural” and “safe”…
However a small scale study examining the effects of St. John’s Wort (n=5) reported:
That patients taking St. John’s Wort & Camptosar (a chemotherapy agent) showed a 40% reduction in blood levels of Camtosar
Suppressant effect may last for at least 3 weeks after discontinuing St. John’s Wort
Source: Boston Globe, April 9, 2002
© Harvard Pilgrim Health Care, Inc
Lack of Trust
In many ethnic communities, there is a distinct lack of trust of medical institutions: African Americans recall the infamous Tuskeegee study
which affected hundreds of African american families.
Forced sterilization of ethnic minority women was a fairly common event well into the 1960’s
In many American medical institutions, ethnic minorities and poor whites were used as experimental subjects without their consent.
© Harvard Pilgrim Health Care, Inc
Lack of Trust•Many ethnic minority patients find it easy to believe that a provider is experimenting on them
•Many believe that medications used to treat whites are “too strong for the system” of ethnic people.
•Patients who are being treated for diseases with no apparent symptoms, find it hard to be compliant with treatment regimens, especially in the context of abuses in the medical care system.
© Harvard Pilgrim Health Care, Inc
Provide Information
•Be persuasive as opposed to commanding•Describe use•Inform about side effects:
Research shows: This does NOT increase
side effects•Tell when and how medication will help•Avoid being too complicated or detailed•Use “plain” English, avoid technical terms•Avoid anxious mannerisms (e.g. touching self, shuffling papers, looking at watch). These may be interpreted as a lack of truthfulness or honesty.
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
Determine the Patient’s View of the Medication Regimen
Ask the person: Do you think there will be any problems with the medication?
Have you taken a medication similar to this in the past?
• Provide Information
• Provide Strategies
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
Causes of Non-AdherenceHealth Beliefs:
Person’s perceptions of• Seriousness of the illness
• Outcomes of non-treatment
• Perceived ineffectiveness of treatment
Lack of social support
Social discouragement
Adverse effects
Lengthy or complicated treatment regimensSource: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
Causes of Non-Adherence
Poor Communication• Minimal medical supervision• Insufficient instruction• Poor Feedback• Interactions with health professional
perceived as unfriendly
perceived as unconcerned
little interaction
unilateral interaction
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
Patient Satisfaction Patient satisfaction increases when clinician uses
psychosocially-oriented interview
Psychosocially oriented interview was LEAST frequently used
Perception among physician that takes more time
BUT: Study found that psychosocial interview did not significantly increase time of the clinical encounter
Roter,DL, Stewart, M., Putnam, SM, Lipkin, M, Stile, W. & Inui, T (1997) Communication patterns of primary care physicians. Journal of the Amer. Med. Assoc., 277(4):350-56.
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical Information
Many languages lack terms equivalent to our medical terminology:
When interviewed in English, patients sometimes responded positively to questions, even when they were confused by the terminology used in the interview.
When interviewed in their language of origin, lack of understanding was more readily identified.
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys, Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical Information
Questions that created problems for respondents included those in which:
The concept or wording was unclear
The translation was difficult
The concept or wording was culturally inappropriate
The request for sensitive information led to untruthful responses
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical Information
Questions which worked better were those which:
used clearly defined concepts
used clear and simple language
asked for factual information
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical Information
Survey questions which were identified as most problematic were those which attempted to elicit:
socio-demographic information
preventive behaviors
attitudes and beliefs
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical Information
Consider the question “When did you have your last check-up?”
Focus groups were conducted in Spanish, English, Cantonese and Vietnamese.
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical Information
“When did you have your last check-up?”
Focus group feedback revealed:
Latinas felt that most Latina respondents would lie, because they knew they were “supposed” to get check-ups, whether they did or not.
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical Information
Focus Group feedback: “Last Checkup?”
Chinese women wondered why one would go to a doctor if one was healthy. They felt that Chinese respondents might associate regular check-ups with a presumption of illness, may not answer truthfully, even if they did indeed have a check-up.
Vietnamese women had trouble understanding the concepts of “routine” and “check-up” though most answered the question in the affirmative when interviewed in English.
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Communication: Soliciting the Patient’s Concerns
Communication is at the heart of the clinician patient encounter:
Physicians actively solicited patient concerns in 75.4% of interviews
Patients’ initial statement of concerns was completed in only 28% of interviews.
In 24.6% of visits, the physician did not ask the patient about his/her concerns.
Marvel, MK, Epstein, RM, Flowers, K & Beckman, HB (1999) Soliciting the patient’s agenda: have we improved? JAMA, 281(3):283-287
© Harvard Pilgrim Health Care, Inc
Communication
The average visit length was 15 minutes.
The average patient who came with one or more concerns used only 32 seconds to complete their review of concerns.
No patient used more than 129 seconds.
Marvel, MK, Epstein, RM, Flowers, K & Beckman, HB (1999) Soliciting the patient’s agenda: have we improved? JAMA, 281(3):283-287
© Harvard Pilgrim Health Care, Inc
Communication
When patients were allowed to complete their initial statement of concerns, there were fewer spontaneous statements of concerns which occurred after the history taking portion of the interview (14.9% vs. 34.9%)
Marvel, MK, Epstein, RM, Flowers, K & Beckman, HB (1999) Soliciting the patient’s agenda: have we improved? JAMA, 281(3):283-287
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