How Clinician-Patient How Clinician-Patient Communication Can Improve Communication Can Improve

Health OutcomesHealth Outcomes

Richard L. Street, Jr.Texas A&M University

June 8, 2010

The problem: How does one The problem: How does one explain these findings?explain these findings?

Kaplan et al (1988)◦ Patient efforts to exert control—lower blood

pressure and lower A1c 8-12 weeks after the consultation

◦ More equal dr-pt floortime—fewer functional limitations 8-12 weeks after visit

Orth et al (1987)◦lower blood pressure at 2 weeks related to:◦ Proportion of physician talk that was

explaining/describing/reporting—◦ Frequency of patient talk that expressed

concerns/described symptoms—lower blood pressure at 2 weeks

Stewart et al (2000)◦Patient perception of dr patient-

centeredness (e.g, exploring problem, finding common ground)—better emotional well-being 2 months after visit

Street et al (1993)◦Less nurse controlling behavior—better

A1c control at 2 monthsWard et al (2003)

◦More active patient participation among lupus pts—less organ damage at three years

But then what about these But then what about these findings?findings?

Amount of dr. information—more functional limitations and lower self-reported health (Kaplan et al, 1988)

Pt effort to participate in decision-making not related to subsequent A1c (Rost et al, 1991)

Dr. patient-centered communication (partnership-building, supportive) not related to lupus patients’ outcomes (Ward et al, 2003)

Negative affect related to better A1c (Kaplan et al., 1988) and poorer A1c (Street et al, 1993)

Or these?Or these?Observer coded PCC (exploring pt. problem,

finding common ground) (Stewart et al., 2000):◦ was not related to pt’s emotional well-being◦ only modestly correlated with pt. perception of PCC

Active pt. participation in deciding breast cancer treatment (Street et al, 1995):◦ did not predict breast cancer patients’ emotional and

functional well-being at 1 year following treatment◦ did predict patient assuming responsibility for

decision at 1 year which in turn predicted well-beingPCC trained doctors and diabetes outcomes

(Kinmonth et al, 1998)◦ With trained drs, patients were happier and fatter

Clinician-Patient

Communication

Patient Health

Outcomes

Theoretical pathways

Conceptual/Measurement challenges

7

8

Patient-Centered COMMUNICATION:Six overlapping functions

Epstein MR and Street RL. Patient-centered communication in cancer care:Promoting healing and reducing suffering. NCI, NIH publication #07-6225, Bethesda MD, 2007 http://www.outcomes.cancer.gov/areas/pcc/communication

Clinician-Patient Communication Processes

Proximal Outcomes*understanding*satisfaction*clinician-patient agreement*trust*feeling ‘known’*patient feels involved*rapport*motivation

Intermediate Outcomes*access to care*quality medical decision*commitment to treatment*trust in system*social support*self-care skills*emotional management

Health outcomes*survival*cure/remission*less suffering*emotional well-being*pain control*functional ability*vitality

Indirect (mediated) path

Direct path

Identify the health outcome of interest Identify the mechanism for improved

health Model the pathway through which

communication can lead to improved health

Select appropriate measures for communication variables, proximal outcomes, and intermediate outcomes

Develop intervention to target communication process to activate that mechanism

Outcome: Better pain control at 2 weeks

Pathway: ◦ Effective use of pain medication

Proximal outcomes◦ Change in pain medication (new medication,

change in dose) Communication variables

◦ Active patient participation about pain (asking questions, expressing concern, being assertive)

Intervention: patient activation coaching intervention

◦ Emphasize importance of patient involvement, educate about pain management, provide opportunities for practice talking to the doctor and feedback on performance

ActivePatientParticipation

Change in pain meds

Coachingintervention

Pain controlat 2 weeks

Research settings◦ Patient of UC Davis Cancer Center, Kaiser

Permanente oncology clinics in Sacramento and Roseville, Sacramento VA Health Care System

Research participants◦ Age 18-80◦ Cancers: breast, prostate, lung, head/neck,

pancreatic, colorectal, esophageal◦ Worst pain of 4 or greater or worst pain of 3

with impairment of daily activities◦ Not in hospice◦ No more than one pain management

consultation

Frequency measures (Street, 2001)◦ Patient involvement-pain specific (frequency of

patients’ questions, assertive statements, and concerns specific about pain) overall and pain-specific

Ratings measures◦ Coders’ ratings of participatory decision-making

(Kaplan et al, 1995) Change in pain medication

◦ Patient self-report to question, “During the visit you just completed, did  the physician recommended any change in your pain medication? “ (Yes--new medicine,; Yes--change in dose or amount of a medicine; No)

InterventionIntervention ControlControl PP

NN 7777 7171

Mean age (yrs)Mean age (yrs) 6060 5757 <.03<.03

% women% women 78%78% 84%84% nsns

% white% white 67%67% 75%75% nsns

% college degree% college degree 37%37% 46%46% nsns

Total PatientParticipation

(N = 148)

Pain-SpecificParticipation

(N = 148)

Predictor Estimate

(SE)

P Estimate

(SE)

P

Patient race = Caucasian

(ref = non-Caucasian)

0.88 (1.43) .54 -0.27 (0.61) .65

Patient’s age-0.20 (0.08) .01 -0.03 (0.03) .29

Patient’s education = HS or

less

(ref = some college plus)

-1.59 (1.48) .29 0.38 (0.64) .56

Patient gender = female

(ref = male)

0.71 (1.75) .69 0.66 (0.76) .39

Patient baseline pain1.01 (0.36) .005 0.48 (0.15) .002

Physician participatory

decision-making

0.26 (0.09) .006 0.13 (0.040 .001

Accompanied = yes

(ref = no)

0.15 (1.60) .93 0.36 (0.69) .60

Education session =

(ref = control)

0.54 (1.32) .68 1.51 (0.57) 0.009

Predictors of Active Patient Participation (Street et al., 2010)

Model 1

(N = 134)

Model 2

(N = 134)

Predictor Estimate

(SE)

P Estimate

(SE)

P

Patient race = Caucasian

(ref = non-Caucasian)

-0.03 (0.09) .ns -0.01 (0.09) ns

Patient’s age-0.01 (0.00) .02 -0.01 (0.00) .02

Patient’s education = HS or less

(ref = some college plus)

-0.01 (0.10) .29 -0.05(0.09) ns

Patient gender = female

(ref = male)

-0.05 (0.11) ns -0.11 (0.11) ns

Patient baseline pain0.03 (0.03) ns 0.01 (0.02) ns

Accompanied = yes

(ref = no)

-0.03 (0.11) ns 0.36 (0.69) .60

Education session =

(ref = control)

0.27 (0.9) 0.003 0.19 (0.08) 0.04

Active patient participation

(pain-specific)

0.06 (0.01) <.0001

Predictors of Pain Medication Adjustment

ActivePatientParticipation

Change in pain meds

Coachingintervention

Pain controlat 2 weeks

Baselinepain

_

Outcome: Better pain control and function

Pathway ◦ Placebo effect through beliefs about

acupuncture

Proximal outcomes◦ Patient expectations that acupuncture will

improve pain and function

Communication Intervention◦ Acupuncturists communicating high vs.

neutral expectations for treatment success

For the first half of the trial half of the acupuncturists were randomly allocated to the high expectations communication style and the other half to the neutral style. In the second half the acupuncturists switched communication styles.

The Houston Arthritis and Acupuncture Treatment Study (HAATS) (PI, M. Suarez-Almazor)

High expectations◦ “I’ve had a lot of success with patients with

your kind of knee pain”◦ “I’m optimistic this is going to work for you.”◦ “You should start feeling better within 4 or 5

treatments”◦ “Sometimes it just takes a little longer to

work, but it usually does” Neutral expectations

◦ “It works for some patients and not for others.” “I am not sure if it’ll work. We just have to wait and see if it helps you”

◦ “It may be that it’s not working, maybe it will after a few more treatments”

Communication expectation measure◦ Coders’ rating on 100mm scale at baseline visit◦ Based on what you heard, rate this practitioner’s communication

style when discussing treatment expectations for improvement. ◦ Neutral ___________________________________High

Patient expectations (assessed at 4 weeks)◦ For each condition (e.g., knee pain, stiffness), please choose how

you would expect it to be 2 MONTHS from now after you have completed the Acupuncture Treatment. (Much worse, Worse, The same. Better, Much Better)

Pain and Function measures◦ WOMAC scale response at + 6 weeks and + 3 months◦ Pain—How much pain do you have ‘walking on a flat surface,’

‘going and down stairs,’ etc◦ Function—What degree of difficulty do you have with ‘ascending

stairs,’ ‘getting in/out of car,’

High Expectations Neutral ExpectationsTCA

N=75ShamN=151

TCAN=78

ShamN=151

p+

GENDER, females – n (%) 51 (68.0%) 97 (64.2%) 50 (64.1%) 98 (64.9%) > 0.20AGE 63.5 (10.4) 65.3 (9.0) 65.5 (7.8) 63.7 (9.1) > 0.20ETHNICITY – n (%) Whites

African American

Hispanic

Other

52 (69.3%)

16 (21.3%)

4 (5.3%)

3 (4.0%)

103 (68.2%)

23 (15.2%)

14 (9.3%)

11 (7.3%)

55 (70.5%)

13 (16.7%)

8 (10.3%)

2 (2.6%)

101 (66.9%)

31 (20.5%)

14 (9.3%)

5 (3.3%)

> 0.20

EDUCATIONAL LEVEL – n (%)Less than high school

High School diploma/some college

College degree

2 (2.7%)34 (45.3%)39 (52.0%)

5 (3.3%)79 (52.3%)67 (44.4%)

3 (3.8%)35 (44.9%)40 (51.3%)

3 (2.0%)72 (48.0%)75 (50%)

> 0.20

DURATION OF KNEE PAIN, years

10.0 (11.7) 8.4 (9.6) 8.4 (7.9) 8.8 (10.4) 0.14

J-MAP 4.4 (1.2) 4.3 (1.3) 4.5 (1.3) 4.6 (1.2) 0.12

WOMAC Pain 43.3 (18.2) 44.8 (18.7) 45.6 (18.6) 45.2 (17.8) > 0.20

WOMAC Function 41.5 (19.3) 45.1 (18.5) 44.2 (18.8) 44.1 (17.6) > 0.20

Baseline demographic and clinical characteristics

.77-.32

.37

.11

Pain

6wk

Patient Expectations Acupuncture Effectiveness

(4 weeks)

Expectations Communicated

(baseline)Pain

3 months

Patient Baseline

Expectations

Results of Path Analysis

All effects were significant, P < .05

good overall model fit: chi-square=5.2, p=.39, RMSEA=.01

Another pathway? Shared Another pathway? Shared MindMind

Epstein and Peters (2009)“Collaborative cognition depends on the

physician being mindful not only of the patient’s values, thoughts, and feelings but also his or her own. Research exploring shared deliberation and shared mind must bridge cognitive science, decision research, and communication skills training and evaluate communication processes as well as patients’ experience of care” (p. 197).

Shared mind is a process:◦A way of thinking◦A way of talking◦A way of collaborating

Shared mind is also an outcome◦Shared understanding of the problem◦Understanding the others’

perspective◦Reaching agreement on a course of

action

Types of shared Types of shared understandingunderstanding

Similar beliefs◦What physician believes coincides with

what patient believesPerceived agreement (fantasy)

◦What physician believes coincides with what physician believes patient believes

Understanding of the other (perspective-taking)◦What physician believes the patient

believes coincides with what the patient believes

PT DR

The CONNECT study The CONNECT study (PI, P. (PI, P. Haidet)Haidet)

Determine how well physicians understand their patient’s health belief models

Identify predictors of greater understanding (more accurate perspective taking)◦Communication factors—more active patient

participation (asking questions, expressing concerns, stating opinion and preferences)

◦Relationship factors—number of previous visits, racial/gender concordance

◦Cultural factors—as assessed by physician-patient demographics

The CONNECT instrument: The CONNECT instrument: Six Six domains of health beliefs domains of health beliefs ((**Haidet et al, Haidet et al,

Patient Education and CounselingPatient Education and Counseling 2008 2008))To what extent:is there a biological cause to the patient’s

health conditionis the patient at fault for his/her health

conditiondoes the patient have control over his/her

health conditiondoes the condition have meaning for the

patientcan the patient’s health condition benefit

from natural/alternative remediesdoes patient want a partnership with the

doctor

Study Design: cross-sectional using pre- and post-visit surveys, audiotapes of primary care encounters

Setting: 10 primary care clinics in Houston, TX

Subjects: 272 adult patients receiving care from 29 physicians

The CONNECT InstrumentThe CONNECT Instrument**

Six domains of explanatory models (cause, fault, control, meaning, alternative treatments, relationship)

Respondent/Focus Instrument Item

Patient Own: “I have control over my illness”

Doctor own: “The patient has control over their illness”

Doc Understanding:The patient thinks he/she has control over their

illness”

*Haidet et al, Patient Education and Counseling 2008

Data AnalysisData AnalysisSummary scores for each

CONNECT domainCompared domain sum scores

between patient own and physician understanding

Used multivariate models to examine predictors of greater physician udnerstanding

Accounted for effect of patients nested within physicians

Results: Study PopulationResults: Study PopulationPatients (n=272) Physicians (n=29)

Mean age, yrs 56 (15)

Female (%) 60

AA (%) 50

Caucasian (%) 39

Hispanic (%) 11

Mean age, yrs 43 (9)

Female (%) 58

AA (%) 26

Caucasian (%) 32

Hispanic (%) 3

Asian (%) 39

Domain

A

Physician

Model

B

Physician Belief

about Patient

Model

C

Patient

Model

Difference

A vs. B

(P-value)

Difference

B vs. C

(P-value)

Cause-Biological 71.4 74.4 67.4 .059 0.009

Patient at Fault 49.1 49.1 55.0 ns <0.001

Patient has Control 78.4 75.8 82.8 0.018 <0.001

Meaning to the Patient 71.0 72.1 79.6 ns <0.001

Value of Alternative

Treatments

50.7 50.8 56.7 ns <0.001

Patient wants to be

Partner in

Relationship

82.5 81.3 89.7 ns <0.001

Differences between patients’ model , physician models, and physician beliefs about the patients’ models

Associations With Better Associations With Better Physician UnderstandingPhysician Understanding**

Greater Patient Participation◦Meaning, Control, Alternative

Treatments, Relationship (p = 0.01-0.05)Race Concordance

◦Control (p = 0.02)Lower Patient Education

◦Control (p = 0.008)Male Physician

◦Control, Relationship (p = 0.004, 0.05)*Lower absolute difference between

patient own and physician understanding score

Association With Poorer Association With Poorer Physician UnderstandingPhysician Understanding**

African American Patients (compared w/ Caucasian)◦Relationship (p = 0.02)

Hispanic patients (compared with Caucasian)◦Meaning (p = O.06)

*Greater absolute difference between patient own and physician understanding score

ConclusionConclusionSignificant gaps in physician

understanding of patient perspectives in routine primary care settings

Certain demographic factors may impact physician understanding

Active patient participation improved understanding in multiple domains

Questions?

ReferencesReferences Epstein RM, Street RL, Jr. Patient-Centered Communication in Cancer Care:

Promoting Healing and Reducing Suffering. Bethesda, MD: National Cancer Institute; 2007. Report No.: NIH Publication No. 07-6225.

P. Haidet, K.J. O’Malley, B.F. Sharf, A.P. Gladney, A.J. Greisinger, & R.L. Street Jr. (2008) Characterizing explanatory models of illness in healthcare: Development and validation of the CONNECT instrument. Patient Education and Counseling, 73, 232-239.

Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989; 27:S110-S127.

Street, R. L., Jr. (2001). Active patients as powerful communicators. In W. P. Robinson, & H. Giles (Eds.), The new handbook of language and social psychology (pp.541-560). New York: John Wiley & Sons.

R.L. Street, Jr., C. Slee, D. K. Kalauokalani, D.E. Dean, D. J. Tancredi, & R. L. Kravitz (2010) press) Improving physician-patient communication about cancer pain with a tailored education-coaching intervention. Patient Education and Counseling, 80, 42-47.

M.M. Ward, S. Sundaramurthy, D. Lotstein, T. Bush, C.M. Neuwelt, & R.L. Street, Jr. (2003). Participatory patient-physician communication and morbidity in patients with systemic lupus erythematosus. Arthritis & Rheumatism, 49, 810-818.

HS Gordon, RL Street, Jr., BF Sharf, & J Souchek. (2006) Racial differences in doctors’ information-giving and patients’ participation. Cancer, 106, 1313-1320.

Street, R. L., Jr. (2001). Active patients as powerful communicators. In W. P. Robinson, & H. Giles (Eds.), The new handbook of language and social psychology (pp.541-560). New York: John Wiley & Sons.

R.L. Street, Jr, M.N. Richardson, V. Cox, and M.E. Suarez Almazor. (2009) (Mis)Understanding in patient-health care provider communication about total knee replacement. Arthritis Care and Research, 61, 100-107.