Patient Information Seeking and DecisionMaking In Clinical Encounters

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Patient Information Seeking and Decision-Making
In Clinical Encounters
MGH INSTITUTE OF HEALTH PROFESSIONS
an academic affiliate of Massachusetts General
Hospital

• Dr Maura Daly Iversen
• CARE IV Conference, Leeds, England.

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Objectives

• To Address the Following Questions
• What do patients want from the patient-provider
  encounter?
• How is information shared in clinical visits?
• What are the models of communication?
• What basic assumptions misconceptions about
  provider-patient communication drive discussion?
• How does clinical communication impact health
  outcomes?

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What Do Patients Want from the Patient-Provider
Relationship?

• Establish rapport and trust!
• Diagnosis
• Receive care information
• Education in self-management
• Understand how to monitor progress identify
  problems
• Address psychosocial issues
• Develop a plan of care with provider
• Relationship quality primary reason for choosing
  another provider (Safran, 2001 Wensing et al,
  1998)

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Information Sharing and Decision-making Models
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Aspects of Communication (Roter Hall)

• Process
• Question asking,information-giving, eye contact,
  clarification, interruptions, body position
• Content
• Statements about symptoms, diagnosis,
  interventions, prognosis, side effects
• Affect
• Feelings, emotions, tone of voice

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What Basic Misconceptions Drive the Clinical
Discussion?

• Provider perspective
• Not enough time to discuss things
• Patients value technical skills more than
  communication
• Patients view provider as primary source of
  information
• Communication does not affect outcomes strongly

• Patient perspective
• The provider will discuss my needs
• Providers recognize the psychosocial impact of my
  disease
• Providers value communication
• Provider recognize and value patients seeking
  information from other sources

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What Basic Misconceptions Drive the Clinical
Discussion?

• Doctors are the primary educators
• Team coordination may not affect outcomes
• Encouraging participation of family members is
  not important
• While most patients may not remember every aspect
  of the treatment plan, they remember their
  diagnosis
• Whether you like your patient/provider does not
  affect information sharing

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What Does the Research Show Us About
Communication Outcomes

• Patients are frequently interrupted
• 72 of patients interrupted in first 23 seconds
  of visit
• When patients allowed to express concerns it
  only required 6 seconds more
• Provider who interrupt patients develop less
  precise diagnoses
• Patients who are interrupted are more likely to
  present their primary concern in the last minutes
  of the visit

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What Does the Research Show Us About
Communication Outcomes

• Patients forget most of what is said in the
  clinic visit
• Patients often cannot recall their correct
  diagnosis (Hull et al, 1987 Gines et al, 1985)
• Caregivers often do not know whether patients are
  following their prescriptions
• Patients have predetermined beliefs and
  expectations when they enter the clinic
• Discussing psychosocial issues improves
  satisfaction and adherence to Rx

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What Does the Research Show Us About
Communication Outcomes

• Patients and providers often disagree about the
  patients functional level and pain (Kwoh, 1992)
• Engaging patient in discussions and
  decision-making increases adherence and
  satisfaction
• Complicated regimens are harder to follow
  (adherence rates drop to 20-25) (Inui et al,
  1985)
• Social Support and social norms influence
  discussions
• Technological advances (eg internet) influence
  information sharing

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What Does the Research Show Us About
Communication Outcomes

• Meta-analysis of Interventions to Improve
  Communication
• Summary of 15 RCTs found a 16 decrease in
  self-reported pain, 22 crease in depression and
  improved functional ability (Mullen et al.,1987)
• RCTs of Patient Instruction in Question Asking
• Daltroy et al (1991) used telephone training and
  found
• Experimentals 13 better on general health
• 69 of experimentals vs 31 of controls had
  better communication at follow-up.
• 20 improved appointment compliance in
  experimental vs control group.

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Information Sharing and Expectations of the
Clinical visit

• In a survey of 10 rheumatology patients (Rao et
  al, 2004)
• 58 reported unmet expectations.
• Of these, 47 reported unmet expectations with
  regard to receipt of general information and 31
  for new medications.
• Failure to elicit patient expectations increases
  the likelihood patient will raise concerns late
  in the visit (Marvel et al, 1999Dupre, 2000)

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What Is Known About Outcomes of Good
Communication?

• Improves patient satisfaction
• Greater patient provider knowledge
• Improved self-efficacy
• Enhances adherence with intervention
• Improved health outcomes
• Both general level of education and
  health-specific knowledge correlates strongly
  with good health outcomes

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Summary

• Patients needs for information participation
  in decision making are not always recognized.
• Failure to elicit patient expectations, beliefs,
  and attitudes toward treatments and to negotiate
  treatment alternatives impacts satisfaction and
  outcomes of care.
• Even passive patients are more satisfied when
  they participate more in negotiations about
  treatments.
• Most communication studies show modest
  improvements in outcomes with intervention

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Practical Implications

• Data (and ethics) from multiple trials indicate
  the need to
• Elicit expectations of visit and Rx
• State Purpose intended Rx outcomes
• Provide Instruction when/how to take Rx
• Explain how treatment works
• Discuss Side effects and Rx drawbacks
• Emphasize how to assess Rx effectiveness-
  timeframe - how long until treatment works
  (especially with SMARDs)

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Practical Implications

• Consider your own attitudes and beliefs
• Encourage patients to ask questions
• Bring prioritized lists
• Use assessment sheets at intake
• Ask about attributions/ address patient concerns-
  especially psychosocial issues
• Develop mutual goals and plans to meet goals

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Practical Implications

• Evaluate patient understanding often during the
  visit and consider literacy
• Provide written instruction and diagnosis
• Develop contingency plans in case of barriers
• Demonstrate when appropriate
• Encourage significant other to be present when
  describing plan
• Refer patients to outside resources
• Help patients evaluate web resources

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Thank you