How Clinician-Patient  Communication Can Improve Health Outcomes<br />Richard L. Street, Jr.<br />Texas A&M University<br ...
The problem:  How does one explain these findings?<br />Kaplan et al (1988)<br />Patient efforts to exert control—lower bl...
Stewart et al (2000)<br />Patient perception of dr patient-centeredness (e.g, exploring problem, finding common ground)—be...
But then what about these findings?<br />Amount of dr. information—more functional limitations and lower self-reported hea...
Or these?<br />Observer coded PCC (exploring pt. problem, finding common ground) (Stewart et al., 2000):<br />was not rela...
Theoretical pathways<br />Clinician-Patient<br />Communication<br />Patient Health <br />Outcomes<br />Conceptual/Measurem...
7<br />
Patient-Centered COMMUNICATION:Six overlapping functions<br />Epstein MR and Street RL. Patient-centered communication in ...
Proximal Outcomes<br />*understanding<br />*satisfaction<br />*clinician-patient<br />     agreement<br />*trust<br />*fee...
Exploring pathways:  A research agenda<br />Identify the health outcome of interest<br />Identify the mechanism for improv...
Coaching<br />intervention<br />Pain control<br />at 2 weeks<br />Active<br />Patient<br />Participation<br />Change in pa...
Cancer Health Empowerment for Living without Cancer Pain  (Ca-HELP) Study (R.L. Kravitz, PI)<br />Research settings<br />P...
Research measures<br />Frequency measures (Street, 2001)<br />Patient involvement-pain specific (frequency of patients’ qu...
Characteristics of the sample(N = 148)<br />
Predictors of Active Patient Participation (Street et al., 2010)<br />
Predictors of Pain Medication Adjustment <br />
Coaching<br />intervention<br />Pain control<br />at 2 weeks<br />Active<br />Patient<br />Participation<br />Change in pa...
Pain Control and Better Knee Function for Patients having Acupuncture for Osteoarthritis<br />Outcome:  Better pain contro...
The Houston Arthritis and Acupuncture Treatment Study (HAATS) <br />(PI,  M. Suarez-Almazor)<br />For the first half of th...
Communicating High vs Neutral Expectations<br />High expectations<br />“I’ve had a lot of success with patients with your ...
Research measures<br />Communication expectation measure<br />Coders’ rating on 100mm scale at baseline visit<br />Based o...
Baseline demographic and clinical characteristics<br />
Results of Path Analysis<br />Expectations Communicated<br />(baseline)<br />.11<br />Patient Expectations Acupuncture Eff...
Another pathway?  Shared Mind<br />Epstein and Peters (2009)<br />“Collaborative cognition depends on the physician being ...
Shared mind is a process:<br />A way of thinking<br />A way of talking<br />A way of collaborating<br />Shared mind is als...
Types of shared understanding<br />Similar beliefs<br />What physician believes coincides with what patient believes<br />...
PT<br />DR<br />Shared<br />Mind<br />
The CONNECT study (PI, P. Haidet)<br />Determine how well physicians understand their patient’s health belief models<br />...
The CONNECT instrument:  Six domains of health beliefs (*Haidet et al, Patient Education and Counseling 2008)<br />To what...
Study Design: cross-sectional using pre- and post-visit surveys, audiotapes of primary care encounters<br />Setting: 10 pr...
The CONNECT Instrument*<br />Six domains of explanatory models (cause, fault, control, meaning, alternative treatments, re...
Data Analysis<br />Summary scores for each CONNECT domain<br />Compared domain sum scores between patient own and physicia...
Results: Study Population<br />Patients (n=272)<br />	Physicians (n=29)<br />
Differences between patients’ model , physician models, and physician <br />beliefs about  the patients’ models<br />
Associations With Better Physician Understanding*<br />Greater Patient Participation<br />Meaning, Control, Alternative Tr...
Association With Poorer Physician Understanding*<br />African American Patients (compared w/ Caucasian)<br />Relationship ...
Conclusion<br />Significant gaps in physician understanding of patient perspectives in routine primary care settings<br />...
Questions?<br />
References<br />Epstein RM, Street RL, Jr. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing S...
HS Gordon,  RL Street, Jr.,  BF Sharf, & J Souchek. (2006)  Racial differences in doctors’ information-giving and patients...
NCI patient centered care in cancer patient
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NCI patient centered care in cancer patient

  1. 1. How Clinician-Patient Communication Can Improve Health Outcomes<br />Richard L. Street, Jr.<br />Texas A&M University<br />June 8, 2010<br />
  2. 2. The problem: How does one explain these findings?<br />Kaplan et al (1988)<br />Patient efforts to exert control—lower blood pressure and lower A1c 8-12 weeks after the consultation<br />More equal dr-pt floortime—fewer functional limitations 8-12 weeks after visit<br />Orth et al (1987)<br />lower blood pressure at 2 weeks related to:<br />Proportion of physician talk that was explaining/describing/reporting—<br />Frequency of patient talk that expressed concerns/described symptoms—lower blood pressure at 2 weeks<br />
  3. 3. Stewart et al (2000)<br />Patient perception of dr patient-centeredness (e.g, exploring problem, finding common ground)—better emotional well-being 2 months after visit<br />Street et al (1993)<br />Less nurse controlling behavior—better A1c control at 2 months<br />Ward et al (2003)<br />More active patient participation among lupus pts—less organ damage at three years<br />
  4. 4. But then what about these findings?<br />Amount of dr. information—more functional limitations and lower self-reported health (Kaplan et al, 1988)<br />Pt effort to participate in decision-making not related to subsequent A1c (Rost et al, 1991)<br />Dr. patient-centered communication (partnership-building, supportive) not related to lupus patients’ outcomes (Ward et al, 2003)<br />Negative affect related to better A1c (Kaplan et al., 1988) and poorer A1c (Street et al, 1993)<br />
  5. 5. Or these?<br />Observer coded PCC (exploring pt. problem, finding common ground) (Stewart et al., 2000):<br />was not related to pt’s emotional well-being<br />only modestly correlated with pt. perception of PCC<br />Active pt. participation in deciding breast cancer treatment (Street et al, 1995):<br /> did not predict breast cancer patients’ emotional and functional well-being at 1 year following treatment<br />did predict patient assuming responsibility for decision at 1 year which in turn predicted well-being<br />PCC trained doctors and diabetes outcomes (Kinmonth et al, 1998)<br />With trained drs, patients were happier and fatter<br />
  6. 6. Theoretical pathways<br />Clinician-Patient<br />Communication<br />Patient Health <br />Outcomes<br />Conceptual/Measurement challenges<br />
  7. 7. 7<br />
  8. 8. Patient-Centered COMMUNICATION:Six overlapping functions<br />Epstein MR and Street RL. Patient-centered communication in cancer care:<br />Promoting healing and reducing suffering. NCI, NIH publication #07-6225, Bethesda MD, 2007 <br />http://www.outcomes.cancer.gov/areas/pcc/communication<br />8<br />
  9. 9. Proximal Outcomes<br />*understanding<br />*satisfaction<br />*clinician-patient<br /> agreement<br />*trust<br />*feeling ‘known’<br />*patient feels involved<br />*rapport<br />*motivation<br />Intermediate Outcomes<br />*access to care<br />*quality medical decision<br />*commitment to<br /> treatment<br />*trust in system<br />*social support<br />*self-care skills<br />*emotional management<br />Indirect (mediated) path<br />Clinician-Patient <br />Communication <br />Processes<br />Health outcomes<br />*survival<br />*cure/remission<br />*less suffering<br />*emotional well-being<br />*pain control<br />*functional ability<br />*vitality<br />Direct path<br />
  10. 10. Exploring pathways: A research agenda<br />Identify the health outcome of interest<br />Identify the mechanism for improved health<br />Model the pathway through which communication can lead to improved health<br />Select appropriate measures for communication variables, proximal outcomes, and intermediate outcomes<br /><ul><li>Develop intervention to target communication process to activate that mechanism</li></li></ul><li>Pain Control in Cancer<br />Outcome: Better pain control at 2 weeks<br />Pathway: <br />Effective use of pain medication<br />Proximal outcomes<br />Change in pain medication (new medication, change in dose)<br />Communication variables<br />Active patient participation about pain (asking questions, expressing concern, being assertive)<br />Intervention: patient activation coaching intervention<br />Emphasize importance of patient involvement, educate about pain management, provide opportunities for practice talking to the doctor and feedback on performance<br />
  11. 11. Coaching<br />intervention<br />Pain control<br />at 2 weeks<br />Active<br />Patient<br />Participation<br />Change in pain meds<br />
  12. 12. Cancer Health Empowerment for Living without Cancer Pain (Ca-HELP) Study (R.L. Kravitz, PI)<br />Research settings<br />Patient of UC Davis Cancer Center, Kaiser Permanente oncology clinics in Sacramento and Roseville, Sacramento VA Health Care System<br />Research participants<br />Age 18-80<br />Cancers: breast, prostate, lung, head/neck, pancreatic, colorectal, esophageal<br />Worst pain of 4 or greater or worst pain of 3 with impairment of daily activities<br />Not in hospice<br />No more than one pain management consultation<br />
  13. 13. Research measures<br />Frequency measures (Street, 2001)<br />Patient involvement-pain specific (frequency of patients’ questions, assertive statements, and concerns specific about pain) overall and pain-specific<br />Ratings measures<br />Coders’ ratings of participatory decision-making (Kaplan et al, 1995)<br />Change in pain medication<br />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)<br />
  14. 14. Characteristics of the sample(N = 148)<br />
  15. 15. Predictors of Active Patient Participation (Street et al., 2010)<br />
  16. 16. Predictors of Pain Medication Adjustment <br />
  17. 17. Coaching<br />intervention<br />Pain control<br />at 2 weeks<br />Active<br />Patient<br />Participation<br />Change in pain meds<br />_<br />Baseline<br />pain<br />
  18. 18. Pain Control and Better Knee Function for Patients having Acupuncture for Osteoarthritis<br />Outcome: Better pain control and function<br />Pathway <br />Placebo effect through beliefs about acupuncture<br />Proximal outcomes<br />Patient expectations that acupuncture will improve pain and function<br />Communication Intervention<br />Acupuncturists communicating high vs. neutral expectations for treatment success<br />
  19. 19. The Houston Arthritis and Acupuncture Treatment Study (HAATS) <br />(PI, M. Suarez-Almazor)<br />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.<br />
  20. 20. Communicating High vs Neutral Expectations<br />High expectations<br />“I’ve had a lot of success with patients with your kind of knee pain”<br />“I’m optimistic this is going to work for you.”<br />“You should start feeling better within 4 or 5 treatments”<br />“Sometimes it just takes a little longer to work, but it usually does”<br />Neutral expectations<br />“It works for some patients and not for others.”<br /> “I am not sure if it’ll work. We just have to wait and see if it helps you”<br />“It may be that it’s not working, maybe it will after a few more treatments”<br />
  21. 21. Research measures<br />Communication expectation measure<br />Coders’ rating on 100mm scale at baseline visit<br />Based on what you heard, rate this practitioner’s communication style when discussing treatment expectations for improvement. <br />Neutral ___________________________________High<br />Patient expectations (assessed at 4 weeks)<br />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)<br />Pain and Function measures<br /> WOMAC scale response at + 6 weeks and + 3 months<br />Pain—How much pain do you have ‘walking on a flat surface,’ ‘going and down stairs,’ etc<br />Function—What degree of difficulty do you have with ‘ascending stairs,’ ‘getting in/out of car,’<br />
  22. 22. Baseline demographic and clinical characteristics<br />
  23. 23. Results of Path Analysis<br />Expectations Communicated<br />(baseline)<br />.11<br />Patient Expectations Acupuncture Effectiveness<br />(4 weeks)<br />.77<br />Pain <br />6wk<br />Pain <br />3 months<br />-.32<br />Patient Baseline Expectations<br />.37<br />All effects were significant, P < .05<br />good overall model fit: chi-square=5.2, p=.39, RMSEA=.01<br />
  24. 24. Another pathway? Shared Mind<br />Epstein and Peters (2009)<br />“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).<br />
  25. 25. Shared mind is a process:<br />A way of thinking<br />A way of talking<br />A way of collaborating<br />Shared mind is also an outcome<br />Shared understanding of the problem<br />Understanding the others’ perspective<br />Reaching agreement on a course of action<br />
  26. 26. Types of shared understanding<br />Similar beliefs<br />What physician believes coincides with what patient believes<br />Perceived agreement (fantasy)<br />What physician believes coincides with what physician believes patient believes<br />Understanding of the other (perspective-taking)<br />What physician believes the patient believes coincides with what the patient believes<br />
  27. 27. PT<br />DR<br />Shared<br />Mind<br />
  28. 28. The CONNECT study (PI, P. Haidet)<br />Determine how well physicians understand their patient’s health belief models<br />Identify predictors of greater understanding (more accurate perspective taking)<br />Communication factors—more active patient participation (asking questions, expressing concerns, stating opinion and preferences)<br />Relationship factors—number of previous visits, racial/gender concordance<br />Cultural factors—as assessed by physician-patient demographics<br />
  29. 29. The CONNECT instrument: Six domains of health beliefs (*Haidet et al, Patient Education and Counseling 2008)<br />To what extent:<br />is there a biological cause to the patient’s health condition<br />is the patient at fault for his/her health condition<br />does the patient have control over his/her health condition<br />does the condition have meaning for the patient<br />can the patient’s health condition benefit from natural/alternative remedies<br />does patient want a partnership with the doctor<br />
  30. 30. Study Design: cross-sectional using pre- and post-visit surveys, audiotapes of primary care encounters<br />Setting: 10 primary care clinics in Houston, TX<br />Subjects: 272 adult patients receiving care from 29 physicians<br />
  31. 31. The CONNECT Instrument*<br />Six domains of explanatory models (cause, fault, control, meaning, alternative treatments, relationship)<br />*Haidet et al, Patient Education and Counseling 2008<br />
  32. 32. Data Analysis<br />Summary scores for each CONNECT domain<br />Compared domain sum scores between patient own and physician understanding<br />Used multivariate models to examine predictors of greater physician udnerstanding<br />Accounted for effect of patients nested within physicians<br />
  33. 33. Results: Study Population<br />Patients (n=272)<br /> Physicians (n=29)<br />
  34. 34. Differences between patients’ model , physician models, and physician <br />beliefs about the patients’ models<br />
  35. 35. Associations With Better Physician Understanding*<br />Greater Patient Participation<br />Meaning, Control, Alternative Treatments, Relationship (p = 0.01-0.05)<br />Race Concordance<br />Control (p = 0.02)<br />Lower Patient Education<br />Control (p = 0.008)<br />Male Physician<br />Control, Relationship (p = 0.004, 0.05)<br />*Lower absolute difference between <br />patient own and physician understanding score<br />
  36. 36. Association With Poorer Physician Understanding*<br />African American Patients (compared w/ Caucasian)<br />Relationship (p = 0.02)<br />Hispanic patients (compared with Caucasian)<br />Meaning (p = O.06)<br />*Greater absolute difference between <br />patient own and physician understanding score<br />
  37. 37. Conclusion<br />Significant gaps in physician understanding of patient perspectives in routine primary care settings<br />Certain demographic factors may impact physician understanding<br />Active patient participation improved understanding in multiple domains<br />
  38. 38. Questions?<br />
  39. 39. References<br />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.<br />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. <br />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.<br />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.<br />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.<br />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.<br />
  40. 40. HS Gordon, RL Street, Jr., BF Sharf, & J Souchek. (2006) Racial differences in doctors’ information-giving and patients’ participation. Cancer, 106, 1313-1320.<br />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.<br />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.<br />

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