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The Case for Communication Intervention

The manner by which patients and their health care providers communicate with each other significantly affects patient perceptions of health care quality and outcomes. Previous work by Hall et al. in 1988 assessing the impact of patient-provider communication in health care settings showed that patient satisfaction improved when physicians: (1) treated patients as partners; (2) used more words with positive connotations; (3) used fewer words with negative connotations; (4) engaged in more social conversation with their patients; and (5) exchanged a greater amount of information. Furthermore, a study by Safran et al. in 1998 found that higher patient ratings of communication are associated with higher rates of adherence to physician recommendation of preventive health activities and higher patient ratings of health status. Kaplan et al. in 1989 showed that blood glucose control and blood pressures improved when there was more patient control and less physician control of the communication, more information provided by the physician, and less negative tone of the communication. In a recent meta-analysis of more than 100 studies, physician communication was significantly positively correlated with patient adherence in which there was a 19 percent higher risk of nonadherence among patients whose physicians communicated poorly than among patients whose physicians communicated well.¹

Despite these beneficial effects, studies assessing patient-provider communication in clinical settings have determined them to be inadequate. A study published in 1984 by Waitzkin et al. showed that physicians spend less than 1 minute out of a 20-minute visit discussing treatment and planning. While patients typically want more information about their illness, recall of the information physicians communicate is frequently lacking. McBride et al. in 1994 found that patients considered communication to be one of the top three competencies a physician should possess, but frequently rated their own physicians' communication skills to be suboptimal.

As patients who are informed and involved in decision-making are more likely to adhere to medical recommendations, having patients fully informed about alternatives and potential risks of treatment is a worthwhile clinical goal.² However, in real practice this does not appear to be occurring. The Braddock et al. study in 1999 audio-recorded 1,057 clinical encounters between patients and their health care providers in which there were 3,552 clinical decisions involved. Information exchange was limited with only a minority of instances having a discussion of alternatives (11.3 percent), pros and cons (7.8 percent), assessment of patient understanding (1.5 percent), and eliciting of patient preferences (21 percent). Similarly, analysis of audio-recorded primary care visits by Ling et al. published in 2008 in which colorectal cancer screening discussions were targeted for analysis, there was a lack of discussion of alternatives (26 percent), pros and cons (17 percent), assessment of patient understanding (6 percent), and eliciting of patient preferences (17 percent) in those instances when a screening test was ordered.

Interventions Enhance Communications

As such, numerous studies have focused on interventions designed to enhance patient-provider communication. A systematic review of the literature in 2004 examined interventions directed at patients to improve patient-provider communications from 25 studies. The review found that interventions involving patients in communication training using techniques such as improved question-asking led to higher levels of patient perceived control over health, preferences for an active role in health care, recall of information, and adherence to recommendations. ³ Physician-directed interventions were also found to be beneficial. A meta-analysis by Zolnierek et al. in 2009 of 21 studies found that training physicians in communication skills resulted in substantial and significant improvements in patient adherence, with odds of patient adherence 1.62 times higher than when a physician received no training.¹

While patient-provider communication has traditionally occurred in person, technology has advanced and now allows patients and providers to communicate electronically outside of the clinic setting. Providers and patients can now communicate electronically to address issues such as following-up on test results, asking questions, exchanging information before a visit, scheduling appointments, sending reminders, and renewing prescriptions. In a study conducted by Hassol et al. (2004) as an online survey of 4,282 members of the Geisinger Health System in which patients are able to communicate electronically with their providers and view selected portions of their electronic health record, patients preferred e-mail communication for some interactions (e.g., requesting prescription renewals, obtaining general medical information), whereas they preferred in-person communication for others (e.g., getting treatment instructions). A 2002 Harris Interactive poll found that 90 percent of those with Internet access would like to communicate with their physicians online, with 55 percent stating that the ability to communicate with their doctors electronically would influence their choice of health plans and 56 percent responding that this capability would influence their choice of physicians.

In conclusion, while patient-provider communication is considered an essential component of quality health care, it seems to be inadequately performed in the clinical setting. Development and implementation of communication interventions directed at patients and/or providers, as well as greater utilization of technology-driven approaches such as e-mail, may be beneficial in improving patient-provider communication.

References

1. Zolnierek KB, DiMatteo MR. Physician Communication and Patient Adherence to Treatment: A Meta-Analysis. Medical Care 2009; 47(8):826-34.
2. Beck RS, Daughtridge R, Sloane PD. Physician-patient Communication in the Primary Care Office: A Systematic Review. Journal of the American Board of Family Practice 2002; 15(1):25-38.
3. Harrington J, Noble LM, Newman SP. Improving Patients' Communication with Doctors: a Systematic Review of Intervention Studies. Patient Education and Counseling 2004; 52(1):7-16.