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VA is making substantial efforts to communicate
the VA mission and goals throughout
its workforce. A recent effort to communicate
this mission across VA is embodied
in our commitment to the core values
represented in the acronym ICARE (Integrity,
Commitment, Advocacy, Respect, and
Excellence). A reflection of VA's mission is
also found in the four themes and 10 strategies
that constitute the VA Blueprint for
Excellence, which details a vision for the future
of VA. Both ICARE and the Blueprint
are national brand campaigns that highlight
the importance of patient-centered care.
The Blueprint identifies patient-centered
care as one of the six aims for high-quality
health care identified by the Institute of
Medicine.
The focus of this response will be on
patient-centered communication, which
is one aspect, but also a main ingredient
in delivering patient-centered care.
Provider-patient communication can be
patient-centered or provider-centered.
Patient-centered communication achieves
several functions including: fostering healing
relationships, exchanging information,
responding to emotions, making decisions,
managing uncertainty, and enabling patient
self-management.
Efforts to improve patient-centered communication
that focus on physicians'
communication have not harnessed the
full potential of patient-centered communication
because they focus on half of the
conversation. Attention to patients' communication
is equally important. Patients'
active participatory communication behaviors
(e.g., asking questions, giving opinions)
are important because these types of active
behaviors are influential in medical encounters.
Because of social norms of communication,
when patients are active (e.g., ask a
question) they can expect to get a reciprocal
response from their provider (e.g., an answer
to their question). That is, providerpatient
communication is a two-way street.
Patients' active participatory communication
is powerful because patients who ask
questions, make assertions or requests, and
communicate concerns and opinions can
influence providers' communication, behavior,
and recommendations.
Several studies have shown that interventions
aimed at teaching patients better
communication behaviors lead to improved
process and outcomes of care. Yet, efforts
to coach patients on how to improve communication
behaviors rarely occur because
coaching interventions require time, labor,
and resources. Paper-based methods of
delivering coaching interventions have had
modest or no effect on patients' communication
behaviors. Intervention options that
bridge the gap between resource intensive
person-to-person coaching interventions
and paper-based interventions need to be
investigated. Alternative ways to coach patients
might involve patient navigators, peer
support, video, and electronic methods. A
video intervention may overcome prior barriers
to implementation because video-based
approaches offer several advantages over
other approaches. Video-based direct-toconsumer
programs are used effectively by
the pharmaceutical industry on television.
These advertisements influence patient behavior
and activate patients to make specific
requests. Few studies have explored video
as a medium for delivery of interventions
to encourage patients' active communication
behavior. I have worked to understand
the full potential of video, which has the
advantage of being significantly less expensive
than interventions requiring coaching
personnel, and may be more easily disseminated
than coaching interventions that rely
on trained personnel.
Patient-centered care depends on clinicians
to use patient-centered communication
and patients (and their companions) to be
prepared to use active participatory communication.
Patients who have difficulty
using active participatory communication
behaviors are less involved in consultations
with their providers, receive less information
and support, and are less satisfied with
their care. In turn, these patients may not
understand their treatment options. Furthermore,
even when a treatment is chosen,
patients may have less knowledge about that
treatment, fewer positive beliefs about it,
and less trust in the providers administering
it. Consequently, patients may have poorer
adherence to treatment and self-care recommendations
and may experience poorer
health outcomes.
As part of my research program, I developed
"Speak Up," an educational video to
encourage patients to use active participatory
communication behaviors in visits
with their provider. Based on focus group
data, literature reviews, and input from our
expert panel, the video presents positive
role modeling of communication in medical
encounters. Role modeling is an effective
method of preparing patients for visits and
for encouraging appropriate behaviors; in
fact, such modeling is a standard approach
in medical education.
In our evaluation, we have found the video
to be acceptable to VA patients and feasible
for use in a busy VA primary care clinic.
We have used the video as part of new patient
orientation at a VA community-based
outpatient clinic. We are currently testing
whether watching the video influences patients'
communication in a project funded
by HSR&D. Another HSR&D project
will evaluate pre-visit video as a means to
promote improved communication in the
setting of clinical video telehealth visits. Our
research projects include provider training
in agenda setting, so that providers are prepared
for activated patients.
Our video intervention provides specific
communication strategies and behaviors
for patients to model in preparation for
their visit. A timely video intervention
that specifically addresses patients' selfefficacy
in a culturally sensitive manner
and prepares patients for the medical visit
may increase patients' active participatory
communication in medical consultations. A
program that prepares providers and activates
patients to use patient-centered communication
has the potential to improve
communication in medical encounters and
to improve both visit and health outcomes.
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