1. How Clinician-Patient Communication Can Improve Health Outcomes Richard L. Street, Jr. Texas A&M University June 8, 2010

2. The problem: How does one 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

3. 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 months Ward et al (2003) ◦ More active patient participation among lupus pts—less organ damage at three years

4. But then what about these 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)

5. 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-being PCC trained doctors and diabetes outcomes (Kinmonth et al, 1998) ◦ With trained drs, patients were happier and fatter

6. Clinician-Patient Communication Patient Health Outcomes Theoretical pathways Conceptual/Measurement challenges

7. 7

8. 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

9. 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

10. 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

11. 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

12. Active Patient Participation Change in pain meds Coaching intervention Pain control at 2 weeks

13. 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

14. 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)

15. InterventionControlPN7771 Mean age (yrs) 6057<.03 % women % women78%84%ns % white 67%75%ns % college degree 37%46%ns

16. Total Patient Participation (N = 148) Pain-Specific Participation (N = 148) PredictorEstimate (SE) PEstimate (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).290.38 (0.64).56 Patient gender = female (ref = male) 0.71 (1.75).690.66 (0.76).39 Patient baseline pain 1.01 (0.36).0050.48 (0.15).002 Physician participatory decision-making 0.26 (0.09).0060.13 (0.040.001 Accompanied = yes (ref = no) 0.15 (1.60).930.36 (0.69).60 Education session = (ref = control) 0.54 (1.32).681.51 (0.57)0.009 Predictors of Active Patient Participation (Street et al., 2010)

17. Model 1 (N = 134) Model 2 (N = 134) PredictorEstimate (SE) PEstimate (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 pain 0.03 (0.03)ns0.01 (0.02)ns Accompanied = yes (ref = no) -0.03 (0.11)ns0.36 (0.69).60 Education session = (ref = control) 0.27 (0.9)0.0030.19 (0.08)0.04 Active patient participation (pain-specific) 0.06 (0.01)<.0001 Predictors of Pain Medication Adjustment

18. Active Patient Participation Change in pain meds Coaching intervention Pain control at 2 weeks Baseline pain _

19. 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

20. 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)

21. 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”

22. 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,’

23. High ExpectationsNeutral Expectations TCA N=75 Sham N=151 TCA N=78 Sham N=151 p+p+ GENDER, females – n (%)51 (68.0%)97 (64.2%)50 (64.1%)98 (64.9%)> 0.20 AGE63.5 (10.4)65.3 (9.0)65.5 (7.8)63.7 (9.1)> 0.20 ETHNICITY – 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-MAP4.4 (1.2)4.3 (1.3)4.5 (1.3)4.6 (1.2)0.12 WOMAC Pain43.3 (18.2)44.8 (18.7)45.6 (18.6)45.2 (17.8)> 0.20 WOMAC Function41.5 (19.3)45.1 (18.5)44.2 (18.8)44.1 (17.6)> 0.20 Baseline demographic and clinical characteristics

24. .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

25. Another pathway? Shared Mind 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).

26. 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

27. Types of shared understanding Similar beliefs ◦ What physician believes coincides with what patient believes Perceived 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

28. PTDR

29. The CONNECT study (PI, P. 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

30. The CONNECT instrument: Six domains of health beliefs ( * Haidet et al, Patient Education and Counseling 2008 ) To what extent: is there a biological cause to the patient’s health condition is the patient at fault for his/her health condition does the patient have control over his/her health condition does the condition have meaning for the patient can the patient’s health condition benefit from natural/alternative remedies does patient want a partnership with the doctor

31. 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

32. The CONNECT Instrument * Six domains of explanatory models (cause, fault, control, meaning, alternative treatments, relationship) Respondent/FocusInstrument 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

33. Data Analysis Summary scores for each CONNECT domain Compared 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

34. Results: Study Population Patients (n=272) Physicians (n=29) Mean age, yrs56 (15) Female (%)60 AA (%)50 Caucasian (%)39 Hispanic (%)11 Mean age, yrs43 (9) Female (%)58 AA (%)26 Caucasian (%)32 Hispanic (%)3 Asian (%)39

35. 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-Biological71.474.467.4.0590.009 Patient at Fault49.1 55.0ns<0.001 Patient has Control78.475.882.80.018<0.001 Meaning to the Patient71.072.179.6ns<0.001 Value of Alternative Treatments 50.750.856.7ns<0.001 Patient wants to be Partner in Relationship 82.581.389.7ns<0.001 Differences between patients’ model, physician models, and physician beliefs about the patients’ models

36. Associations With Better Physician 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

37. Association With Poorer Physician 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

38. Conclusion Significant 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

39. Questions?

40. References 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.

41. 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.