Richard L. Street

Analyzing Patient Participation in Medical Encounters

An essential component of the delivery of health care is the consultation between the patient and health care provider. Participation in the medical consultation is fundamentally a communicative event in which clinicians and patients use talk to exchange information, to share their expertise and points of view, to build a trusting relationship, and to make health-related decisions. A growing body of evidence indicates that patients who more actively participate in these encounters are more satisfiedwiththeirhealthcare, receivemorepatient-centeredcare(e.g., information, support) from providers, are more committed to treatment regimens, have a stronger sense of control over health, and even experience better health following the visit than do more passive patients (for reviews, see Kaplan, Greenfield, & Ware, 1989; Roter & Hall, 1993; Street, 2001). Because patient involvement is an important part of thehealthcareprocess, it is imperative that investigatorsanalyze thephenomenon using reliable and valid measures that have a solid conceptual foundation. In this article, we have three objectives. First, we describe the conceptual foundation and measurement strategies used in our approach to analyzing the communicative acts that constitute patient participation in medical encounters. Second, we apply our method to an analysis of nine videotaped recordings of physician–patient interactions. Two research questions (RQs) will be examined: (a) To what extent do patients ask questions, express concerns, and engage in assertive behavior in their interactions with physicians? and (b) Are patients more active communicators when their physicians use partnership building (e.g., soliciting the patient’s opinion) and supportive talk (e.g., reassurance, encouragement)? Finally, we conclude with a discussion of challenges and prospects for HEALTH COMMUNICATION, 13(1), 61–73 Copyright

How clinician–patient communication contributes to health improvement: Modeling pathways from talk to outcome

OBJECTIVE Although researchers have long investigated relationships between clinician-patient communication and health outcomes, much of the research has produced null, inconsistent, or contradictory findings. This essay examines challenges in the study of how clinician-patient communication contributes to a patients health and offers recommendations for future research. DISCUSSION Communication may directly impact outcomes, but more often it will have an indirect effect through its influence on intervening variables (e.g., patient understanding, clinician-patient agreement on treatment, adherence to treatment). For example, a patient communication skills intervention may not directly improve pain control for cancer patients. However, it may do so indirectly by activating patients to talk about cancer pain, which prompts the physician to change pain medication, which leads to better pain control. Additionally, communication measurement is complicated because relationships among communication behavior, meaning, and evaluation are complex. CONCLUSION Researchers must do more to model pathways linking clinician-patient communication to the outcomes of interest, particularly pathways in which the communication effects are indirect or mediated through other variables. To better explicate how communication contributes to health outcomes, researchers must critically reflect on the assumptions they are making about communication process and choose measures consistent with those assumptions.

The role of perceived affect and information in patients’ evaluations of health care and compliance decisions

The social interaction model distinguished between the communication and informational component of medical practitioners’ communication and predicts that perceived communication style plays a more important role in patients’ evaluations of care than perceptions of the informational component. The health belief model, by contrast, implies that perceptions of the informational component is more salient to patients’ compliance decisions than perceptions of communication style. A survey of patients from an anesthesiology clinic supported these predictions.

Acceptability of narratives to promote colorectal cancer screening in an online community.

OBJECTIVE To assess the acceptability of narratives to promote colorectal cancer (CRC) screening among members of an online weight loss community. METHOD Members of online weight loss community completed an Internet survey in 2010. Multiple logistic regression models examined demographic and attitudinal correlates of interest in sharing and receiving CRC screening narratives. RESULTS Participants (n=2386) were 92% female with mean (SD) age 58 (6) years; 68% were up-to-date with CRC screening. Among those who were up-to-date, 39% were interested in sharing their narratives with other members. African-Americans were more likely than other racial groups to be interested in sharing narratives (adjusted OR 2.02, 95% CI 1.14-3.57). Older, married members and those with greater CRC screening worries were less likely to be interested in sharing narratives. Among those not up-to-date, 63% were interested in receiving narratives from online community members, and those with higher perceived salience of CRC screening were more likely to be interested in receiving narratives (adjusted OR 1.86, 95% CI 1.31-2.65). CONCLUSIONS Members of this online weight loss community expressed interest in sharing and receiving narratives for CRC screening promotion. Attitudes and demographic characteristics may predict successful recruitment of those who would share and receive narratives.

The Prospects for Web 2.0 Technologies for Engagement, Communication, and Dissemination in the Era of Patient-Centered Outcomes Research: Selected Articles Developed From the Eisenberg Conference Series 2010 Meeting

The Eisenberg Conference Series 2010 Meeting on The Prospects for Web 2.0 Technologies for Engagement, Communication and Dissemination in the Era of Patient-Centered Outcome Research was conducted by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, Texas under contract to the Agency for Healthcare Research and Quality Contract No. HHSA290200810015C, Rockville, MD. The authors of this article are responsible for its content. No statement may be construed as the official position of the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services. Address correspondence to Michael Fordis, Baylor College of Medicine, One Baylor Plaza, MS BCM 155, Houston, TX 77030, USA. E-mail: fordis@bcm.edu Journal of Health Communication, 16:3–9, 2011 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print=1087-0415 online DOI: 10.1080/10810730.2011.598398

Analyzing messages and their outcomes: Questionable assumptions, possible solutions

One of the most popular traditions in communication research is the study of “message effects,” the impact of particular message features on a recipients evaluative, perceptual, and behavioral response to the message. However, this research is not without its limitations. This essay examines several problems created by questionable assumptions frequently embraced by researchers. Several solutions to these problems are offered.

Patient priorities and the doorknob phenomenon in primary care: Can technology improve disclosure of patient stressors?

OBJECTIVE Patients with multiple chronic conditions face many stressors (e.g. financial, safety, transportation stressors) that are rarely prioritized for discussion with the primary care provider (PCP). In this pilot randomized controlled trial we examined the effects of a novel technology-based intervention called Customized Care on stressor disclosure. METHODS The main outcomes were stressor disclosure, patient confidence and activation, as assessed by self-report and observational methods (transcribed and coded audio-recordings of the office visit). RESULTS Sixty patients were enrolled. Compared with care as usual, intervention patients were 6 times more likely to disclose stressors to the PCP (OR=6.16, 95% CI [1.53, 24.81], p=0.011) and reported greater stressor disclosure confidence (exp[B]=1.06, 95% CI [1.01, 1.12], p=0.028). No differences were found in patient activation or the length of the office visit. CONCLUSION Customized Care improved the likelihood of stressor disclosure without affecting the length of the PCP visit. PRACTICE IMPLICATIONS Brief technology-based interventions, like Customized Care could be made available through patient portals, or on smart phones, to prime patient-PCP discussion about difficult subjects, thereby improving the patient experience and efficiency of the visit.

A Research Agenda for Communication Scholars in the Precision Medicine Era

The 2015 announcement of the Precision Medicine Initiative (PMI) galvanized and energized efforts to reconsider medical practice through tailoring of prevention and treatment recommendations based on genetics, environment, and lifestyle. Numerous disciplines contributed white papers identifying challenges associated with PMI and calling for discipline-specific research that might provide solutions to such challenges. Throughout these white papers, the prominence of communication in achieving the PMI’s goals is obviously apparent. In this article, we highlight opportunities for communication scholars’ contributions to the PMI based on challenges identified in white papers from other disciplines and work already conducted by research teams in the field of communication.

Enhancing Health Communication Outcomes Among Ethnic Minority Patients: The Effects of the Match Between Participation Preferences and Perceptions and Doctor–Patient Concordance

Ethnic minority patients are less participative in medical consultations compared to ethnic majority patients. It is thus important to find effective strategies to enhance ethnic minority patients’ participation and improve subsequent health outcomes. This study therefore aimed to investigate the relation between the match between patients’ preferred and perceived participation and doctor–patient concordance in preferred doctor–patient relationship on patient satisfaction, fulfillment of information needs, and understanding of information among Turkish-Dutch and Dutch patients. Pre- and postconsultation questionnaires were filled out by 136 Dutch and 100 Turkish-Dutch patients in the waiting rooms of 32 general practitioners (GPs). GPs completed a questionnaire too. Results showed that a match between patients’ preferred and perceived participation was related to higher patient satisfaction, more fulfillment of information needs, and more understanding of information than a mismatch for both patient groups. For doctor–patient concordance a conditional main effect on all outcome measures emerged only among Turkish-Dutch patients. That is, for patients who were discordant with their GP, higher perceived participation was related to lower satisfaction, worse fulfillment of information needs, and worse understanding of the information. In order to improve medical communication GPs should thus primarily be trained to tailor their communication styles to match patients’ preferences for participation.

Supporting informed decision making when clinical evidence and conventional wisdom collide: papers developed from the Eisenberg Center Conference Series 2012

AHRQ involvement in exploring issues that impact clinical decision making The AHRQ Effective Health Care (EHC) Program was created in 2003 under the legislative provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA). The EHC Program supports individual researchers, research centers, and academic organizations working together with AHRQ to produce effectiveness and comparative effectiveness research for various audiences (http://www.effectivehealthcare.ahrq.gov). The EHC Program does this through: 1) reviewing and synthesizing published and unpublished scientific evidence; 2) generating new scientific evidence and analytic tools; and 3) compiling research findings that are synthesized and/or generated and translating these materials into useful formats for clinicians, consumers, and policymakers. Much of the work focusing on translation and dissemination of research findings is done through the John M. Eisenberg Center for Clinical Decisions and Communications Science (the Eisenberg Center), a specialized Center within the EHC Program charged with working in concert with other EHC Program components to organize research results into summaries and other tools that are useful to clinicians, healthcare policy makers, and patients. An important function of the Eisenberg Center involves planning and implementing the Eisenberg Conference Series. This series brings together experts in health communication, health literacy, shared decisionmaking, and related fields to produce white papers (and stakeholder commentaries) that explore developments and advances in the fields of clinical decisionmaking and health communication. The papers from the 2012 Conference Series are assembled here as a supplement in BMC Medical Informatics and Decision Making.