Richard L. Street Jr., Ph.D.
Professor and Head
Department of Communication
Texas A&M University
Dr. Baile: Good afternoon. Why don't we get started so we can have some time after Dr. Street's lecture for getting some dialog and interchange with questions? I'm Walter Baile and I'm Director of the I*CARE Program here MD Anderson and it's my great pleasure today to introduce Dr. Richard Street who is our Achieving Communication Excellence lecturer for today, and just a few words of introduction. Dr. Street is Professor and Head of Communication and Research Professor in Medicine at Texas A&M University and Director of Health Communication and Decision-Making Program in the Houston Center for Quality of Care and Utilization Studies at Baylor College of Medicine. Rick has a long and distinguished career in research examining issues related to provider-patient communication and especially medical outcomes and involving patients more in their own care. And Rick has published extensively in this area having been first or second author on many, many articles around in the area of healthcare communication. I think one of the most significant publications is his collaboration in a book called "Patient Centered-Communication in Cancer Care: Promoting Healing and Reducing Suffering" which was published by the National Cancer Institute in which we'll give you some information at the end of the talk about how to obtain a copy of it. So, without further ado, I think I'll turn the microphone over to Dr. Street. Thank you so much, Rick.
[ Applause ]
Dr. Street: Thank you very much, Walter, for those kind words and good afternoon everyone. It's certainly a pleasure to be here this afternoon and talk with you about some of the work that we're doing in the study of clinician-patient communication and its relationship to improved health outcomes. And I think a good starting point for our conversation today is to pose to you what some of the interesting, most perplexing challenges in the health communication literature, and that is how do you explain findings like this? Like next and go to slide. No, not findings like that, sorry. Is it this one?
[ Inaudible Discussion ]
Alright, and that is how do we explain findings like these? These are two studies, first of their kind that I'm aware of to find the relationships between the ways in which physicians and patients communicated with one another in subsequent health outcomes, physiological health outcomes, weeks and months after that particular encounter. As you can see, it looks like the more that the patient was involved in the encounter there's better balance of participation and the more physicians were informative, that those patients are the ones that ended up experiencing better metabolic control and having lower blood pressure. And since these two studies, in the mid '80s, there have been a whole host of other studies that have also looked at the relationship between communication and outcomes, including some of our own. The Stewart study is one that's often cited, and that study when patients perceive their physicians as more patient centered in terms of exploring problems and finding common ground. Two months later, those patients reported better emotional well-being than did the patients who perceived their doctors as less patient-centered.
Some of our work, we found that when patient--when diabetic nurses were more directive and controlling and authoritarian in their communication, their patients actually experienced worst control, metabolic control after those consultations. And then another study that had some fairly interesting--although I'm not sure how to make sense out of it in one of our investigations. Patients who are more involved in their consultation in terms of asking questions or expressing their concerns and stating their opinions, 3 years later, those patients were experiencing less organ damage, those lupus patients, than were patients who are more passive. Now some people will look at evidence like this and say there's proof that you need, that communication matters. If you have a good communication, then you can improve health outcomes. In my opinion, statements like that based upon this evidence, even though it's promising, are really overly simplistic if not grossly misleading. Because how do you explain findings like these? And that Kaplan study, actually when doctors were giving more information to patients, there were some poorer outcomes. Patient involvement in decision making, not related to metabolic control. Doctor's patient centeredness, not related to lupus outcomes. And then how about a study like that, in that Kaplan study, they found that when patients expressed more negative affect in terms of expressing negative feelings and emotions, frustrations, et cetera, ultimately they experience better outcomes. We used an almost identical measure and we found just the opposite. Those patients actually had worse outcomes.
But then what about findings like these? Remember that Stewart study? Remember, patient's perceptions of their doctor's patient-centeredness were related to the patient's emotional well being 2 months later? Observers of those very same interactions using the exact same measure of patient-centeredness, their ratings were not related to patient outcomes. Not only that, their ratings were only modestly correlated with the patient's perceptions. One of our own studies, we've found that active patient participation in deciding treatment for early breast cancer, not related to functional and emotional well-being 12 months later. However, 12 months later, it was related to the degree to which patients assumed responsibility for the decision, and that was predictive of functional and emotional well-being. And then of course, we have one of my favorite studies, this one by Kinmonth in which doctors after they went through some patient-centered communication training and whatnot, indeed after the consultation, their patients were happier. They thought their doctors were better communicators and they ultimately got fatter.
So, does communication matter? If you have good communication, can you improve health outcomes? Well, based upon this evidence, the answer might be maybe or perhaps more accurately, it depends. It depends on which outcomes we're interested in and how we're measuring those and when we're measuring those. It depends on which communication behaviors we're studying. How we're measuring those, when and who's doing the assessment. In short, we just haven't done a very good job yet explaining how and why communication matters. Now, in this area of research, we're really faced with two challenges. One is we got a clinician-patient communication here and we've got health out--patient outcomes that we might be interested in. So one of our challenges is being able to find, discover theoretical pathways through which communication might lead to better health. In other words, something has to happen in the consultation communication-wise that accomplishes some things immediately or sets into play a sequence of events that ultimately results into improved outcomes and we need to do a better job modeling those. And that's going to be mostly what I'm going to talk about today.
The other challenge we have to deal with some conceptual and measurement challenges with regard to how we even study clinician-patient communication processes, and that is a mess. Communication is a very complex phenomenon, and I can spend hours on that in terms of identifying, you know, what count as effective behavior. How do we identify that? How do we measure? How do we operationalize that? Do we focus on processes? Do we focus on behaviors? There's a lot of work that we need to do better if we're going to advance to science of clinician-patient communication research. And I'm going to talk mostly about patient health outcomes, but let me just make a comment about my conceptual orientation to the work that we're doing. In 2007, Ron Epstein, my colleague, Ron Epstein and I wrote a monograph for NCI. This is the one that Walter was talking about, Patient-Centered Communication and Cancer Care: Promoting Healing and Reducing Suffering. And in that monograph what we argued for is that we ought to take a functional approach. We ought to look at communication from a functional approach. And a functional approach has several advantages. One of which is, it focuses on the tasks, the activities, the work that communication needs to do, needs to do well in order to have quality cancer care and lead to improved outcomes.
So here, we've identified six functions that we thought were particularly important. Some may say, well, there could be more. That's true. But we thought these six were important. We understand that while they are distinctive, they do not necessarily overlap. I mean, they're not necessarily independent of one another. They do overlap and they're sometimes embedded. But what the communication, as communicators, when doctors and patients are interacting with one another, what they need to do is a good job of exchanging and managing information, creating shared understanding of the problem and agreement on what to do. They need to foster a relationship characterized by trust and rapport. They need to respond effectively to the patient's emotional states and manage that appropriately.
They need to contribute to quality decisions that are based upon the best clinical evidence, the understanding of the best clinical evidence that are consistent with patient values and that are feasible to implement. The communication needs to contribute to the effective management of uncertainty. Uncertainty is ubiquitous in cancer care, "Am I going to live? Will the treatment work? Will my cancer come back? How will this affect my life?" Critical things that need to be managed well that can be managed from a communication point of view. And of course the communication should also be able to contribute to enabling patient self management. The talk between clinicians and patients, one function that it could perform is patients are able to leave there with information or resources in which they have a good idea of how to take care of themselves outside clinical contexts such as managing symptoms or the side effects of treatment. So, another advantage of the functional perspective that's really important for us to realize is that these are not the responsibilities of any one of the participants. It's not just the doctor's job. It's not just the patient's job. These are things that doctors and patients need to do together collaboratively, cooperatively, to perform these things well in order to have quality cancer care.
Alright, so with that in mind, let me move now toward talking about some pathways. On the one hand, what we have here is our clinician-patient communication, and here might be a variety of health outcomes that we might be interested in. So, on the one hand, we might have an arrow like that and assume that communication has a direct effect on outcomes. And indeed, there are probably some instances in which that's the case. Talk can be therapeutic. It can console, it can comfort, it can reassure, in many ways as a form of communication, so my touch, or so my smile. And those can alleviate anxiety and distress in such a way that it could contribute to emotional well-being at least in the short term, for a period of time. But, if communication is going to contribute to better health outcomes, more often than not, it's not going to be a direct effect. More often than not, it's going to be a more indirect or mediated path in that you hope that the conversation accomplishes some things immediately.
The patient has an understanding of their, an accurate understanding of their health condition. The clinician has an understanding of the patient's values in preferences. The patient has an understanding of treatment options. They've reached agreement of what to do. They fostered a relationship characterized by trust and rapport. The patient leaves with the sense of motivation and self efficacy. And if you can accomplish those things immediately after--during and after the consultation, then that might contribute to some intermediate outcomes, like the patient got access to the care that they need. The patient contributed to a higher quality medical decision, indeed based upon the best evidence and consistent with patient values, and one the patient could follow through on. Maybe it contributed to the patient activating resources in their social support network, or being able to develop self care skills to manage symptoms and side effects. And if you can accomplish those, then that could be the thing that could lead to health outcomes, improved health outcomes. So that's my call for folks today.
We need to be doing work like this in terms of modeling relationships between communication and the outcomes. So, if we look at this from a research agenda in terms of how we might explore these pathways, one thing we might do is talk about the outcome of interest. Let's start at the end of point and work our way backwards in terms of what might need to be a place. So, let's just use a--might need to be in place. So, let's just use a hypothetical example right now. How about managing hypertension? What we have, we have patients who are hypertensive. We want their blood pressure at normal levels. Alright, so that's the outcome we're interested in, blood pressure control. Then we got to identify the mechanism. How is that going to happen? Well, let's say we tried lifestyle, lifestyle sort of worked, not really, so what we want to do is try medication. So we need to have the appropriate medication taken appropriately. Alright, so that's the mechanism for lowering blood pressure. Now what we have to do is model that particular pathway. So then we--we'd identify what are the immediate proximal outcomes of the interaction that might contribute to that. Patient understands the risks of untreated hypertension and what their treatment options are. The doctor has an understanding of the patient's preferences as it relates to side effects, of treatments and medications they are willing to tolerate and they're not willing to tolerate. They reach explicit agreement on what to do. They have a plan for follow up to see if that's going to work.
Okay, those are the proximal outcomes, then what communication variables might contribute to that? Well, the physician providing explanations, clear explanations on the threats of hypertension and treatment options. Patient talking about their lifestyle and the kinds and ways in which different side effects might affect them. Periodic checks for understanding, specific examples of reaching agreement. And if those are the communication behaviors that we need, then perhaps what we need to do then is to develop interventions that would target these kinds of behaviors so that they occur in the consultation to then lead to these immediate proximal outcomes that then has the patient committed to a treatment plan that works. So, that's the logic, it's not difficult logic but it's very simple as we go from the point of the consultation to the health outcomes of interest. Alright, so that's a hypothetical example.
What I would like to do now and spend the rest of the time talking about today is talk about three studies that we've done which we've tried to explore these particular pathways. The first that I want to talk about is pain control in cancer, and really what we want is we want the-- we have patients with advanced cancer experiencing moderate to greater levels of pain and what we want to have is better pain control. At the consultation they're in pain, two weeks later we want them to have less pain. Alright, what might lead to less pain? Well, we're not, I'm not always you know, a really sophisticated thinker so I might say, really? I think one pathway might be pain medication, the effective use of pain medication. That might work, that might be something. Well, what might get--have the patient have the effective use of pain medication? What might be an outcome at the end of the consultation that might contribute to that? The doctor makes a pain medication recommendation or changes pain medication, alright? Great. What could get a doctor to do that? Well, let's have the patient actively talk about their pain concerns. The problems that they're having either with their medication and their side effects or that it's not working, or that they need some help or something, get them to talk about pain-related concerns. Okay. Then do we need an intervention to do that? In this study I'm about to talk about, we thought so.
So what we did is then developed an intervention designed to get the patient to talk more about their pain concerns. And in this particular intervention, I'll go ahead and just describe it briefly now is we had two conditions. In one condition, what we called educationally enhanced usual care, those patients prior to their consultation got information on pain management. The patients in the tailored education coaching group had a--not only that pain medication, but they also had a patient activation intervention to talk to them about the importance of talking about their concerns including pain related. The doctor wants to hear about those. Here, let me help you write down some things, practice talking about those things. Let me give you some feedback on your performance. That was the tailored coaching intervention. And so we had a fairly simple model, coaching intervention is going to elicit active patient participation. That's going to create change in medication, that's going to lead to better pain control at 2 weeks, alright.
So, the study that we're talking about right here is one that Rich Kravitz at University of California at Davis is the PI on, and this involved various clinics in the Sacramento area. As you can see, that patients had had a variety of cancers. All of them, most of them advanced and having at least moderate pain or worse. Alright, we had several research measures. First, we had frequency measure of a measure I've used a lot of active patient participation. It is simply how often did the patient asked a question, express a concern, having an--offer opinion, make a request, introduce a topic. Those are considered active forms of communication because they explicitly interject the patient's perspective into the consultation and they tend to have a pretty powerful effect on the way the direction, of course, of the conversation as well as the clinician's behavior. And we had two measures of this. First of all, overall active participation about anything and then pain specific, those aspects of active participation that focused on pain-related issues of hurt, pain, pain medications and things like that. These were generated from audio recordings of the consultations that the patients had. We also had a rating measure. We had a rating measure of the physician's participatory decision making. This is a measure developed by Sherrie Kaplan and some of her colleagues which basically represents ratings or perceptions of the degree to which the clinician engaged in trying to facilitate the patient's involvement in the consultation, in the decision-making, and in their care.
The reason why we want to include that is because we need to realize communication behavior can be affected by a number of factors. Yes, you can have an intervention designed to increase communicative activity on the part of the patient, but communicative activity also is in part a function of what your partner is doing in the conversation to support your involvement or not. So independently, you could have effects related to the doctor's efforts to facilitate the patient's involvement, and that's why that's in there as well. And then our measure of changing the medication was a fairly simple one and that is the patients responded at the end of their consultation if there was a change in pain meds or if they got a new med. If so, that was a change in meds, and if the answer was no, then the answer then that was not. Alright, so here's the characteristics of our example in this study. And as you can see, this group of patients were mostly women and mostly white and they did not differ in terms of any of these demographics or any of these characteristics. Except on one, that is age, and that is women are the patients in the intervention group tended to be a little older, and that will be become significant a bit more here in a minute.
Alright, so let's first of all look at the effective, the intervention on patient participation. And so, I've got your two columns here, one--at least the two variables. One, the total active patient participation and then the other one being pain specific active participation. Let me first draw your attention down to the very bottom where we can see the effect of the education session. As we can see, the educational intervention had no effect on the patient's overall participation but it did have an effect in the desired direction on pain-specific active participation. Alright, and that is not terribly surprising because it was focused on pain management and talking about pain concerns. So in that sense, the intervention worked as we might have expected. Let me now draw your attention to the where it says--up to where it says physician's participatory decision making. Independent of the coaching intervention, when doctors were more facilitative of the patients' involvement in the consultation, the patients were more actively involved overall and more actively involved on pain specific concerns. We spent a lot of time with the coaching intervention. Sometimes I think, you know, if we just simply had a clinician or the doctor actually trying to support and encourage patient involvement, we wouldn't have needed all of that time necessarily to encourage patients to be more participatory, although it did have--the education session did have an independent effect in addition to that.
One other factor to turn your attention to right about that is the patient's baseline pain. Patients more in pain, they were more participatory overall and with regard to pain-specific participation. Perhaps not surprising 'cause you had another factor affecting communication is your motivation. Perhaps patients in more pain are more motivated to be more involved to try to get problems solved. What's important to realize about this is that when we study communication, it's good for us to think about it in that overall ecology in which the factors that affect how people talk with one another and include both personal and partner and intervention types of factors that come into play. And the only other variable I'll talk--draw your attention to is the notion of patient age. As you can see, on patient age, the second independent variable there, patient's who were older tended to be less participatory overall. And this is, although age is not always related to active patient participation, when it is, it often is in this direction, older patients tend to be more passive. But notice then in the experimental condition, there was no age effect related to pain-specific participation indicating that perhaps the coaching intervention mitigated some of the disparities in participation often associated with the age. And in fact, since this tended to be an older patient group, some research indicates that of the types of patient activation interventions, coaching tends to work particularly well for older patients. Alright, so that looks at the relationship of the intervention in terms of the--its effect on active patient participation.
Now, let's look at it's affect as it--on change in meds mediated through active patient participation. So, if you look at that first model, model 1, that includes all the variables in there without active patient participation. As you can see, there is a significant effect, highly significant effect for the education session. Now, in model 2, what we do is we put in the active patient participation measure, particularly as it relates to pain, and then we see a particularly highly significant effect on change meds. In other words, patients who didn't get a change in pain medications, well they spent more time talking about their pain-related concerns. And then of course the education session, even though it's effect is mitigated to some degree, it still ended up being significant. So that--so, so far most elements of our model are in place and notice I haven't talked yet about the effect of the change in medication on outcomes. So this is particular--this is what our model was, and as we can see, we see some effect, some success in identifying that model and having it hold true. But then when we looked at the relationship between change in pain meds and pain control, then this is what happens.
Basically we found no relationship between changing meds and whether or not people had pain control. And the best predictor of pain two weeks later was pain at baseline, and that perhaps is not surprising. So while the idea of changing meds seemed to be a good idea perhaps providing a chance for pain control, that effect was not significant suggesting that, well, even if you change meds, you may not be able to have the pain control that you want or need from the patient's point of view. Alright, so there's one example of pain control. I mean, at looking at ways in which we've tried to model communication in the consultation using an intervention to improve health outcomes.
Now let me move to another study, and this is also dealing with pain control and functioning improvement among patients with osteoarthritis of the knee using acupuncture. The outcome here for these patients, we want them to have better pain control and function. The pathway that we're looking at is a placebo effect related to beliefs that acupuncture is a good form of treatment for my knee pain, when it's due to osteoarthritis. So the proximal outcome that we wanted is that the patient would have higher expectations that acupuncture would work, not only at baseline but certainly later on during the course of their treatment. And then the communication variable that we wanted was a manipulation of the acupuncturist communication style. And in one condition what the acupuncturist will do, would talk, communicate in high expectations about this treatment being able to work for the patient. And in the neutral expectations condition, they would be more equivocal and uncertain in talking to the patient about whether or not that would work.
Alright, so this is the design of the study and the PI on the study is Maria Suarez Almazar, your very own MD Anderson Maria Almazar. And as you can see we have--this was a randomized controlled trial and we had two manipulations. The second row there deals with the expectations. Then we also had whether or not patients got real acupuncture, meaning put needles in the meridian points and things like that, or if they got sham. And I'm not going to talk about that because it had no effect on any of the outcomes. So I'm mainly just going to talk about the communication of high versus neutral expectations. Alright, so in terms of our high expectations, this is what we train the acupuncturist to do. Half the acupuncturists started out being high expectations. When they would talk to the patient, they would talk about, "You know, I've had a lot of success with patients with this kind of knee pain. I'm optimistic it's going to work for you. You should start feeling better within 4 or 5 treatments." Sometimes--and then when it wasn't working, they say. "Sometimes it just takes a little longer but I'm still sure, hopeful it's going to work for you."
Then in neutral expectations, what they would do is talk about, "Well, we're not sure, it works for some patients, not for others. We'll have to wait and see. Maybe it's not working, we'll just have to wait and see if something--if it gets better later on." So they are more equivocal in their communication of the likelihood of success. And in that study, we divided the acupuncturists in half, so half of them were high expectations and half were neutral expectations, and then midway through the study, the roles were reversed and the neutral then became the high and the high then became the neutral. We're looking at this in terms of--patients came in for acupuncture treatment over about a 10 to 12 session period and what we're only looking at it is at the baseline visit, because baseline visit and the second visit, those are the ones where people do most of the talking about treatment, about what to expect and the like. So, if we look at our research measures then with that in mind. First of all, we had coders who were blind to the manipulations. They simply listened to the audio recordings and they simply made a mark on a hundred millimeter scale about the extent to which they thought the acupuncturist was communicating high versus neutral expectations. And by the way, their perceptions tended to confirm the manipulation that, yes, indeed high were perceived to be more high, neutral were perceived to be less enthusiastic and more neutral.
So, this was at baseline. This was at the baseline visit on terms of talking about acupuncture. Then our proximal outcome was patient expectations at 4 weeks. So 4 weeks later, what beliefs did the patients have the likelihood that acupuncture would work and would be a good form of treatment and treat their knee pain and improve their function? So that was the proximal outcome of expectations, raised expectations. And then the pain and function measures were ones that were collected at 6 weeks and at 3 months and they sort of show on the WOMAC scale and we, as I said, used both the subscales that are related to pain and to function. Alright, so that's the model. The expectation, communication of style leads to expectations at 4 weeks. Expectations at 4 weeks predict outcomes at 6 weeks. Outcomes at 6 weeks predict outcomes at 3 months.
Here are characteristics of the samples. As you can see, they were not different on any of these kinds of attributes. And here are the results of that analysis, the path analysis results. As you can see, pretty much the pathway we had talked about was confirmed. And communication of high expectations, the communication style of high expectations indeed predicted patient expectations acupuncture would work 4 weeks later. Patient's expectations acupuncture would work 4 weeks later predicted pain improvement at 6 weeks. Pain improvement at 6 weeks also predicted pain improvement at 3 months. And the same pattern of results held true for the function measure as well. Now note also something else. Notice that patient's baseline expectation also was a significant factor along that pathway. In other words, patients more optimistic going in perceived that they had better results from the treatment. Now, the communication of expectation is completely independent of patient's baseline expectations. So even though more optimistic patients ended up having better outcomes, the communication style of higher versus neutral expectations or higher expectations additionally contribute to raised expectations that led to ultimately to improve pain and function at 6 weeks and at 3 months. Alright, so that's the second study.
Now, the last study that I want to talk about is what we may refer to as a shared mind. In 2009, Ron Epstein and Ellen Peters wrote an article, a commentary in JAMA on this notion of shared mind. Now, I put this up here just to describe what they described shared mind as. I'm going to read it to you because they're very deep thinkers. Collaborative cognition depends on the physician being mindful not only of patient values, thoughts, feelings, but also his or her own research exploring, shared deliberation, shared mind, must bridge cognitive science, decision research, communication skills, evaluate communication process, as well as patient's experience of care. I find that really complicated. But if you break that down, we really think that their notion of shared mind represents two things. One thing, it is a process by which you go about achieving that. It's a way of thinking, it's a way of talking, it's a way of collaborating. A shared mind may also be looked at as an outcome. It's a shared understanding of a problem, it's a shared--it's an understanding of one another's perspective and it's a--and it's where they reach agreement on a course of action.
Now in this study I'm about to talk about, we don't have any outcome data. But the idea here about exploring this as a possible pathway is one that I think is particularly exciting, because it's the idea that when doctors and patients are on the same page at multiple levels, then that may contribute to better decisions that patients stay committed to that could lead to better treatment outcomes. So, let's look at how we might think about shared understanding, and it's something we may think that we would know but we could really think about it in a number of different ways. On the one hand, clinicians and patients could have similar beliefs. So what the physician believes coincides with what the patient believes. Physician says patient has high blood pressure and the patient says, "My blood pressure is too high." Physician says, "I think this cancer treatment will work." The patient says, "I think this cancer treatment will work." They share the same beliefs. Now, that does not necessarily mean that they know that each other shares the same beliefs. So another way you could look at agreement, shared understanding is perceived agreement or what we might call fantasy. The physician is saying, "You know, I think that patient realizes that patient's blood pressure is too high, I think that patient realizes her blood pressure is too high," when in fact that may not be the case at all. Or the physician is saying, "I think that patient understands that this cancer treatment may or may not work and I don't think it--I think it's real 50-50 whether it does." The patient may be saying, "Oh, I'm really hopeful and optimistic now." One could argue that this notion of perceived agreement actually is the critical thing that guides behavior because it bases itself upon our perceptions of the world and whether or not we think others see the world the same way we do.
Then there's another type of shared understanding, and that is perspective taking, and that is the ability to accurately understand and predict what your partner is thinking. So the physician is saying, "I think that the patient doesn't think their blood pressure is a problem." Patient thinks, "My blood pressure is not a problem." The physician is saying, "I bet that patient is putting a lot of hope in this particular treatment. Patient is saying, "Yeah, this treatment is going to work for me. And that has another kind of shared understanding in terms of understanding the perspective of the other. Now, you put all three of those together, if you're going to create shared mind, you would hopefully--what would happen that communication would contribute in a way that would bring all three of those in alignment with one another so that you can create this notion of shared mind. Alright, now that's kind of the conceptual orientation that we might have, so now let's talk about this particular study that we explored some of those issues.
This is the CONNECT study and the PI on this study was Paul Haidet. Many of you know Paul. Paul used to be at Baylor, he's now at Penn State. And basically this aspect of the study that we did is we wanted to know how well the doctors know what their patient's health beliefs were. That's the stuff there. How good are they at predicting what their patients know? And then the other thing is we thought, why don't we identify predictors of that understanding. So we identified 3 types of predictors. Communication variables included active patient participation. Yes, you can see the theme here of what we're talking about. Most anything I do focuses on active patient participation. We've figured that patients who are more active and talking about concerns and beliefs and opinions and asking questions, they would be interjecting into the conversation, explicit information for the doctor to get a sense of, okay, I see where that patient is coming from. So that was one communication predictor. Another one might be relationship factors. You might think that the more that doctor and patient had seen one another over time, doctor probably might have a better understanding of that patient. We also put the racial and gender concordance in here.
Some of you that may be familiar with the literature know that there are some literature that says when doctors and patients are racially concordant or ethnically concordant or gender concordant, they tend to have more positive interactions in part because maybe there is a sense of shared identity or perhaps common experience that lets a person have a better insight into their partner. And then we have cultural factors that might affect how well physicians understand their patients. We didn't have a good measure of culture so what we used in this particular case for accrued measure, that would be demographic characteristics. So basically what we wanted to do is to assess patient's beliefs using the CONNECT instrument.
Now I'm not going to talk about the details of the psychometric properties of how we did CONNECT instrument. But basically this instrument taps into 6 domains of a physician's and patient's beliefs about a patient's particular health condition. To what extent is there a biological cause to this? To what extent is the patient's fault? To what extent does the patient have control? To what extent does it have meaning for the patient? To what extent does this condition, would it benefit from natural alternative remedies? And to what extent does a patient want a partnership with the doctor? Alright, those were the 6 domains and we assessed a total of about 19 items. Alright, so before I talk about how we worded the measures and things like that, let me talk a little bit about the design. This is the cross sectional design and just an observational study, all in the Houston Texas area with the VA and Baylor clinics participating. Alright, now the way we did the CONNECT instrument is after the patient completed the consultation, they filled out the CONNECT instrument and we would have items like this. I'm sick because my body is having problems. If I take care of myself, my health problem will get better. This is in the context of a specific kind of condition. So the doctor, after the consultation, would fill it out as well and the doctors would be the patient is sick because their body is having problems. Or the doctor would fill it out. If the patient takes care of him or herself, their health problem will get better.
But then the doctors also filled it out a second time. How did they think that the patients filled this out? So the wording of that would be the patient thinks he or she is sick because their body is having problems. The patient thinks that if they take care of themselves, their health problem would be better. And so these were all items, types of items on Likert scales. Alright, so now if we look at the way we did the analysis to understand how well doctors understood their patients, we simply did summary scores on each of their health domains and compared the doctor's model, patient's model and what the doctors thought the patient's model was. In order to predict better understanding of the patient's model, we took the absolute difference between the patient's model and the doctor's understanding of the patient's model and then used that in a multivariable model using the predictors that we had that I talked about previously. Alright, so now there are characteristics of our sample, a pretty diverse group of both physicians and patients.
Now, let's look at the results of how well doctors understood their patients. And so, what we have here is we have the physician score on each of those 6 domains, we have the physician's belief about the patient's model, and we have the patient's model. Let me draw your attention first to the column farthest away, and that is the difference between B and C. That is how well the doctors understand their patient's model. Physician's belief about the patient's model compared to the patient's model. As you can see, there were significant differences across all of them, indicating not a real good understanding. Not only that, in all but one case, doctors underestimated the degree to which the patient believed their health was related to that particular attribute. So, patients thought they were more at fault, they had more control, it had more meaning, benefit more from natural remedies and it--and they wanted more of a partnership than doctors thought that they wanted. The only one that was different that was in the opposite direction was patients thought that there was less of a biological cause and what the doctors thought the patients thought.
Contrast that with the column right next to it where we compare the physician's model with the physician's belief about the patient's model. On four of those dimensions, there are no significant differences, meaning physicians tended to think that patients thought about their health condition the same way they did. On two of them, they acknowledged some differences but they were opposite the direction of the actual difference. Doctor said, "I bet the patient thinks they are less at fault than let's say that's not the one." I bet the patient thinks there is more of a biological cause than what I think. In fact, patients thought there was less of a biological cause. I bet the patients think they are less in control than what I think. No, patients thought they were more in control. So, when there was recognition of differences, there were differences in the other direction. Alright, okay, we got a problem, so what might contribute to better understanding?
So, let me just summarize the results. On two of the domains, there were no differences as it related to whether the cause--that the patient was at fault and there was a biological cause. But by far, the most significant predictor of less discrepancy between what doctors thought patients thought and what patients actually thought was more active patient participation. When patients were more active participants, doctors had a better sense of the meaning of the condition to the patient, patients sense a control over it, the value of alternative treatments and the desire to which the patient wanted to be a partner in that relationship. Now, there are some other factors that were associated with better understanding as well. Racial concordance contributed in one domain in sense of control. Interestingly, physicians had at least on one domain of control a better sense of the patient's model when they were high school educated or less. And then this is one that may raise eyebrows or may not, in that male physicians tend to be better at understanding their patient's sense of control and relationship than with female patients.
The reason why you might raise your eyebrows about that is some of you may be familiar with the research both in gender studies as well as in gender and health and medical context that women are much better judges of people's emotional states than are men, more accurate at being able to detect what someone's true feelings and emotions are. Alright, well either this could be an anomaly or the fact we're talking about beliefs and not emotions here. So the fact that we have only 29 physicians though means that we shouldn't, you know, make too much out of that finding. What was associated with poor understanding mostly dealt with race and ethnicity. Physicians had a poor understanding of African-American's desire for partnership in the relationship and Hispanic patients the meaning that the condition had for them. So from this study, as we talk about shared understanding, we might make--draw conclusions that there are gaps between how well doctors understand their patients, and that some demographic factors may contribute to that. But one thing that can certainly mitigate that discrepancy is when patients are more actively involved in their consultation.
So, what I wanted to do today, in talking about this stuff, is give you an idea from a communication perspective how we can make communication matter. Some people would say that good communication is an outcome in and of itself and I would agree that that in and of itself. But at least in the work that I do and that a lot of my colleagues are interested in, we want to find out ways in which we can look and link communication to improved health outcomes, at least to tap into the processes that should lead to improved health outcomes. And that I think is a challenge for all of us in health communication but particularly for those of us interested in cancer communication and quality of care. So as Walter had mentioned, he wanted me to put contact information about the monograph, the NCI monograph. You can contact Neeraj Arora who has a lot of copies that he can send you. Or if you Google that term or go to that URL, you can download a copy of that monograph. There's no charge or anything, it's something that you can just get by, by asking for it. So, that concludes the presentation, so I'll open the floor up for questions right now.
[ Pause ]
Dr. Baile: questions. Dr. Reddy, question? Could you say who you are and what--what department you are in?
[ Inaudible Remark ]
Dr. Reddy: Thanks for coming down. My name is Suresh Reddy. I'm one of the faculty in palliative care here, M.D. Anderson.
[ Inaudible Remark ]
Dr. Reddy: Sure, my name is Suresh Reddy. I'm one of the faculty here at palliative care at M.D. Anderson. My question is about the acupuncture study. It's very interesting. So if you sugarcoat and tell the patient that this is going to work, it does seem to work. Should we be doing that though?
[ Laughter ]
Dr. Street: I would say that if you think about pain, I mean think about the experience of pain. Pain while real is subjectively interpreted. And so if you want to have people think about their pain in a different way so that it is less distressful, then I think you can communicate hope and optimism for the effectiveness of acupuncture in this particular case. So the fact that real or sham didn't have an effect may be less relevant than the patient's belief that it would and having gone through the process, it indeed had. And so I think--I think, you know, when you think about that, it's okay to do things like that. I mean, can you lie? Then I wouldn't say no. You can't tell something that's not there, but can you take advantage of psychological mechanisms to help alleviate patient's distress. Then I think that that is certainly within grounds of what you ought to be able to do in order to accomplish that.
Dr. Reddy: But I think there is a--our experience is it is opposite. I mean if you really sugarcoat, patients and families do expect really high-tech kind of things that need to be done to them. And you know that, you know, pain is not simple and pain usually comes back, especially cancer pain. So if you really tell the truth of limitations of your treatment, we found that that really alleviates a lot of emotional components. Otherwise you are postponing to talk about these emotional components, and there's a danger that you are really imposing, you know, high tech interventions. And it's not only expensive but it's not really doing right things to patients, in our opinion.
Dr. Street: Well, and that's a very good point. And the other thing I think that might be a difference there that you mentioned that was very important, patients came in with high expectations that you're talking about for symptom relief, I believe, right? And when that's the point that they have high expectations for symptom relief, and where with acupuncture, one might think there's a lot more variable expectations that you might have with regard to whether or not, you know, that would work. You know the thing about--you know, the study--you know, care just doesn't end there, that's another thing. Well, doctor it was working but now it doesn't seem to be. Well, maybe we ought to try something else. You know, I mean those are all things that are within someone's, you know, repertoire of what they could be able to do in terms of managing a patient over the long term. But the circumstances of these types of clinical settings may be different to where that becomes using placebo effect with cancer pain may be less relevant than perhaps something dealing with alternative treatments. Thank you.
Dr. Reddy: Thanks.
Dr. Street: Other questions?
Question: I'm a patient, so I come at this from a little different perspective. One thing that the patients experience is how do you get your clinician to slow down to actually have a talk with you about these concerns? They have, you know, I find that extremely tight schedule. They're moving from patient to patient very quickly and, you know, a lot of times it seems like their intent is to get in and out of your examination room as quickly as possible and on to the next. How do you slow that process down and get the clinician to actually listen to?
Dr. Street: Well, there is a fairly straightforward piece of advice that you would get, but let me first of all talk about what--about the nature of the problem. Nature of that particular problem is actually three fold. You want some of the clinician's time to be talking to you and addressing your concerns. The clinician does indeed have a very busy schedule and they're trying to see a lot of different patients. Third, very importantly, you are reluctant about being an imposition in that. I mean I'm just making some assumptions of things that come to play that we've done before. Here is the thing is that how would you go about doing that and say, doctor you may be in a hurry or something, but I tell you, there really is something that I wish we could spend some time talking about. Most of the time when, you know, clinicians, they may be rushed, they're trying to do a zillion things, they are not bad people. They want to help, and sometimes patients just have to give them some direction. You know, take a leash and say, "I need you to walk over here with me." And most of the time clinicians are going to be very helpful in terms of once they get a specific idea about what it is that you are interested in and want to talk about, they'll spend some tine doing that.
One of the best predictors of whether--of the information that patients get from clinicians is whether they're asking questions, because that's letting doctors know explicitly what the patient's needs are. And that helps the doctor out a lot. So I think, you know, I mean I don't want to be cavalier in an answer because I know that this can be kind of difficult and we're not sure what to do. But I guess the thing that I would suggest that would probably work a lot of the time, the next time you find something like that is to actually say something like, "You know, you seem to be in a hurry and--but really, I'd really like to ask you a couple of questions, could we spend some time talking about that for a minute?" And I think that changes. What you've done is you've intervened your perspective in the course of the conversation. There's one very fundamental principle of conversation, conversational norms are powerful. And that means that each patient has as much influence on the course and the direction of the conversation as does the clinician.
So with that in mind, you know, you really do have as a communicator, you know, a large number of things that you might be able to use but of course the challenge there would be to do that in a way that comes off as not being disrespectful but at the same time being polite. And I don't know if that really helps or answers your question. But if we look at it from a communication point of view, those would be the kinds of things that you could do. In addition to helping, you know, inform clinicians or educate clinicians, you know, your style, the way you do this, it really makes you seem like you're in a hurry and that you don't have a lot of time for the patient. Is that really what you are trying to communicate? Then you can work on that end as well. So you know, we don't want to put all the onus on the patient, but the clinicians have a responsibility there too.
[ Inaudible Remark ]
Dr. Street: Well, and you raised a good point about the 3 things, you know, what you're talking about there is prioritizing the agenda from your point of view. You know there could be a zillion things you could talk about, but you've basically self selected and identified what you thought were the 3 most important things. And that helps 'cause we don't have time for 10, we've got time for 3 perhaps. So that's an excellent suggestion. Yeah. Thanks.
Dr. Baile: Okay. Well, I was very interested in your comments about patient participation and the consultation because I think to address the point that, you know, patients are often very anxious and they make assumptions also about, well, if there's a problem that I guess my doctor will tell me or I guess they'll ask me about my concerns. Unfortunately, you got clinicians on automatic pilot and you sort of got to turn the switch off from automatic pilot to manual to kind of get people's attention, and I think there is a certain amount of coaching that's involved with that. That's why I was really impressed with that study on coaching patients because we really need more of that done, and in fact there are some literature that shows that coaching patients prior to their initial consultation in oncology increases their satisfaction and the amount of information they get. So, you know, I think as much focus as we've had on training doctors to be better communicators, I think we sort of left out the patient piece that often this is a highly emotionally charged situation and that patients need help in sort of figuring out how to get the doctors or the nurses or anyone's attention. So that was really I think important study. Any other questions? So, I want to thank Dr. Street for coming and [applause] giving us this presentation. Please, please fill out your--please fill out your evaluation forms 'cause this is our quarterly CME evaluation and it would really, really help us in supporting the program. Thanks again.
Dr. Street: Okay, thank you.
©2010 The University of Texas MD Anderson Cancer
1515 Holcombe Blvd, Houston, TX 77030
800-392-1611 (USA) / 713-792-6161