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Improving doctor–patient communication in the outpatient setting using a facilitation tool: a preliminary study

Naama Neeman, Thomas Isaac, Suzanne Leveille, Clementina Dimonda, Jacob Y. Shin, Mark D. Aronson, Steven D. Freedman
DOI: http://dx.doi.org/10.1093/intqhc/mzr081 357-364 First published online: 21 December 2011

Abstract

Quality problem Patients often do not fully understand medical information discussed during office visits. This can result in lack of adherence to recommended treatment plans and poorer health outcomes.

Choice of solution We developed and implemented a program utilizing an encounter form, which provides structure to the medical interaction and facilitates bidirectional communication and informed decision-making.

Implementation We conducted a prospective quality improvement intervention at a large tertiary-care academic medical center utilizing the encounter form and studied the effect on patient satisfaction, understanding and confidence in communicating with physicians. The intervention included 108 patients seen by seven physicians in five sub-specialties.

Evaluation Ninety-eight percent of patients were extremely satisfied (77%) or somewhat satisfied (21%) with the program. Ninety-six percent of patients reported being involved in decisions about their care and treatments as well as high levels of understanding of medical information that was discussed during visit. Sixty-nine percent of patients reported that they shared the encounter form with their families and friends. Patients' self-confidence in communicating with their doctors increased from a score of 8.1 to 8.7 post-intervention (P-value = 0.0018). When comparing pre- and post-intervention experiences, only 38% of patients felt that their problems and questions were adequately addressed by other physicians' pre-intervention, compared with 94% post-intervention.

Lessons learned We introduced a program to enhance physician–patient communication and found that patients were highly satisfied, more informed and more actively involved in their care. This approach may be an easily generalizable approach to improving physician–patient communication at outpatient visits.

  • quality improvement
  • patient satisfaction
  • patient-centered care
  • patient–provider communication/information
  • shared decision-making

Background

Patients often do not recall nor do they fully understand medical information discussed during a medical visit. Forty to 80% of medical information provided by healthcare practitioners is forgotten immediately after a doctor visit and almost half of the information that is remembered is incorrect [1]. Improving communication and patient engagement during patient–doctor visits can help patients make more informed decisions about their care, which in turn can lead to better adherence and improved quality care [25].

One of the major reasons for the gap in patients' recall and understanding is that patients are frequently not treated as active partners in their care [69]. They often do not participate fully in clinical decision-making and do not understand the reasons for their tests and treatments [1012]. Further complicating this issue is the low rate of what has been termed health literacy. According to the 2003 US Department of Education National Assessment of Adult Literacy survey, 36% of the adult US population has basic or below basic health literacy levels [13].

Patients want to be involved or at least informed as to why certain medical decisions are being made [14]. They view getting more information from the doctor and taking part in decisions as major priorities in care delivery [1518]. Ensuring that patients are active participants in their care and that clear and thorough patient–doctor communication occurs at every encounter is crucial [13]. Improving patient understanding of medical information and engaging patients to participate more fully in their care could potentially improve many aspects of healthcare delivery [19, 20].

Initial assessment

Beth Israel Deaconess Medical Center (BIDMC) is a large tertiary-care academic medical center in Boston, MA. The Department of Medicine (DOM) at BIDMC is committed to patient-centered care and follows the tenets of the patient-centered medical home model. Each patient has an ongoing relationship with a personal physician. Physicians also strive to provide a ‘whole person orientation’, in which physicians are responsible for coordinating and providing all the patient's healthcare needs.

A group of BIDMC DOM physicians across several sub-specialties noted inadequate communication experiences with their patients and reported their experiences to the Department Vice Chair for Quality and Safety. These physicians felt that more often than not their patients did not seem to understand why certain tests or medications were being ordered and that this may be a barrier to patient compliance with treatments. During a critique session, this group of physicians suggested that creating a standardized communication process during office encounters would help facilitate communication and patient understanding of their diagnoses and treatment plans.

Choice of solution

Based on the above feedback and in order to facilitate patient–doctor communication and encourage patients to be an active and informed partner in their care, a multi-disciplinary team of providers across different sub-specialties devised a tool—termed: ‘the TRUST encounter form’—which can be used during any ambulatory medical encounter. Input regarding the content of this form was also solicited from select patients of these providers.

We then conducted a prospective quality improvement (QI) intervention utilizing the encounter form and studied its effects on patient satisfaction, understanding and confidence in communicating with their physicians defined as the medical encounter. We hypothesized that patients who received care using this tool would report higher levels of satisfaction with their medical encounter. At the completion of this QI project, qualitative interviews of the participating physicians were performed to assess feasibility and barriers to use within their standard office visit.

The TRUST encounter form

The ‘TRUST’ acronym stands for ‘Together, Responsible, Understanding, Satisfaction and Thorough’. The TRUST encounter form is a 3-fold document with templated headings, where the physician lists the problem and presenting symptoms, possible causes of the patient's symptoms in lay terms, recommended tests or treatments, the timeline for each step, how subsequent communication will occur and the patients/family's thoughts or concerns (see Fig. 1).

Figure 1

TRUST encounter form (front and back sides).

The TRUST encounter form was designed to provide a structure to every patient–physician interaction and to facilitate bidirectional communication and informed decision-making between the doctor and patient as well as family members. The physicians who participated in this pilot were instructed to fill in the information in the 3fold document sitting next to the patient while conducting an active discussion with the patient and any family members in attendance. The goals of the discussion were: (i) to create a partnership between the patient and physician; (ii) to identify the physician as the point provider and as being responsible for addressing the patient's problem; (iii) to verify patient understanding and (iv) to encourage patients to become more active in their care. Physicians were also instructed to provide additional sources of information to the patient (i.e. various forms of decision and visual aids, such as medical images), as well as their contact information (including office telephone number) for follow-up results, questions and concerns.

Implementation

Project design

We conducted a prospective QI intervention during the months of September 2009–January 2010. The intervention was conducted within five outpatient specialty services at the BIDMC, a full-service, adult teaching academic medical center in Boston, MA. It included 108 patients seen by 7 volunteer attending level physicians, representing the following five sub-specialties: gastroenterology, hematology/oncology, pulmonary, rheumatology and general medicine. These specialties were chosen to broadly cover the major areas of medicine as well as primary care and urgent visit care. The physicians chose to participate voluntarily and were selected as a convenience sample within BIDMC.

All patients were either new to the physicians participating in this project or were presenting with a new problem. Physicians were instructed on how to use the tool during a 10-min training session. They were asked to initiate the use of the TRUST encounter tool during office visits and encouraged to take the time to fill out all portions of the tool as well as elicit patient concerns. At the end of each visit, patients were given the TRUST encounter form with the information described above and were encouraged to review this document with their family as well as to use it as a reference for their care and a guide to follow along with their caregivers. A copy of the form was saved to be scanned into the electronic medical record as a PDF file.

Evaluation

Patient surveys

Prior to the implementation of the ‘TRUST’ QI project, we queried patients about their general health and function, sociodemographic characteristics and their attitudes about communicating with their physician. Telephone surveys were administered by qualified interviewers within 1 week prior to a scheduled clinic visit and, for the follow-up, approximately 1 month post-visit. Self-rated health was assessed using the standard rating scale (excellent, very good, good, fair or poor). Patient's self-confidence regarding patient–physician communication was measured at baseline as well as post-intervention, using the validated five-item Perceived Efficacy in Patient–Physician Interaction Questionnaire (PEPPI) [21]. Items measured patient's confidence in the following areas: knowing what to ask the doctor, getting the doctor to take their chief concern seriously, making the most of the visit, getting the doctor to answer patient's questions and getting the doctor to do something about their chief health concern. Responses were scored 1–10 on a numeric rating scale, with 1 indicating not at all confident and 10, extremely confident. The PEPPI score is the average of the five responses.

At the completion of this project, we conducted patient follow-up surveys 1-month after the TRUST encounter. In the follow-up surveys, we re-assessed patients' general health and function as well as attitudes about patient–physician communication. Patient satisfaction with the TRUST encounter and trust in physicians were also assessed during the second survey, using a set of items from the Consumer Assessment of Health Plans Study, a well-validated and reliable instrument developed for patient populations [22]. Response options were truncated for the survey as follows: ‘yes, definitely; yes, to some extent; no’. Lastly, we included a set of items developed for this project to assess patients' experiences related specifically to the intervention.

Physician interviews

At the end of this QI project, we also conducted qualitative interviews, performed by a trained interviewer, with the participating physicians (see Appendix 1—Physician Interview Tool). The interviews were conducted within a few weeks following the completion of the project to learn about physicians' experiences with the TRUST encounter, and their perceptions of its impact on communication, workflow and satisfaction as well as their perceived feasibility of expanding this program to other settings and institutions. Items on the physician interview were developed specifically for this project. Data from these interviews were subsequently synthesized by the interviewer to create coherent themes.

Data analysis

Baseline characteristics and follow-up measures of patient satisfaction and trust in physicians were evaluated using descriptive statistics, means and percentages. Pre–post comparisons were performed using χ2-tests for categorical variables and t-tests for continuous measures. Information from the physician interviews was evaluated for general themes and patterns in response to primarily open-ended questions.

All activities reported here were reviewed and approved by the BIDMC Institutional Review Board, under a special waiver covering QI and patient safety activities. All statistical analyses were performed using SAS version 9.2 (SAS Institute, Cary, NC, USA).

Results

Results from the patient satisfaction survey

Of the 108 patients who participated in the QI project, 97 patients (89.8%) completed the pre-visit patient survey, 70 (64.8%) completed the post-visit survey and 55 completed both surveys. Sixty-eight percent of the respondents were women, 87% were white and 57% were college graduates (see Table 1). Thirty-three percent of respondents reported their health was fair or poor at the time of the pre-visit interview, with no significant change in reported health status before and after the intervention.

View this table:
Table 1

Sociodemographic characteristics of patients in the TRUST program

CharacteristicsPatients (n= 97)
Age in years, mean (SD)52.7 (18.1)
Female, n (%)66 (68.0)
Race, n (%)
 White83 (86.5)
 Black7 (7.3)
 Other6 (6.3)
Education, n (%)
 Did not attend college18 (18.8)
 Attended college, no degree23 (24.0)
 College graduate27 (28.1)
 Graduate school28 (29.2)
Employed/self-employed, n (%)47 (48.5)
Unable to work, n (%)11 (11.3)
Retired, n (%)21 (21.7)
Unemployed, n (%)14 (14.4)
Homemaker, n (%)4 (4.1)
Fair or poor self-rated health, n (%)31 (32.6)

In the post-visit survey, patients showed an exceptionally high level of satisfaction with the TRUST encounter. Ninety-six percent of the patients replied ‘yes, definitely’ or ‘yes, completely’ to the following four questions: ‘did the doctor listen carefully to what you had to say?’; ‘were you given enough time to discuss your health or medical problem with the doctor?’; ‘were you involved as much as you wanted to be in decisions about your care and treatment?’ and ‘did the doctor explain the reasons for any treatment or action in a way that you could understand?’ (see Table 2). When patients were asked: ‘did you have confidence and trust in the doctor?’ 91% replied ‘yes, definitely’ and the remaining 9% replied: ‘yes, to some extent’. None (0%) of the patients replied ‘no’ to any of the questions above. When patients were asked if the doctor treated them with respect and dignity, all (100%) replied ‘yes, all the time’.

View this table:
Table 2

Patient experiences in post-program interview

Patient experiencePost-interview respondents (n= 70), n (%)a
Did doctor listen carefully to what you had to say?
 Yes, definitely67 (95.7)
 Yes, to some extent3 (4.3)
 No0
Did you have confidence and trust in the doctor?
 Yes, definitely64 (91.4)
 Yes, to some extent6 (8.6)
 No0
Did the doctor explain the reasons for any treatment or action in a way that you could understand?
 Yes, completely67 (95.7)
 Yes, to some extent1 (1.4)
 No0
 I did not need an explanation0
 No treatment or action was needed2 (2.9)
Were you given enough time to discuss your health or medical problem with the doctor?
 Yes, definitely67 (95.7)
 Yes, to some extent3 (4.3)
 No0
Were you involved as much as you wanted to be in decisions about your care and treatment?
 Yes, definitely66 (95.7)
 Yes, to some extent3 (4.4)
 No0
Did your doctor provide you with a written summary of the plan to address your concerns?
 Yes62 (88.6)
 No4 (5.7)
 Don't know4 (5.7)
If Yes, did you find the summary helpful?
 Yes60 (96.8)
 No0
 Don't know2 (3.2)
If Yes, did you share the summary with others in your family or with your friends?
 Yes43 (69.4)
 No19 (30.7)
 Don't know0
Did your doctor treat you with respect and dignity?
 Yes, all of the time69 (100)
 Yes, some of the time0
 No0
How satisfied are you with the current plan to address your symptoms or health problem?
 Very satisfied54 (77.1)
 Somewhat satisfied15 (21.4)
 Not satisfied and not dissatisfied1 (1.4)
 Somewhat dissatisfied0
 Very dissatisfied0
Do you feel that your problems and questions were adequately addressed at this visit?
 Yes, all of the time66 (94.3)
 Yes, some of the time4 (5.7)
 No0
Do you feel that your problems and questions were adequately addressed by your other physicians prior to this visit?
 Yes, all of the time26 (37.7)
 Yes, some of the time28 (40.6)
 No15 (21.7)
  • aNumbers do not all add to 70 because of missing responses.

Ninety-seven percent of the patients who were provided with a written summary of the plan to address their concerns (i.e. the TRUST encounter form) found the summary helpful and 69% of patients shared this written summary with family and/or friends. When asked: ‘how satisfied are you with the current plan to address your symptoms or health problem?’ 77% reported they were very satisfied and 21% reported they were somewhat satisfied.

When patients were asked about their past experience with doctors prior to the TRUST intervention—‘do you feel that your problems and questions were adequately addressed by your other physicians prior to this visit’?—only 38% replied ‘yes, all the time’ (41% replied ‘yes, some of the time’, and 22% replied ‘no’). In contrast, when patients were asked the same question about the TRUST encounter (‘do you feel that your problems and questions were adequately addressed at this visit’?) 94% of patients replied ‘yes, all the time’, and the remaining 6% replied ‘yes, some of the time’.

The TRUST encounter has also demonstrated an improvement in patients' self-confidence in communicating with their physicians. Among the 55 patients who completed both surveys, the average score on the PEPPI scale (range 1–10) increased from 8.1 in the pre-visit survey to 8.7 in the post-visit survey (paired t-test, P-value = 0.0018).

Results from physician interviews

Qualitative interviews of the physicians were performed to assess feasibility and barriers to use within their standard office visit. Results from the physician interviews suggest a generally high level of satisfaction with the TRUST program. Four of seven (57.1%) of participating physicians indicated that they were ‘very satisfied’ and three of seven (42.8%) were ‘somewhat satisfied’ with the TRUST encounter. Five of seven (71.4%) of participating physicians thought that their patients were ‘very satisfied’ with the program and two of seven (28.5%) were ‘unsure’ how satisfied their patients were.

Participating physicians indicated that they found the TRUST encounter form beneficial in formulating, organizing and documenting thoughts. They thought that this form is informative, helpful and understandable for patients, and that it creates a formalized roadmap for both the patient and the physician. Some physicians commented that patients who participated in the TRUST encounter were more informed and engaged and that the program has enhanced the patient–physician interaction and improved the management of the differential diagnosis as well as patients' expectations. Additionally, physicians felt that their patients liked going home with a written record and that patients seemed more likely to follow through on medical instructions following the TRUST encounter.

The main concerns cited for successful expansion of the program to other institutions and services are the busy workflow of office visits and time restraints. Using the TRUST encounter form was found to add ∼1–5 min to each office visit, with exact time depending on the complexity of the issues at hand. There was some redundancy noted in terms of physician workload (e.g. the need to re-type or dictate some of the content of the TRUST form into the medical note). A suggestion for improvement that was repeated by most physicians was to develop an electronic version of the TRUST form that will be linked automatically to the electronic medical record.

Discussion and lessons learned

We performed a prospective QI intervention involving the use of a communication tool, termed: ‘The TRUST encounter form’. The form was designed to restructure the medical visit and facilitate bidirectional communication between the physician and the patient. We found that using this tool improved patients' self-confidence in communicating with their doctors. Patients also reported exceptionally high levels of satisfaction with their medical visits, including with regard to understanding their illness and treatment plan. Strikingly, when comparing pre- and post-intervention experiences, only 38% of patients felt that their problems and questions were adequately addressed by other physicians prior to the TRUST visit, compared with 94% post-intervention.

Patients play a critical role in their care, and adherence to recommended treatment plans rely heavily on how well they understand and remember the information provided during a medical encounter. Both patients and physicians are inclined to overrate patient comprehension of medical information and treatment plan recommendations [23, 24]. Deficiencies in understanding and remembering medical information result in significant negative consequences, including the lack of adherence to recommended treatment plans with associated adverse health outcomes [2, 25]; increased malpractice claims [26] and an astonishing cost to society, estimated at $106–$238 billion annually [13].

When devising an effective and realistic format for improved communication and patient involvement in their care, one needs to take into account time constraints of the office encounter. Complex and time-consuming methods of educating patients are not realistic during short visits. Experts have suggested using practical tools, based on research, to assist with patient–doctor communication [14]. The QI intervention described here attempts to fill this void, and based on participant physicians' feedback, we are currently developing an electronic version of the TRUST encounter form designed to interface with the patients' electronic medical record.

There have been other similar efforts nationally at enhancing patient's understanding and active participation in their care. These include ‘after-visit summaries’, used by medical centers, such as the Group Health Cooperative and Kaiser Permanente as well as other decision aids, such as medical images, pamphlets, videos and interactive computer-based multimedia programs, used by various medical centers and clinics [27, 28]. What makes the TRUST encounter program unique is that it does not only provide take-home decision aid materials, but also offers a formal structure to the patient–physician encounter, focused on making patients and their family informed and active partners in their care. The latter is reinforced by the fact that 69% of patients shared this with their family members, which can help increase understanding and compliance with treatments and therapies.

The QI intervention described in this article has several limitations. First, this was a small-scale project with only 7 physicians and 108 patients, using a non-randomized intervention. Second, we were only able to reinterview 57% of patients who completed the first survey. It is possible that patients who were less satisfied with the program were less likely to respond to the second survey. Third, we performed the QI intervention at a single institution. Further studies will be necessary to examine the effects of similar interventions in other settings, such as community ambulatory care facilities. Further research will determine whether using such an approach improves patient adherence to recommended treatment plans and patient health outcomes.

Funding

This study was funded through the generosity of a grateful patient of Dr S.D.F.

Acknowledgements

We are indebted to Drs David Roberts, Robert Shmerling, Reed Drews, Daniel Leffler and Caitlin Fawcett for their volunteered participation in the QI intervention described in this study.

Appendix 1: TRUST Program Physician Interview Tool

Content

1. Tell me what you think of working with your patients using the TRUST tool.

2. Tell me what you think of your patients receiving a written record of the diagnostic and treatment plan.

Impact on Patient Care

3. Tell me how you think using the tool has impacted your patients.

4. Tell me how you think the TRUST tool has impacted how you care for your patients who are participating.

Impact on Patient Communication

5. Tell me what you think about communicating with your patients using the TRUST tool.

Relationship

6. Tell me how using the TRUST tool may have influenced your relationship with patients who are participating in the program.

Time Commitment

7. Tell me how you think using the TRUST tool has impacted your workflow.

8. Tell me about how the TRUST program changes the time needed and the time spent during patient visits?

Logistics

9. Tell me about any technical or logistic issues or problems you faced in implementing the TRUST program?

Satisfaction

10. Overall, how satisfied were you with the TRUST tool?

□ Very dissatisfied

□ Somewhat dissatisfied

□ Somewhat satisfied

□ Very satisfied

□ don't know

11. How satisfied do you think your patients were with this tool?

□ Very dissatisfied

□ Somewhat dissatisfied

□ Somewhat satisfied

□ Very satisfied

□ don't know

Expanding the program

12. Do you feel it is feasible to expand the practice of the TRUST tool to all your patients?

□ Yes

□ No

□ Not sure/ don't know

 a. Please explain why:

13. Do you feel it is feasible to expand the practice of the TRUST tool to other physicians in your division?

□ Yes

□ No

□ Not sure/ don't know

 a. Please explain why

14. Do you feel it is feasible to expand the practice of the TRUST tool to other services at BIDMC?

□ Yes

□ No

□ Not sure/ don't know

 a. Please explain why

15. What other recommendations do you have about the tool or the implementation of the program?

Footnotes

  • These authors equally contributed to this study.

References

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