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The Clinician-Patient Partnership Paradigm: Outcomes Associated With Physician Communication Behavior Noreen M. Clark, Michael D. Cabana, Bin Nan, Z. Molly Gong, Kathryn K. Slish, Nancy A. Birk and Niko Kaciroti Clin Pediatr (Phila) 2008; 47; 49 originally published online Sep 27, 2007; DOI: 10.1177/0009922807305650 The online version of this article can be found at: http://cpj.sagepub.com/cgi/content/abstract/47/1/49

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The Clinician-Patient Partnership Paradigm: Outcomes Associated With Physician Communication Behavior

Clinical Pediatrics Volume 47 Number 1 January 2008 49-57 © 2008 Sage Publications 10.1177/0009922807305650 http://clp.sagepub.com hosted at http://online.sagepub.com

Noreen M. Clark, PhD, Michael D. Cabana, MD, MPH, Bin Nan, PhD, Z. Molly Gong, MD, Kathryn K. Slish, MA, Nancy A. Birk, MA, and Niko Kaciroti, PhD Objective: To identify physician communication behaviors associated with perceptions of quality of care and predictive of positive patient outcomes. Patients and Methods: A total of 452 families seeing 48 pediatricians for a child’s asthma participated. Perceptions and health care use were assessed at baseline and after 12 months through interviews and medical records. The measures used were 10 physician communication behaviors and 6 items describing physician’s performance, asthma office visits, emergency department visits, and hospitalization.

at-home management, nonverbal attention, interactive conversation, tailoring short-term goals, and long-term therapeutic plan. Loss in health care use was predicted (P ≤ .05) by interactive conversation, short-term goals, criteria for decision making, long-term treatment plan, and tailoring according to needs. The use of these techniques did not lengthen the patient visit. A clinician-patient partnership paradigm is provided based on these findings. Conclusions: The specific clinician communication behaviors predicted reduced health care use and positive perceptions of quality of care.

Results: Positive perceptions of physicians’ performance were related to (P ≤ .05) careful listening, inquiring about

Keywords: physician communication; asthma; physician education

M

association has become a longer-term arrangement. The patient’s perspective and experience over time are necessarily considered in treatment regimens. Increasingly, health systems and clinicians have come to emphasize that control of chronic conditions depends on what happens outside the physician’s office—that is, how the patient uses the clinician’s recommendations to tend to the illness on a day-to-day basis by himself or herself. It has become apparent that during clinical encounters communication must be optimum if physicians are to effectively assist patients to learn to independently manage their conditions.1,2 These needs have given rise to the concept of a physician-patient partnership that has taken hold across most medical communities. The communication skill of the clinician is thought to be central to a strong partnership.3,4 This study explored particular behaviors on the part of physicians that had an impact on the patient’s health care use and perceptions about the

ost health care systems were originally organized to deal with emergencies and urgent treatment of patients. As increasing numbers of individuals experienced chronic conditions for which no cures are available, the nature of the relationship between physicians and the majority of their patients changed. Because a health problem and efforts to manage it can be expected to extend into the future, the From the Center for Managing Chronic Disease (NMC, ZMG, NK), the Department of Biostatistics, School of Public Health (BN, KKS), and the Center for the Study of Higher and Postsecondary Education, School of Education (NAB), University of Michigan, Ann Arbor, Michigan; and the Department of Pediatrics (MDC), University of California, San Francisco, California. Address correspondence to: Noreen M. Clark, PhD, Center for Managing Chronic Disease, University of Michigan, 109 S. Observatory, Ann Arbor, MI 48109-2029; e-mail: nmclark@ umich.edu.

outcomes;

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quality of care they received. The 2 objectives of this study were to identify very specific clinician communication strategies associated with (a) positive patient assessments of physicians’ performance and (b) subsequent reductions in patients’ health care use. The findings were used to construct a theoretical model of behavior on the part of the clinician and responses on the part of the patient that might be expected to optimize their partnership and efforts to reach the goals of clinical care.

Methods This study was conducted as a part of a larger investigation assessing a physician education program in 10 cities across the United States. The participants of the larger study included 76 general practice pediatricians and 870 randomly selected families under their care that had a child with asthma. The larger study required random assignment of pediatricians and their patients with asthma to a treatment or control group. This substudy involved only patients in the control condition. The participating pediatricians sent a letter that explained the study to each family. The parents of patients could contact the physician’s office to have their names removed from the list of potential participants. Consent was obtained from the child’s parent or legal guardian. The institutional review board of the University of Michigan approved the study protocol.

Physician Sample Using listings from yellow pages and membership lists from local professional societies and asthma coalitions, recruitment was targeted at pediatricians from 10 different regions of the United States: Corpus Christi, Texas; Fresno/Bakersfield, California; Nashville, Tennessee; Jacksonville, Florida; Omaha, Nebraska; St Paul, Minnesota; Kent County, Michigan; New Castle County, Delaware; Columbus, Ohio; and Indianapolis, Indiana. Over a 4-month period, up to 3 letters and brochures were sent to physicians, inviting them to participate in the study. The providers had to be involved in the direct primary care of children and be able to provide a registry of their patients with asthma. A total of 1219 physicians were contacted. Of these, 101 met the

study criteria, agreed to participate, and provided baseline data. Although the clinicians were a convenience sample and not necessarily representative of all practicing pediatricians, they were likely to be similar to other clinicians who would take part in continuing education and university-sponsored research.

Patient Sample To be eligible for the study, children who were patients of the participating physician had to meet the following criteria: a diagnosis of asthma; between 2 and 12 years of age (the diagnosis of asthma can be difficult before 2 years of age); no other diseases associated with pulmonary complications, such as tuberculosis, sickle cell disease, or cystic fibrosis; and with active asthma. Active asthma was defined as having at least one hospitalization, emergency department visit, or urgent office visit for asthma within the previous 2 years. An urgent visit was defined as any visit for asthma that required the administration of epinephrine subcutaneously or a β2-agonist bronchodilator for nondiagnostic purposes. Study physicians provided lists of their pediatric asthma patients, constituting a registry of 3368 individuals. On the basis of previous experience from similar studies,5,6 we assumed that only 40% of patients would be both eligible and consent for participation. From the 3368 patients, using a random number generator, we randomly selected 2300 patients (only one child per family) to be contacted to recruit a final sample of approximately 1000 patients. Figure 1 describes the patient assignment and flow. A total of 882 patients were not eligible. Reasons for ineligibility included no diagnosis of asthma (n = 140), no visit for asthma in the previous 2 years (n = 225), no visit to the study physician (n = 139), not between 2 and 12 years of age (n = 153), parent works for study physician (n = 5), sibling of current study patient (n = 3), other major disease (n = 3), and a combination of the above (n = 214). The patients constitute a random sample of 870 children from the practices of 101 clinicians (48 randomly assigned to control and 53 to intervention) who participated in the study. As noted, only those 452 families seeing the 48 control physicians were included in this substudy. The median number of patients for each provider was 7 (intraquartile range, 4–12). Patients and their parents were blind to physicians’

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The Clinician-Patient Partnership Paradigm / Clark et al

Figure 1.

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Profile of patient enrollment and assignment.

involvement in the study. Physicians were blind to which patients were selected for the survey.

Data Collection Data were collected from parents by telephone at baseline and 12 months after the educational intervention.

The parent interviews were conducted with the person who “is usually responsible for the child’s healthrelated care and takes him/her to the doctor.” The interview was conducted in English. Reasons for no baseline interview were the following: having moved from physician’s practice, no useable phone number could be located, lack of interest in the study, and no consent form returned. One-year follow-up was

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completed with 731 of the 870 parents (84% response rate), with 368 respondents constituting the control group. Trained interviewers contacted the households to administer the questionnaires to the parent in a standardized manner. Pediatricians completed a self-administered mailed survey at baseline and 12 months later. Of the 101 physicians, 94 (47 were control) returned baseline questionnaires. Twelve months later, 76 (38 were control) returned follow-up questionnaires.

Measures Data provided by the parents of the patients were used to assess correlates and predictors of physician communication behavior. Items in the physician survey concerned the physician’s communication and asthma therapy practices.

Physician Behavior Questions in the parents’ interview concerned the physician’s behavior and the parents’ perceptions of the care the child had received. Ten items described physician communication strategies identified as beneficial in a physician-patient encounter.3 Parents were asked to report the physician’s behavior during their most recent office visit. The items included 1. 2. 3. 4. 5. 6. 7.

showing nonverbal attentiveness, giving nonverbal encouragement, giving verbal praise for things well done, maintaining interactive conversation, finding out underlying worries/concerns, giving specific reassuring information, tailoring the medication schedule to family’s routine, 8. reaching agreement on a short-term goal, 9. reviewing the long-term therapeutic plan, and 10. helping patient to use criteria for making decisions about asthma management.

Items required a response on a 5-point Likert scale indicating disagreement to full agreement on each statement about the physician’s performance. Physicians were categorized as engaging in behavior when the patient response was 5 on the 5-point scale.

Parents’ Perceptions of Care Items employed in previous studies5,7 were used to tap elements of respondents’ satisfaction and their

perceptions regarding the care rendered by the physician. These items include experiencing relief from worry about the condition, doctor attended to patient concerns, doctor provided criteria for making decisions at home, doctor spent enough time, doctor was thorough, and satisfaction with the care received.

Patient Outcomes To assess changes in patient health care use for asthma, parents indicated the number of emergency department (ED) visits, hospitalizations, and urgent office visits for asthma that were made in the previous 12 months. Urgent office care was defined as any visit for asthma that required the administration of epinephrine subcutaneously or a bronchodilator by aerosol for nondiagnostic purposes. Because analysis was based on reports of asthma events from parents, a medical chart review of a sample of approximately 6% of the study patients (n = 50) was conducted to verify reports. The mean difference between documented versus reported hospitalizations was 0.02 events (median, 0; intraquartile range [IQR], 0–0); for asthma ED visits, 0.62 events (median, 0; IQR, 0–1); and for asthma office visits, 1.12 events (median, 0; IQR, −1 to 2). The small median differences (all medians 0) suggest that although an individual parent report may have differed from a medical chart, the aggregate parent reports were similar to medical charts.

Data Analysis To examine parent perceptions of physician behavior, multivariate logistic regression analyses were conducted using generalized estimating equations (GEE) analysis to control for the occurrence of clustering of patients with physicians. Each parent perception (eg, our worries were relieved, etc.) comprised the dependent variables, and the independent variables were the specific physician communication behavior (eg, using open-ended questions), the patient’s age and sex, and the severity of the asthma (as described in National Asthma Education and Prevention Program [NAEPP] guidelines).8 To examine physician behavior predicting outcomes for the patient, multivariate Poisson regression analyses were conducted and GEE employed. Dependent variables were the outcome of interest (eg, health care use), and the independent variables

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The Clinician-Patient Partnership Paradigm / Clark et al

Table 1.

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Physician and Practice Characteristics

Variable

Subvariable

Male Years since medical school graduation Race White Black Hispanic/Latino Other Private practice Practice setting Solo physician Small group (2–5 physicians) Large group (>6 physicians) Hospital or government clinic No response Number of asthma patients in practice (mean) Male Age of child (mean) Persistent asthma Asthma subspecialist involved Under physician care (mean) Health care use

Number (N)

Percentage (When Applicable)

22 19.8

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31 0 2 9 32

74 0 5 21 76

5 15 20 3 2 171 284 7 (2.9) 172 174 174 (38)

12 30 47 7 5 65 38 38

Hospital admissions per year (mean) Emergency department asthma visits per year (mean) Emergency doctor visits per year (mean)

0.12 0.66

Mother Father Other

418 21 11

93 5 3

Private Medicaid CHIP Government (non-Medicaid) Self-pay Other

376 48 8 7 9 4

83 11 2 2 2 1

Respondent age (mean) Relationship

1.7 36

Insurance type

were the physician’s behavior, the patient’s age and sex, and the severity of the asthma.

Findings Table 1 presents demographic information for the 48 pediatricians and 452 families. Just over half of the physicians were men, and on average, the physicians in the sample had graduated from medical school 20 years ago. Just under three-quarters were

white, and just over three-quarters were in private practice. On average each pediatrician saw 171 children with asthma. The children they saw were more likely to be male (in children, asthma is more evident in boys than in girls) and the mean age of the children was 7 years. Thirty-eight percent had persistent asthma. The mean for urgent doctor visits was just less than 2 per year. The majority of participating parents (93%) were mothers, and the mean age of the parents was 36. About 97% of families had some form of health insurance.

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Clinical Pediatrics / Vol. 47, No. 1, January 2008

Table 2.

Physician Behavior and Parent Perceptions of Carea

Patient/Family Perception

Physician Behavior

Estimate

P Value

Our worries were relieved

Listened carefully Reviewed the long-term plan Inquired about day-to-day management at home Showed nonverbal attention Used interactive conversation Reviewed the long-term plan Used interactive conversation Tailored the regimen to our daily routine Reviewed the short-term goals of therapy Paid nonverbal attentiveness Paid nonverbal attentiveness Used interactive conversation Tailored regimen to our daily routine

−1.65 −1.25 −0.97 −0.86 −0.58 −0.61 −0.71 −0.60 −0.63 −0.91 −2.01 −1.35 −1.05

.05 .0006 .005 .001 .055 .04 .01 .05 .03 .03 .005 .02 .02

MD attended to our concerns

MD provided criteria for decision making at home

We were satisfied with the care MD spent enough time with us MD was thorough a. General estimation equations.

Physician Behavior and Patient Perceptions of Care Table 2 presents in the left-hand column the perceptions of parents regarding 6 dimensions of quality of the physician’s care for their children as experienced in their most recent office visit. In the right-hand column is the behavior of the clinician significantly associated with each perception. When patients reported that the worries that had led to the visit were relieved, they were also significantly more likely to say that the physician had listened carefully, had reviewed with them the long-term treatment plan, and had inquired about how the patient managed the condition at home. Patients who reported that their physicians had attended closely to their concerns were significantly more likely to report that their clinicians were nonverbally attentive, were interactive (used more than just yes/no questions) in their conversation, and reviewed the long-term treatment plan (ie, the clinicians discussed their strategies for therapy over the longer term to achieve and maintain control of the condition). When patients reported that physicians had enabled them to prepare for making decisions on their own (eg, provided criteria for decision making at home), they were significantly more likely to report that clinicians interactively conversed, tailored the medical regimens to their daily routine, and reviewed with them the short-term goals of therapy (ie, what should result between the current visit and the next). Patients who, in general, expressed satisfaction with their physician’s care reported that clinicians had been attentive nonverbally. Those

who reported that the physician spent enough time with them were significantly more likely to state the clinician paid nonverbal attention and used interactive conversation. Those patients who reported that the physician was thorough were significantly more likely to say he or she tailored the regimen to the family’s daily routine.

Predictive Value of Physician Behavior Table 3 presents the 4 physician behaviors at baseline that were significantly associated with outcomes for patients 12 months later. Significant reductions in office visits for asthma were associated with the physician using interactive conversation, reviewing the short-term goals of therapy, and providing criteria for decision making at home regarding the recommended therapies. Reductions in ED visits were predicted by physicians tailoring the medical regimen to their patients’ daily routines. The physician behavior with the greatest impact on health care use was reviewing with the parent the long-term therapeutic plan. This action was significantly associated with subsequent reductions in patients’ emergency department and urgent office visits and in their hospitalizations. Review of the long-term plan also reduced the frequency of telephone calls to physicians’ offices.

Discussion Few areas at the intersection of the behavioral sciences and medicine have spawned more articles

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The Clinician-Patient Partnership Paradigm / Clark et al

Table 3. Physician The more the MD: Used interactive conversation Reviewed the short-term goal Provided criteria for decision making Reviewed the long-term plan

Tailored the regimen

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Physician Behavior Predicting Patient Health Care Usea Patient/Family The less the Patient:

Estimate

Made office visits Made office visits Made office visits Made ED visits Made urgent office visits Made phone calls Was hospitalized Made ED visits

0.35 0.31 0.42 0.49 0.50 0.53 0.38 0.46

P Value .03 .05 .005 .04 .01 .01 .03 .03

Note: ED, emergency department. a. Generalized estimation equations.

than the physician-patient relationship. There are hundreds of articles that describe aspects of the clinical interaction that are thought to be important from the beliefs, attitudes, and behavior of the clinician to the expectation, participation, and reaction of the patient.9 Most of the work undertaken on this subject began at the point when the health care system in particular and society in general were becoming aware of the shift of the health burden from acute to chronic conditions. These articles and commentaries, in part, led to the evolution of the concept of patient-physician partnership. Experience and some studies10,11 illustrate that patients do not want to be the primary deciders of a course of action during an exacerbation of disease or during an urgent phase of a health problem. However, patients and, increasingly, their physicians12 have come to value, indeed expect, patient involvement in deciding the therapeutic ways in which chronic illness can be managed. Over time, the expectation for the relationship between the doctor and the patient has shifted from dominance of the technically informed expert to a collaboration between the expert in medicine (the physician) and the expert in how the disease manifests in daily life (the patient). This new conception of the relationship has become normative in discourses on quality of health care among health professionals.2 Nonetheless, surprisingly few studies have actually examined in detail physician behaviors related to developing a partnership with the patient.11 For example, specific types of clinical communication behavior have not been rigorously examined (eg, what the physician does that enhances interaction with the patient). Furthermore, the impact of specific aspects of a physician’s communication behavior on important health outcomes

has not been extensively explored. The findings of this study help shed light on these important questions. Several aspects of the findings are interesting. One is that the behaviors that influenced the patient to rate his or her physician highly regarding the quality of care rendered were the same behaviors predictive of reduced health care use. There was little apparent disconnect between the patients’ view of a good clinical encounter and subsequent outcomes. This suggests that effective clinical communication is not just an amenity but contributes in a real way to achievement of desired results for patients and health care providers. Communication behavior of the type explored here likely makes both the problem and the clinicians’ judgments about therapeutic actions clearer, more acceptable, and more relevant to the patient. Patients subsequently are better able to carry out recommendations and communicate about them to their physicians. Different behaviors on the part of the clinician were associated with different parent perceptions and different health outcomes for the patient. This suggests that a repertoire of communication skills on the part of the clinician are needed to enhance the various perceptions of families that constitute quality of care and the several forms of health care use that indicate good control of disease (eg, less need for urgent care). One communication behavior—review of the long-term therapeutic plan—was especially relevant to improving health care use, to reducing patients’ worries, and to fostering the belief that the clinician had attended to the patient’s concerns. Experience in asthma studies13 suggests that when the physicians are taught to lay out their plan for treating the

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Clinical Pediatrics / Vol. 47, No. 1, January 2008

Figure 2.

Clinician and patient partnership paradigm.

condition over the long term, patient perceptions and behavior are influenced. This practice on the part of the physician likely convinces the patient that the treatment regimen is not based on episodic care but is selected to fit the chronic nature of the disease. Furthermore, knowing the long-term plan may provide motivation for the patient to follow clinical recommendations in that it makes clear to the patient the physician’s view of treatment success or benchmarks. In other words, reviewing the longterm plan may make it evident how both physician and patient will know that control is being attained. Understanding the clinician’s view of the trajectory of asthma and the means by which he or she can respond most effectively may position the patient to be more fully involved in day–to-day management

and control efforts. The plan may even provide the patient with “light at the end of the tunnel” in the form of a future with less medicine, fewer symptoms, and fuller functioning. In these data, reviewing the long-term plan appears to be at the core of the physician’s repertoire of successful communication strategies.

A Physician-Patient Partnership Paradigm Based on the findings of this study, we propose a model of clinical communication behavior that might be expected to enhance patient perceptions and health care use. Figure 2 presents elements of

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The Clinician-Patient Partnership Paradigm / Clark et al

an office visit in which the physician uses a repertoire of skills in an attempt to optimize his or her communication with the encouragement of the patient. Each of the 8 physician communication behaviors significant to patient perceptions of care and to outcomes are included in this model of the clinician-patient encounter. Two practical considerations spring to mind on review of such a model. First, can clinicians be taught to use or enhance their use of these communication skills? Second, given the limited period of time available for the clinical encounter in most health care settings, do physicians have the time to communicate more effectively? Data regarding these questions are available in earlier work by the authors that illustrated 10 specific communication behaviors could be successfully introduced into a continuing education program and clinicians would increase their use of these behaviors.4,5,13 Furthermore, studies have illustrated that physicians who participated in continuing education designed to enhance their communication skills spent no more time with their patients than control physicians and had more desirable patient outcomes.5,13 The clinical encounter is influenced by a range of factors including guidelines for disease treatment, regulations and incentives for care, the structure and organization of the clinical setting, and the resources of both the physician and the patient.14 For the clinician, effective communication with the patient and maintenance of a productive partnership are important resources for achieving clinical goals.

Acknowledgments The research was supported by Grant HL-44976 from the Lung Division of the National Heart, Lung and Blood Institute and by a grant from the Robert Wood Johnson Foundation, Princeton, New Jersey.

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3. Clark NM, Nothwehr F, Gong M, et al. Physicianpatient partnership in managing chronic illness. Acad Med. 1995;70:957-959. 4. Clark NM, Gong M, Schork MA, et al. Long-term effects of asthma education for physicians on patient satisfaction and use of health services. Eur Respir J. 2000; 16:15-21. 5. Clark NM, Gong M, Schork MA, et al. Impact of education for physicians on patient outcomes. Pediatrics. 1998;101:831-836. 6. Clark NM, Gong M. Management of chronic disease by practitioners and patients: are we teaching the wrong things? BMJ. 2000;320:572-575. 7. Marquis Y, Chaoulli J, Bordage G, Chabot JM, Leclere H. Patient-management problems as a learning tool for the continuing medical education of general practitioners. Med Educ. 1984;18:117-124. 8. National Asthma Education and Prevention Program Expert Panel Report II. National Institutes of Health Publication No. 98-4051. Bethesda, MD; 1997. 9. Potter SJ, McKinlay JB. From a relationship to encounter: an examination of longitudinal and lateral dimensions in the doctor-patient relationship. Soc Sci Med. 2005;61:465-479. 10. Gibson PG, Talbot PI, Toneguzzi RC. Self-management, autonomy, and quality of life in asthma. Population Medicine Group 91C. Chest. 1995;107:1003-1008. 11. Adams RJ, Smith BJ, Ruffin RE. Impact of the physician’s participatory style in asthma outcomes and patient satisfaction. Ann Allergy Asthma Immunol. 2001;86:263-271. 12. Caress AL, Beaver K, Luker K, Campbell M, Woodcock A. Involvement in treatment decisions: what do adults with asthma want and what do they get? Results of a cross sectional survey. Thorax. 2005;60:199-205. 13. Cabana MD, Slish KK, Evans D, et al. Impact of physician asthma care education on patient outcomes. Pediatrics. 2006;117:2149-2157. 14. Stibolt TB. Influences on physician practice. Paper presented at the European Respiratory Society 14th Annual Congress; September 4-8, 2004; Glasgow.

References 1. Volovitz B, Friedman N, Levin S, et al. Increasing asthma awareness among physicians: impact on patient management and satisfaction. J Asthma. 2003;40:901-908. 2. Saba GW, Wong ST, Schillinger D, et al. Shared decision making and the experience of partnership in primary care. Ann Fam Med. 2006;4:54-62.

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