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Patient-Physician Communication:Impact on Clinical Outcomes
Meds 1 January 29, 2004
Moira Stewart, Ph.D.Moira Stewart, Ph.D.
Department of Family MedicineDepartment of Family Medicine
Canada Research Chair in Primary Health CareCanada Research Chair in Primary Health Care
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Objectives
1. to reinforce your learnings on research methods
2. to learn about the results of a research program on patient-centred communication
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Tie to Meds 1 Curriculum
1. follow-up to your Community Health lectures on research methods last fall
2. the results have implications for your evidence-based clinical practice from Year 3 on
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Outline of the 3 hour session today
Hour 1 Lecture on Evidence for Patient-Physician Communication 25 min
Small Group Discussion on what are the effective components 20 min
Break 15 min
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Outline continued
Hour 2 Mini-lecture on how to evaluate cohort designs 5 min
Lecture on A Study of the "Impact of Patient-Centred Communication on Patient Outcomes in Family Practice” - a cohort study 20 min
Small group discussion- design your own cohort study 20 min
Break 15 min
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Outline continued
Hour 3 Mini-lecture on how to evaluate clinical trial designs 5 min
Lecture on A Study “InnovativeTraining to Improve PhysicianCommunication with Breast Cancer Patients: Results of a Randomized Controlled Trial” 15 min
Small group discussion- design your own clinical trial study 15 min
Closing - a synthesis and summary oftake-home messages with examples of exam questions 15 min
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Hour 1 Lecture on Evidence for Patient-Physician Communication 25 min
Small Group Discussion on what are the effective components 20 min
Break 15 min
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Study Designs
Randomized controlled trials (level I)
Controlled trials without randomizaton (level II - 1)
Cohort or case-control studies (level II - 2)
Comparisons between times or places (level II - 3)
Opinions, descriptive studies (level III)
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CTF Recommendation GradesA. Good evidence to recommend
B. Fair evidence to recommend
C. Conflicting evidence, does not allow for a clear recommendation and other factors may influence decision-making
D. Fair evidence to recommend against
E. Good evidence to recommend against
I. Insufficient evidence (quantity and/or quality) tomake a recommendation
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Clinical Significance
versus
Statistical Significance
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Does Patient-Physician Communication Matter?
Moira Stewart, Ph.D.
ABMS-ACGME ConferenceABMS-ACGME Conference onon
Assessment of Physician-Patient Assessment of Physician-Patient CommunicationCommunication
March 22, 2002March 22, 2002
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Synthesis of Evidence
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What kind of evidence matters?
A - evidence Results with clinical significance
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Does the evidence on patient-physician communication measure up to these standards?
YES
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The evidence includes
Randomized controlled trials
Clinically significant results on important outcomes
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PHYSICIAN OUTCOMES
PATIENT OUTCOMES
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PHYSICIAN OUTCOMES
Malpractice claims
Time
Physician satisfaction
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PATIENT OUTCOMES
Satisfaction
Adherence
Health
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Stewart. Effective Physician-Patient Communication and Health Outcomes: A Review. Canadian Medical Association Journal. 1995;152(9):1423-1433
Stewart, Brown, Boon et al. Evidence on Patient-Doctor Communication, Cancer Prevention and Control, 1999;3:25-30
Brown, Stewart & Ryan. Outcomes of Patient-Provider Interaction, Handbook of Health Communication, Clinics in Geriatric Med, 2000;16:25-36
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PHYSICIAN OUTCOMES
Malpractice claimsMalpractice claims Time
Physician satisfaction
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Malpractice Claims
8 studies
RCTs and other designs
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Malpractice Claims
Important differences
eg. Hickson et al., 1994
% PoorPatient-PhysicianCommunication
No claims 8.2
All others 17.7
High frequency 27.6
High pay 24.7
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Malpractice Claims
1) time: feeling rushed, short visit
2) explanation: inadequate/minimal information, fewer orienting statements
3) connection: feeling ignored, no acknowledgement of patient statements, no reflection of affect, no eye contact, no friendly physical contact, no humour
4) facilitation: not understanding patient and family perspectives, no eliciting patients’ opinions and cues
5) support: devaluing patient and family views, harsh critical tones
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Physician Outcomes
Malpractice claims
TimeTime Physician satisfaction
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Time
19 studies
RCTs and other designs
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Time 6 studies found no differences in time
but communication was increased in terms of
exploration of psychosocial issues
collaboration with patients
exploring patients’ ideas and concerns
patient volume of communication
patient-centred communication
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Time
10 studies found differences in visits of longer duration in terms of
more counselling
more prevention (e.g. vaccination)
larger proportion of patient needs recognised
higher patient satisfaction
more follow-up
better guideline implementation
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family practice average 10 minutes
primary care internal medicine average 21 minutes
Time
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Time
In the situation of limited time, patient satisfaction is related to:
• a brief period of time to "chat" about non medical topics
• providing patients with feedback on clinical findings
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Physician Outcomes
Malpractice claims
Time
Physician satisfactionPhysician satisfaction
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Physician Satisfaction
one study
cohort study
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Physician Satisfaction
Important difference in physician satisfaction when the communication was rated as participatory
(Roter et al., 1997)
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PHYSICIAN OUTCOMES
Malpractice claims
Time
Physician satisfaction
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PATIENT OUTCOMES
Satisfaction
Adherence
Health
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PATIENT OUTCOMES
SatisfactionSatisfaction Adherence
Health
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Satisfaction
many studies, none were RCTs
3 key review papers
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Satisfaction
Consistent and important effects of communication on patient satisfaction
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Satisfaction
1) Warmth/caring
2) Medical competence
3) Balanced communication of both psychosocial and biomedical concerns
4) Continuity of relationship
5) Expression of patient expectations
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PATIENT OUTCOMES
Satisfaction
AdherenceAdherence Health
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Adherence
16 studies and review papers
No RCTs
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Adherence
Communication is the most important determinant of patient adherence
e.g. Stewart, 1984
PhysicianPatient-Centered
% Adherence
Low 55.4
High 73.1
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Adherence
1) information exchange and patient education
2) finding common ground regarding expectations
3) active role for the patient
4) positive affect, empathy and encouragement
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PATIENT OUTCOMES
Satisfaction
Adherence
HealthHealth
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Health Outcomes
23 studies
12 RCTs: 11 demonstrated significant effects
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Health Outcomes
(Kaplan & Greenfield, 1989)
Important effects
e.g. BP (diastolic)
Experimental Control
Pre 95 93
Post 83 91
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Health Outcomes Important effects
e.g. Pain (Egbert et al., 1964)
Experimental Control
Severity of Pain 1.2 1.7
1
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Health Outcomes Affected
Patient anxiety Psychologic Distress Symptom Resolution Functional Status Self-reported Health Status Physiologic status e.g.
HA1
BP
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“If a new drug was shown to be as effective in rigorous
studies as patient-physician communication is, the
industry would aggressively market that drug!”
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Health Outcomes
Physician during history taking
asks many questions about patient’s ideas and expectations
asks about patient’s feelings
shows support
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Health Outcomes
Physician during discussion of the management plan
encourages patient to ask questions and get information
provides information packages
provides emotional support
willing to share decisions
physician and patient agree on the nature of the problem and the follow-up
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PATIENT OUTCOMES
Satisfaction
Adherence
Health
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Does Patient-Physician Communication Matter?
Yes - to the physician
Yes - to the patient
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Evidence-based guidelines for patient-physician communication
Clear information provided to the patient
Asks about patient ideas, expectations and feelings
Mutually agreed upon goals
An active role for the patient
Positive affect, empathy, and support from the physician
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Hour 1 - Small Group Discussion
a) quality of the evidence presented
b) effective communication components
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Hour 2 Mini-lecture on how to evaluate cohort designs 5 min
Lecture on A Study of the "Impact of Patient-Centred Communication on Patient Outcomes in Family Practice” - a cohort study 20 min
Small group discussion- design your own cohort study 20 min
Break 15 min
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Categories of Research Design Observational or experimental
In an observational study the researcher collects
information but does not influence events(Level II - 2)
By contrast, in an experimental study the researcher
deliberately influences events (Level I)
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Observational studies
cohort design
case-control study
cross-sectional study
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Cohort study
Selection of subjects
Loss to follow-up
Other problems
Long-term studies may sufferfrom problems associated with
changes and over time
Surveillance bias
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THE IMPACT OF PATIENT-CENTRED CARE ON PATIENT
OUTCOMES IN FAMILY PRACTICE
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Grant #04106
Health Services Research, Ministry of Health of Ontario
Investigators:Moira Stewart, Ph.D.
Judith Belle Brown, Ph.D.Allan Donner, Ph.D.
Ian R. McWhinney, M.D.Julian Oates, M.D.
Wayne Weston, M.D.
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That adult patients whose first visit in an episode of illness is patient-centred will more frequently demonstrate recovery from the discomfort of the symptom after two months (and recovery from the concern about the symptom) and will experience less subsequent medical care (i.e. fewer patient-initiated visits, fewer tests and referrals) in the two months of study.
HYPOTHESIS
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PATIENT-CENTRED MEASURES
Measures of Patient-centred communication based on analysis of audiotapes (continuous)
Patient perception of patient-centredness total score (continuous)
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PATIENT-CENTRED MEASURES
Patient perception, subscore that the illness experience had been explored (continuous)
Patient perception, subscore that the patient and doctor found common ground (continuous)
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PATIENT HEALTH OUTCOMES
Patients’ level of discomfort, post-encounter and two months later (continuous)
Patients’ level of concern, post-encounter and two months later (continuous)
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PATIENT HEALTH OUTCOMES
Medical Outcomes Study (MOS) variables assessed two months after the study visit:
physical health (continuous) mental health (continuous) perceptions of health (continuous) social health (continuous) pain (continuous) role function (dichotomous)
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MEDICAL CARE OUTCOMES
Lab tests ordered during the two months (dichotomous)
Referrals during the two months (dichotomous)
Number of visits during the two months after the study visit (continuous)
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ANALYSIS confounding variables assessed; confounding variables included; multiple regression for continuous
outcomes adjusting for practice using PROC MIXED
multiple logistic regression for dichotomous outcomes adjusting for practice using PROC LOGISTIC and PROC IML
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RESULTS
random sample of physicians 52% refusal rate participants were:
– same year of graduation and location of practice
– more likely to be CCFP n = 39
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RESULTS
28% patient refusal rate participants were:
– same age as all eligibles
– more likely to be male than all eligibles
n = 315
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DEMOGRAPHIC CHARACTERISTICSOF THE PATIENTS
54% female 40% > 45 years of age 60% married 42% had some post-secondary education
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Outcome - Patients’ Level of Discomfort
B Estimate SE p
Independent Variables:
Total Patient Perception Score 6.04 2.70 0.03
Baseline level of discomfort 0.84 0.037 0.0001
Patients’ main presenting problem
–Musculoskeletal 2.42 3.39 0.48
–Respiratory 6.56 3.25 0.04
–Other 2.42 3.24 0.46
–Digestive 6.18 4.07 0.13
Patients’ marital status 0.63 2.03 0.76
Multiple Regression of Perception Scores in Relation to Patients’ Discomfort
n = 297
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Mean Level of Discomfort by Quartiles of the Total Patient Perception Score
Mean Level of Discomfort
Perceptions: x
First quartile - perception that the visit was patient-centred 42.5
Second quartile 45.0Third quartile 45.2Fourth quartile - perception that the
visit was not patient-centred 48.8
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Proportion Receiving Diagnostic Tests by Quartiles of the Score on Patient Perception of Patient Centredness
Proportion Receiving
Perceptions: Diagnostic Tests
First quartile - perception of finding common ground 14.6%
Second quartile 17.0%Third quartile 19.5%Fourth quartile - perception of not finding
common ground 24.3%
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Proportion Referred by Quartiles on Patients’ Perception of Patient Centredness
Proportion Perceptions: Referred
First quartile 7.9% - perception of finding common ground Second quartile 4.3%Third quartile 6.9%Fourth quartile 16.2% - perception of not finding common ground
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Measure of Patient-Centred Communication
OUTCOMES Measure of patient-centredcommunication
Patient perceptionof patient-centredness
Patients’ level of discomfort NS S
Patients’ level of concern NS NS
SF-36 NS S
Diagnostic tests NS S
Referrals NS S
Number of subsequent visits NS NS
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Relationships Among Measure of Patient-Centred Communication, Patient Perceptions of Patient-Centredness, and Outcomes
Measure of Patient-Centred Communication
N.S.
N.S. Significant p=.01Health and Medical Care Outcomes
Patient Perception that doctor explored the illness experience
Patient perception that the doctor and patient found common ground
N.S.
Significant p<.05
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Surprising ResultThe communication score (what we think is good communication) was not related to outcomes.
BUTThe patients’ perception (what the patients noticed) was related to outcomes.
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Conclusion
Only when physicians’ level of patient-centredness reaches a level that patients notice, outcomes are affected.
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Hour 2 - Small Group Discussion
Design your own cohort study on the topic
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Hour 3 Mini-lecture on how to evaluate clinical trial designs 5 min
Lecture on A Study “InnovativeTraining to Improve PhysicianCommunication with Breast Cancer Patients: Results of a Randomized Controlled Trial” 15 min
Small group discussion- design your own clinical trial study 15 min
Closing - a synthesis and summary oftake-home messages with examples of exam questions 15 min
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Intervention Studies - Validity Was the assignment of patients to
treatment/placebo randomized?
true randomization
pseudo-randomization or deterministic method of allocation
treatment/placebo allocation
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Were all patients properly accounted for and attributed at its conclusion?
completeness of follow-up
intention to treat analysis
Intervention Studies - Validity
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Were patients, clinicians and study personnel “blind” to intervention?
double blinding
methods used to ensure blindness
creative ways to “unblind” a study
Intervention Studies - Validity
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Were groups similar at the start of the trial?
carefully consider all importantbaseline characteristics of both groups
post-hoc analysis accounting for differences in the groups
Intervention Studies - Validity
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Aside from the experimental interventions, were the groupstreated equally?
co-interventions
How large was the treatment effect?
Intervention Studies - Validity
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Innovative Training to Improve Physician Communication With
Breast Cancer Patients: Results of a Randomized Controlled Trial
Principal Investigator: Moira Stewart, Ph.D.
Funded by:
Canadian Breast Cancer Research Initiative &
National Cancer Institute of Canada
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Breast Cancer Survivors: Louisette Smith
Brenda McKelvey-Donner
Research Expertise: Judith Belle Brown, Ph.D.
Carol McWilliam, M.Sc.N., Ed.D.
Allan Donner, Ph.D.
Clinical Expertise: Ron Holliday, M.D.
Ken Leslie, M.D.
Tim Whelan, M.D.
Alan Gavin, M.S.W.
Irene Cohen, M.D.
Marjorie Wood, MB,ChB
Praful Chandarana, MB,ChB
Education Expertise: Wayne Weston, M.D.
Tom Freeman, M.D.
Susan McNair, M.D.
Consultants: Ian R. McWhinney, M.D.
Jack Laidlaw, M.D.
Don Cowan, M.D.
Project Coordinator: Joanne Galajda
Research Assistant: Jo-Anne Aubut
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Co-Chairs: Louisette Smith Registered Nurse
Brenda McKelvey-Donner Vice-Principal
Members: Sharron Bearfoot R.N. at Coronary Care Unit
Barb Barton-McMillan Social Worker
Anne Buchanan Volunteer, Canadian Cancer Society
Katherine DeCaluwe Hair Stylist
Barbara Garvin Regional Manager, London Canadian
Cancer Society
Addie Gushue Medical Claims Assessor for the
Ministry of Health
Sandy Krueger Independent Business Woman
Margie McPhillips Homemaker
Breast Cancer Advisory Group
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Does intensive training improve
physician communication with
breast cancer patients?
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To design an education program for physicians based on real life experiences of breast cancer survivors, with the goal of improving physicians’ communication
To evaluate the program
Purpose of the Study
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3. Evaluate the education program in a randomized controlled trial
3 Phases of Study
1. Qualitative Study
2. Pre-test education program
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Relationship-building
Information Sharing
Creating the Experience of Control
Mastering the Whole Person
Qualitative Study Findings
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•Introduction•Physician’s Perspective•Patient’s Perspective - Video•Patient’s Perspective - Discussion With Breast Cancer Survivors•Video Demonstration•Lunch•Videotaped Standardized Patient Interviews (2)•Video Feedback•Evaluation of the Course
Overview of the 6 Hour CMEPatient-Physician Communication
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6 hour education
Phase 3 - Randomized Controlled TrialRecruitment - 51 family physicians, surgeons, oncologists
Randomization
2 hour education
2 standardized patient appointments
2 standardized patient appointments
2 standardized patient appointments
2 standardized patient appointments
10 patient questionnaires
10 patient questionnaires
Oncologists & Surgeons Only
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Outcome Measures
1. Audiotaped standardized patients in office setting
2. Patient questionnaires
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Mastering the Whole Person Experience:
9. Eliciting & Validating Issues of the Person
Measuring CommunicationBuilding Relationships: 1. Eliciting & Validating Feelings
2. Eliciting & Validating Ideas
3. Offering Support
Sharing Information: 4. Opportunity to Ask Questions
5. Mutually Discussing the Problem & Management Plan
6. Clarification of Agreement
Creating the Experience of Control:
7. Eliciting & Validating Expectations
8. Eliciting & Validating Impact on Function
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RESULTS
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p-value
Oncologists: N.S.
Surgeons: N.S.
Family Physicians:
Eliciting & Validating Issues of the Person .02
(Validating Issues of the Person) .05
Offering Support .02
Physician Communication Scores from Audiotaped Office Visits(6 hour vs. 2 hour education)
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Pre Post
6 hour education
(n = 8) 72.0 82.8
2 hour education
(n = 9) 60.1 58.7
Multiple regression:
* (p=.02) Statistically significant difference between the 6 hour education and the 2 hour education at post-intervention controlling for pre-intervention scores
Family Physicians
Eliciting and Validating Issues of The Person*
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Perceptions of patient-centredcommunication N.S.
Satisfaction with Dr.’s information-giving & interpersonal skills .03
Psychological distress N.S.
Feel better after visit with Dr. .02
Differences in patient outcomes between oncologists and surgeons who had 6 hr. education vs. those who had 2 hr. education:
Patient Outcomes
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6 hour education 88.2%(n = 51)
2 hour education 70.6%(n = 51)
Logistic Regression
* (p=.02) Statistically significant difference between the patients whose doctor was in the intervention group vs. the control group at post-intervention controlling for patient’s education and number of medical conditions
Patient Feeling BetterAfter Visit With Doctor*
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Patients of oncologists & surgeons had greater satisfaction & felt better after visit
Conclusions About Effectiveness of the 6 Hour Education
Family physicians improved communication (audiotapes)
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Hour 3 - Small Group Discussion
Design your own randomized controlled trial on the topic.
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Take-home messages
– there is an evidence-base for patient-centred communication
– there are 5 key communication elements revealed by the literature
– cohort studies have a role in explaining the impact of patient-centred communication
– the cohort study revealed a pathway
– communication of practising physicians and surgeons can be improved through CME
– the RCT revealed an effect on behaviour and patient perceptions
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Take-home messages
– Lessons from research need to take account of quality of study design (Level I-III and A to E)
– Lessons also need to take account of clinical significance as well as statistical significance
– There were 6 criteria presented to evaluate the quality of cohort studies
– There were 6 criteria presented to evaluate the quality of the RCT
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Sample examination questions1. Which is a correct label for a Level of Study Design?
a) 100%
b) II - 1
c) 3 - 6
d) B
2. Which is a correct label for a Recommendation for the Evidence created by the Canadian Task Force on Preventive Health Care?
a) 2
b) A
c) 80%
d) III
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Sample examination questions
3. Clinical significance means the chances the study results could have occurred by chance alone.
a) True
b) False
4. How many communication elements does the literature reveal to affect outcomes?
a) too many to learn
b) 75
c) two
d) five
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Sample examination questions
5. Which is a key criterion to evaluate a cohort study?
a) measure the outcome first
b) measure the factor before the outcome
c) be sure the patients are “blind” to the intervention
d) be sure the subjects were selected over a long period of time
6. What is the key criterion to evaluate an RCT?
a) follow patients over time
b) lose patients to follow-up
c) measure the outcome first
d) the assignment of participants is randomized