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The Evolving Roles of Patient and Physician
Arch Fam Med. 2000;9:65-67.
THE ARTICLE "The Effects of Patient Communication Skills Training on Compliance" by Cegala et al1 reinforces significant research literature that support the value of training patients to be more active and effective participants in the medical encounter. Consistent with previous researchers, they recommend that clinicians encourage greater patient involvement in health communications. Noteworthy is their choice of compliance as the outcome variable. More than patient satisfaction, compliance serves as an intermediate variable to positive disease outcomes. The increase in compliance with behavioral interventions in those who are trained as compared with those who are not is also interesting. The possibility of increasing behavior change, especially in such areas as weight loss, exercise, diet, and smoking, is an important link with improved disease outcomes.
The seminal work of Kaplan et al2 on training patients for more active involvement in the patient-physician relationship is now more than 10 years old. Their findings, which documented improved clinical parameters in diabetes and hypertension as a result of training patients, deserve special attention. In contrast with the written training materials of Cegala et al, the patient training in this earlier research involved several face-to-face interventions with a research assistant. This work stands out in the communication literature for the documented strength of its impact on disease outcome. While this work is frequently referenced in the communications literature, it failed to create an avalanche of programs to train patients for greater involvement. Over the past decade, the medical world has not demonstrated readiness to fully embrace their recommendations.
Now, at the turn of the century, have the roles of both patients and physicians evolved to a point of readiness for more active collaboration of patients in the medical decision-making process, as advocated by Cegala et al? Consider how far the patient-physician relationship has evolved over the past 50 years. Imagine the response by both patients and the medical community in the early 1950s to direct pharmaceutical marketing to consumers. Neither was ready, and the pharmaceutical industry knew that it was not the time for public advertising.3 The physician-patient relationship of that period might be best described by the model of activity-passivity or guidance-cooperation developed by Szasz and Hollender,4 or by the paternalistic model of Emanuel and Emanuel.5 Most references to the "physician-patient relationship" placed the physicians first, a convention that symbolized the perceived power order in the dyad.
Gradual but substantive change occurred over the next 50 years, with especially rapid change over the past decade, a time when managed care, consumers' rights, and direct marketing to consumers have all become mainstream. While in some emergency situations the model of activity-passivity will always be appropriate, the more collaborative model of mutual participation developed by Szasz and Hollander and the deliberation model of Emanuel and Emanuel seem to be gaining wider acceptance as we face the millennium. Few would contend that paternalism is as prominent in the patient-physician relationship today as it was in the 1950s, but how far have patients and physicians come in the direction of mutual participation? What barriers and challenges to change still prevent increasing patient involvement by incorporating the suggestions of Cegala et al?6
If full, honest, and respectful disclosure of each person's ideas, concerns, and expectations helps to define a collaborative, deliberative relationship, are we there? The reservations that many patients have for full disclosure of their issues and concerns is revealed in the way that they cautiously introduce their ideas into the medical interview. Fewer than 25% of the patient's real ideas of causation and concerns are explicitly expressed.7-11 When patients do introduce their real concerns, they frequently append them to answers of questions initiated by the physician12 or embed them in statements and behaviors that only imply, but do not state, their ideas and concerns.13 While the reasons for this are multiple, part of the explanation is the fear of ridicule, embarrassment, or taking too much of the physician's time.14 The state of patient-physician communications is still a distance from uniform, deliberative, collaborative dialogue.
Recently, a study of patients with breast cancer found that one third of these women wanted to delegate the responsibility of selecting cancer treatment to their physicians, 44% wanted to select their treatment collaboratively, and 22% wanted to select their own cancer treatment.15 In another study examining patients' choices of several screening tests for colorectal cancer (a procedure for which there is not yet a national medical consensus), patients were able to comfortably choose among the choices when provided information on the pros and cons of the various options. However, most would comply with a physician's recommendation for one procedure or another, even when that recommendation is different from their choice.16
Likewise, physician response to the growing patient empowerment movement varies widely. Physician groups are split, and individual physicians are frequently ambivalent about increased patient involvement. Most physicians recognize that direct-to-consumer advertisements encourage patients "to take a more active role in their care." However, more than 85% disagree that such advertisement had successfully enhanced relationships with patients.3 In another study, more than 30% of requests to physicians for specific medical interventions created negative feelings of either objection or anger on the part of the physician. An additional 20% expressed a lack of interest in the request generated by the patients.17 In another report, Levinson et al18 suggest that the desire for control implied by patients' requests for medical tests can create frustration for many physicians.
Even when physicians are ideologically committed to a collaborative relationship with patients, the strong emphasis on being a medical diagnostician, with its resulting focus on the cardinal manifestations of disease, can make it difficult to hear patients' offers.19 It seems that at this moment, patients and physicians vary widely in their beliefs and expectations. Many patients and physicians are torn by factors that pull them in opposing directions for and against patient empowerment. Such diversity of expectation suggests that a "one communications approach fits all" model will lead to frustrations and problems on both sides. It should be noted that a patient-centered approach does not insist on patient decision making. An approach that is truly patient-centered explores the patient's preference for involvement and decision making and respects that preference.20
How should we reconcile the demonstrated benefits of increased patient involvement with the variable preferences of patients and physicians? First, it seems reasonable to inform patients, either in writing or verbally, that active involvement in health care tends to promote better health outcomes. That considered, clinicians should individually explore with patients their preferences for involvement and decision making. An approach similar to this has recently been recommended by the American Academy on Physician and Patient; they created and have made available to clinicians a waiting room flyer that provides guidance to patients on becoming more involved in their own medical care.21 The physician's decision to place such a flyer in the waiting room may be a seed that will nourish the kind of fruit described by Cegala et al and others who would promote greater patient involvement.
The results of this article carry implications for medical education and research. To accommodate greater patient participation, complementary changes in physician training need to occur; for example, teaching the appropriateness of different models in different clinical situations. In a medical crisis, physicians need to practice communicating their competence and providing direction and guidance in a manner that instills confidence and decreases fear. In most other situations, such as those involving long-term interventions, clinicians require training and practice with the language and skills of collaboration and avoiding the pitfalls of paternalism. In addition, the ability to listen for, explore, and acknowledge patients' ideas and expectations when such are implied but not stated needs to be part of all physicians' training.13
There also needs to be greater attention on how to best respond to patients' expectations, requests, and demands, especially when such expectations run counter to the judgment and recommendations of the clinician. Patients' statements of expectation for the visit should serve as the starting point for an interactive dialogue that incorporates some of the newly developing skills in reaching common ground.22-23 Knowing patients' expectations can expand the relationship to a higher, more challenging, and potentially more rewarding level of interaction. Researchers, educators, and clinicians alike will need to emphasize the part of the interview that occurs after the history and physical examination, a time in the interview for bringing the patient's and physician's worlds to common ground.
The article by Cegala et al should stimulate other researchers to continue this focus of study. Future studies should pay careful attention to the patient's educational level as an independent variable to ensure that outcomes are related to the educational intervention and not to the patient's prior education. Which approaches work best with patients with low literacy levels? A recent project suggests that use of a low-literacy patient education tool can significantly increase patient-physician discussions about vaccination.24 Additional issues include how much contact is necessary and sufficient to effect patient and physician behavior change. Is this done as effectively in writing (the approach of Cegala et al) as with an interactive discussion (as per Kaplan and Greenfield)? Should the effort occur immediately prior to a visit or at a more remote prior time? Are there different, more-effective educational interventions for patients of different racial or cultural backgrounds? It seems that cross-racial relationships pose barriers to the appreciation of more active patient involvement. How can this be overcome?25-26
These studies make it possible to explore the boundaries of both patient and physician comfort and interest in a decision-making model that is deliberative and collaborative. If we know the range and limits of patients' true preferences for involvement, there may be a day when patients choose physicians' style of communication and decision making. At that time, physicians may routinely collect information on patients' preferences for involvement in decision making, and provide some form of training for patients in how to establish a more collaborative relationship. The work of Cegala et al will hopefully serve to stimulate needed research into and education on how to help patients and physicians adjust to the evolving roles of each.
Forest Lang, MD
Department of Family Medicine
James H. Quillen College of Medicine
East Tennessee State University
Johnson City
(e-mail: lang{at}etsu.edu)
REFERENCES
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1. Cegala DJ, Marinelli T, Post D. The effects of patient communication skills training on compliance. Arch Fam Med. 2000;9:57-64.
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17. Cohen O, Kahan E, Zalewski S, Elizer K. Medical investigations requested by patients: how do primary care physicians react? Fam Med. 1999;31:426-431.
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24. Jacobson TA, Thomas DM, Morton FJ, Offutt G, Shevlin J, Ray S. Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates: a randomized controlled trial. JAMA. 1999;282:646-650.
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25. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583-589.
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