The Effects of Patient Communication Skills Training On Compliance

Objective

This study examines the relationship between communication skills training for patients and their compliance with recommended treatment.

Design

A randomized control design was used, with patients nested within physicians. Each physician was audio tape recorded with 6 patients, 2 patients in each of the following three intervention conditions. A trained group (N =5) received a training booklet in the mail 2-3 days prior to the scheduled appointment, an informed group (N = 49) received a brief written summary of the major points contained in the training booklet while in the waiting room prior to the scheduled appointment, an untrained group (N =51) did not receive any form of communication skills intervention.

Setting

Participants included physicians and patients from 9 different primary care, family practice locations. Two locations were clinics associated with a large, university-based medical school and hospital, while seven were private practice offices in the community.

Participants

The sample included 25 family physicians (averaging 11 years post-residency) and 150 patients. Patients were randomly selected from appointment records and randomly assigned to one of three intervention conditions.

Intervention

The primary intervention consisted of a training booklet designed to instruct patients in information seeking, provision and verification.

Outcome

The outcome measure was patients' compliance with medications, behavioral treatment (e.g., diet, exercise, smoking cessation) and/or follow up appointments/referrals.

Results

Trained patients were more compliant overall than untrained or informed patients. Training positively influenced compliance with behavioral treatments and follow up appointments/referrals.

Conclusions

Training patients in communication skills may be a cost effective way of increasing compliance and improving overall health of patients.

Introduction 

Information exchange between physicians and patients is central to the quality of health care. 1-5 Yet, considerable research indicates that physicians sometimes do not meet patients' information needs. 3, 6, 7 8-12 Although effort has been expended to address communication issues in medical school curricula and resident training programs, 13-15 this only speaks to half of the physician-patient dyad. Little attention has been given to patients' communication skills during medical interviews. 16

The purpose of this research is to test the effectiveness of patient communication skills training on compliance with physicians' treatment recommendations. This report is based on a subset of data from a larger project investigating patient communication skills training. The following sections provide a brief review of research into patient communication skills training and a rationale for examining training's impact on patient compliance.

Patient Communication Skills Training

While considerable attention has been given to patient education in general, very little work is directed specifically to communication skills training. 16-19 However, studies consistently show that many patients could benefit from such training. For example, patients typically engage in little information seeking during medical interviews, even though virtually all patients claim they want as much information as possible. 10, 20-23 Other research shows that when patients do seek information they often do so indirectly. 24-26

Although relatively few studies have examined the effects of patient communication skills training, findings suggest that such training is potentially valuable. 16 For example, some research indicates that trained patients participate more actively in medical interviews. 27-31 Other studies report that trained patients elicit more factual information from physicians per-controlling-act spoken by patients. 30-32 In related research, Robinson and Whitfield 28 found that trained patients had more accurate and complete recall of physicians' treatment information and recommendations.

Training, compliance and other outcomes. Some researchers 30, 31, 33 report a positive relationship between patient training and physiologically-measured health outcomes (e.g., blood sugar control, blood pressure control). Greenfield et al.30, 31 also found higher self-reported health assessments on the part of trained patients. They speculate that these enhanced health outcomes on the part of trained patients may have been due to closer adherence to the treatment plan. In a related finding, Roter 34 reports that trained patients had a higher ratio of appointments-kept-to-appointments-made over a four month period following training. Together, these results suggest that training may have a positive effect on patient compliance and other health outcomes.

In this study, we chose to focus on the relationship between patient communication skills and compliance. Our decision to do so was based on two reasons. First, patients' noncompliance with treatment recommendations is costly both in terms of poorer health and financial strain on the health care system. 35-37 Yet, despite considerable effort to improve patient adherence, noncompliance continues to be a significant problem. 38, 39 Thus, to the extent that enhanced communication between physicians and patients can reduce noncompliance, and in ways that do not infringe on patients' autonomy or decision making, 40 communication skills training may offer a relatively inexpensive and effective way of addressing problems associated with noncompliance. Second, several other health outcomes such as disease control or disappearance of symptoms are indirectly related to patients' compliance with recommended treatment. Thus, we viewed patient compliance as a fundamentally important outcome to examine and chose to begin our research program there.

While a limited number of studies suggest that patient communication skills training may positively affect compliance, additional research is needed to determine what communication skills are most important to include in interventions and how best to instruct patients. 16-19 Our research to date has provided needed guidelines for determining what communication skills to teach patients, particularly with respect to information exchange. 41-44 Other previous work assessed the effects of a 30 minute, face-to-face communication skills training procedure.45 In this study, we tested the effectiveness of printed material designed to instruct patients in effective information exchange skills.

Rationale and Hypotheses

Some research suggests that patients who ask questions, state preferences and generally more actively participate in medical interviews have measurably better health outcomes than less active patients.46 Previous research into patient communication skills training shows that trained patients typically are more active participators in medical interviews.16, 45 This was also the case for trained patients in this study, as they asked more questions, elicited more information from physicians per-question-asked, used more summarizing utterances to verify information, and provided more detailed information to physicians than patients in control groups.47 As a result of participating more actively in their interviews, we expected that trained patients would obtain more desired information about diagnosis and treatment options and, therefore, acquire a better understanding of the rationale and purpose of treatment recommendations. Given this enhanced understanding of recommended treatment, it is hypothesized that trained patients will demonstrate greater overall compliance than either informed or untrained patients. Additionally, it is hypothesized that trained patients will be more compliant with medication, behavioral treatments and follow-up appointments/referrals than either informed or untrained patients.

Design

A nested design was used, such that patients were nested within physicians. Each physician was audio taped with six different patients, two patients in each of following three intervention conditions. The untrained group (N = 51) did not receive any intervention prior to their scheduled appointment. The trained group (N = 50) received a training booklet in the U. S. mail 2-3 days prior to their scheduled appointment, while an informed group (N = 49) received a brief written summary of the major points contained in the training booklet in the waiting room prior to seeing the physician.

Participants

Participants for this study included 25 family practice physicians and 150 patients. The physicians and patients were recruited at nine different locations in and around a large metropolitan area in central Ohio. Nine of the physicians practiced in a large clinic that is part of a university hospital complex, while the remaining 16 physicians practiced in private offices with two-to-four physicians per site. Table 1 contains demographic information relevant to the patient sample. Among physicians, 17 were males, 8 were feamles. Twenty two physicians were White, 3 were African American. On average, physicians were 11 years post-residency (range: 1 month to 36 years).

Table 1

Frequency Demographics for Patients in Three Intervention Groups.

Sex
Male	13	17	13
Female	37	32	38
Race
White	35	36	38
African American	13	11	11
Hispanic	1	0	2
Asian	1	2	0
Mean Age	43	46	46
Education
Grammar School	0	0	2
High School	14	15	20
Some College	14	22	10
College	14	9	14
Graduate Degree	8	2	5
Status
New	7	4	7
Return	41	40	40
New-Return	2	5	4

Procedures

Data collection was completed at one location before moving to another site. The data were collected from July 15, 1997 to November 7, 1997. All participants signed an IRC consent form.

Patient selection and assignment. Each patient listed on the appointment records for a given day was assigned a number. Patients were randomly assigned to an intervention condition, then randomly selected from the list and telephoned. Patients were told that their physician had agreed to participate in a study of physician-patient communication and that they were being contacted to determine if they had interest in participating in the study as a patient. Overall, 84% of the patients contacted agreed to participate in the study.

Physician selection. Physicians agreed to participate in the study prior to data collection. They were told they would be audio taped with six different patients. They knew that a portion of the patients would receive an educational intervention of some kind, but they did not know any of the specific content or objectives of the intervention. To further mask intervention conditions, untrained patients were given a copy of the consent form with a cover exactly like the cover of the training booklet and brief summary given to trained and informed patients. In most instances, physicians did not know which interviews were being taped because they had no way of knowing if the microphone in the examination room was operational or not, and taping usually was done over the course of several hours whereby physicians saw a mixture of patients who were and were not part of the study.

Administration of materials. All patients were met in the waiting room by one of the researchers or an assistant. They were given a pre-interview questionnaire to complete and were asked to sign a consent form. Trained patients were then asked if they experienced any problems using the training booklet (they also returned a completed an evaluation form that was sent with the booklet), and the booklet was briefly examined for evidence of usage (e.g., written notes, underlining). In all but five instances there was both written and oral evidence that the booklet had been read. Five patients forgot to bring the booklet with them to the appointment, but each of these patients reported having read the booklet. Informed patients were given a brief summary of key points covered in the training booklet and encouraged to read the summary before seeing the physician. Untrained patients were simply told that they would soon be taken to an examination room to await the physician. Two examination rooms at each site were equipped with wireless microphones. The recording equipment and base of operation at each site was not visible to the microphoned examination rooms. When patients were taken to the exam room, the recording equipment was turned on. When the physician arrived, recording began and a stop watch was started to record the length of the interview. The entire interview was monitored as it was recorded. As soon as the interview ended, patients were taken to the waiting room and given two post-interview questionnaires to complete. When they completed the questionnaires they were paid ($30 for trained patients, who were asked for a greater time commitment, and $20 for untrained and informed patients) and all patients were given a copy of the training booklet. They were encouraged to use it for their next physician appointment or consider sharing it with family or friends. At the end of the day's taping, physicians were given a folder for each taped interview. Within the folder were two post-interview questionnaires and a consent form. The items on the two questionnaires were parallel to the items comprising the patients' questionnaires.

Telephone survey. Approximately two weeks after the taped interview patients were telephoned and engaged in an interview designed to assess compliance with recommendations made during the taped interview.

Training Interventions

Training booklet. The 14 page training booklet was based on previous work in physician-patient communication 24, 41-45 and results of an assessment of earlier versions of the training materials.44 The booklet was designed to instruct patients in information provision, seeking and verifying. It was formatted like a workbook with examples and space for notes.

Regarding information provision, patients were first instructed to list the topics they wanted to discuss with the physician. Additionally, they were encouraged to consider any psychosocial issues relevant to their medical condition, such as worries, stress, feelings of depression. Next, they were instructed to list items of personal and family history relevant to the topics they wanted to discuss (e.g., Had the patient seen a physician about the problem before? How was the problem treated?). Then, patients were instructed to respond to a series of questions regarding symptoms (e.g., What symptoms were experienced? How long had they experienced them? How often did they occur?). In addition, patients were asked to specify anything that helped to alleviate symptoms and what they expected the physician to do about their medical condition.

The next section of the booklet addressed information seeking. The following topics were covered, each with several sample questions: diagnosis, recommended medication(s), behavioral treatment recommendations (e.g., exercise, diet), and prognosis. This section ended with space for patients to write any additional questions they wanted to ask that were not already covered by the topics and sample questions.

The last section of the booklet was designed to instruct patients in information verifying. They were reminded that, when necessary, they could check on their understanding of information they received from the physician by asking questions of clarification, repeating what the physician had just said, or summarizing their understanding of what was said. Each of these strategies was illustrated by examples.

The booklet was analyzed for readability using the Flesch Reading Ease and Flesch-Kincaid Grade Level indices. The reading ease score was 68.96, which falls within the range for standard reading difficulty. The Flesch-Kincaid score was at the fifth grade level.

An evaluation form was mailed with the booklet, which trained patients were asked to complete after using the booklet to prepare for their appointment. The evaluation form was developed for and used in previous research which pilot tested an earlier version of the training booklet. 44 Overall, the booklet was evaluated highly, indicating that trained patients found it useful and informative.

Brief summary. The informed group received a brief summary of the major points covered in the training booklet. Although they received information on major points, informed patients were not given sample questions or other examples to illustrate the ideas presented. However, they were encouraged to engage in such behavior as organizing their thoughts, writing down important items, expressing their concerns, asking questions, and using information verifying strategies to make sure they understood information that was given to them. In virtually all instances, informed patients had adequate time (e.g., 20 minutes or more) to read and think about the recommendations provided, as they usually had to wait several minutes before seeing the physician.

Compliance Measure

A self-report measure of compliance was used in this study because it was most appropriate for assessing the varied forms of treatment characteristic of a primary care setting. Although self-reports of compliance are not free of problems, there appear to be key factors that improve their validity. For example, Hays & DiMatteo 48, Sackett 49, and others suggest that patients' self-reports are more valid if they are asked about their compliance to treatment in a non-threatening way. In addition, Hays & DiMatteo 48 and Thompson 50 suggest that patients' self-reports of compliance are likely to be more accurate when data are gathered by a person unconnected with the medical establishment. The data gathering procedure used here met both of these conditions.

Following Gordis,51 a distinction was made between noncompliance due to the patient's intent not to follow treatment recommendations and noncompliance resulting from factors other than the patient's intent (e.g., forgetfulness or lack of understanding about treatment procedures and/or their rationale). Unintentional noncompliance was assessed with two sets of items. Patients were first asked a series of questions designed to assess their recall of treatment recommendations regarding medications, behavioral changes, follow-up appointments and referrals. Patients' responses to these questions were assessed against transcripts of the interviews to determine the accuracy of their recall of treatment information. The logic of this procedure was based on the assumption that if a patient could not correctly recall treatment information, he/she was not likely to have followed the recommendation, or at minimum did not follow the treatment as prescribed. In either instance, it was assumed that lack of recall about treatment information was indicative of unintentional noncompliance. Second, patients responded to two unintentional noncompliance items based on work reported by Brooks, Richards, Kohler, Soong, Martin, Windsor and Baily,52 and DiMatteo et al. 35 Finally, intentional noncompliance was assessed with 12 items based on work by Becker and Maiman 53 and Donovan and Blake. 54 The recall probes, unintentional and intentional items are listed in Table 2.

Table 2

Recall Probes, Unintentional and Intentional Noncompliance Items.

Data collection. Patients were contacted by telephone approximately two weeks after their taped appointment. They were asked if the physician had recommended any of four treatment categories at the taped interview (a) prescribed medication(s), (b) behavioral recommendations (e.g., diet, exercise, smoking cessation), (c) follow-up appointments, or (d) referrals to another physician. For each category indicated with a "yes," the interviewer first asked the patient the recall probes, then the set of unintentional and intentional compliance items. One of the authors conducted all of the compliance interviews. This person was blind to the intervention condition of each patient.

Patients' responses were relied on to determine compliance with medication and behavioral recommendations, but patients' charts were checked approximately four months after the taped interview to verify their responses to telephone interview questions about follow-up appointments and referrals.

Compliance scores. Computation of the compliance scores involved two related data sets that were gathered during the telephone survey. A recall proportion score was computed for each patient by dividing the number of facts about the treatment recommendation correctly recalled by the total number of facts provided by the physician. These proportion data were used to score patients' recall along a 0 to 4 scale (0=100% recall; 1=76% to 99% recall; 2=51% to 75% recall; 3=26% to 50% recall; 4=1% to 25% recall). This scale is comparable to the 0 to 4 scale used for recording patients' responses to the unintentional and intentional items.

The three compliance sub-scores (all ranging from 0 to 4) for each treatment category were summed to compute a compliance score for each treatment (where 0 indicated 100% compliance). Because so few patients received a referral recommendation (N=7), these scores were combined with follow-up appointment scores to produce a single compliance score for follow-up appointments/referrals. In addition, an overall compliance score was computed by summing the compliance scores for medications, behavioral changes and follow-up appointments/referrals.

Data Analysis

Approximately 11% of the sample reported that they did not receive a recommendation for any of the four treatment categories (verification against the transcripts indicated that two patients erred in their reporting). Thus, compliance was not an issue for these patients. Of the remaining 89% of the sample, approximately 75% were noncompliant with one or more of the four treatment categories. Ideally, data would have been analyzed with a nested ANOVA (i.e., using the physician-by-treatment mean square as the error term). However, this method of analysis was precluded due to missing cell data for individual treatment category scores (i.e., medications, behavior treatments, follow-up appointments/referrals). As an alternative, the noncompliance scores of patients within each physician-by-intervention cell were averaged. In instances where there was a datum for only one patient in a physician-by-intervention cell, just that single datum was used. Paired t-tests were then computed on these scores (i.e., physicians were matched across the three intervention treatments). This procedure resulted in an ultra conservative test, since the sample sizes and associated degrees of freedom were reduced considerably. However, this procedure retained the advantages of the nested design and it accounted for the potential lack of independence across intervention conditions. Although it is customary to adjust the initial alpha level when conducting multiple t-tests, this was not done here because the procedure used already resulted in conservative tests. An alpha of p < .05 with one-tailed tests was used to assess the hypotheses. For large effect sizes, the power of statistical tests ranged from .75 (N = 11) to .98 (N = 25).

The first hypothesis predicted that trained patients would be more compliant overall than either informed or untrained patients. The pattern of means reported in Table 3 is consistent with the hypothesis. Trained patients were significantly more compliant overall than either untrained or informed patients. It should be noted that informed patients were also more compliant overall than untrained patients. However, the effect of training was much more dramatic than merely informing patients. Training accounted for over 60% of the variance in noncompliance scores, while informing accounted for only 22% of the variance. Overall, there is substantial support for the first hypothesis.

Standard deviations are within parentheses.

The degrees of freedom listed in this table do not accurately reflect the actual number of individual patient scores involved in each test because the sample size was reduced by averaging patients' scores within doctor. As a rule, the actual number of individual patient scores involved in a test is approximately two times the listed degrees of freedom.

Probabilities for tests involving trained patients are one-tailed, the remaining tests are two-tailed.

The second hypothesis predicted that trained patients would be more compliant than informed or untrained patients with each of the three categories of compliance. The data relevant to medications are reported in the second row of Table 3. While the pattern of means is consist with the hypothesis, none of the tests are significant. However, trained patients were significantly more compliant with behavioral treatments than untrained patients, although the difference between trained and informed patients was nonsignificant. There was no difference in behavioral compliance between informed and untrained patients. Similarly, trained patients were significantly more compliant with follow up appointments/referrals than untrained patients, but there was no reliable difference between trained and informed patients. Informed and untrained patients did not differ in their compliance with follow-up appointments/referrals.

This study was not designed to address possible interactions between patient characteristics, training and compliance. However, relevant data were examined for possible implications for future research. A moderate, but significant correlation was obtained between overall compliance and patients' education, such that more educated patients were more compliant (r = -.29, p = .001, two-tailed). This relationship was consistent within the intervention groups, although it was slightly less strong in the trained group (untrained: r = -.28, p = .06; informed: r = -.29, p = .07; trained:r = -.23, p = .11, all two-tailed).

The correlation between patients' race and overall compliance was nonsignificant (r = .16, p =.07, two-tailed). Correlations within intervention groups revealed a significant correlation for the untrained group, such that minority patients were less compliant overall than non-minority patients (r = .33, p = .03, two-tailed). There was no relationship between patients' race and compliance among informed or trained patients (r = .-.01, p = .94; r = .07, p = .65, both two-tailed, respectively). As a follow up analysis, an ANOVA was computed on overall compliance scores across intervention groups consisting of only minority patients. The results indicated that trained and informed minority patients were more compliant overall than untrained minority patients (F [2,35] = 5.48, p = .008, eta2 = .31). No significant correlations were obtained between patients' overall compliance and sex, status (i.e., new versus returned), age or illness severity.

The purpose of this study was to examine the impact of printed materials designed to instruct patients in communication skills. In light of research indicating that many patients do not competently engage in information exchange during medical interviews, training was designed to enhance patients' information exchange skills. The results provided some support for the training booklet.

Most support for the effectiveness of training are the results of patients' overall compliance. Trained patients were more compliant than untrained patients (p < .001) and were also significantly more compliant than informed patients (p = .03). These results suggest that providing patients with instruction in communication skills relevant to information exchange may enhance their compliance with treatment recommendations.

The results concerning compliance with specific treatment recommendations were mixed. Training did not have a statistically significant effect on compliance with medications, but the pattern of compliance score means were consistent with the expectation that trained patients would be more compliant than informed or untrained patients (see Table 3). The conservativeness of the statistical test used to assess this hypothesis should be kept in mind in interpreting these results. Additionally, the proportion of patients in each intervention condition who were compliant with medications suggests that training had a noticeable effect (i.e., trained = .52; informed = .24; untrained = .33). Still, the effect of training on patients' compliance with medications was not statistically significant. Additional research is needed to determine if communication skills training can enhance immediate and long-term compliance with medications. Such research will likely need to account of other factors that may impact compliance with medications, such as patients' age and severity of illness, which were not controlled systematically by the research design for this study.

Results pertinent to behavioral treatment recommendations and follow-up/referral appointments were more supportive of training effects. This was most evident with respect to behavioral recommendations. Trained patients were more compliant with behavioral recommendations than untrained patients (p = .004), accounting for 37% of the variance in compliance scores. Trained patients were also more compliant than informed patients, although the difference was not significant (p = .07). Given the conservativeness of the statistical test, this result may be meaningful, as it accounts for 16% of the variance in compliance scores.

Overall, the results concerning compliance with behavioral treatment recommendations is encouraging. Researchers have noted that compliance with life style changes, such as diet, exercise and smoking cessation are the most difficult for patients to follow,38, 55 especially if they are not motivated to make such changes.56, 57 The results of this study indicate that trained patients were especially compliant with treatment recommendations involving life style changes. While this may suggest that the training booklet was particularly effective with these patients, it may also reflect differences in patients' readiness for important life style changes. Although we did not directly assess patients' readiness, six patients reported not being ready or not wanting to make appropriate life style changes as the reason for noncompliance. Of these six patients, three were in the informed group and three were in the untrained group. Thus, patient readiness may have contributed to at least some of the trained patients' compliance with life style changes beyond any effects of the training booklet.

Finally, the results concerning follow-up/referral appointments indicated that trained patients were significantly more compliant than untrained patients (p = .02). However, there was no reliable difference between trained and informed patients' compliance (p = .11), even though the sample means were in the predicted direction. On the other hand, perhaps the communication skills training examined here is less relevant to compliance with this category of treatment recommendations, especially follow-up appointments. Approximately 61% of the patients who received a recommendation for a follow-up appointment were return patients. If patients have already made a commitment to see a particular physician on a regular basis, especially for chronic illness, the extent of information exchange within a single visit may not be an overriding factor in determining whether or not they keep a follow-up appointment. Perhaps future research should examine the role of communication skills training on patients' decision to continue seeing a physician, or their adherence to follow up appointments over an extended period of time.

Although the results of this study show reasonable support for the effectiveness of the training booklet it should be recognized that patients receiving only a brief summary of key points in the booklet also were more compliant overall than untrained patients (p = .02), and they did not differ significantly in compliance with separate treatments from trained patients. On the surface at least, this suggests that even minor efforts to encourage patients to be more active in medical interviews potentially can have positive effects on health outcomes. On the other hand, our previous research 45 and some other work in patient communication skills training 16 suggest that more extensive, face-to-face training may have dramatic effects. Following social leaning theory, a face-to-face training component could be used to emphasize modeling and practice as a means of promoting learning and self-efficacy.58 While researchers have advocated multiple-component interventions, 38, 55, 59 relatively few studies have actually examined the effects of such interventions, particularly within randomized control designs. 39, 55 To the authors' knowledge no studies have been conducted on multiple-component communication skills interventions.

Although most private practices and even many small clinics are not likely to have the resources to hire a person exclusively for extensive patient training, our observations of both clinics and private practices in this study suggest that staff nurses often perform training-like functions in their normal dealings with patients prior to the physician's appointment. Nurses could be instructed to engage patients in conversation relevant to topics covered in printed or videotaped materials and, as such, provide a version of face-to-face instruction. This may be especially effective if patients are given printed material, such as the training booklet used here, well in advance of their appointment. Along these lines, several of the physicians who participated in this study asked for copies of the training booklet after receiving a summary of the results. Some of these physicians indicated that they had certain patients in mind for whom training would be especially beneficial. This suggests an efficient "distribution strategy" for targeting patients and disseminating instructional materials where they may do the most good.

Training patients in communication skills appears to be a potentially effective way of facilitating health outcomes that are important to both physicians and patients. A fruitful direction for future research into patient communication skills training is determining the most efficient and effective ways of delivering such instruction. Another topic for future research is to access the possible effects of training on various clinical outcomes. Along these lines, future research may be especially informative by examining the effect of training on clinical outcomes where patients are not formally participants in a study. It is possible that at least part of the impact of the training booklet used here was due to the fact that patients knew they were participants in a study (e.g., perhaps they devoted more time to reading the booklet). Observing the effects of training materials on patients' clinical health outcomes in a more natural setting would provide valuable insight into the limitations and promise of patient communication skills training.

This research was made possible by grant R03 HS90110-01T from The Agency for Health Care Policy and Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Agency for Health Care Policy and Research.

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