The Effects of Patient Communication Skills Training on the Discourse of Elderly Patients During a Primary Care Interview

Objectives

To test the effects of a communication skills training intervention on elderly patients' discourse during a primary care interview.

 Design

A quasi-experimental design involving two intervention conditions.

 Setting

The Family Practice Center of a university-based clinic.

 Participants

Thirty three patients averaging 72 years and 9 family practice physicians.

 Intervention

A communication skills training booklet received approximately 3 days prior to the scheduled appointment, and a 30 minute, face-to-face follow-up session prior to seeing the physician.

 Measurements

Patients' information seeking, provision, and verifying were coded from transcripts of the 33 interviews.

 Results

Trained patients engaged in significantly more information seeking, provision, and summarizing of information received than untrained patients. Additionally, trained patients obtained significantly more information from physicians than untrained patients, both in terms of the number of total information units and the number of units per-question-asked.

 Conclusion

Patient communication skills training appears to be an effective means of enhancing patients' participation in the medical interview without increasing the overall length of the interview.

Introduction

Extensive research over the last 30 years has been conducted on various features of physician-patient communication and its impact on health outcomes. Relatively little of this research has focused on communication between physicians and elderly patients. Available research findings suggest that elderly patients experience more difficulty in seeking and obtaining information during medical interviews than non-elderly patients, however much of this work is based on self report data rather than direct observation. More research is needed to document, understand, and develop ways to enhance communication between physicians and elderly patients.

The purpose of this research is to assess the effects of communication skills training on elderly patients' participation in the medical interview. While considerable research has examined the effects of physician communication skills training, relatively little attention has been given to patient communication skills. Patients' communication is important for both physicians and patients. For example, physicians' rely extensively on information from patients in making diagnostic and treatment decisions, thus underscoring the importance of patients' competence in information provision. On the other hand, many patients complain about the lack of information they obtain from physicians, but patients often fail to ask questions even about matters that are important to them. Thus, many patients could benefit from enhanced skills in information seeking. More generally, research indicates that active participation on the part of patients during the medical interview is associated with better health outcomes. If the research into elderly patients' communication accurately characterizes them as being especially reluctant to participate in medical interviews, it would appear that communication skills training for elderly patients is needed and is potentially beneficial.

Patient Communication Skills

While the research into the effects of patient communication skills training is scant, there is evidence supporting its value. For example, some studies show that training enhances patients' participation in the medical interview. Other studies show that trained patients are more compliant with treatment recommendations and/or have measurably better clinical outcomes than untrained patients.

Most of the attention to patients' communication has focused on information seeking skills, particularly question-asking during the medical interview. The results of this work have been inconsistent, with some studies finding an increase in question-asking among trained patients, and other studies reporting no difference between trained and untrained patients.

Relatively little attention has been given to what we call information verifying skills, and when verifying is addressed it is often limited to clarifying questions, which are not analyzed separately from information-seeking questions. Verifying skills involve utterances designed to check on one's understanding of information that has been received from a conversation partner. They include requests for repeats, clarifying questions, and summaries or re-statements of received information. These skills are important for clarifying information and enhancing understanding and recall during medical interviews.

Virtually no attention has been given to detailed training of patients' information provision skills, which is surprising given the importance of patients' provision of information to physicians' diagnostic and treatment decision-making. When provision has been addressed at all, training typically consists of brief references or prompts to raising concerns, stating symptoms, or providing information completely and clearly.

Overall, the research into patient communication skills training shows potential for enhancing patient participation and valued health outcomes. However, most of the research has focused on information-seeking skills with relatively little attention to other important information exchange skills. In contrast, our program of research into patient communication skills has included attention to information seeking, verifying, and providing. So far, we have examined the effects of our communication skills training on adult patients in a primary care setting. While our samples of patients have included adults over 65 years of age, we have not modified and tested our training materials specifically for an elderly population. The purpose of this research is to conduct such a test. Given results of our previous research, we hypothesize the following:

1. Trained patients will ask more direct questions about medically-related topics than untrained patients.

2. Trained patients will elicit more information about medical topics than untrained patients.

3. Trained patients will provide more information about their medical problem than untrained patients.

4. Trained patients will engage in more information verifying than untrained patients.

 

Method

 Setting

Data were gathered at the Rardin Family Practice Center at The Ohio State University. The Center is located off-campus and serves residents of central Ohio and the campus community.

 Participants

A total of 33 patients and 9 physicians participated in the study. The physician sample included 8, board-certified, faculty with considerable clinical experience and 1 chief resident who was approximately two months from graduation. Three of the faculty physicians were female, 5 were male. The chief resident was male. The patient sample consisted of all return patients, 42% of whom were male. Additional information about the patient sample is provided in Table 1.

 Patient recruitment. For about 50% of the sample, patients who met the selection criterion (i.e., age 65 or older) were randomly selected from appointment records of participating physicians and randomly assigned to either the trained or untrained intervention condition. These patients were telephoned and asked if they were interested in participating in a study of physician-patient communication. Due to a limited patient pool and conflicts between researchers' and physicians' schedules, the remaining patients consisted of a convenience sample. Untrained patients were recruited in the waiting room and trained patients were randomly selected to be telephoned from a list of available patients. Overall, 84% of the patients telephoned agreed to participate in the study. All of the patients recruited in the waiting room agreed to participate.

 Design

The trained group consisted of 16 patients, while the untrained group consisted of 17 patients. Four of the 9 physicians interviewed 2 patients in each intervention condition (i.e., trained, untrained). Due to accounting errors, 1 physician was inadvertently assigned to interview 2 trained patients and 3 untrained patients, while another physician was assigned to interview 2 trained patients and 1 untrained patient. Due to unavailability of qualified patients, 2 physicians interviewed 1 trained patient and 2 untrained patients, while 1 physician interviewed just 1 patient in each intervention condition.

 Procedures

Untrained patients were met in the waiting room and asked to sign an IRB consent form. They were given a brief Pre-Interview Questionnaire, then taken to an examination room to await the physician. Trained patients were asked to come to the clinic 40 minutes prior to their appointment time. When they arrived, they were taken to a meeting room on the second floor of the clinic, asked to sign an IRB consent form, and engaged in the face-to-face component of the training intervention (described below). Upon completion of the training component, the patient was taken back to the waiting room to complete a Pre-Interview Questionnaire, and eventually was taken to an examination room to await the physician.

All interviews were audio taped recorded. As a patient was escorted into the examination room, one of the researchers placed a wireless microphone in the room. Audio monitoring and tape recording was done in a central location in the clinic. One of the researchers monitored the examination room. When the physician arrived, the recording equipment was turned on and a stop watch was started. The interview was monitored, and when finished, the equipment was turned off and the researcher met the patient in the examination room, then escorted him/her to another area in the clinic to complete a Post-Interview Questionnaire.

Upon completion of the Post-Interview Questionnaire, the patient was paid for participating in the study (untrained patients received $20, while trained patients received $30 due to the extra time that was required of them) and released. The physician was then given a Post-Interview Questionnaire and IRB consent form to complete. Typically, physicians completed these items at the end of the day as they made chart notes.

Physicians knew when they agreed to participate in the study that some patients would receive an intervention, but they did not know the exact nature of the intervention, nor did they know to which condition patients were assigned. Although we did not take explicit steps to ensure that physicians remained blind to patients' assigned condition, there was no evidence to suggest otherwise. For example, no patient made a verbal reference to the booklet during the interview, even though a few patients made reference to the study. Additionally, all trained patients returned the booklet to the plain mailing envelope after the face-to-face session. Some patients carried the envelope into the exam room along with other items (such as a coat), while other patients put the envelope in a purse or other container.

 Intervention Materials and Procedures

The untrained patients did not receive any communication skills intervention. The only activity they engaged in besides that associated with their normal visit was to complete Pre- and Post-Interview Questionnaires. However, all untrained patients were given a copy of the training booklet prior to leaving the clinic.

The trained patients received two forms of training. First, they were mailed a training booklet approximately 3 days prior to their appointment. Second, patients were engaged in a 30 minute, face-to-face session just prior to the interview with their physician.

Training booklet. The training booklet used in this study was based on a training booklet we developed and tested in prior research. The version of the booklet used here was designed for elderly patients. It was shorter and less wordy and had larger font than the original booklet. The Flesch Reading Ease score is 64.7 and the Flesh-Kincaid Grade Level is 6.9. Like the original booklet, this version was formatted like a workbook, with lined space for patients to write answers to questions and make notes about what they wanted to convey to the physician.

The information provision section of the booklet asked patients to list concerns they wanted to discuss with the physician, then to complete answers to several questions about the symptoms associated with each concern (e.g., how often and when are they experienced; if pain is experienced, describe it; how long have symptoms been experienced; what, if any, medication or other treatment has been used, and to what effect, etc.). The information seeking section of the booklet posed several sample questions about diagnosis, prognosis, treatments, and concerns about treatments. Each of these sample questions had a space for patients to check if the question was relevant to their concerns so they could make a note to ask the physician. Lined space was provided so the patient could write any additional questions about these or other topics. Finally, the information verifying section of the booklet listed suggestions for checking on information patients obtained from their physician (e.g., repeat the information, ask for clarification if something is unclear, summarize your understanding of what the doctor just said).

Face-to-face session. Upon arriving at the clinic 40 minutes early, trained patients were taken to a meeting room to discuss their use of the booklet. First, the booklet was examined for evidence of use, such as written notes. Nearly all trained patients arrived with booklets containing considerable writing and a bag with their medication bottles (which they were instructed to do in the booklet). Then, one of the researchers went over the booklet page by page with the patient. Where the patient had written something (e.g., description of a symptom), the researcher discussed the item with the patient (e.g., checking to be sure all the detail was included, if the patient wanted to add anything, if he/she thought of something related since writing the item, etc.). Where the patient had not written anything, the researcher verified that that was the patient's intention and checked to see if there might be something of relevance by probing the patient. When the booklet was completely examined, the researcher helped the patient to organize how he/she would approach the interview. For example, the concerns were discussed and an order was suggested for presenting them to the physician. At the same time, the patient was reminded of key points he/she wanted to make and/or seek according to what was discussed during the booklet examination. Finally, the patient was asked if there was anything else he/she wanted to discuss about the appointment or related matters.

 Discourse Coding

Transcripts were prepared from the audio tape recordings of the interviews. The transcripts were verified against the tape recordings by one of the authors.

Participants' discourse was unitized into t-units, which is the smallest meaningful, stand alone utterance. Then, each t-unit was coded according to a content category scheme developed for and applied in our previous research. Because the details of the coding scheme are available elsewhere, a more general description will be provided here.

Coding scheme. The coding scheme is designed to assess participants' information exchange by identifying discourse units of information seeking, providing, and verifying. Each unit is also coded for theme, or general topic of discussion. The data reported here consist of discourse units about medically-related themes only (i.e., life style behaviors, such as smoking, exercise, sleeping habits, etc.; symptoms; diagnosis; prognosis; treatment; procedures and tests; follow-up appointments and referrals; state of one's medical condition). Each discourse unit is coded for speaker (i.e., patient or physician), chronology (i.e., utterance about history or the current medical problem), theme (as indicate above), and functional code. The three main functional codes are information seeking, provision and verifying. Each of these main codes has several sub-categories. In the interest of space, the sub-categories will not be discussed here in great detail.

Information seeking is defined by three types of questions: direct, assertive and embedded. Direct questions consist of closed, moderately closed, or open questions that appear in standard form (i.e., raised inflection toward the end of the utterance and inverted subject-verb order) and function (i.e., are intended to solicit information on some specified topic). Assertive questions are declarative utterances but are marked in some way as serving an information-seeking function. For example, a physician might say, "I want you to tell me about this stomach pain you are having." Or a patient may say, "Another thing I want to ask. I'm having pain in my right shoulder and ..." (followed by a description of symptoms). The term "assertive" is used in reference to these information-seeking utterances to emphasize that they appear as assertions, rather than in standard interrogative form.

The third type of question, embedded, is the most indirect compared to the other 2 types of information seeking. These utterances are also phrased in declarative form, but they are not marked as having an information-seeking intent. For example, a patient might say, "I tried Pepcid, but Maalox worked better. I don't know why, it just did," or "I've been having trouble sleeping and I think it's due to the medication I'm taking." Within the context of the medical interview, these utterances suggest that the patient is actually asking for information--Why does Maalox work better? Could my medication be affecting my sleep?---even though the utterances are not in interrogative form or are not otherwise marked as information-seeking in intent. Embedded questions are indirect because they place the burden on the conversation participant to determine that information is being sought. In this study, the frequencies of direct and assertive questions were combined because they both directly seek information and are clearly recognized as such by the conversation partner.

Information provision was coded as one of three types of utterances, solicited reply, elaboration, or unsolicited information. A solicited reply is the minimum information needed to answer a question (e.g., D: Do you drink alcohol? P: Yes). An elaboration follows a solicited reply in that it adds relevant information that was not directly asked in the question (e.g., D: Do you drink alcohol? P: Yes, I have two martinis before dinner, and a glass of wine with dinner each night). Unsolicited information consists of informative utterances that are not prompted by a question, but rather are offered without prompting.

Information verifying consisted of several sub-categories. Repetitions are utterances that either request a repetition or provide a complete or partial repetition of another's utterance. Clarifications are questions that seek additional or clarifying information about something that was incomplete, unclear, or otherwise incoherent. Formulations are summaries of key points of either one's own discourse, another's discourse, or part of a conversation to which multiple parties have contributed. Finally, bracketing involves the forecast that either additional information will follow or that additional information will be sought on a particular topic.

Reliability of coding. The senior author unitized and coded all of the transcripts blind to the intervention condition to which patients were assigned. Approximately 12% of the transcripts were randomly selected and coded independently by a second author, also blind to the intervention condition to which patients were assigned. Reliability was calculated by subtracting the number of units where disagreement occurred from the number of units where agreement occurred, and dividing the result by the total number of units coded. The unitizing reliability for 742 units was .91. The content reliability for the same number of units was .85. It should be noted that the content reliability is quite substantial given that each discourse unit consists of a 6 digit code reflecting speaker, chronology, theme, and function (theme and function each have two digits). A code was considered a disagreement if any of the 6 digits differed.

 Data Analysis

Because each physician interviewed multiple patients, a nested ANOVA was used to analyze the data, such that patients were nested within physicians. Discourse units were summed for each participant and used as dependent variables, while intervention condition served as the independent variable.

Reported in Table 1 is the distribution of demographic and medical status information relevant to the samples of patients comprising the two intervention conditions. T-tests computed on age and medical status were nonsignificant. Chi squares for sex, education, and participants were also nonsignificant. The chi square for ethnicity was borderline significant (x² = 3.69, df = 1, p = .055). However, the within intervention group correlations between ethnicity and the dependent variables were all nonsignificant. Overall, then, the data suggest reasonable equivalence of the intervention group samples.

Table 1 

Patient Demographics and Medical Status in Trained and Untrained Groups

^These means reflect a judgment of the medical condition as moderately severe and complex.

Hypothesis 1 predicted that trained patients would engage in more direct question-asking than untrained patients. The results of the ANOVA on the frequency of patients' direct and assertive questions was significant [F (1, 8) = 10.48, p = .01, eta² = .57], such that trained patients asked more questions about medically-related topics than untrained patients. The means and standard deviations associated with this test are reported in Table 2. Although trained patients asked more embedded questions than untrained patients (means = 1.94 and 0.88, respectively), the difference was not statistically significant [F (1,8) = 2.48, p = .15].

Table 2

Means and Standard Deviations Associated with ANOVAs.

The second hypothesis predicted that trained patients would elicit more information from physicians than untrained patients. The results of the ANOVA were significant [F (1,8) = 15.23, p = .005, Eta² = .66]. The means in Table 2 indicate that trained patients elicited more information than untrained patients. While the results of hypothesis 2 are supportive, they do not provide information about the effectiveness with which trained patients elicited information. To examine this, the amount of information units obtained from physicians in response to patients' information seeking was divided by the number of direct and assertive questions asked by patients. The resulting analysis revealed a significant difference between trained and untrained patients [F (1,8) = 6.00, p = .04, Eta² = .43]. The data reported in Table 2 indicate that trained patients obtained more information-per-question-asked than untrained patients, thus indicating that trained patients elicited information more effectively than untrained patients.

The third hypothesis predicted that trained patients would provide more information about their medical problem than untrained patients. The ANOVA resulted in a significant intervention effect [F (1,8) = 24.40, p = .001, Eta² = .75], indicating that trained patients provided more information than untrained patients (see Table 2). A follow-up analysis was conducted to probe this result. A MANOVA was computed using the three information provision sub-categories (i.e., solicited replies, elaborations, volunteered information) as dependent variables. The multivariate effect was significant (Lambda = .1700, p = .01). Univariate F-tests revealed that trained patients had significantly more solicited replies [F (1,8) = 10.69, p = .01, Eta² = .57] and elaborations [F (1,8) = 10.24, p = .01, Eta² = .56], but that trained and untrained patients did not differ in provision of unsolicited information [F (1,8) = 3.56, p = .10, Eta² = .31]. However, it might be noted that the latter result accounted for moderately substantial variance (i.e., 31%) even though the test was not statistically significant.

Finally, hypothesis 4 predicted that trained patients would engage in more information verifying than untrained patients. The results were nonsignificant [F (1,8) = 2.36, p = .16], although the means were in the predicted direction (see Table 2) and a moderate amount of variance accounted for (i.e., Eta² = .23).

Previous research has suggested that elderly patients participate less in medical interviews than their younger counterparts. In this study elderly patients were assigned to either a communication skills training intervention or control group to determine if training would enhance patients' verbal participation. The results indicate that trained patients engaged in significantly more information seeking and providing than untrained patients. Indeed, the training intervention accounted for large amounts of variance in all of the discourse measures except information verifying (mean = .60, range .43 to .75). Trained patients asked nearly 3 times more questions about medically-related topics as untrained patients. Similarly, trained patients elicited 3.5 times more information units from physicians as their untrained counterparts, and they did so by eliciting nearly twice as much information-per-question-asked. Trained patients provided over twice as much information about their medical problem as did untrained patients. Follow-up tests revealed that trained patients' provision was accounted for mostly in the form of solicited replies and elaboration of details. Since elaborations can only follow solicited replies in the coding scheme, these results suggest that trained patients' provision consisted mostly of detailed information beyond what was minimally sufficient to answer a question. Thus, thinking about and writing information about such matters as symptoms prior to seeing the physician allowed trained patients to provide added detail without being directly asked for it. Although trained patients engaged in moderately more information verifying than untrained patients, the difference was nonsignificant. This result is discussed in more detail below.

Overall, these results are similar to the training effects obtained in our previous research with adult patients, although the results obtained here overall accounted for more variance. The major difference in the training procedure used here was a 30 minute, follow-up, face-to-face session in which a researcher discussed the patient's responses to the training booklet in detail and aided the patient in organizing his/her presentation of information and information seeking. In one of our previous studies we used only a face-to-face intervention and the effects obtained there were similar to the amount of variance accounted for here. Although it is tempting to suggest that the face-to-face component significantly adds to the training effect, it is not possible to discern the relative contribution of training components in this study. Additional research is needed to determine the independent and combined effects of the booklet and face-to-face training components. Such research is important to pursue, as a face-to-face component adds significant cost to training.

Although a moderate effect was observed for information verifying (i.e., eta² = .23), it was not statistically significant. The comparatively less dramatic effect for information verifying may be accounted for by the relative lack of attention given to verifying skills compared to information-seeking and information-provision skills. The information verifying section of the training booklet is brief and contains little detail and verifying was not even mentioned in the face-to-face component. Given that information verifying is the only discourse variable that did not result in strong, significant differences between trained and untrained patients, there is the implication that communication skills instruction requires more than merely mentioning information to patients. Indeed, in their review Anderson and Sharpe conclude that the communication skills interventions that produced the largest effect sizes were ones that involved modeling and practice. Accordingly, a significant issue for future research is to determine what combination of instructional strategies and modes of delivery provide the best balance between learning effects, cost, and efficiency of delivery.

Beyond issues related to the intervention format, this study indicates that communication skills training is amenable to elderly patients. If previous studies are correct in their characterization of elderly patients as less active in medical interviews, the results here are especially important in suggesting how communication skills training may enhance elderly patients' participation in their health care. Related research shows that active patients have measurably better health outcomes than less active patients Thus, communication skills training for elderly patients has the potential of not only enhancing patients' participation, but also improving their health.

An issue that is typically raised about more active patients is whether they increase the length of interviews and, thus, result in excess time and cost. Most of the previous research into patient communication skills training has found no difference in the length of interviews involving trained versus untrained patients. Consistent with this trend, there was no difference here between trained and untrained dyads in overall appointment length (trained mean = 18.81, untrained mean = 22.59, [F (1,8) = 0.61, p = .46, Eta² = .07] or time in which the patient and physician were engaged in talk (trained mean = 16.25, untrained mean = 14.41, [F (1,8) = 0.18, p = .68, Eta² = .02]. Thus, communication skills training has the potential to enhance patient participation and improve health outcomes without increasing the length of appointments. If such training can be accomplished with relatively inexpensive methods, communication skills training may prove to be a cost effective, yet significant, way of enhancing patient participation and the quality of health care.

While the results of this research are encouraging, the study has some important limitations. First, we did not gather baseline data on patients, so it is difficult to determine the exact impact that training had on patients' discourse. Although one might suspect that with baseline data, the training effects in this study may have been even more dramatic. Second, the results would be more impressive if the entire sample of patients were randomly selected and randomly assigned to the intervention conditions. Along similar lines, it would be beneficial to test for training effects under a more normal clinical setting (e.g., where patients received training materials from their physician rather than a researcher). Additionally, a larger sample of patients and physicians would provide more generalizable results. However, the findings of this study suggest that communication skills training leads to enhanced patient participation and is, therefore, worth pursuing in future research.

This study was made possible by the support of the Department of Family Medicine and a grant obtained from the Crisafi-Monti Endowment Fund, College of Medicine and Public Health, The Ohio State University.

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49.	Hunt KW. Differences in grammatical structures written at three grade levels, the structures to be analyzed by transformational methods. Tallahassee, FL: U. S. Department of Health, Education, and Welfare, 1964.
50.	Hunt KW. Grammatical structures written at three grade levels. Champaign, IL: National Council of Teachers of English, 1965.

51.	Cegala DJ. Communication skills training for primary care patients: Final technical report. Rockville, MD: Agency for Health Care Policy and Research, 1998.

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