Looking at you, looking at me: The effect of clinical encounters

I’ve been browsing the databases for information on clinical encounters. I do this because while I’m well aware of many papers produced on the topic of patient-related predictors of outcome, the swing towards considering clinician characteristics as predictors of outcome means I hope to see more published on this incredibly important topic.

A wee while I ago I wrote about patient self-report measures of chronic pain clinical encounters (Stomski, MacKintosh & Stanley, 2010), in which I discussed the lack of reliable, valid measurement tools in which people with pain are asked about their clinical encounters – and worse still, the glaring omission in any of the reviewed measures of actually asking people with chronic pain whether the constructs being assessed actually mattered!

Today I came across this paper by Cvengros and colleagues, looking at the influence of congruence between what a patient prefers, and the actual dynamics of the clinical encounter.  As these authors point out: patients can vary in the degree to which they want patient-centred (active) or clinician-centred (passive) participation in a clinical encounter – and so do clinicians.  Their hypothesis was that if the preference of each clinical dyad was congruent, then the outcomes, particularly in terms of adherence to clinical recommendations, would be better.

Now, sadly, I couldn’t find a study like this in pain management.  This paper is drawn from the diabetes literature.  The relevance of this to people working in the field of chronic pain is pretty clear – both groups of patients ultimately need to self manage their chronic health condition, both groups of patients will have biomedical as well as psychosocial aspects of management to consider, and the consequences of failing to manage their condition well can lead to some fairly dire outcomes in both cases.  I guess the major differences are that the contribution and acceptance of psychosocial factors and self management is greater in diabetes management, and the messages in the community about the way to manage diabetes are somewhat more consistent than in the case of chronic pain (not too many ‘I can cure you!’ adverts for diabetes – actually, I tell a lie: I just took a quick look on a popular search engine and there are adverts like this “Simple 3 step natural approach heals diabetes within a month”)

Anyway, how did these researchers go about exploring this complicated area of health provider:patient interaction?

The first point they make is that rather than looking at a global indicator or trait measurement of attitudes, they chose to explore visit-specific behaviour.  As they point out, the content of each encounter can differ widely from when a provider first gives a diagnosis, through to treatment options, through to ascertaining whether the interventions have been effective.  They identify three main domains to examine – (a) information sharing and shared decision-making,
(b) encouragement of self-care, and (c) provision of socioemotional support.

They identified 621 patients who met their study criteria of language, diagnosis and at least two visits with their health care provider in the past six months (the latter in order to choose patients who had an established relationship with their provider).  A rather smaller group of 241 patients agreed to participate, with a further 23 patients excluded for various reasons.  Not exactly a great response rate!

Putting that aside for a moment, let’s take a look at the really interesting aspects of this study.  The authors didn’t believe there was an appropriate measurement instrument for assessing provider behaviour, so they developed one and it’s included in the paper.  It’s called the Provider Behaviour Questionnaire, and has nine items in three domains: Information sharing and shared decision-making; Behavioral involvement and self-care; and Provision of socioemotional support.  The items were closed statements with a yes or no answer such as “Dr. Smith gave you information about your health to read or to look up at home.” and “Dr. Smith suggested that you take an active role in managing your diabetes.” and “Dr. Smith asked about your personal life.”

Now I could argue that these statements may not exactly represent ideal provider behaviour, but they were developed from established measures such as the two subscales of the KHOS (Krantz Health Opinion Survey), and the caring scale of the PPOS (Patient Practitioner Orientation Scale).  The researchers also didn’t ask participants whether these were their preferred areas of support, and psychometric characteristics of the questionnaire are not reported.

Participants were asked to complete both pre- and post-consultation measures.

What did they find?

Cutting to the findings, Cvengros and Christensen found that symmetry in information sharing and shared decision-making, F(2, 208) = 3.71, p = .03 and behavioral involvement in health care, F(2, 205) = 3.60, p = .03, emerged as
significant predictors of patient satisfaction, with socioemotional support, F(2, 211) = 2.83, p = .06, emerging as a marginally significant predictor.

Symmetry in information sharing and socioemotional support were both nonsignificant predictors of self-reported diabetes adherence. However, symmetry between patient preferred and reported behavioral involvement was a significant predictor of self-reported diabetes adherence, F(2, 195) = 3.39, p = .04.

Finally, the found that congruence in the information sharing domain was marginally associated with lower hemoglobin A1c values, indicative of better glycemic control.

Now while the hypotheses were only partially supported, the limited recruitment, and the dichotomous nature of the questions in the Provider Behaviour Questionnaire mean that the findings are not all that robust, this is an interesting study because it starts to pose questions about the nitty gritty of interactions between providers and patients.  I haven’t reported some of the more detailed outcomes, but these show that it’s not just the match between patient and provider communication behaviour, it’s the direction of that match Cvengros and Christensen suggest that people with greater preferences in the information sharing and behavioral involvement domains may be demonstrating a greater preference for control over the health care experience.

Now this is important because, as they argue, when patients perceive limited control over their health care encounter they may attempt to regain this control by being nonadherent with provider recommendations.

What does this mean for me?

I’m not sure how much I can rely on these findings to change clinical practice at this time, but this study starts me thinking that it’s time to go beyond simplistic explanations of clinical encounters and the effect on patient self-management.  It also highlights that we have held assumptions about how clinical consultations work and while some of us may have learned to moderate a ‘just do it because I say so’ approach, many health professionals either have no clue that this is ineffective in many cases, perhaps haven’t been aware that there are other options, or maybe haven’t been trained or supported to develop alternative behaviour.

A final point I take from this study is that the influence of interactions seem to have quite clear and measurable effects on clinical outcomes.  It’s not easy to ignore changes in hemoglobin A1c.  I only wish there were similar measures available in chronic pain management!

Cvengros, J., Christensen, A., Cunningham, C., Hillis, S., & Kaboli, P. (2009). Patient preference for and reports of provider behavior: Impact of symmetry on patient outcomes. Health Psychology, 28 (6), 660-667 DOI: 10.1037/a0016087
Stomski, N., Mackintosh, S., & Stanley, M. (2010). Patient Self-report Measures of Chronic Pain Consultation Measures: A Systematic Review The Clinical Journal of Pain, 26 (3), 235-243 DOI: 10.1097/AJP.0b013e3181c84e76



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