March 02, 2018 04:18 pm Chris Crawford –
A study in the January/February 2018 issue of Annals of Family Medicine observed primary care interactions and communication with patients with newly diagnosed diabetes and highlighted challenges to successful dialogue.
For the study, health-related interactions of 32 patients with newly diagnosed type 2 diabetes were videotaped and the patients were tracked as they were treated in the New Zealand health care system for about six months.
The videos were used to analyze patient interactions with health care professionals (i.e., family physicians, nurses and other health professionals such as dietitians).
Family physician and corresponding author Anthony Dowell, M.B.Ch.B, told AAFP News that the impetus for this research was recognizing that diabetes and other chronic medical conditions account for an increasing portion of the health care workload.
"It's also clear that in the management of such conditions, the quality of communication between clinicians and patients affects health outcomes," he said.
Dowell works as a professor in the Department of Primary Health Care and General Practice at the University of Otago, Wellington, New Zealand, and practices at the Island Bay Medical Center, also in Wellington.
The research project was conducted by Applied Research on Communication in Health (ARCH), a multidisciplinary group of researchers based in the university's primary health care and general practice department. The ARCH group studies all aspects of communication in health care, with a special focus on analyzing how people behave in real-life health care interactions.
Patients were recruited from general practices in the Auckland and Wellington regions of New Zealand. Ten practices were selected to participate based on their demographically diverse population bases and willingness to participate in intensive qualitative research.
Patients were purposely recruited to create a diverse sample group based on age and ethnicity, and to provide equal numbers of men and women.
The number of consultations per patient ranged from one to 12, and the total duration of individual patient visits with health care professionals over the six-month study period ranged from 27 minutes to seven hours, 12 minutes.
Physician consultations averaged 22 minutes (ranging from six to 56 minutes), nurse consultations averaged 41 minutes (ranging from eight to 95 minutes) and dietitian consultations averaged 24 minutes (ranging from 17 to 52 minutes).
Dowell said the ARCH group's work has been particularly focused on how relatively straightforward conversational and linguistic interventions can significantly impact the quality of consultations.
"In the case of diabetes, we were aware that many different health professionals were involved in the care, and we had little idea to what extent those inputs provided an effective system of care," he said. "We were also interested in beginning the research at the starting point of diagnosis and seeing how the patient's knowledge and experience evolved over the first six months after diagnosis."
Dowell said videotaping the patient/physician interactions offered a sort of "black box" recording of clinical consultations.
"Unlike research methods that rely on reported data from interviews or surveys, recordings make it possible to directly observe the way patients and providers interact with one another in real-life situations without a researcher present and to tease out specific practices that foster or hinder effective communication and improved outcomes," he said.
First off, Dowell wanted to emphasize that he and his fellow researchers were struck by how the clinicians observed displayed high levels of technical knowledge and communication skills, spent significant amounts of time with patients and worked hard to coordinate the services provided.
"Family physicians and primary care professionals are often exquisite communicators, and this research was about enhancing good communication," he said.
The biggest communication challenge observed, Dowell said, was physicians trying to balance listening to patients' narratives with providing useful information and explanation.
"In general (and this is certainly not specific to diabetes care), clinicians tend to talk too much and not listen enough," he said.
For example, Dowell shared an interaction recorded as part of the study of himself with a patient who has been told for the first time that he/she has diabetes.
Dowell: "For this, I don't know how much you know or don't know about diabetes but it's …"
Having asked the patient what he/she knows, Dowell could have waited for an answer. Instead, without pausing, he talked -- perhaps unnecessarily -- for a minute about what he, the physician, knew.
Now compare that interaction to another consultation from the study with a different physician and patient.
Another physician: "I'd like firstly to know, briefly if you like, what you know or understand about diabetes currently, and I'd also like you to tell me how you feel about that or how you react to that."
According to Dowell, the quality of communication within an individual consultation led to varying degrees of effectiveness in terms of patient engagement and agreement on patient self-management, with the evolutionary pathway from patient as novice to patient as expert depending on both health professional and patient factors.
"Acknowledgement of the patient's social conditions and pre-knowledge allowed a more rapid development of the patient's evolution to being an 'expert diabetic,'" he said.
Among other communication challenges, Dowell said, were overuse of biomedical terminology and health care professionals trying to "do it all" in terms of providing basic explanations and "global" input into diabetes management.
"This led to a misperception that other health care professionals would not provide that input," leading to, for example, "doctors trying to provide detailed dietary advice when the patient would be seeing a dietitian later," he said.
Dowell said the researchers determined consultations could be made more efficient and effective by the health care team meeting and discussing each member's role and agreeing on individual duties.
One of the most important and interesting direct observations of the patient/physician interactions was how easy it was to forget or not appreciate the patient's social and personal circumstances, Dowell said.
"It's easy to give advice about 'good nutrition,' and not ask about the patient's ability to pay for food, or to acknowledge how '(damn) hard' many people's lives are," he said.
Dowell said many patients already know they have (or are likely to develop) diabetes, from a strong family history or their perception of their own risk factor profile.
"They already have their own ideas about causation, management and prognosis," he said. "Their own prediabetes stories can be helpful, since recognition of the pre-existing knowledge can be a platform to encourage patient engagement and self-management strategies."
Dowell said recommendations family physicians can take away from the study include employing a framework for communications with patients who have diabetes that acknowledges the importance of the patient's specific situation and social needs.
The researchers also found time could be allocated more effectively and efficiently when patients need to see multiple clinicians.
"The work we are doing also makes us appreciate the importance of listening more and possibly talking less in consultations, and we see research of this sort as helping us understand how to improve health care one sentence at a time," Dowell concluded.
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