Video: What's Up Robodoc?

Robots have not yet replaced doctors. But one physician has found way to use a videoconferencing robot to check on his patients when he is miles away.

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Coaching For Doctor Office Visits Helps Patients Ask Right Questions

Asking more questions during a visit to the doctor might help patients get care that is more satisfactory, but many patients are not sure where to start.

A new review of 33 studies found that giving patients question checklists or providing in-office coaching can help them ask more questions of their health care provider and get more information that is useful — often extending the length of the consultation as well.

“For outcomes like satisfaction, the patient’s response is likely to cover the whole experience in the clinic — coaching and consultation — and thus the patients will feel like they got a better deal than usual as they had a nice time with the coach,” says lead review author Paul Kinnersley.

The review appears in The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

When interventions took place immediately before a consultation, they resulted in a small but significant increase in the duration of the office visit. Interventions that occurred some time before the consultation had no effect.

In general, interventions produced small increases in patient satisfaction, plus a possible reduction in patient anxiety before and after visits. Coaching had a slightly larger benefit in patient satisfaction than providing question checklists.

“Coaching is a more intensive intervention and may have some therapeutic impact,” says Kinnersley, co-director of the Communications Skills Unit at Cardiff University in Wales.
At the very least, coaching helps patients voice and rehearse their concerns.

“Patients need to have the courage and confidence to ask questions,” says Sherrie Kaplan, co-director of the Center for Health Policy at the University of California, Irvine. “Many patients don’t want to look stupid. Studies have shown that even doctors find that when they are patients, they don’t want to ask questions that will make them look stupid.”

The review also looked at the value of refresher courses in communication skills for doctors.
Doctors can underestimate their patients’ information needs for a variety of reasons, according to the review authors. When treating patients with serious or life-threatening illnesses, doctors might be reluctant to dispense information that they feel could be harmful or disturbing.

Alternatively, they sometimes focus so hard on confirming a diagnosis that they do not take the time to encourage patient involvement in constructing more individualized treatment approaches.

“Doctors are prepared to ask questions, to formulate what’s wrong, find it and fix it,” Kaplan says. “In studies we’ve done, the patient will talk for about 30 seconds before the doctor interrupts with more questions and takes over.” Kaplan was not involved with the Cochrane review.

According to Kinnersley, doctors do benefit from refresher courses in communication, even if they are not always eager to go.

“Pretty much every medical school will teach communication skills and assess them before qualification, but we still have evidence that patients are dissatisfied with doctors’ communication skills,” Kinnersley says. “I think the problem is that after qualification, doctors learn a lot more clinical knowledge and they get more enveloped by medical culture. Thus, their communication skills often deteriorate. They focus on curing the patient rather than caring for them.”

The review found small increases in consultation time when doctors received training, but found no significant increase in patient satisfaction. Ultimately, the review recommended more studies to compare methods of intervention, intervention timing and the possible benefits of additional training for health care providers.

The review studies covered a variety of settings and diagnoses, including primary care, cancer, diabetes, women’s issues, heart problems, peptic ulcers and mental illness. It is possible that the more serious the illness, the greater the level of anxiety might be and the more intimidated a patient will feel about asking questions, Kinnersley suggests.

“If patients are anxious or the answer to a question might be frightening, you’re going to need more encouragement to ask questions,” he says.

For Kaplan, the key to getting the most out of any doctor visit and reducing anxiety is preparation. She compares preparing for a doctor visit to studying for a test.

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Learning From Both Ends of The Stethoscope

A systematic review of studies published over the past four decades has confirmed that good doctor-patient communication makes a difference not only in patient satisfaction but in patient outcomes including resolution of chronic headaches, changes in emotional states, lower blood sugar values in diabetics, improved blood pressure readings in hypertensives, and other important health indicators.

The review, published by researchers from the Indiana University School of Medicine and the Regenstrief Institute, Inc. and colleagues from the US Centers for Disease Control and Emory University, appears in the April 2007 issue of Medical Care, a journal of the American Public Health Association.

“In looking at these 36 studies we learned many things. For example, research on non-adherence to doctor’s instructions has focused on bad or poor behavior by patients rather than on the clarity of the physician’s instructions or whether the physician actually checked to see if his or her instructions were understood by the patient. The physician assumed that the patient understands and thus will comply. But is this a logical assumption? We don’t assume that when a pilot and an air traffic controller converse that they have understood each until there is an affirmation of understanding. That acknowledgement is lacking in most patient-physician encounters,” says Richard Frankel, IU School of Medicine professor of medicine and Regenstrief Institute research scientist, senior author of the study.

Frankel is a sociologist who studies ways to improve the doctor-patient relationship. He is currently investigating how behavioral changes by both doctors and patients impact medical care.

“From previous work, including a well regarded 1999 study from the University of Washington, we know that doctors ask patients whether they understand what was discussed during a medical appointment only about 1.5 percent of the time,” Frankel says. “It is extremely important that a patient be given the opportunity and probably even encouraged to ask questions. Doctors should be trained to routinely check for understanding to ensure that there is neither miscommunication nor mismatch between what the patient wants and what doctors assume the patient wants.”

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