Improving Team Structure and Communication

A Key to Hospital Efficiency

David M. Friedman, MD; David L. Berger, MD

Arch Surg. 2004;139:1194-1198.

ABSTRACT

Hypothesis Improving team structure and heightening communication will help provide
cost-effective and high-quality patient care for general surgery patients.

Design This study surveys teamwork initiatives and their effects on specific
variables related to patient care.

Patients The study population comprised all patients admitted to the

hospital’s general surgery teams during 5 years 3 months.

Setting Tertiary care hospital.

Interventions A complete restructuring of the patient care team for

general surgery patients admitted to the hospital. The intervention occurred
midway through the study period.

Main Outcome Measures Mean length of stay for general surgery patients
as a marker of team efficiency and a standardized patient satisfaction
survey.

Results The mean length of stay after initiation of the restructured care
team was significantly shorter than before initiation. The significance was
present despite a consistent patient acuity measure and was associated with
a high patient satisfaction level.

Conclusions Restructuring the patient care team yielded a decreased mean

length of stay while maintaining a high level of patient satisfaction. This
analysis helps validate a hospitalwide initiative to maintain a high level of
patient care while increasing patient volume.
INTRODUCTION

The population of the United States is aging, and the mean life expectancy is
increasing. In addition, newer and more advanced medical technology is
expanding the breadth of possible medical and surgical interventions. To
maintain viability, hospitals and health care systems need to successfully
react to population-based trends and revised insurance reimbursements.
Hospital consolidation due to limited financial resources has increased the
demand on the remaining institutions. This combination of events has led to
an increased demand on the limited resources of health care providers in this
country.

This increased volume can be accommodated by physically expanding a

hospital’s resources, a costly endeavor. To limit operating expense, it is
necessary to increase the volume of patients treated by providing more
efficient care with the same amount of available resources.

At our hospital, a clinical performance management team pursued this goal

of increasing volume without expanding costs by identifying and correcting
gaps in hospital efficiency. An internal review was performed of the systems
and practices in place on the general surgery team. After a thorough
evaluation, changes were initiated to facilitate increased productivity and
communication while caring for general surgery patients.

The goal of the study was to evaluate the effects of restructuring the surgical
care team on the length of stay and patient satisfaction. Our belief was that
length of stay would be significantly decreased but that the quality of patient
care would not be compromised.

METHODS

Team Restructuring

The general surgery patient care team was previously an informal concept,
lacking well-structured collaboration between physicians, nurses, and case
managers. Meetings between team members were unscheduled and often
did not include all necessary team members. This disorganized system led to
poor communication between team members. In addition, the duplication
of roles that existed secondary to poor communication often frustrated
team members and compounded problems.

At the inception of this program, specific changes were introduced into the
patient care system to correct these weaknesses. The concept of a patient
care team became well defined, with each member having specific
responsibilities. Redundancy between roles was removed to increase the
effectiveness of time spent caring for patients. There was an emphasis
placed on improving regular open communication and collaboration
between all team members. In addition, a formalized schedule of meetings
was designed to facilitate this collaborative effort. A general outline of the
newly created system of interactions between team members is provided
herein.

The first part of each morning involves the residents’ seeing their patients on
the floors. Then, on a daily basis, the staff surgeons speak with the residents
regarding each patient’s hospital course, potential discharge date, and
anticipated services required on discharge. Finally, the senior residents have
daily morning rounds at 7:30 AM, before going to the operating room, with
the case managers and charge nurses. This meeting includes the same core
group of people and occurs at the same time and location each morning so
as to avoid confusion or delay. The goal of this daily meeting is to facilitate
team communication and update the discharge planning. This information
then allows the case managers and nurses to prepare in advance for the
patient’s needs at discharge and highlights potential obstructions to
discharge. In addition, specific duties surrounding patient discharge are
assigned to residents, nurses, or case managers to allow increased focus on
well-defined tasks.

The entire patient care team meets monthly to orient new members
(specifically rotating residents), highlight ways to improve the team’s
efficiency, identify successes of the team, and deconstruct failures. This
monthly meeting is in addition to the regular daily morning rounds. The
opportunity for timely feedback improves collaborative efforts between team
members, allowing for constant improvement in the system.

Data Acquisition

Data were collected from hospital-maintained databases for the period

between the beginning of fiscal year 1998 and the end of the first quarter of
fiscal year 2003. The data were sorted to identify general surgery patients
who had been admitted to the 2 primary general surgery floors after
surgery. Patients, on admission, were divided between a private service and
a ward or urgent care service. Private service patients were defined as
already having a preestablished staff surgeon denoted as caretaker on
admission. Ward service patients had no such identified staff surgeon
identified on admission, with most patients coming from the emergency
department or an urgent care surgical clinic.

Statistical Analysis

The collected data were initially adjusted based on several criteria. This
adjustment standardized the data across the individual years, making
statistical comparison feasible. Factors used for adjustment, including age,
sex, mean case weight, and admission source, were selected based on their
perceived potential to unaccountably skew the data between study periods.
Case weights were assigned to each patient based on diagnosis-related
groups, with the mean case weight serving as a surrogate measure for
patient complexity and acuity. Admission source is a hospital code assigned
to each patient identifying whether he or she was admitted from home for
elective surgery, through the emergency department, as a hospital transfer,
or via some other route. The adjustment factors included a mean age of 54
years, 53% of patients as female, and a mean case weight of 2.6. The
adjusted data were analyzed on an integer scale and a log scale using
multiple linear regression models. Significance was set at P<.05.

Patient Satisfaction Survey

The use of a nationally recognized patient satisfaction survey, created by

Press Ganey Associates Incorporated (South Bend, Ind), was instituted in
2001. The survey contained a series of questions pertaining to the quality of
care during the hospital stay. The possible answers to each question were
"very poor," "poor," "fair," "good," and "very good." Patient survey results
were entered into a hospitalwide database that maintains patient anonymity.
The survey results were broken down by year and by hospital floor. There
was no standardized system of measuring patient satisfaction in place at the
hospital before 2001.

RESULTS

The general surgery service has 2 primary floors to which patients are
admitted. There are 85 beds comprising the floors. At any given time, most
patients on these floors are on the general surgery service. The staff
surgeons and residents cover both floors equally.
The number of patients operated on and admitted increased on the private
general surgery service, from 2302 patients in fiscal year 1998 to 3450
patients in fiscal year 2002. Of these patients, approximately 68% were
admitted to the primary general surgery floors. The number of patients
operated on and admitted by the ward general surgery service remained
stable during the studied years, from 961 patients in fiscal year 1998 to 972
patients in fiscal year 2002. Of these patients, approximately 79% were
admitted to the general surgery floors. Across both services, the total
number of inpatient days (defined as the sum of all inpatient days for the
studied patients) decreased. The ward service had a noticeable
corresponding decrease in admissions between time periods compared with
the private service (Table 1).

For the unadjusted data, there was a decrease in the mean length of stay
across the 2 time periods for the private and ward services (Table 1);
however, these data were not statistically analyzed. Comparing the adjusted
mean lengths of stay on an integer scale, there was a significant decrease
(P<.001) between the first and second time periods for the private service
but not for the ward service (Table 2). By using an integer scale, there can
be a significant effect on the data by the presence of outliers (patients who
stayed for an unexpectedly long time as an inpatient). The standard
deviation of the unadjusted mean length of stay for the ward service was
11.7 days, compared with a standard deviation of 8.8 days for the private
service. Although not statistically analyzed, this suggests that there was an
increased range, and possibly more outliers, among inpatient stays on the
ward service vs the private service.
For adjusted length of stay on a log scale, which reduces the effect of outlier
data points, there was a significant decrease in the mean length of stay for
both services between time periods (Table 3). The amount of decrease in the
mean was greater for the ward service than for the private service in both
time periods, suggesting a greater presence of extended inpatient stays in
this group.

Although there are no patient satisfaction survey data available before 2001,
data after 2001 are crucial to assess any negative aspects of the new
initiatives. By using 2 recently analyzed quarters (the second and fourth
quarters of fiscal year 2002) as marks of progress to date, the percentage of
patients responding with "good" or "very good" overall responses ranged
from 82.1% to 87.9% for the 2 general surgery floors (Figure 1 and Figure
2). Both floors had scores at or above the hospital mean in the areas of
discharge speed and preparation of home care services on discharge. Also,
both floors were above the hospital mean in regard to the perceived skill of
the physician by the patient. These data suggest not only that patients are
efficiently and well prepared for their discharge but also that there was no
sacrifice in the physician-patient relationship by restructuring the treatment
team. Potentially, there was an enhancement of the physician-patient
relationship, as more of a physician’s time could be spent interacting about
the care plan and less time was needed to plan all of the discharge details.

The clinical performance management team was initiated at the hospital to

deconstruct practice patterns, with the goal of increasing hospital efficiency
while maintaining excellent patient care. Our results show that this project is
a success thus far. Comparing the adjusted mean lengths of stay for the
years before the program implementation with those after implementation,
there was a significant reduction in length of stay across ward and private
services on the 2 primary general surgery floors. The length of stay
reduction was, on average, more than 1 day for private service general
surgery patients and almost 1 day for ward service general surgery patients.

When evaluating these results, it is important to translate them into benefits

for the hospital, the staff, and the patients. A practical way to look at this
study is to note that, for each hospital admission to the general surgery
service, there is 1 fewer inpatient day. In fiscal year 2002, in which 4422
patients were admitted, this translates to approximately 4400 fewer
inpatient days. It follows that these "open days" could subsequently be filled
by new admissions to the hospital for surgery. Alternatively, if these
available bed spaces went unfilled, the hospital could scale back or
restructure staffing on floors that have this increased turnover, as the daily
census would be lower. Our medical center has more than 90% of its beds
filled at any given time. This high census pushes the administrative and
ancillary supports to their limits of efficiency. By lowering the census, the
strain on these services is decreased and the hospital can run more
efficiently.

These results can also aid the surgeon. If a surgeon maintained a stable
volume of cases, then the reduction in length of stay could correspond to a
decreased personal inpatient census. However, the extra number of hospital
days could instead be used to allow an increase in surgical volume. This
increase could come from elective cases and from increased ability to add
emergency cases because of vacant patient beds. Fortunately, regardless of
the patient source, the surgeon’s referral base and patient load can
substantially increase. In addition, waiting periods for patients to have
elective surgery, which often stretch to weeks, could be decreased.

The benefits of this new system for the staff are several. There is a strong
sense of collaboration instilled among team members who work toward a
common goal. Well-integrated multidisciplinary care teams have been shown
to be beneficial in other health care settings.1-2 In this case, although there
is a hierarchy present among the members of the team, every member has
equal opportunity to provide input regarding a patient’s care plan. With the
removal of overlapping roles among team members, each person approaches
the care of the patient from a unique perspective and provides unique input.
In addition, each team member can begin to hone his or her skills to
maximize the effect toward the overall care of the patient.

The second benefit for the care team relates to residents and their medical
training. As of 2004, there are new nationwide rules limiting the work hours
of residents. There is significant concern that these limitations could have
negative effects on the quality of surgical training.3 One common resolution
of this problem has been to employ physician extenders such as physician
assistants and nurse practitioners. The use of physician extenders,
specifically nurse practitioners, has been studied and has become
commonplace in settings such as a trauma surgery care team.4-5 In that
setting, the use of nurse practitioners reduced residents’ workloads and
improved the quality of patient care. However, the cost of employing
physician extenders is not trivial and can be prohibitive in some instances.
This study highlights another method to decrease residents’ workloads while
maintaining quality patient care. Eliminating duplicated tasks provides an
opportunity to reduce residents’ work hours. In addition, decreasing the
length of stay of surgical patients, and possibly the inpatient census, creates
an opportunity to decrease each resident’s patient load. Fortunately, even if
there proved to be no significant decrease in the census (ie, the open patient
beds were filled with an increase in surgical volume), the residents would
have a denser learning experience by taking part in a larger number and
variety of patients’ care for the same total number of patient days.
Therefore, the efficiency of the care team would facilitate a richer resident
experience, making the effect of lost time to work hour limitations less
significant. Although some may question whether additional daily rounds
take up time from the resident’s schedule, our experience shows that the
benefit of increased efficiency during the day far outweighs the cost.

The final, and most important, group to benefit from this new collaborative
team is the patients. By defining early in the hospital stay those resources
that will be necessary on discharge, the patients can make a seamless and
safe transition from the inpatient setting to the outpatient setting. There is
less time lost while a patient remains in the hospital waiting for bed
availability at a nursing home or rehabilitation center. In the daily rounds
between the residents, the case managers, and the nurses, there is a strong
sense of partnership toward a common goal. The residents provide
information about potential postoperative problems related to the patient’s
medical condition, the case managers relay the patient’s desires and
concerns regarding the upcoming discharge, and the nurses highlight the
patient’s functional status. It is expected that this also leads to a significant
decrease in errors, as there is the potential for more oversight as the
medical environment becomes busier and more complex.

Although this study shows significant positive results from our restructuring,
there are certain limitations in the study design. The first limitation relates to
the study population. Although there were several factors used to adjust the
data for analysis, these are only markers of identifiable patient
characteristics. It is complex to determine true patient acuity based solely on
diagnosis-related groups; however, it is likely true that most patients
receiving similar operations will have similar acuity when you also adjust for
age, sex, and admission source. In addition, there are noticeable differences
between ward service and private service patients that limit direct
comparisons between these patient groups. Whereas private service patients
are usually admitted for elective surgery after a full preoperative evaluation,
ward service patients typically undergo procedures that are less elective in
nature and can have increased complexity based on their admission source
(the emergency department). Also, ward service patients often have more
complex social backgrounds, leading to delays in disposition from the
hospital. Given these differences, it is remarkable that both groups displayed
a decreased length of stay after implementation of the team restructuring.

A second limitation to this study is that there are no formalized

preintervention patient satisfaction survey data with which we can compare
our present survey results. Although this hinders performing any statistical
analysis regarding the significance of the survey results, we believed that
some empirical inferences could be made. Part of the goal of this research
was to evaluate the effect of team restructuring on patient care, with patient
satisfaction as a surrogate marker of perceived quality. By noting that most
(82%-88%) patients surveyed were satisfied with their care, we
extrapolated that the changes could not have made a large-scale difference
in overall patient approval.

Finally, the patient care setting is a complex multidimensional place.

Therefore, it is difficult to prove that this restructured patient care team was
the only change responsible for the noted decrease in length of stay.
However, it appears more than circumstantial that such a significant
decrease was present after the inception of this collective effort.

This newly created collaborative team works well on a high-volume general

surgery service with resident participation. Whereas the collaborative team
approach is well suited to this type of system, it may not be adaptable to all
types of general surgery services. Our team was able to increase productivity
and efficiency. However, there are some inpatient settings in which case
managers may not be as well integrated into the team, residents may not be
present, or there is lower inpatient volume. In those types of settings, this
system would have to be adapted for the available resources.

The restructured general surgery team is just one type of model for the
larger goal of streamlining hospitals. As the volume of patients increases,
trimming inefficient patient care systems becomes essential to offset
increasing costs and decreasing reimbursements. The goal of this study was
to evaluate how restructuring a care team’s duties and attitudes could make
the team more efficient. Preliminarily, it appears to be a success, with
benefits for the hospital, the physicians, and the patients.

AUTHOR INFORMATION

Correspondence: David L. Berger, MD, Department of Surgery and Clinical

Performance Management Team, Massachusetts General Hospital, Wang
Ambulatory Care Center, Suite 465, 15 Parkman St, Boston, MA 02114
(dberger@partners.org).

Accepted for Publication: May 20, 2004.

Acknowledgment: We thank the clinical support staff, including Rosalia

Chow. In addition, we thank the general surgery nursing service, including
Marie LeBlanc. Finally, we acknowledge the consistent hard work of the
general surgery case managers, including Laurene Dynan, RN, Roberta Dee,
RN, and Christine Moulton, RN.

Author Affiliations: Department of Surgery and Clinical Performance

Management Team, Massachusetts General Hospital, Boston.

REFERENCES

1. Baggs JD, Ryan SA, Phelps CE, et al. The association between
interdisciplinary collaboration and patient outcomes in a medical intensive
care unit. Heart Lung. 1992;21:18-24. WEB OF SCIENCE | PUBMED

2. Warren ML, Houston S, Luquire R. Collaborative practice teams: from

multidisciplinary to interdisciplinary. Outcomes Manag Nurs Pract.
1998;2:95-98. PUBMED

3. Whang EE, Mello MM, Ashley SW, et al. Implementing resident work hour
limitations: lessons from the New York State experience. Ann Surg.
2003;237:449-455. PUBMED
4. Curtis K, Lien D, Chan A, et al. The impact of trauma case management
on patient outcomes. J Trauma. 2002;53:477-482. PUBMED

5. Spisso J, O’Callaghan C, McKennan M, et al. Improved quality of care and

reduction of housestaff workload using trauma nurse practitioners. J
Trauma. 1990;30:660-663. WEB OF SCIENCE | PUBMED
The Effects of Patient Communication Skills Training on
Compliance
Donald J. Cegala, PhD; Terese Marinelli; Douglas Post, PhD

Arch Fam Med. 2000;9:57-64.

ABSTRACT

Objective To examine 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 audiotaped with 6 patients, 2 patients in each of the 3 intervention
conditions: (1) a trained group (n = 50) received a training booklet in the mail 2 to 3 days
prior to the scheduled appointment, (2) 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, and (3) 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 7 were private practice offices in the community.

Participants The sample included 25 family physicians (averaging 11 years postresidency)

and 150 patients. Patients were randomly selected from appointment records and randomly
assigned to 1 of 3 intervention conditions.

Intervention A training booklet designed to instruct patients in information seeking,

provision, and verification.

Main Outcome Measure Patients' compliance with medications, behavioral treatment (eg,
diet, exercise, smoking cessation), and/or follow-up appointments and referrals.

Results Trained patients were more compliant overall than untrained or informed patients.
Training positively influenced compliance with behavioral treatments and follow-up
appointments and referrals.
Conclusion Training patients in communication skills may be a cost-effective way of
increasing compliance and improving the overall health of patients.

INTRODUCTION

INFORMATION exchange between physicians and patients is central to the quality of health
care.1-5 However, considerable research indicates that physicians sometimes do not meet
patients' information needs.3, 6-12 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 Whitfield28 found
that trained patients had more accurate and complete recall of physicians' treatment
information and recommendations.

Some researchers30-31,33 report a positive relationship between patient training and

physiologically measured health outcomes (eg, blood glucose control, blood pressure
control). Greenfield et al30-31 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 because of closer adherence to the treatment plan. In a
related finding, Roter34 reports that trained patients had a higher ratio of appointments kept
to appointments made over a 4-month period after 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 2 reasons. First, patients'
noncompliance with treatment recommendations is costly in terms of both 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 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. We also believe that trained
patients will be more compliant with medication, behavioral treatments, and follow-up
appointments/referrals than either informed or untrained patients.
MATERIALS AND METHODS

DESIGN

A nested design was used, such that patients were nested within physicians. Each physician
was audiotaped with 6 different patients, 2 patients in each of the 3 intervention conditions.
Those in the untrained group (n = 51) did not receive any intervention prior to their
scheduled appointment. Those in the trained group (n = 50) received a training booklet in
the US mail 2 to 3 days prior to their scheduled appointment, while those in the 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 9 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 2 to 4 physicians per site. Table 1 contains demographic information relevant to
the patient sample.

View this table: Table 1. Frequency Demographics for Patients in 3 Intervention

[in this window]
[in a new window] Groups*

Among physicians, 17 were men, 8 were women. Twenty-two physicians were white, 3 were
African American. On average, physicians were 11 years postresidency (range, 1 month to
36 years).

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 institutional
review committee 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 audiotaped with 6 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 while 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 us (D.J.C. or T.M) or an assistant. They
were given a preinterview 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 evaluation form that was sent with the booklet),
and the booklet was briefly examined for evidence of usage (eg, written notes, underlining).
In all but 5 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 were 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 operations at each site was not visible. The recording
equipment was turned on when patients were taken to the examination room. When the
physician arrived, recording began and a stopwatch 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 2 postinterview 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 2 postinterview questionnaires and a consent form. The items on the
2 questionnaires were parallel to the items constituting the patients' questionnaires.

Telephone Survey

Approximately 2 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

communication24, 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, or feelings of
depression. Next, they were instructed to list items of personal and family history relevant
to the topics they wanted to discuss (eg, 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 (eg, 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 (eg, 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 that 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 (eg, 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 seem to be key factors
that improve their validity. For example, Hayes and DiMatteo,48 Sackett,49 and others
suggest that patients' self-reports are more valid if they are asked about their compliance
with treatment in a nonthreatening way. In addition, Hayes and DiMatteo48 and Thompson50
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 caused by the patient's
intent not to follow treatment recommendations and noncompliance resulting from factors
other than the patient's intent (eg, forgetfulness or lack of understanding about treatment
procedures and/or their rationale). Unintentional noncompliance was assessed with 2 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 2 unintentional noncompliance
items based on work reported by Brooks et al52 and DiMatteo et al.35 Finally, intentional
noncompliance was assessed with 12 items based on work by Becker and Maiman53 and
Donovan and Blake.54 The recall probes and unintentional and intentional noncompliance
items are listed in Table 2.

View this table: Table 2. Recall Probes and Unintentional and Intentional
[in this window]
[in a new window] Noncompliance Items

Data Collection

Patients were contacted by telephone approximately 2 weeks after their taped appointment.
They were asked if the physician had recommended any of 4 treatment categories at the
taped interview: prescribed medication(s), behavioral recommendations (eg, diet, exercise,
smoking cessation), follow-up appointments, or 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 us (T.M.) 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 4 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 2 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 with the 0- to
4-scale used for recording patients' responses to the unintentional and intentional items.

The 3 compliance subscores (all ranging from 0 to 4) for each treatment category were
added up 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 4 treatment categories (verification against the transcripts indicated that 2
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 1 or more of
the 4 treatment categories. Ideally, data would have been analyzed with a nested analysis
of variance (ie, using the physician x treatment mean square as the error term). However,
this method of analysis was precluded because of missing cell data for individual treatment
category scores (ie, medications, behavior treatments, follow-up appointments/referrals). As
an alternative, the noncompliance scores of patients within each physicianx intervention cell
were averaged. In instances in which there was a datum for only 1 patient in a physician x
intervention cell, just that single datum was used. Paired t tests were then computed on
these scores (ie, physicians were matched across the 3 intervention treatments). This
procedure resulted in an ultraconservative 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 level when
conducting multiple t tests, this was not done here because the procedure used already
resulted in conservative tests. An of P .05 with 1-tailed tests was used to assess the
hypotheses. For large effect sizes, the power of statistical tests ranged from 0.75 (n = 11)
to 0.98 (n = 25).
RESULTS

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 more than 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.

View this table: Table 3. Means (SDs) and t Test Results for Compliance Scores
[in this window]
[in a new window]

The second hypothesis predicted that trained patients would be more compliant than
informed or untrained patients in each of the 3 categories of compliance. The data relevant
to medications are reported in Table 3. While the pattern of means is consistent with the
hypothesis, none of the test results is 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 = -0.29; P = .001, 2-tailed). This relationship was consistent within the intervention
groups, although it was slightly less strong in the trained group (untrained: r = -0.28, P =
.06; informed: r = -0.29, P = .07; trained: r = -0.23, P = .11; all 2-tailed).

The correlation between patients' race and overall compliance was nonsignificant (r = 0.16;
P = .07, 2 tailed). Correlations within intervention groups revealed a significant correlation
for the untrained group, such that minority patients were less compliant overall than
nonminority patients (r = 0.33; P = .03, 2-tailed). There was no relationship between
patients' race and compliance among informed or trained patients (informed: r = -0.01, P =
.94; trained: r = 0.07, P = .65; both 2-tailed). For a follow-up analysis, an analysis of
variance 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 (F2,35 = 5.48; P = .008; 2 =
.31). No significant correlations were obtained between patients' overall compliance and sex,
status (ie, new vs returning patients), age, or illness severity.

COMMENT

Jump to Section
• Top
• Introduction
• Patient communication
skills...
• Rationale and
hypotheses
• Materials and methods
• Results
• Comment
• Author information
• References

Our study examined 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 as an effective tool.

Hypothesis 1 received the most support. Trained patients were more compliant overall 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 significant effect on compliance with medications, but the pattern of
compliance score means was consistent with the expectation that trained patients would be
more compliant than informed or untrained patients (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 (ie, trained, 0.52;
informed, 0.24; and untrained, 0.33). Still, the effect of training on patients' compliance
with medications was not 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 for other factors that may affect
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 for 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 are
encouraging. Researchers have noted that compliance with lifestyle changes, such as diet,
exercise, and smoking cessation, is the most difficult for patients,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 lifestyle
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 lifestyle
changes. Although we did not directly assess patients' readiness, 6 patients reported not
being ready or not wanting to make appropriate lifestyle changes as the reason for
noncompliance. Of these 6 patients, 3 were in the informed group and 3 were in the
untrained group. Thus, patient readiness may have contributed to at least some of the
trained patients' compliance with lifestyle 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 herein 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 illnesses, the extent of
information exchange within a single visit may not be an overriding factor in determining
whether they keep a follow-up appointment. Perhaps future research should examine the
role of communication skills training in patients' decisions to continue seeing a physician
or their adherence to follow-up appointments over an extended period.

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 from trained patients in compliance with separate
treatments. On the surface at least, this suggests that even minor efforts to encourage
patients to be more active in medical interviews can potentially have positive effects on
health outcomes. On the other hand, our previous research 45 and some other work in patient
communication skills training16 suggest that more extensive, face-to-face training may
have dramatic effects. Following social learning 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 our knowledge, no studies have been conducted
on multiple-component communication skills interventions.

Although most private practices and 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 we
used, 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 seems 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 through examining the effect of
training on clinical outcomes when patients are not formally participants in a study. It is
possible that at least part of the impact of the training booklet we used was related to the
fact that patients knew they were participants in a study (eg, 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.

AUTHOR INFORMATION

Jump to Section
• Top
• Introduction
• Patient communication
skills...
• Rationale and
hypotheses
• Materials and methods
• Results
• Comment
• Author information
• References

Accepted for publication June 2, 1999.

This research was made possible by grant R03 HS90110-01T from the Agency for Health
Care Policy and Research, Rockville, Md (Dr Cegala).

The content of this article is solely the responsibility of the authors and does not necessarily
represent the official views of the Agency for Health Care Policy and Research.

Corresponding author: Donald J. Cegala, PhD, 3016 Derby Hall, 154 N Oval Mall, Columbus,
OH 43210 (e-mail: cegala.1@osu.edu).

From the School of Journalism and Communication (Dr Cegala and Ms Marinelli) and the
Department of Family Medicine (Drs Cegala and Post), Ohio State University, Columbus.

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• Comment
• Author information
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