Enabling Seniors to Overcome Barriers in Health Care Communication
William Godolphin1, Angela Towle1, Sheila Dyer2, Donald Cegala3, Jennifer Manklow4, Holly Wiesinger4 & Lionsview Seniors’ Planning Society5
1Informed
Shared Decision Making Project, Division of Health Care Communication, College of Health Disciplines, University of British Columbia, Vancouver BC Canada V6T 1Z3, Tel: (604) 822-8002, Email: isdm@interchange.ubc.ca 2Clinical Skills Resource Centre, Standardized Patient Client Program,
Vancouver BC Canada 3Professor of Communication and Family Medicine, Ohio State University, Columbus, Ohio USA 4Medical Undergraduate Program, Faculty of Medicine, University of British Columbia, Vancouver BC Canada 5North Vancouver BC Canada
Supported by the Vancouver Foundation 2000, 2002
Communications Skills
Training for Patients
 Communications skills training for
patients directly associated with
physicians’ offices has been shown
in research studies to make a
difference in the nature of the
interaction (more questions and
control by patients) and improved
outcomes (disease-related,
functional status and adherence to
treatment).
 But - community-based
interventions have the potential for
greater dissemination, lower cost
and are consistent with the patient
empowerment movement.
Objective
To develop, implement and evaluate a
community-based workshop to assist
seniors to communicate more
effectively with their physicians.
University-Community
Partnership Research
UNIVERSITY OF
BRITISH COLUMBIA
Needs Assessment
Workshop
Telephone interviews..
Implementation
.. with 21 seniors following a
community workshop “High blood
pressure: What are your risks and
can they be reduced with prescription
drugs?”.
They were asked if they discussed
what they had learned with their
physicians and about the response
they received.
.. with 8 seniors interested in a
workshop to improve communications
with their doctors.
Take home booklet
(http://patcom.jcomm.ohio-state.edu)
Workshop Model
1½ hours with a break for tea
& biscuits
1. Use of PACE
communications skills
structure
 Though the quality of
communication they described
appeared to be less than satisfactory
they made excuses for the
physician.
2. A simulated office interview
between doctor and patient
illustrating common health
and communications
problems
Conclusions
Implications for
workshop design
They could not imagine how
they might make a difference.
provide a vicarious
experience
They were very tolerant of poor
communication - up to a point beyond that their only response
was to ‘fire the doc’.
It was difficult to focus on what
they might do to improve
Communication.
They had no control in the
medical interview.
teach them conflict
negotiation skills
3. Facilitated discussion and
role scripting/playing to
explore solutions to the
communications problems
3. Facilitators’ Guide
 Introductions: What do you expect
when you see your doctor?
 Explanation of PACE framework.
 1st video clip: Identify skills the
patient demonstrates
 2nd video clip: What are sources of
conflict? What did the patient do
that was helpful? Not helpful? What
could you do if you are not like the
patient?
 3rd video clip: Work in pairs to write
a dialogue to resolve the conflict and
stay on PACE. Facilitators circulate
to the groups. Read out (or better
yet, act out) the scripts.
Cegala et al: Patient Educ
Counseling 2000; 41: 209-222
They were asked to describe
communications problems and what
they would like to be able to do about
them.
 They described a general sense of
dis-empowerment when faced with
the medical profession.
 Asking questions if desired information is
not provided. (information seeking)
 Expressing any concerns
about the recommended
treatment.
 A variety of barriers to discussion
with their physicians included
lack of time, lack of doctor’s
interest and ‘doctor knows best’.
Focus group ..
 Presenting detailed information about how
you are feeling. (information providing)
 Checking your understanding of
 Co-facilitation by professional (coinformation given to you. (information
investigator) and volunteer (senior)
verifying)
 They shared the information
widely with friends and family
 They wanted to focus on what the
doctor should do.
The Seniors Benevolent Fund
The Roy and Bertha Wrigley Fund
 Presented at community centres
associated with ‘keep well’
program for seniors and promoted
by co-investigators (community
partners: LSPS).
1. PACE Communications
Skills Model
 4th video clip: Compare outcomes
with discussion of scripts.
 Closure: What will you try? Hand
out booklet.
 Based on personal experience(s) of
seniors involved in ‘standardized
patient/client’ program.
Acceptability: 57 participants at 5
workshops indicated lots of
enthusiasm and support for the
project (verbally and in written
evaluations). Word-of-mouth
prompted other seniors’
organizations, patient support
groups and community centres to
request workshops.
Effectiveness: Post-workshop
‘opinionnaires’: the most
frequently identified learning was
about preparation (eg, “How to get
ready for our visit”) and
presentation (eg, “The importance
of giving a clear history of the
problem”)
Follow up
 A long-term doctor-patient
relationship, with good rapport
Two months after workshops 9
participants took part in telephone
interviews that were audio taped.
Interviews were semi-structured and
lasted 10-15 minutes.
Workshop on talking with your doctor
 Sources of conflict: • Treatment
preference • Peter’s enthusiasm about
the locum (doctors have feelings too!)
 Peter illustrates each of the
elements of PACE and
conflict negotiation skills.
 7 minute interview in 4 sections:
- small talk and presentation
- development
- impasse
- resolution
Interview transcripts were subjected
to Grounded Theory analysis
Examples of change
were reported ..
Change was
limited by:
Communicate expectations:
“I learned to be more forthright and
tell him exactly what it was I wanted
from him.”
 Expressed satisfaction with
existing relationship; low
drive to change.
 Most barriers to
communications were
attributed to the doctor;
beyond patient’s control.
Expressing concerns:
“There was a bump on my abdomen
and he said, ‘Oh what’s that?’ And I
just passed it off and then I got home
and I was worried about it, ‘ I wonder
if I’ve got an aneurysm.’ And so,
when I went back I asked him and I
might not have done that before the
workshop.”
 Importance of maintaining
good rapport; attempts to
make a change are
perceived to put rapport at
risk.
 The difficulty of changing
an established relationship;
lack of tactics to signal
this intent.
Asking questions:
“The specialist - I had some questions
that I wanted to know, so I thought
about them before going.”
.. but the subjects identified specific
communications difficulties; on
analyses these were categorized as:
“Most of the time I felt that I
was intruding on their time ...
I felt that they wanted it to be
over and done with in the 4
minutes and 59 seconds.”
Dr Joan & Peter
“Well you’re already in an
inferior position ... with you
sitting down below and they’re
standing up, looking down at
you, you know, that’s, well,
intimidating.”
Conclusions
 Change is slow and difficult
and needs support and
reinforcement.
 Sustainability requires
embedding in existing
programs and training of local
facilitators.
 Perceived risk to rapport
requires endorsement of
workshop by physicians.
 They need ‘evidence’ (role
models, testimonials) of what
is possible — countering disempowerment by
demonstrating it can be done
— that they can put these
skills into practice.
Next Steps
Presenting information:
“I might not have told him about how
I was feeling without that workshop. I
was feeling very vague, not very great.
I was rather surprised that he was
concerned but I think he was
concerned because I do have a
chronic condition. Lo and behold it
was that. So I’m on antibiotics.
Caught it early because I did tell
him.”
“I’m afraid that I feel that I can’t do
much about fostering a good
relationship between the doctor and me
because I think that’s something they
don’t teach in university and [doctors]
don’t learn it in medical school.”
Futility
“I think the doctors maybe
feel that the patient
Time
wouldn’t understand
Communication
anyway if they tried to
Difficulties
explain it to them in little
words.”
Reluctance to
Anxiety
Language
bother doctor
provide for problem-solving
and simulated practice
teach them a structure for
communications
Evaluation
Efficiency: The high cost of
professional facilitator cannot be
sustained in the community
2. Video Scenario
 Peter had unusually severe asthma
attacks while his GP Dr Joan was on
holiday. Peter now wants to try some
‘alternative’ therapy (eg, yoga
suggested by locum). Dr Joan does not
approve and is concerned about full
investigation of his worsening asthma.
Evaluation & Follow up
Memory
“Usually I forget
something or the other I
wanted to talk about.”
“You’re always feeling that you
shouldn’t bother them too
much. In fact, they have a sign
on the door, ‘only one problem
per visit.’”
 Follow up intervention to
reinforce the learning and
support problem-solving.
 Embed in existing community
programs by training volunteer
peer facilitators who are also
role models.
 Similar workshops for other
patient groups. The major
difference will be the video
scenarios.
 ‘Endorsement’ from physician
professional body, eg, licensing
college or medical association.
 Our current funding focuses on
more seniors’ groups, a
support group for stroke
patients and a community
mental health program.
These are high health care
users and in an ‘information’
age they are disadvantaged in
accessing information and
more likely to be disempowered in the doctorpatient encounter.