Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms

Abstract

PURPOSE Patient participation in clinical decision making improves outcomes, including quality of life (QOL), but the typical problem-oriented approach may impede consideration of functional goals. We wondered if patients could encourage primary care physicians to pay attention to their QOL goals by writing them on pre-encounter forms. METHODSWe conducted a randomized controlled trial comparing the impact of 2 different pre-visit questionnaires on the content of patient-physician encounters in a family medicine practice at an academic medical center. Using investigatorblinded block randomization, we arranged for 8 faculty and 8 resident physicians to participate in 2 intervention and 2 control videotaped encounters each for a total of 64 encounters. The intervention questionnaire included questions about QOL goals and concerns, while the control questionnaire asked about symptoms. Videotapes were reviewed to determine whether the patients' QOL goals were mentioned and whether they were used in decision making. We also scored encounters using Modified Flanders Interaction Analysis, which assesses and codifies patient and physician communication, and the Modified Carkhuff-Truax Scale, which measures empathy, attending, congruence, and positive regard. RESULTSPatients were able to record QOL goals and concerns, but QOL issues were mentioned in only 2 of the 64 encounters, once by a patient and once by a physician. In neither case was this information used in decision making. More empathy was expressed by physicians during control encounters (P = .03). CONCLUSIONSPatients were able to articulate their QOL goals on paper, but that did not prime them or their physicians to alter the process or content of the clinical encounters. In fact, providing QOL information was associated with reduced physician empathy. Ann Fam Med 2016;14:221-226. doi: 10.1370/afm.1905. INTRODUCTIONP atient participation in clinical decision making improves outcomes, including quality of life (QOL). [1][2][3][4][5][6][7] Yet physicians tend to focus on diseases and symptoms rather than on patient-oriented outcomes such as the ability to participate in meaningful life activities. [8][9] This problem-oriented approach is the one taught in most medical schools and reinforced by coding and billing requirements, clinical practice guidelines, and electronic medical record systems.10 Such an indirect approach to goal attainment assumes that patients' health goals will be achieved if their problems can be solved or ameliorated, which may or may not be the case. It has been shown that verbal agreement between patients and physicians concerning what problems need to be addressed facilitates problem-solving and leads to better outcomes.11-12 Perhaps a more direct, patient-centered approach is needed in order to improve clinical decisionmaking and patient QOL.We wondered if patients could encourage their primary care physicians to use a more direct, patient-centered approach to care by using routine pre-encounter forms to alert their physicians to ...

A Qualitative Interpretation of Challenges Associated with Helping Patients with Multiple Chronic Diseases Identify Their Goals

“…Purkaple et al . [ 23 ] reported fairly good response rates from patients with the use of written answers for three questions that may relate to goals: (1) “What is a typical day for you and what things are you unable to do as a result of your health problems?” ; (2) “What other things would you like to be able to do that you can’t do now?” ; and (3) “What activities make life worthwhile for you (that you wouldn’t want to give up? )” .…”

“…This hypothesis has actually been ratified recently through the paper of Purkaple et al . [ 23 ] who found that the goal-related issues identified by patients were only mentioned in two out of 64 primary care encounters. In neither case was this information used in clinical decision-making.…”

Glaucoma patient-provider communication about vision quality-of-life

“…Work in other disease areas has found that physicians tend to focus on symptoms and treatments rather than on patients' ability to participate in meaningful life activities [4, 5]. This may be because it is difficult for patients to bring up meaningful life activities during medical visits naturally or some patients might prefer that their physicians start the quality-of-life discussion [6]. Nonetheless, empowering and involving patients in decisions made during medical visits can improve patient quality-of-life [7-12].…”

Physicians' Response to Patients' Quality-of-Life Goals

“…Physicians almost never addressed patients' QOL priorities but almost always addressed symptoms expressed on the control forms. 25 Furthermore, the QOL data appeared to have a negative effect, reducing physicians' expression of empathy. Other studies have shown modest effects on physician-patient communication after pre-encounter priming for patients and clinicians, 14 but no other studies have investigated interventions involving both patients and practitioners that can be easily integrated into primary care settings.…”