Health Services Research & Development

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Response to Commentary

VA is making substantial efforts to communicate the VA mission and goals throughout its workforce. A recent effort to communicate this mission across VA is embodied in our commitment to the core values represented in the acronym ICARE (Integrity, Commitment, Advocacy, Respect, and Excellence). A reflection of VA's mission is also found in the four themes and 10 strategies that constitute the VA Blueprint for Excellence, which details a vision for the future of VA. Both ICARE and the Blueprint are national brand campaigns that highlight the importance of patient-centered care. The Blueprint identifies patient-centered care as one of the six aims for high-quality health care identified by the Institute of Medicine.

The focus of this response will be on patient-centered communication, which is one aspect, but also a main ingredient in delivering patient-centered care. Provider-patient communication can be patient-centered or provider-centered. Patient-centered communication achieves several functions including: fostering healing relationships, exchanging information, responding to emotions, making decisions, managing uncertainty, and enabling patient self-management.

Efforts to improve patient-centered communication that focus on physicians' communication have not harnessed the full potential of patient-centered communication because they focus on half of the conversation. Attention to patients' communication is equally important. Patients' active participatory communication behaviors (e.g., asking questions, giving opinions) are important because these types of active behaviors are influential in medical encounters. Because of social norms of communication, when patients are active (e.g., ask a question) they can expect to get a reciprocal response from their provider (e.g., an answer to their question). That is, providerpatient communication is a two-way street. Patients' active participatory communication is powerful because patients who ask questions, make assertions or requests, and communicate concerns and opinions can influence providers' communication, behavior, and recommendations.

Several studies have shown that interventions aimed at teaching patients better communication behaviors lead to improved process and outcomes of care. Yet, efforts to coach patients on how to improve communication behaviors rarely occur because coaching interventions require time, labor, and resources. Paper-based methods of delivering coaching interventions have had modest or no effect on patients' communication behaviors. Intervention options that bridge the gap between resource intensive person-to-person coaching interventions and paper-based interventions need to be investigated. Alternative ways to coach patients might involve patient navigators, peer support, video, and electronic methods. A video intervention may overcome prior barriers to implementation because video-based approaches offer several advantages over other approaches. Video-based direct-toconsumer programs are used effectively by the pharmaceutical industry on television. These advertisements influence patient behavior and activate patients to make specific requests. Few studies have explored video as a medium for delivery of interventions to encourage patients' active communication behavior. I have worked to understand the full potential of video, which has the advantage of being significantly less expensive than interventions requiring coaching personnel, and may be more easily disseminated than coaching interventions that rely on trained personnel.

Patient-centered care depends on clinicians to use patient-centered communication and patients (and their companions) to be prepared to use active participatory communication. Patients who have difficulty using active participatory communication behaviors are less involved in consultations with their providers, receive less information and support, and are less satisfied with their care. In turn, these patients may not understand their treatment options. Furthermore, even when a treatment is chosen, patients may have less knowledge about that treatment, fewer positive beliefs about it, and less trust in the providers administering it. Consequently, patients may have poorer adherence to treatment and self-care recommendations and may experience poorer health outcomes.

As part of my research program, I developed "Speak Up," an educational video to encourage patients to use active participatory communication behaviors in visits with their provider. Based on focus group data, literature reviews, and input from our expert panel, the video presents positive role modeling of communication in medical encounters. Role modeling is an effective method of preparing patients for visits and for encouraging appropriate behaviors; in fact, such modeling is a standard approach in medical education.

In our evaluation, we have found the video to be acceptable to VA patients and feasible for use in a busy VA primary care clinic. We have used the video as part of new patient orientation at a VA community-based outpatient clinic. We are currently testing whether watching the video influences patients' communication in a project funded by HSR&D. Another HSR&D project will evaluate pre-visit video as a means to promote improved communication in the setting of clinical video telehealth visits. Our research projects include provider training in agenda setting, so that providers are prepared for activated patients.

Our video intervention provides specific communication strategies and behaviors for patients to model in preparation for their visit. A timely video intervention that specifically addresses patients' selfefficacy in a culturally sensitive manner and prepares patients for the medical visit may increase patients' active participatory communication in medical consultations. A program that prepares providers and activates patients to use patient-centered communication has the potential to improve communication in medical encounters and to improve both visit and health outcomes.