Veterans often experience difficulties in self-management of chronic conditions, resulting in poor health outcomes. In the setting of stroke, self-management of hypertension is a major concern. Data from VISN 11 indicated that only 26% of Veterans with stroke met the established VA performance criteria for hypertension management of having at least 75% of blood pressure measurements at or below goal.
Veteran self-management of hypertension is a critical component in the secondary prevention of stroke. Provider-patient relationship quality and communication have been identified as inhibiting or facilitating care processes and outcomes such as self-management. Patient-centered communication skills are associated with improved adherence, self-care, and health outcomes. Prior research shows that physicians and patients exert reciprocal influences on one another's communication. Models of successful self-management require physicians with excellent communication skills and patients who are active and knowledgeable about their conditions.
One model of communication enhancement - the Four Habits Approach - was developed by VA investigator and PI Richard Frankel more than a decade ago. The approach has been empirically validated and adopted broadly. In our randomized-controlled study, Controlling Hypertension Outcomes by Improved Communication & Engagement (CHOICE) (RRP 09-190), we tested the feasibility of two communication interventions: one with Veterans who have had a stroke and now demonstrate poorly controlled hypertension; the other with their treating VA primary care physicians.
The communication intervention had two goals: (a) coaching to enhance Veterans' abilities to communicate their questions and concerns about self-management for hypertension to their physician; and (b) improving physicians' communication skills for enhancing and encouraging self-management of hypertension.
This study was conducted in the Richard L. Roudebush VA Medical Center's primary care clinics, where 75 clinicians provide care to over 20,000 Veterans during 66,000 annual visits. This study enrolled 10 VA primary care physicians to participate in the randomized-controlled trial and 30 Veterans (up to 3 Veterans from the panel of each of the 10 participating physicians) who had a prior stroke event and had evidence of hypertension within the last 12 months.
An initial set of baseline visits in the outpatient clinic were videotaped and transcribed. A few weeks after the baseline visit, providers assigned to the intervention group reviewed their videotaped clinical encounters with PI Richard Frankel and received "executive coaching" in the Four Habits model, with a special focus on agenda-setting. Around the same time, Veterans in the intervention group likewise received one-on-one coaching after the baseline visit with a patient educator about strategies they could use to discuss hypertension management with their providers during their next clinical visit. A second set of outpatient visits in the outpatient setting were then videotaped and transcribed for all providers and Veterans enrolled in the CHOICE study.
For each provider-patient dyad, CHOICE investigators conducted qualitative data analysis by viewing the videotapes and transcripts of the visits to evaluate how discussions of hypertension management by providers and Veterans during the 2nd set of visits compared with their baseline visits. CHOICE staff also administered and compared results of the Patient Activation Measure to Veterans in the intervention and control groups.
Inviting providers to watch themselves on videotape proved to be a powerful method for learning and professional development. None of the five providers in the intervention group said they had ever seen themselves on videotape before nor were they defensive when reviewing their individual videotapes during the coaching sessions. Providers consistently recognized opportunities for growth and improvement in agenda-setting on their own without prompting. All five providers were MDs with extremely busy schedules in the outpatient clinics yet, three of the five enthusiastically asked for extended and/or additional coaching sessions with PI Frankel.
To obtain the videorecordings, multiple challenges needed to be met in addition to the traditional IRB, R&D committee, and informed consent requirements to protect human subjects. Providers were not always comfortable with the idea of being videotaped, and the CHOICE team had to respond to their concerns. The videorecordings were made with a small, unattended videorecorder attached to a tripod propped in an inconspicuous corner of the room. CHOICE study staff had to coordinate closely with clinical staff to get access to the correct room just minutes before the start of the visit and then return to the room just minutes after the visit had concluded to retrieve the equipment. In successfully recording 33 separate clinic visits, the CHOICE study demonstrated the viability of this method within the busy outpatient clinical setting of the Roudebush VA.
The videorecordings also led to the discovery of an emergent finding. In viewing them, CHOICE investigators unexpectedly noted specific, recurring patterns in the ways that providers and patients interacted that persisted across visits. CHOICE investigators now refer to this set of patterns as the "internal logic of the outpatient visit" because it transcended individual providers and patients and was often remarkably consistent across visits. Limited agenda setting by physicians turned out to be a particular challenge driven by this internal logic. Given the private nature of provider-patient encounters, CHOICE investigators realized how few people would ever be in a comparable position to note patterns across visits and providers. The CHOICE team plans to study this phenomenon in greater depth and report out on it in a separate analysis.
The CHOICE study indicates that individual coaching with busy primary care physicians at the VA is feasible and can lead to discernible changes in physician communication in general and agenda-setting in particular. These findings come at a time when there is renewed interest in coaching for experts and professionals, including physicians.
Improved physician patient communication has been linked with positive functional and clinical outcomes. A one-hour professional coaching intervention based on the "Four Habits" Model produced measurable change in communication. The approach may have applicability to other aspects of communication between patients who have had a stroke and their primary care physicians. Conversations about quality of life, functional ability, and life style change are three areas that could benefit from further coaching and training in the Four Habits Approach.
- Sternke EA, Miech EJ, Apel K, Carlson K, Allen A, Frankel RM. Coaching for Improved Physician-Patient Communication: Feasibility and Implementation in the Primary Care Setting. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD.