“Four Habits” goes abroad: Report from a pilot study in Norway

https://doi.org/10.1016/j.pec.2008.05.012Get rights and content

Abstract

Objective

“Four Habits” is the first larger generic clinical communication program to have a documented effect. It has not been evaluated outside USA. In a pilot study, Norwegian hospital physicians assessed its usefulness, and we developed a questionnaire where patients reported “Four Habits”-specific physician behaviour.

Methods

We ran a 3-day course with 16 participants and three US facilitators. The questionnaire mapping “Four Habits” with 23 items was distributed by participating physicians to 210 patients. Participating physicians met in evaluative focus groups 3 months after the course.

Results

The questionnaire was condensed to 10 items after factorial analysis. The resulting scale performed well. A large amount of missing data on some items suggested that patients found it difficult to evaluate details of “Four Habits”-specific physician behaviour. Participants found that the “Four Habits” short course led to improvement of their encounters. Some elements of the method were not perceived as relevant for all types of encounters (habits II and III).

Conclusion

“Four Habits” is applicable outside US with some adjustments. A shortened version of the questionnaire will be used in a planned randomized controlled trial.

Introduction

Communication skills have evolved as an important part of medical training, mainly in general internal medicine, family medicine, psychiatry, and oncology [1], [2], [3]. The first larger training program meant for all clinical specialties was the “Four Habits Approach” developed in the US Health Maintenance Organization Kaiser Permanente and used over the last 15 years [4], [5]. The program was developed using principles of adult learning and a systematic review of the evidence in the medical literature linking specific communication skills with functional and biomedical outcomes of care [5]. “Four Habits” refer to what should happen in clinical consultations; that it has a friendly and well-planned beginning, a search for the patient's perspective, empathic response, and thorough information giving, shared decision making, and check of the patient's understanding and adherence to advice towards the end. The “Four Habits” program consists of fairly short introductory courses (2 h for each habit) available in all Kaiser Permanente's medical groups, and a more extensive course over 5 days for physicians with low patient satisfaction ratings. For the latter, observational studies have shown that the approach is effective in increasing and maintaining patient satisfaction for at least 6 months (the length of follow up) [5]. In terms of assessment, a valid and reliable coding method for video observation of the behaviour elements of the “Four Habits” has been developed, the Four Habits Coding Scheme (4HCS) [6]. No such instrument has been developed for patients, who are typically asked to fill out retrospective questionnaires assessing global aspects of communication with little specificity. In summary, a gap exists in methods for assessing patient experience of care and physician performance of communication skills.

Studies indicate a discrepancy between physicians’ and patients’ perceptions of what happens during a medical encounter [7], [8]. If the Four Habits teaching method proves effective and is implemented on a large scale, routine use of videotapes for assessment would be less feasible than a valid and reliable questionnaire. There is a general trend toward the use of questionnaires that map specific behaviours more than opinions, and so are actionable by physicians. Hence, a questionnaire utilized by patients to evaluate whether “Four habits” behaviour elements were present in their encounters would be helpful.

As preparation for a large-scale trial of the Four Habits Approach a pilot study was conducted with two purposes in mind. One was to test the feasibility of a questionnaire based on the types of behaviour recorded in the 4HCS. Secondly, as specialist care is organized differently in Norway and the US, we wanted to explore how the “Four habits” approach was experienced by Norwegian hospital physicians in their practice.

Section snippets

Course

The course was held on 21–23 August, 2006 with three of the authors as facilitators (RF, EK, DGS). The main outline of the course was to present and discuss the Four Habits in plenary sessions separated by training sessions for each habit, with role-plays in groups of 5–6 physicians with one American facilitator and one Norwegian co-facilitator (AF, PG, Øivind Ekeberg). The physicians played both patients and physicians with feedback from the facilitators. As a didactic tool we used parallel

Questionnaires

Two hundred and ten questionnaires were received, 56 from men, 148 from women, 6 did not identify their gender. The age distribution was skewed. For further analysis, patients were grouped into four with equal age ranges. Eleven patients were 23 years or younger, 60 patients were 23.1–46 years, 88 patients were 46.1–69 years, 47 patients were older than 69 years. Four patients did not give their age. Thirty-one patients knew the physician well, 48 patients knew the physician a little, while 130

The questionnaire

The questionnaire was designed to map the occurrence of specific physician behaviour, as perceived by the patients. We derived a scale that satisfied formal criteria [15], [16]. Its validity was supported by correlations with general satisfaction and knowledge of the physician. Lack of correlation with age and gender is an advantage.

The items excluded due to high level of missing values were with one exception from habits III and IV, and the exception was the item about asking the patient about

Acknowledgements

We thank the anthropologist Ellen Kristvik for her independent review and interpretation of the focus group notes.

Funding: The study was funded by the regional health authorities in south-east Norway and the Norwegian Medical Association. They did not influence the study.

Conflict of interest: None.

References (18)

There are more references available in the full text version of this article.

Cited by (40)

  • Upscaling communication skills training – lessons learned from international initiatives

    2021, Patient Education and Counseling
    Citation Excerpt :

    Several effectiveness and efficiency studies have shown that communication skills training based on the Calgary-Cambridge Guide (8) can significantly increase the health professionals’ self-efficacy (14–16). Communication skills training based on that and other guidelines/framework are increasingly being implemented in several countries as post-graduate training (17–19). In order to gain the most optimal effect of the training in clinical practice, it is important also to consider the context where the implementation takes place and the many factors that influence successful and sustained implementation of knowledge and skills (20,21).

  • Patient affect, physician liking for the patient, physician behavior, and patient reported outcomes: A modeling approach

    2020, Patient Education and Counseling
    Citation Excerpt :

    taken from The Consumer Assessment of Health Care Providers and Systems [22]. Patients assessed the physician’s behavior using the Four Habits Patient Questionnaire (4HPQ), with 15 4-point items (definitely no, somewhat no, somewhat yes, definitely yes) that were amalgamated to one score for each habit [17,23]. Patients completed six communication and information items from the Outpatient Experiences Questionnaire [24] (5-point all-anchored scales; Was the physician well prepared for the encounter, Did the physician talk to you in a way that you could understand, Did you trust the physician’s medical competence, Did you feel that the physician cared for you, Were you able to tell the physician what was important for you, Was it clear to you what you would have to do yourself after the encounter).

View all citing articles on Scopus
View full text