Review articleDoes patient coaching make a difference in patient-physician communication during specialist consultations? A systematic review
Introduction
Research shows that patients want to be heard and to be taken seriously in consultations with physicians [1]. Patients with a chronic illness are increasingly expected to self-manage their disease, which implies being involved in treatment decisions as well. In most cases, treatment is initiated by a medical specialist, therefore a patient’s ability to communicate effectively during these consultations is essential [2], [3], [4]. Patients need to be aware of and skilled to disclose relevant personal information about preferences, values and concerns [5]. Several factors reduce the likelihood that patients get the communicative approach they want and need during medical consultations, even though healthcare providers are doing their best to serve the patient’s needs [6].
Barriers to communication have been reported in a systematic review on shared decision making [7]. Thirty three papers concerned studies in secondary care. Patients in these studies were diagnosed with various diseases, like cancer, cardiac diseases, diabetes, osteoporosis, hernia or asthma. Reported barriers related to how the healthcare system is organized and the interaction between patient and physician during consultation [7].
The complex hospital environment with full waiting rooms, difficult navigation through departments and clinic, dealing with many different healthcare professionals, and time constraints imposed by busy healthcare professionals, challenges communication during clinical consultations [8], [9].
In the interactional context barriers relate to the power imbalance between patient and physician. This involves, from a patient’s perspective, presumptions about their role and undervalued expertise in relation to the physician’s knowledge [7]. Furthermore, the communication style of individual healthcare professionals may hinder effective communication with patients, for example by being hasty or by communicating in an excessively technical and instrumental way [8]. Patients also perceive several barriers within themselves, for example being overwhelmed by emotions, counterproductive values and beliefs [8], and lacking conversational skills or cognitive abilities, to be an active participant during healthcare visits [10].
The influence of barriers declines as patients become more experienced in their treatment trajectory. Van Bruinessen et al. identified a pattern of three states in patients communicating with healthcare professionals: 1) being overwhelmed and passive, 2) being pro-active and 3) being self-motivated, proficient and empowered. In line with the ‘conscious competence learning’- model by Maslow, moving towards a next state in this trajectory might be facilitated by increasing patients’ awareness on the role patients can play and the benefits of active participation [11], and additionally acquire the skills to communicate about their values, concerns and context in a participatory manner. Although most chronically ill patients move to subsequent states as time evolves after diagnosis, some patients remain in the first state of being unconsciously incompetent [8] during their treatment trajectory.
To increase the number of patients that move from the first state to the second or even third, or accelerate this transition Van Bruinessen et al. suggested interventions should focus on creating awareness about the role patients can play during consultations and on training their communication skills [8]. Joseph-Williams et al. suggested to use alternative ways to prepare a patient for the shared decision making encounters: in addition to decision aids supporting the patient’s ability to participate in the shared decision making process, focus should also be on how to handle the power imbalance between patient and physician [7].
Standardized communication and educational strategies to achieve patient empowerment are challenging, because patients’ support needs are complex (influenced by health literacy level, social and cultural differences), can change over time and vary between contexts [12]. The identification in clinical practice of patients who will benefit most from coaching is challenging as well and requires further investigation.
Personal attention may be best suited to adapt to changing needs and circumstances. After all, human connection is fundamental in person centered patient care, and patients require human connection to feel respected and equal [13]. In a study among patients visiting medical specialists in Dutch hospitals, 16.6% of patients stated that they would appreciate a personal coach to help them prepare, execute, and evaluate medical consultations. Patients expressed the need for support to inform the provider about their preferred position in the process of medical decision-making, and help them to articulate their most important values and concerns at different stages during the treatment trajectory [14].
Previous reviews investigated such patient coaching interventions in different healthcare settings [15], [16], [17], [18], [19], [20], [21], [22], [23]. The majority of these studies however, were limited to interventions provided before consultations [20], [23], to patients with cancer [18], or directed only at practitioners [22]. The effects of personal, patient directed interventions for patients consulting a medical specialist, aiming to improve communication, and its effective components have not yet been systematically reviewed. This review therefore aims to increase understanding in these interventions and their effect on communication during consultation.
We performed a systematic review according to the PRISMA guidelines [24] to address the following research questions:
- (1)
Which patient coaching interventions have been developed and studied with respect to effectiveness on communication?
- (2)
How are these interventions provided (what elements are included, at what moment related to the consultation, how often and by whom)?
- (3)
Do coaching interventions significantly influence patient communication in specialist consultations?
Answers to these questions can be used to develop new or adapt existing patient coaching interventions.
Section snippets
Search strategy
We conducted a systematic literature search in PubMed, Cochrane, PsycInfo, Cinahl and Embase until November 2015. The search strategy was developed by the first author (IA), with librarian support, primarily for PubMed (Appendix A) and adjusted accordingly for the other databases.
The search was divided into three aspects to find relevant references on (1) patient coaching interventions (Intervention) to improve (2) patient-physician communication (Outcome) with medical specialists, in (3)
Included studies on patient coaching interventions.
Seventeen articles were included, describing thirteen unique interventions on a total of 3787 patients. Three interventions were investigated in multiple studies: Expanding Patient Involvement in Care (EPIC) [32], [33], [34], Tailored Education and Counselling (TEC) [35], [36] and Consultation Planning (CP) [37], [38].
Research quality in ten studies was high. Control conditions varied in the included studies. Most studies compared a single intervention to a control group [28], [29], [32], [33],
Discussion
This systematic review of studies on personal coaching interventions directed at improving patient-physician communication during specialist consultations showed that personal support is able to improve patient communication (1) immediately, i.e. during consultation, (2) intermediately, i.e. as perceived after consultation, and (3) at the long term follow-up, i.e. the effect was sustainable. Even though these outcomes are promising, it was not possible to be conclusive about the effectiveness
Conflict of interest
The authors declare no conflict of interest.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
We thank Harm-Wouter Snippe for the provision of a very useful digital tool to select references for inclusion based on title and abstract; Elmie Peters and Linda Schoonmade for their support in creating the proper search strategy; Fuusje de Graaff, Nicolien Kromme and Antoine Bakx for their advice on previous versions of this paper.
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