The Establishing Focus Protocol: Training for Collaborative Agenda Setting and Time Management in the Medical Interview.



Families, Systems & Health; 6/22/2001; ROBINS, LYNNE

Time management concerns may inhibit primary care physicians from regularly eliciting a complete list of patient concerns. An educational intervention integrating time management skills with full elicitation of patient concerns to reach mutual agreement on the interview focus was piloted and evaluated. Ten family medicine residents and 7 faculty were randomly assigned to control and experimental (EF) groups. EF physicians read the protocol and watched an educational video. Data came from 162 patient encounters.

The results showed that EF physicians charted more problems and more follow-up requests but did not use more of their appointment times. EF providers rated their patients as more satisfied and were as satisfied as controls. Patients of EF providers were more satisfied, perceived more complete problem elicitation and collaborative prioritization.

These promising pilot data indicate a need to do an expanded study of the EF protocol. Ideas for research and training are discussed.

Fam Syst & Health 19:14 7-157, 2001

In their seminal study of 1000 audio-taped medical encounters, Byrne and Long (1976) determined the need for a critical phase of the medical interview that they called, "discovering the reason for the patient's attendance" (p.22). They learned that the patient's first spoken reason for the visit was not always the most important issue affecting their health and well being. In addition, patients possessed a variety of expectations for physician response and these expectations often went unstated. For their part, physicians approached patient encounters with their own collections of concerns, questions, and expectations. Because patient and physician concerns and expectations are frequently not aligned, dissatisfaction can result on both sides. For physicians, the prospect of negotiating a mutually agreed upon list of concerns is daunting mostly because it feels like there is not enough time. Despite 25 years of endorsements for Byrne and Long's recommendations, research suggests that most of the time collaborative establishment of focus does not occur between primary care physicians and patients. We describe the initiation of research to define a training process for establishing interview focus that addresses the time management concerns of providers and includes communication skills to improve patient care. We outline a training protocol named Establishing Focus (EF) adapted from earlier work of the first author (Mauksch, 1997), report the results of a pilot study, and discuss issues for future training and research.

There are several reasons to establish focus in clinical encounters. Achieving mutual agreement decreases the likelihood that patients will introduce new concerns at the close of their interviews (White, Levinson, & Roter, 1994), and increases patients' (Williams, Weinman, & Dale, 1998) and physicians' satisfaction (Roter et al., 1997). There are indications that when physicians base their diagnostic effort on a fuller understanding of the patient's illness experience, physicians are better able to involve patients in tailoring treatment to their individual needs (Glenn, 1984; Lazare & Eisenthal, 1977). Physicians who support patient autonomy and shared decision making enhance patient motivation to care for themselves, resulting in better adherence and health outcomes (Eisenthal, Emery, Lazare, & Udin, 1979; Kaplan, Greenfield, & Ware, 1989; Williams, Frankel, Campbell, & Deci, 2000). Also, contemporary medical ethics emphasizes an approach that fosters informed consent and mutuality in the physician--patient relationship (Braddock, Edwards, Hasenberg, Laidley, & Levinson, 1999). Further, for half a century, psychotherapists have posited that the patient's identification of a focus is a nuclear ingredient for change (Bennett, 1983; Budman, 1988; Gendlin, 1981; Mynors-Wallis, 1996; Rogers, 1951). In summary, patient involvement in decision-making, beginning with the determination of problem focus, is essential to quality healthcare (Henbest & Stewart, 1990; Kroenke, 1998; Quill, 1983; Simpson et al., 1991; Stewart et al., 1999).

Despite compelling reasons to work with patients to achieve consensus about visit focus, primary care physicians frequently do not exhibit this practice (Barry, Bradley, Britten, Stevenson, & Barber, 2000; Beckman & Frankel, 1984; Marvel, Epstein, Flowers, & Beckman, 1999). Physicians interrupt patients at an average of 18-23 seconds to redirect the interview, preventing 75% of patients from completing their list of concerns (Beckman & Frankel, 1984; Marvel et al., 1999). About 50% of interruptions occur after patients voice one concern, and 25% of patients are cut off before expressing any concerns. Patients are explicitly invited into the decision making process less than 10% of the time (Braddock et al., 1999). Between 30% and 80% of patients' expectations are not identified or addressed (Kravitz et al., 1996; Marple, Kroenke, Lucey, Wilder, & Lucas, 1997; Schor, Lerner, & Malspeis, 1995). Even in 30-60 minute general medical exams mutual agreement is more the exception than the rule (Boland, Scheitel, Wollan, & Silverstein, 1998; Scheitel, Boland, Wollan, & Silverstein, 1996).

Why do primary care physicians use collaborative agenda setting so infrequently? Fear is a primary factor. Physicians fear the loss of control of time (Dugdale, Epstein, & Pantilat, 1999). Communications experts rightly extol the value of "listening to the patient's story" but rarely address physicians' time management anxiety. Physicians who thoroughly explore patients' needs often feel compelled to address all of the patient's problems on the same day (Bergh, 1996; Hornberger, Thom, & MaCurdy, 1997). This means lengthening the visit. Thus, there is fear associated with eliciting a full list of patient concerns. Further, in the uncertain world of primary care, where many presentations are medically unexplained (Kroenke, Jackson, & Chamberlin, 1997; Kroenke & Mangelsdorff, 1989), physicians may be drawn to address problems that are diagnosable or curable, offering themselves a sense of control and comfort (Byrne & Long, 1976). Health maintenance check lists and poorly controlled chronic illnesses (Miller, 1997) may preoccupy physicians who may impose agendas on theft patients (Bass et al., 1986; Stewart, McWhinney, & Buck, 1979).

Establishing Focus Protocol Design

The language used for decades, "agenda setting," may be problematic because the term "agenda" may be interpreted by clinicians as a mandate to create a list of problems, all of which must be addressed in one visit. The name of our protocol intentionally emphasizes the establishment of "focus" (rather than "agenda") to stress the importance of collaboratively defining reasonable goals for the available time. Goal setting should take into account problem complexities and the variable capacities of patients to negotiate multiple changes at the same time.

The goals of Establishing Focus are to ensure that:

1. Patients feel that the physician has heard all of their concerns.

2. Physicians are able to maintain a non-anxious, relationship-centered presence in the face of complex or lengthy problem lists.

3. Problem list lengths do not determine appointment lengths.

4. Physicians and patients have the opportunity to mutually determine which goals are most important.

5. Patients and physicians agree on a priority listing of problems needing attention.

The EF protocol combines microskills and cognitive cues. A microskill is one interview behavior or stance that is part of a series of skills comprising the process of establishing focus. A cognitive cue is a phrase for physicians to say to themselves to re-structure their thinking where we believe common, pre-existing ideas counteract establishing focus. Following are the eight microskills and cognitive cues comprising the Establishing Focus protocol. These skills and cognitive cues occur in the order in which they are listed but after rapport is established.

1. Microskill: Make a list. Never accept the first answer; ask "anything else" until the patient indicates completion.

2. Cognitive cue: Remind yourself that you need not address all problems in one visit.

3. Microskill: Place the relationship above the need to establish focus. A small subset of patients in crisis may need to tell their story before attempting to organize their health concerns into manageable bites. Listen to these patients and track their concerns.

4. Microskill: Avoid premature diving.(1) Postpone diagnostic interview sequences, and similarly redirect patients from telling in-depth stories until the patient indicates that all problems and concerns are listed.

5. Microskill: Ask the patient to prioritize the list.

6. Cognitive cue: Ask yourself if you can address all the problems; if not, suggest follow-up.

7. Microskill: Express concerns about particular issues when your rank order is different from the patient's. Negotiate in a way that does not undermine patient autonomy.

8. Microskill: Seek confirmation and commitment.

This pilot study tested two hypotheses looking at 1) physician variables and 2) patient variables:

Hypothesis 1: We predicted that EF trained physicians would be more satisfied, rate their patients as more satisfied, chart more problems, and chart more requests for follow-up visits without using more of their scheduled appointment time compared to control physicians.

Hypothesis 2: We predicted that patients who saw EF trained physicians would be more satisfied and report that their providers were better at eliciting problems, collaboratively prioritizing problems, but not addressing more problems compared to patients seeing control group physicians. Some evidence suggests that when patients and providers agree on the reasons for follow-up, outcomes are better (Starfield et al., 1979; Starfield et al., 1981). Therefore, as part of the patient hypothesis, we predicted that even though EF physicians would request follow-up more frequently, the percent of EF patients returning to clinic by one month would be no greater than the percent of patients who saw control group physicians.

METHODS

Setting

The pilot study was conducted at a family medicine residency clinic located at a large, urban academic medical center. The institutional Human Subjects Review Committee and the clinic Research Oversight Committee approved the study. Physician Participants

All twelve second- and third-year residents and all seventeen clinically active faculty were invited to participate in the study. Two residents were unavailable. Ten faculty were not enrolled because of membership on the clinic Research Oversight Committee (4), unpredictable schedules or on leave (4), refusal (2). Seven faculty, five second-year residents and five third-year residents consented to participate. Consent forms explained that our study would examine communication skills, visit length, and patient satisfaction. Physicians were monitored in half-day blocks until 10 consented patient encounters had occurred. Physicians knew when their visits were being monitored. Random assignment to control and experimental groups was done separately for faculty and residents and for males and females within the faculty and resident groups to balance experience levels and physician gender. Nine physicians were assigned to the control group, three males and six females, five residents and four faculty. Eight physicians were assigned to the experimental group, four males and four females, five residents and three faculty.

Experimental Group Training

Physician training included viewing a 13-minute videotape. First the viewer observed a role-played interview without the EF process in which the physician set the agenda, and the patient brought up other concerns at the end of the interview. Next, the step-by-step EF process was explained followed by a role-played interview demonstrating the EF protocol. Finally, the video oriented physicians how to complete research surveys. Participants were given an 1165 word description of the protocol. EF physicians were given one page written prompts every three to four months until monitoring of their patient encounters was completed. Experimental group physicians were free to consult with investigators but rarely did.

After completing their training and prior to being monitored, experimental group physicians were asked to complete and return a six-item questionnaire assessing their understanding of the protocol and compliance with training (watching the video and reading the description). The six-item experimental group questionnaire was examined using a thematic analysis. All EF physicians returned their questionnaires. They believed the number of new concerns surfacing at the end of the visit would decrease, more concerns would be expressed, and the doctor-patient relationship would be improved. Some respondents expressed concern that patients might be frustrated if addressing some problems was postponed to future visits. All physicians believed that time use would be more effective and efficient if they remembered to use the protocol. One provider stated, "the hardest part will be learning/remembering to use the protocol and feeling relaxed about eliciting more problems. This is when my anxiety titer goes up! I feel the need to do it all!!!"

Patient Participants

After timing the prior visit the second author or a research assistant approached the next available patient of study physicians in the waiting room before seeing their physician. Patients were told this was a study of physician-patient communication and its impact on visit length and patient satisfaction. Patients consenting to participate had to be English speaking, at least 18 years of age, and have seen the physician at least once before. No information was collected about patients who refused participation in the study.

Sources of Data

Immediately after the visit physicians and patients filled out surveys with 10 point Likert-type questions and yes/no questions. Physicians and patients were asked about overall satisfaction ranging from "not satisfied at all" (1) to "very satisfied" (10). Physicians were asked to estimate patient satisfaction using the same satisfaction scale. Patients were asked if the physician made "an adequate effort to elicit all the issues you want to address." The scale ranged from "not at all" (1) to "very thorough" (10). Patients were asked two "yes" or "no" questions. "Did you and your physician discuss which problems to address first?" "Did the physician address all of your concerns today?" All visits were timed and divided by scheduled appointment length to control for an uneven distribution of appointment lengths between providers. The clock was stopped while residents discussed patients with faculty preceptors. Patient charts were reviewed one month after the visit to collect data on age, gender, number of problems charted, whether a follow-up request was charted for problems elicited but not addressed, and whether the patient returned. Data were collected between July 1996 and July 1997.

Analysis

The unit of analysis was the physician using the mean of means of each physician's group of encounters. In keeping with recommendations in the 1994 Edition of the Publication Manual of the American Psychological Association (American Psychological Association, 1994), effect sizes are reported to examine evidence of meaningful educational effect as originally suggested by Cohen (1988) and more recently by others (Hevey & McGee, 1998; Thompson, 1999). Unlike traditional "p" values, effect sizes are not as influenced by sample size. Standard deviations are pooled (Rosenthal, 1994). Conventional interpretation of effect sizes uses the following framework: small [is greater than] .2; medium [is greater than] .5; large [is greater than] .8. A t-test was used to analyze differences between male and female physician survey responses and patient demographic variables between controls and cases. Subgroup analysis between gender groups or between residents and faculty is limited because the sample sizes were too small.

RESULTS

Physicians in the control group were monitored across 80 patients, and physicians in the experimental group were monitored across 82 patients. One male faculty physician left the practice after seeing 4 patients. The range of visit numbers for the remaining 16 physicians was between 8 and 12 with a mean of 9.5 for all 17 physicians. The average age of patients was 42.2 years and 66.9% were female. There were no significant differences in mean age or gender percentages between control and experimental group patients.

Physician variables (Hypothesis 1). There was a large positive effect size difference showing EF physicians to chart more requests for follow-up visits and a medium effect size difference showing EF physicians to chart more problems. A small positive effect size difference shows EF physicians to perceive higher patient satisfaction. There was no effect size difference between EF physicians and controls in the proportion of scheduled time used. EF physicians were as satisfied as control physicians.

Patient Variables (Hypothesis 2). Large positive effect size differences show experimental group (EF) patients to report higher satisfaction and a higher degree of collaborative prioritization of concerns. There was a medium positive effect size difference showing EF patients to rate their providers higher at completely eliciting all concerns. A small effect size difference shows EF patients to perceive their physicians as addressing all concerns. No effect is evident on patient return at one month.

A secondary analysis found that male physicians (3 controls and 4 cases combined) reported lower satisfaction than female physicians (6 controls and 4 cases combined), 7.1 vs. 8.4; t = 3.19, p [is less than] .006. Male physicians also perceived their patients to be less satisfied than female physicians, 7.3 vs. 8.3; t = 2.98, p [is less than] .009. This suggested that some training effects may have been masked by differences in how men and women evaluate their experiences. When examining differences in means (SD) between controls and EF physicians within gender groups, we found female EF physicians to be more satisfied 8.7(.36) than female controls 8.2(1.1), with an effect size difference of .47. Male EF physicians 7.15(.8) did not differ in satisfaction from controls 7.12(.71). Female EF physicians rated their patient satisfaction higher at 8.5(.46) compared to 8.1(.8) for female controls, with an effect size difference of .55. Male EF physicians rated patient satisfaction higher 7.43(.67) than male controls 7.17(.47), with an effect size difference of .43. Two other differences within gender groups are masked by results for the entire sample. Female EF physicians took slightly more of their scheduled appointment times .93(.24) compared to controls .86(.19), with an effect size difference of .36. Conversely, male EF physicians took much less of the scheduled appointment time .88(.15) than controls 1.08(.24), with an effect size difference of -1.04. A larger percentage of patients seeing female control physicians returned by one month 61.7% (20.5) than patients seeing EF female physicians 45.2% (10.98), effect size difference -.94. Conversely, patients of EF male physicians were more likely to return 51.9% (21.63) compared to patients seeing male controls 34.9% (30.27), effect size difference .67.

DISCUSSION

These results suggest that the EF training produced desired and predicted effects on physician behaviors and that these behavioral changes were viewed positively by patients. Hypothesis 1: Compared to controls, EF physicians charted more problems, charted more requests for follow-up, and perceived their patients to be more satisfied. Despite eliciting more problems, EF physicians did not use more of their scheduled time than controls, and they were as satisfied with their encounters as controls. Hypothesis 2: Patients seen by EF physicians were more satisfied with their physicians and they indicated that their physicians were better at eliciting and collaboratively prioritizing their concerns than patients seen by control group physicians. There was no difference in patient return rates between controls and cases. Secondary analysis within gender groups suggests that male and female physicians may evaluate training and respond to training differently.

Limitations

Our sample size was small and consisted of physicians practicing in an academic environment. Results may be different in a community practice. Physicians in this study knew when they were being observed, so we can not estimate the durability of the training. No pre-test measures were collected so we cannot rule out that differences between groups existed prior to the study. As with many medical communication studies, this study does not measure patient outcomes (Hulsman, Ros, Winnubst, & Bensing, 1999). The patients who consented to participate in this study may be different from those who refused, the latter group possibly reporting different experiences. Monitoring patient return rates for periods longer than one month may have yielded different results. The study did not include the essential training component of repeated direct observations with feedback. As such, while the training effect in this pilot study is promising, it should not be taken to represent behavioral change produced from a more comprehensive training design (Kurtz, 1998).

Future Research

The results of this pilot study generate more questions than answers about how physicians learn and practice establishing focus. Collectively, our findings suggest that males and females with EF training may handle multiple problem encounters and time management in different ways. Our findings are consistent with another study showing female physicians to take more time, mostly in the initial phase of the interview (Roter, Lipkin, & Korsgaard, 1991). Other studies support our impressions that female physicians may respond to training differently from male physicians (Bertakis, Helms, Callahan, Azari, & Robbins, 1995; Ockene, Wheeler, Adams, Hurley, & Hebert, 1997). The actual communicative behaviors leading to these gender differences need to be elucidated.

Our data do not tell us how often physicians completed the elicitation of patient concerns or how many of the problems elicited are actually charted. Does training in establishing focus influence physician behaviors in subsequent phases of the interview such as eliciting the patient's perspective on the illness and arriving at a mutually agreeable plan? Does the length of the physician-patient relationship affect the use of EF skills? Are there differences in the way students, residents, and physicians with several years experience respond to training? When suggesting follow-up visits to patients for problems not addressed, should physicians adjust the next appointment length to match the complexity of the patient's problem list? These and other differences between physicians with and without EF training will only be understood through directly listening to or observing physician-patient encounters and following the health status of patients over time.

Training Observations

The first author has been teaching the EF process over the last 6 six years to medical students, residents, and Community practice physicians. Through direct observation and videotape review of over a hundred trainees several themes have emerged about the value and challenges of learning these skills. These themes are shared below to assist others who wish to teach Establishing Focus skills or conduct further research.

Physicians, particularly those in training, highly value the organizational and time management strategies built into this protocol. When physicians hear patients rank a poorly controlled chronic illness at a low priority, the physician gains a new perspective on the patient's readiness to change and the relative importance of other issues in the patient's life (Rollnick, Mason, & Butler, 1999). After mastering these skills many physicians report that their patients returned with lists prioritized, often with enhanced motivation to address complex or chronic problems for which they were initially labeled "non-compliant."

There are some predictable struggles in learning to reach mutual agreement on problem focus. Physicians often forget to orient the patient to the purpose of creating a prioritized list of concerns. When patients prematurely dive into extended descriptions of problems, some physicians are hesitant to interrupt the patients and return them to the process of listing all their concerns. Many physicians also feel obliged to address all problems and need to be reminded that doing a good job often means being more thorough with fewer problems.

To help trainees overcome some of these challenges it is helpful to suggest phrases to communicate key points. For example, "Before we address any of your problems today I would like to hear a list of all your concerns" (first time EF orientation). Or, "What is on your list today?" (orientation for patients familiar with establishing focus). "Excuse me, before we talk further about your headache I'd like to know if you have any other concerns so we can make sure to use our time in the best possible way" (interruption to prevent the patient from prematurely diving and return to complete the problem listing). Or, "The first problem on your list is complex, and to do a good job with it may mean not giving the same attention to other issues today" (phrase to orient the patient to time management and quality concerns in decision making).

CONCLUSION

The Establishing Focus intervention enables patients to participate in healthcare decision-making at the same time that it enables physicians to achieve professional autonomy in relation to time use and other aspects of the medical encounter. Because the protocol addresses the concerns of both partners in the patient-physician relationship, both are likely to exhibit more participatory styles (Kaplan, Greenfield, Gandek, Rogers, & Ware, 1996; Ryan & Deci, 2000). To our knowledge this pilot study is the first prospective randomized trial testing a training protocol that combines time management strategies with skills to reach mutual agreement on visit goals. These initial results are promising and call for further studies to help us learn more about how to train physicians to help their patients help themselves.

TABLE 1 
 
                                                               Effect 
                               Control (SD)      EF (SD)       Size(#) 
 
Physician Variables 
  Visit length/Appt. length 
    ratio                        .93 (.23)       .91 (.19)       -.12 
  Number of problems charted    1.63 (.33)      2.0 (.73)         .68 
  Physician satisfaction        7.87 (1.11)     7.91 (.96)        .00 
  MD rating of patient 
    satisfaction                7.79 (.82)      7.95 (.78)        .20 
  Charted F/U request(*)        8.9 (16.2)     25.9 (9.62)       1.04 
 
Patient Variables 
  Overall patient 
    satisfaction                9.0 (.64)       9.5 (.43)         .85 
  MD effort to elicit your 
    issues                      9.23 (.43)      9.45 (.48)        .49 
  Did MD address all your 
    concerns?(*)               89.57 (10.39)   92.47 (10.37)      .28 
  Did you and MD prioritize 
    concerns?(*)               84.92 (11.22)   93.75 (7.44)       .92 
  Did the patient return in 
    one month?(*)              52.76 (25.93)   48.53 (16.26)     -.19 
 
n: 9 controls and 8 cases 
 
(#) effect size .2=small effect, .5=medium effect and .8=large effect 
 
(*) mean percent yes 

(1) In the original protocol, step 4 used the title phrase, `Interrupt with caution.' The term `avoid premature diving' emerged during the year of study.

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Financial support: The second author (LH) received a $2000 stipend for medical student summer research support from the University of Washington School of Medicine for work done between July, 1996 and August, 1996.

Larry B. Mauksch, M.Ed., Department of Family Medicine, University of Washington, Box 354775, 4245 Roosevelt Way NE, Seattle, WA 98105; (206) 598-6577; mauksch@u.washington.edu.

Lena Hillenburg, M.D., Departments of Internal Medicine and Pediatrics, Loma Linda University, 1111 Cornell Avenue #C, Redlands, CA 92374.

Lynne Robins, Ph.D., Departments of Medical Education and Family Medicine, University of Washington School of Medicine, H-205 HSB, Box 357240, Seattle, WA 98195.

The authors thank Lucas Dreamer for his assistance in data collection and Eric Larson, Ph.D. for assistance in data analysis.

The authors wish to thank the following people for their comments on earlier drafts of this manuscript: Laura Mae Baldwin, M.D., M.P.H., Ronald Epstein, M.D., Kim Marvel, Ph.D., Ken Schellhase, M.D.M.P.H., and four anonymous reviewers.

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