Patient Education

Chapter 13 Patient Education



Robert B. Kelly



Chapter contents


Rationale 160

Opportunities 161

Principles of Patient Education 161

A Model of Health Behavior Change 161
Stages of Change 161

When and How to Intervene 162

Planning for Patient Education in Your Practice 163
Who Will Be Involved 163

Using Verbal Instruction 163

Using Printed Materials 163

Writing Your Own 164

Health Literacy 164

Role of Computers 164

Other Materials and Modalities 165

Office Systems and Design 165


Key Points


• Encouragement of healthy lifestyles by family physicians and acceptance of responsibility for health behaviors by patients are part of a new paradigm of the physician-patient relationship.

• Enhanced patient satisfaction and realistic expectations as a result of education can reduce risk of malpractice actions.

• Use a SOAPE note to document adding education to your plan.

• Match your message to each patient’s stage of change.

• Use feedback, reinforcement, individualization, facilitation, and multiple channels when providing education.

• Learn brief techniques of motivational interviewing to be more successful in facilitating behavior change.

Family medicine has long embraced the concept of patient education as an integral part of patient care. It is an official policy of the American Academy of Family Physicians (AAFP) that “family physicians should take a leadership role in improving the health of the American public by providing accurate and meaningful patient education.” The AAFP produces guidelines for residency curriculum in patient education; includes patient education materials in its journal, American Family Physician; and sponsors an award-winning resource (FamilyDoctor.org). The Joint Principles of the Patient-Centered Medical Home (2007) include patients’ active participation in medical decision-making and the use of information technology to support patient education.


Patient education continues to evolve. Patients who are informed are more likely to be active participants in their care and adhere to treatment (Epstein et al., 2004). Although physicians have technical knowledge about medical conditions and treatments, patients have more knowledge about their own experience, values, and cultural considerations. Effective patient-centered education requires physicians to individualize information according to each specific patient’s needs, values, and culture, and consider these when working with patients to make treatment decisions (Falvo, 2004).



Rationale


Most people want to be better informed about every aspect of their health care. Apart from patients’ expectations and satisfaction, there are a number of compelling reasons for physicians and other health providers to educate patients. The most important of these is better adherence to therapies (Gray et al., 2004; Rogers et al., 2005). Although the results of typical patient education efforts are modest (Haynes et al., 2002; Schroeder et al., 2004; van Eijken et al., 2003), education has the potential to improve health outcomes and reduce morbidity. Additional benefits to the physician include practice marketing through enhanced patient satisfaction (Aragon, 2003; Ganz, 2002) and prevention of malpractice actions (Eastaugh, 2004; Wissow, 2004).11,12


Existing data suggest that the most effective interventions available to clinicians for reducing the incidence and severity of the leading causes of disease and disability in the United States are those that address the personal health practices of patients (USPSTF, 1996). This implies movement of health care providers and patients toward a nontraditional relationship, in which encouragement of healthy lifestyles by providers and acceptance of responsibility for health behaviors by patients become the cornerstones of a new preventive care paradigm. Education of patients is critical to the implementation of this paradigm.



Opportunities


Education of the patient or the family can make a contribution to every medical interaction. Every recent medical school graduate is familiar with the SOAP note format (i.e., subjective data, objective data, assessment, and plan) for documenting a medical encounter. Adding education (E) to the plan by using a SOAPE note serves as a reminder to educate patients and to document the education.


All excellent family physicians are also excellent teachers of patients. Such physicians typically incorporate education continuously during the interaction with the patient, not as a separate step. When taking a history, the physician can assess attitudes, knowledge, and skills. When performing an examination, the physician can instruct about the purpose of the examination and the meaning of findings. When discussing a diagnosis, the physician can share its meaning and the process of decision making in approachable terminology. When suggesting therapy, the physician can assess understanding, willingness, and barriers to implementation.


Although patient education may largely occur in the context of individual provider-patient interactions, there are many additional opportunities to become involved in health education. Health education is a regular part of curricula in schools, may be found in workplace programs in many communities, and is routinely featured in the mass media. Family physicians who have become involved in health education can have greater impact from the ripple effects of networking in their community. Involvement can begin with small, manageable actions. Physicians can offer to come for question-and-answer sessions during health classes, offer to be a consultant to the school board regarding health curricula, or become a team physician for junior high or high school teams. Media involvement can come from volunteering to comment on current issues in health for local radio and television stations or from writing a regular health column for the local newspaper.


Within their own practice, many family physicians struggle to include all the education they want to provide. There are a variety of creative solutions to this problem. The physician can expand services to include group classes for common topics such as smoking cessation, perinatal care, and healthy diet. Group visits can be done for patients with chronic problems that need regular monitoring, such as diabetes and hypertension (Loney-Hutchinson et al., 2009). Also, patient education can be made the responsibility of the entire practice, involving office nurses, medical assistants, and receptionists as a team. Larger practices may have access to dieticians or pharmacists.


It is important not to overlook existing resources in the community that can be used to expand what is offered in the physician’s office. These include national and local disease-specific support organizations such as the American Diabetes Association (ADA), American Heart Association (AHA), American Cancer Society (ACS), American Lung Association, Weight Watchers, and Alcoholics Anonymous (AA). Educational resources in the form of groups or short courses may also be sponsored by local libraries, YMCA chapters, churches, or other community organizations.



Principles of Patient Education


The system of patients accepting the advice of all-knowing physicians in an unquestioning and docile manner no longer applies. Instead, physicians should strive toward a doctor-patient partnership in which the patient sees the physician (and physicians see themselves) as a health consultant. In such a role, the question becomes how to educate most effectively. Research has consistently demonstrated that patient benefits are greatest when interventions follow sound educational principles, including the following (Simons-Morton et al., 1992):


Feedback means that the patient is informed about progress toward goals and objectives.

Reinforcement refers to encouragement or rewards for patient progress.

Individualization takes into account the needs, desires, and characteristics of the patient and demands that specific goals and objectives are negotiated for each patient.

Facilitation refers to materials, cues, and skill training that assist the patient in making changes.

Relevance to the learner means that the content is appropriate for an individual patient’s circumstances.

Multiple channels imply combined learning strategies and a team approach to education.

These principles have been incorporated into the U.S. Preventive Services Task Force (USPSTF) recommendations for patient education and counseling shown in Table 13-1.


Table 13-1 USPSTF Recommendations for Patient Education and Counseling



























Frame the teaching to match the patient’s perceptions.
Fully inform patients of the purposes and expected effects of interventions and when to expect these effects.
Suggest small changes rather than large ones.
Be specific in recommending new behaviors.
Emphasize that it is easier to add new behaviors than eliminate established ones.
When feasible, link new behaviors to established ones.
Use the “power of the profession.”
Obtain explicit commitments from the patient.
Use a combination of strategies.
Involve office staff.
Refer to community agencies, voluntary health organizations, reference material, and even other patients.
Monitor progress through follow-up contact.

From US Preventive Services Task Force: Guide to Clinical Preventive Services. Baltimore, Williams & Wilkins, 1996, p 953.



A Model of Health Behavior Change



Stages of Change


The purpose of patient education efforts often is to inform and to change behavior. Typically, the goal is to improve adherence to therapeutic regimens, encourage new lifestyles, or help the patient adopt other behaviors that prevent disease and disability. One of the most useful ways to understand the process of behavior change is the transtheoretical model, often called the “stages of change” model (Zimmerman et al., 2000). This model proposes stages called precontemplation, contemplation, preparation, action, and maintenance (Table 13-2). Precontemplation, contemplation, and preparation can be thought of as stages of motivation and readiness for change. In at-risk populations, typically 40% are precontemplators, 40% are contemplators, and 20% are in preparation (Prochaska and Velicer, 1997). Research has shown improvements in process and outcome measures when stage-matched interventions and recruitment methods are used (Prochaska et al., 2005). Although the model is described in a linear fashion, experience has demonstrated that patients naturally move back and forth among stages.


Table 13-2 Stages of Health Behavior Change













Precontemplation: Not intending to take action in the foreseeable future, usually measured as the next 6 months.
Contemplation: Intending to change in the next 6 months; aware of the pros and cons of changing, leading to procrastination.
Preparation: Intending to take action in the immediate future, usually measured as the next month; have a plan.
Action: Have made specific overt modifications to behavior within the last 6 months.
Maintenance: Working to prevent relapse, increasing confidence; typically lasts 6 months to 5 years.

From Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38-48.


This model emphasizes the critical importance of the stage of change. Fortunately, it can usually be assessed with simple questions. Given typical constraints of time and resources in a primary care practice, most patient education efforts should focus on patients in the stage of preparation. Giving such patients the proper cue or knowledge to make a beneficial change is generally easy to provide. For simple behaviors (e.g., stretching before exercise), simple recommendations or an instructional pamphlet may be sufficient to accompany the physician’s strong statement of support for the new behavior. For more complicated behaviors (e.g., dietary changes), one or more additional scheduled visits with the physician, a dietician, or other provider may be needed to set goals, convey knowledge or skills, and reinforce behavior change. A basic implementation of this thinking for health promotion has been called the “five As”: ask, advise, assess, assist, and arrange. This approach has been promoted primarily for tobacco cessation (Kenford and Fiore, 2004).19


An important implication of the stages-of-change model is that encouraging action for patients in the precontemplation or contemplation stage is wasted energy. Instead, if the behavior is an important one, the goal should be to increase the patient’s readiness for change. Research has shown that an increase in the “pros,” or perceived benefits of change, is the most common finding when patients move from precontemplation to contemplation. Contemplators are usually weighing the perceived pros and cons of change in a manner that leaves them ambivalent about this decisional balance. Research indicates that movement from contemplation to action is most strongly associated with a decrease in the perceived cons of change. To reduce the cons for contemplators, the physician needs to identify these through open-ended questioning.

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Oct 3, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Patient Education

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