Cross-talk about the menopause: enhancing provider-patient interactions about the menopause and hormone therapy

PTiENT EdUCATiON aNd COUNSEhNq ELSEVIER

Patient Education and Counseling 27 (1996) 177-184

Cross-talk about the menopause: enhancing provider-patient interactions about the menopause and hormone therapy’ Sarah E. Hampsona’*, “Department

of Psychology, hUniversity

University of Oregon,

Judith H. Hibbardb of Surrey, Guildford, GU2 Eugene, Oregon, USA

5XH.

UK

Received 31 January 1995; revision received 4 April 1995; accepted 23 May 1995

Abstract Although many women make the menopausetransition without problematic symptoms,the current tendency to prescribe hormone replacement therapy (HRT)’ as a preventive measure against potential life-threatening conditions for postmenopausalwomen has mademenopausea medical issuefor all women. Informing the millions of womendue to experiencemenopauseover the next decadesof the possiblelong-term risks and benefitsof HRT presents a major challenge to primary care. Recent research suggeststhat women are dissatisfiedwith their interactions with their health-careproviders regardingmenopauseand the options for menopausemanagement.We identify barriers to effective communication between providers and patients about these issues,and make recommendationsfor both research and practice to facilitate more effective provider-patient interactions concerning menopauseand its management. Keywords:

Menopause; Provider-patient interactions; Menopausal hormone therapy

1. Introduction * Corresponding author, Department of Psychology, University of Surrey, Guildford GU2 SXH, UK. Tel.: (+44-1483) 259 175; Fax: (+44-148.3) 32 813. 1This paper is based, in part, on a presentation given at the symposium on doctor-patient communication at the 46th Annual Scientific Meeting of the Gerontological Society of America, New Orleans, November 1993. *We have chosen to use the term ‘hormone replacement therapy’ because it is widely used as an inclusive short-hand for the various regimens of estrogen and combinations of estrogen and progesterone. It should not be inferred from our use of the term ‘replacement’ that we view menopause as defficiency disease.

In the next two decades, nearly 40 million American women will pass through menopause. This universal transition for women is a significant milestone in the aging process. For the most part, the medical community views menopause as signalling changes that may have significant consequences for a woman’s health. As ovarian hormone levels decline, it is believed by some that women’s risks for serious morbidity rises. Increasingly, the implications of this life transi-

0738-3991/96/$15.00 @) 1996 Elsevier Science Ireland Ltd. All rights reserved SSDI 073%3991(95)00817-J

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tion for health care in general, and providerpatient interactions in particular, are being recognized. The women now reaching menopause are different from previous cohorts in several ways. They are better educated, they have had more experience of employment outside the home, and they have developed a more consumer-oriented approach to health care. They want more information, involvement, control, and choice regarding their care [l]. Hormone replacement therapy (HRT)2 is becoming increasingly popular among providers as the recommended treatment both for the short-term symptoms of menopause and for the prevention of cardiovascular disease and osteoporosis that may be associated in the long term with decreased levels of ovarian hormones [2-51. Nevertheless, there is controversy about the role of reduced ovarian hormones in the onset, and the value of HRT in prevention, of these diseases [6,7]. There are alternative approaches to the management of menopause that do not involve taking hormones, such as changes in nutrition and physical activity, which some women prefer and which may be more appropriate for women for whom estrogen is contraindicated [8,9]. Consequently, for each individual patient, decision-making regarding menopause management is complex requiring consideration of numerous potential risks and benefits, and the woman’s personal values, preferences and lifestyle. These decisions are further complicated by the fact that there are still no definitive answers about the long-term safety and efficacy of HRT, particularly for the combined estrogen and progestin therapy that is commonly prescribed [lo]. The menopause transition remains a topic shrouded in myth and social stigma [ll]. Thanks to the ‘baby boomers’ it is being talked about more than ever before but, for many women, communication with their health-care providers around this topic remains at best difficult, and for some impossible. Contrary to the general tendency for patients to report relatively high levels of satisfaction with their medical care [12,13], there is evidence that women are dissatisfied with

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the care they receive for menopause and its consequences. They report receiving inadequate information and that their providers do not listen to them [14,15]. One consequence of these unsatisfactory aspects of the provider-patient relationship is that women are not in a position to be informed participants in decision-making concerning the use of HRT, or in the management of their menopause transition. Given the uncertainty regarding the medical benefits and risks of HRT, this lack of informed involvement on the part of the patient is a particular cause for concern. Although randomized clinical trials are now underway that should resolve many of the uncertainties about HRT [lo], it will be at least ten years before the results of these trials will be known. Therefore, over the next decade, a massive educational effort will be required that will enable the millions of menopausal and postmenopausal women to be informed participants in decision-making concerning HRT and its alternatives [16]. In this paper, we explore what is known about provider-patient interactions concerning menopause and HRT, and make recommendations for increasing the efficacy of communications on these topics.

2. Barriers to provider-patient

interaction

From previous studies, we know that, although women desire information about menopause and HRT [15], they are reluctant to discuss these issues with their physicians [14]. Moreover, in Schnebly et al.% [17] study of women’s experiences and attitudes concerning menopause, only two-thirds of those participants who were experiencing symptoms that they identified as menopause-related actually discussed them with their physician. When these women did discuss menopause and its management with their physicians, these encounters did not appear to be viewed with the same degree of satisfaction as other types of medical encounters. Below, we identify barriers to provider-patient communication on menopause and its management.

S E. Hampson,

2.1. Incongruent

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agendas

Patients are primarily concerned with shortterm symptoms, whereas providers are primarily concerned with long-term health risks [15]. Thus women and their providers may have only partially overlapping agendas when discussing menopause management. The patient wants a solution to short-term symptoms, whereas the physician is also concerned about mitigating the risks of life-threatening diseases such as osteoporosis and cardiovascular disease. The patient’s concerns focus on an immediate solution to short-term problems, not a long-term commitment to ward off diseases of old age. Given these beliefs and differences in perspective, the low rate of long-term adherence to HRT is not surprising. The average length of time that women take HRT has been estimated to be 9 months [US]. Another incongruence between providers and patients is the tendency for providers to view menopause as a hormone deficiency disease requiring treatment by hormone ‘replacement’ therapy. Their patients, on the other hand, may view menopause as a natural part of aging [19]. Whereas patients may wish to discuss emotions of grief and loss associated with this normal transition, providers are concerned about the potential health risks associated with declining hormone levels [ll]. Where such fundamentally differing perspectives exist, effective communication will be difficult. 2.2. The ‘squeaky

womb ’

Women who are experiencing menopausal symptoms (e.g., prolonged sleep deprivation due to hot flashes) may attempt to discuss their problems with their health care provider, however difficult they may find such encounters. However, women with severe menopausal symptoms appear to be in the minority. As few as lo-15% of women are estimated to be seriously affected by the menopause transition. The remainder have moderate difficulties that come and go over a period of years, and a few have no

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symptoms at all [20]. Therefore, the majority of women may never seek medical care for menopausal management, and many may avoid discussing menopause management and possible HRT use with their providers. As a consequence, these women are less likely to use HRT or alternative menopause management strategies than those who seek out medical help for menopausal symptoms, and hence are less likely to have the opportunity to obtain the possible long-term health benefits that may be associated with HRT use or other preventive approaches.

2.3. Patients ’ lack of information

Women are hungry for information about menopause and its management. The recent spate of popular books, magazine articles, television shows, and videos on the topic attests to this need. Presumably, they want this information in order to better understand what is happening to them and the ways of managing these changes. Moreover, being in possession of such knowledge would allow them to make better quality decisions [16]. Without adequate information about menopause and its management, women patients are at a disadvantage in their encounters with their providers. Lack of knowledge may result in the patient not realizing that her symptoms could be menopause related. Consequently, she may not make the connection when describing them to her doctor or nurse who, in turn, may fail to attribute them to menopause. For example, headaches and muscle pain are highly non-specific symptoms that point to numerous possible causes including menopause, and the physician may explore a number of other possible explanations, perhaps with the aid of costly tests, before considering the menopause. Alternatively, lack of knowledge may result in the over-attribution of symptoms to menopause when in fact they reflect some other underlying cause, which could be ignored and left untreated as a result [ll]. In the absence of knowledge, women cannot participate as equal partners in deciding about menopause management. They do not know

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what questions to ask about risks and benefits or alternatives to HRT. As a result, they may not question the prescription of HRT during the medical interview, but when it comes to filling the prescription and then taking the medication over a period of years, they may feel unconvinced and unclear as to the value of HRT and hence fail to adhere [18]. Indeed, many women receive prescriptions for HRT that remain unfilled [21]. 2.4. The stigma of menopause

With the aging of the baby boomers, menopause has come out of the closet, but it is still not quite appropriate for dinner-time conversation. Recent findings by Schnebly et al. [17] indicate that women perceived other women to view menopause more negatively than they did themselves, and that women believed that other men viewed menopause even more negatively than other women. Thus menopause fits the definition of stigma [22]. The target of stigma is aware that he or she is viewed negatively by others, although he or she may not agree with these negative attributions. Given that most physicians are men, women’s belief that men view menopause negatively is not conducive to good communication. 2.5. Gender

The majority of physicians are men, so women are more likely to consult a physician who is a man about their menopausal concerns. Research on gender and physician interaction styles provides some insight into possible barriers to good communication [23]. Analyses of audiotaped medical encounters between physicians and their adult patients with chronic illnesses indicate that physicians who are men are more imposing and presumptuous than physicians who are women, engaging in less partnership-building, positive talk, and question asking. Men physicians also provide their patients with less information [24]. Although these encounters were not menopause related, these findings reflect women’s complaints about medical encounters regarding

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menopause management: they are not listened to, and they are not given adequate information. Women physicians are more attentive and nondirective, giving more subjective and objective information to patients [25], and patients have been shown to have a positive affective response to gynaecological exams by women practitioners [26]. Thus it appears that the typical interaction style of men providing medical care may be counter-productive for women who wish to discuss their menopausal concerns. This style of interaction, combined with women’s beliefs that men view menopause as a stigmatized event may pose a significant barrier to effective communication about menopause management between women and their physicians who are men. 2.6. Older patients’

communication

styles

The mean age of menopause in the United States is 51 years. Although discussions about estrogen replacement may take place with younger women who undergo surgical menopause, or who develop menopausal symptoms early, such discussions also occur for older postmenopausal women at risk for osteoporosis and cardiovascular disease. Studies of older patients’ communication styles suggest that older women may be particularly vulnerable to being left out of the decision-making process when hormone therapy is advocated. Older patients typically are less skillful at successfully negotiating the medical encounter than are younger patients [27]. In work focussing on older patients in a general clinic population, Rost and Frankel [28] found that 27% of patients’ problems were never discussed during their medical visits, and over half of all patients had a least one important medical problem that was never raised. Furthermore, the problem identified by the patient as most important was not the problem 70% of patients mentioned initially to the physician. Research by Adelman, Greene, Charon, & Friedmann [29] suggests that even if an older woman were to be assertive and raise the topic of HRT, the physician would be less responsive than if the physician had initiated the discussion. Finally, although the older woman patient may

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not experience the specific stigma of menopause, she does experience the more general stigma of aging (and its association with ill health) that prevails in our society [30].

3. Research and practice directions Many of the current upheavals in the United States health-care industry are the result of a greater appreciation of the role of the consumer of health care, and trends indicate that the consumers’ role will assume even greater importance in the future [1,31,32]. In light of these changes, it would be unwise to ignore the concerns of the 40 million women passing through menopause over the next two decades. Accordingly, we propose some directions for both research and practice to address women’s concerns about menopause and its management. 3.1. Research

Given that the existing evidence suggests that perimenopausal women and their physicians are not communicating adequately, resulting in women’s dissatisfaction with those interactions, research that illuminates these deficiencies and their potential consequences for women’s health and utilization of medical care is needed. First, it would be useful to determine the extent to which women are currently discussing menopause with their physician. One of the goals of Healthy People 2000 is to increase to 90% the proportion of perimenopausal women who have been counseled about the benefits and risks of estrogen [33]. We do not know what percent of women are currently counseled, but the barriers identified above suggest that only a minority of women discuss menopause and its management with their health-care providers. Schnebly et al.‘s [17] study indicated that even in a sample of motivated, well-educated white women, a third of those experiencing significant discomfort from menopausal symptoms did not discuss them with their doctors. Surveys of providers and patients would provide one measure of the proportion of

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perimenopausal women receiving health care with whom menopause issues are discussed. However, these self-report data should be adjusted on the basis of objective estimates obtained from audio or video recordings of provider-patient encounters. In collecting such data it will be important to include both physicians and nurses as health-care providers, given that some women prefer to receive their annual pelvic exams and gynaecological care from the latter. Likewise, family practitioners and internists prescribe HRT as well as obstetricians and gynaecologists, and so should be included in estimating counselling rates [5]. Once more is known about the base rates of menopause discussions for women with various kinds of providers, it will then be appropriate to begin to study provider and patient factors that facilitate or inhibit such discussions (e.g., provider specialty, patient age, class, race, perceptions of stigma). In addition to these broader contextual factors, it will also be valuable to study quantitative and qualitative aspects of provide-patient interactions concerning menopause and its management. For example, who initiates them and what are the characteristics of initiating physicians and initiating patients? Further, what determines the degree to which information is given and received in these interactions? And, what are the factors that are related to patient and provider satisfaction with the interaction? In order to answer these and related questions, it will be necessary to go beyond self-report in order to examine the interaction between providers and patients. An important research strategy should be the coding of provider-patient interactions concerning menopause either from video or audio tape. A number of coding systems already exist that could be adapted for this purpose and could combine both qualitative and quantitative elements [34]. The findings would be helpful for interventions to improve both providers’ and patients’ communication behaviors. Little is known about utilization associated with menopause and HRT, although one study indicated that utilization does not increase with menopause [35]. For those women who choose to

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use HRT, utilization rates may increase in the short run while fine-tuning of the regimen is taking place. However, a knowledgeable patient who is able to recognize side-effects and to negotiate regimen changes with her physician is more likely to make effective use of these visits. One consequence of better provider-patient communication about menopause management may be that patients who choose HRT will stay longer with the regimen [36]. Thus, assessing the degree to which providers and patients discuss the menopause and the quality of those interactions is an important priority for improving menopause-related care. Further, it will be important to assess the impact of educational interventions on provider-patient interactions, including the effect of interventions on satisfaction with care, adherence to the chosen menopause management strategy, and the type and amount of services used. For all these suggested research directions, we advocate studying women from minority populations and women of low socioeconomic status. The majority of research on menopause and its management has been conducted on nonrepresentative samples of predominantly white, middle-class women [35], and little is known about the subcultural differences among populations within the United States. However, socio-cultural factors affect the perceptions and experience of menopause [37]. Therefore, there is good reason to believe that important differences in beliefs and attitudes towards menopause and its management will be found among the various subcultures of the United States.

3.2. Practice

The goal to counsel 90% of perimenopausal women about the risks and benefits of estrogen therapy poses two kinds of challenge to the health-care system. One is the enormous task of informing such large numbers of patients about a complex issue for which there are no definitive answers. Another is ensuring that those women who should be so informed are identified and counseled. Given the numbers of patients involved, every advantage of modern technology

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will need to be taken in an effort to keep costs down. Nurses, nurse practitioners, and health educators can provide both individual and group educational programs in the primary care setting aimed at increasing women’s knowledge, efficacy in provider-patient partnership, and decisionmaking skills. However, it may be more practical to supplement such sessions, or even to replace them, with new technologies such as interactive videodisc and tailored newsletters, both of which are effective ways of providing personalized information for individual patients at relatively low cost [38]. The trend towards managed care will result in more women entering organized systems of health care such as HMOs, which will facilitate mechanisms for cuing physicians and patients to initiate discussions about menopausal management among perimenopausal women. Such mechanisms (e.g., automatic prompts to the provider in the computer records of women patients who reach a certain age) will increase the likelihood that providers will initiate discussions of menopause. Computer reminders and feedback consistently improve the frequency of such provider behaviors [39]. To be effective and wise consumers of health care, patients need to be knowledgeable and assertive. Brief interventions can be effective at increasing patient question-asking during the medical encounter, and have been associated with subsequent improvements on outcomes such as appointment keeping [40], health status [36] and, in some studies, increased satisfaction [41]. More generally, the movement towards empowerment in patient education should have much to offer women wishing to work as partners with their providers in the management of menopause [42]. If these counseling and education efforts result in a greater percentage of women who actively make a choice to use HRT, there may be an increase in these women’s medical utilization, particularly initially when they are fine-tuning their regimen. Many of their questions and problems will be appropriate for the nurse or nurse practitioner to handle because they provide less expensive care, are more likely to be

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women, and may well be more empathic. In addition, some of the issues may be able to be resolved by telephone discussion and support, which is a less costly and more convenient means of administering this type of care (for both the provider and the patient). Telephone support has been found to be effective in promoting self care [43], and in reducing the number of clinic visits while improving physical functioning [44]. Such an approach is consistent with the cost-effective strategies being adopted by managed care organizations and integrated systems of care. The above practice recommendations are designed to increase the quality of care provided to perimenopausal women. Despite the use of technologies, there may still be some cost increases in the short term. These short-term costs may, however, be offset by reductions in costs in the long term as a result of better care and improved outcomes.

4. conclusions In the changing climate for health care, both demand reduction strategies and consumer satisfaction will be of increasing import~ce. Provider-patient interactions concerning menopause management are a source of dissatisfaction for many women, and the numbers of women facing this transition are increasing. We believe that enhancing women’s ability to work with their health-care providers to make informed choices about menopause management, including whether or not to use HRT, will be an important way to increase consumer satisfaction in this growing and vocal segment of the population. Improved communication and education for women in this transition may also contribute to decreases in the demand for services and possibly decreases in the long-term morbidities associated with the menopausal years.

References [l] Moloney TW, Paul B. Tbe cons~er movement takes hold in medical care. Health Aff 1991; 10: 268-279.

27 (1996) 177-184

183

PI Belchetx PE. Hormonal treatment of postmenopausal

women. N Eng J Med 1994; 330: 1062-1071. [31 Harris RB, Laws A, Reddy V. Are women using postmenopausal estrogen? A community survey. Am J Public Health 1990; 80: 1266-1268. [41 Ross RK, Paganini-Hill A, Roy S. Past and present preferred prescribing practices of hormone replacement therapy among Los Angeles gynecologists: possible implications for public health. Am J Public Health 1988; 78: 516-519. [51 U.S. Congress. Office of Technology Assessment. The menopause, hormone therapy, and women’s health, OTA-BP-88. Washington, DC: US Government Printing Office, 1992. E. Pos~enopa~al estrogen and pre14 Barrett-~nnor vention bias. Ann Intern Med 1991; 115: 455-456. 171 Vandenbroucke JP. Postmenopausal oestrogen and cardioprotection. Lancet 1991; 337: 833-834. PI Fillion A, Lorrain J. Nutritional advice for the menopausal woman. In l&rain J, Plouffe L, Ravnikar V, Speroff L, Watts N, editors. Comprehensive management of menopause. New York: Springer-Verlag, 1994; 418-420. 191 Snow-Harter C, Chay C, Marcus R. Exercise and its relationship to bone mass and cardiovascular function. In Lorrain J, Plouffe L, Ravnikar V, Speroff L, Watts N, editors. Comprehensive management of menopause. New York: Springer-Verlag, 1994; 159-170. IlO1 Rosenberg L. Hormone replacement therapy: the need for reconsideration. Am J Public Health 1993; 83: 16701673. WI Page L. Menopause and emotions, Vancouver, BC: Primavera Press, 1994. WI Aharony L, Strasset S. Patient satisfaction: what we know about and what we still need to explore. Med Care Rev 1993; 50: 49-79. 1131 Weiss BD, Senf JH. Patient satisfaction survey instrument for use in health maintenance organizations. Med Care 1990; 28: 434-444. [I41 Kaufert PA, Gilbert I? Women, menopause, and medical~ation. Cult Med Psychiatry 1986, 10: 7-21. WI Rothert M. Perspectives and issues in studying patient’s decision making. Proceedings of the AHCPR Conference on primary care research: theory and methods. Washington, DC: US Department of Health, 1991: 175179. WI Hibbard JH, Hampson SE. Evaluating women’s partnership with health providers in hormone replaosment therapy: research and practice directions. J Women Health 1993; 5: 17-29. 1171 Schnebly ML, Hibbard JH, Hampson SE, Harvey, SM. Women’s perceptions of menopause. Presented at the Annual Meeting of the American Public Health Association, San Francisco, CA, 1993, WI Cauley JA, Cummings SR, Black DM, Mascioh SR, Seeley DG. Prevalence and determinants of estrogen replacement therapy in elderly women. Am J Obstet Gynecol 1990; 163: 1438-1444.

184

S.E. Hampson,

I.H.

Hibbard

I Patient

[19] Prior JC. One voice on menopause. J Am Med Women’s Assoc 1994; 49: 27-29. [20] Ziegler J. After menopause begins: the dilemma of estrogen replacement. Am Health 1992, H(3): 68-71. [21f Ravnikar VA. Compliance with hormone therapy. Am J Obstet Gynecol 1987; 156: 1332-1334. [ZZ] Goffman E. Stigma. Englewood Cliffs, NJ: Free Press, 1963. [23] Hall JA, Irish JT, Roter DL, Ehrhch CM, Miller LH. Gender in medical encounters: an analysis of physician and patient communication in a primary care setting. Health Psycho1 1994; 13: 384-392. [24] Roter D, Lipkin MJ, Korsgaard A. Sex differences in patients’ and physicians’ communication during primary care medical visits. Med Care 1991; 29: 1083-1093. [25] Meeuwesen L, Schaap C, Van der Staak C. Verbal analysis of doctor-patient ~mmunication. Sot Sci Med 1991; 32: 1143-4450. [26] Ragan SL, Pagan0 M. Communicating with female patients: affective interaction during contraceptive counseling and gynecal~gical exams. Women’s Stud ~ommun 1987; lO(2): 46-57. [27] Hibbard JH, Weeks EC. Consumerism in health care: Prevalence and predictors. Med Care 1987; 25: 10191032. 1281 Rost K, Frankel R. The introduction of the ofder patients problems in the medical visit. J Health Aging 1993; 5: 387-401. (291 Adelman RD, Greene MG, Charon R, Friedmann E. The content of physician and elderly patient interaction in the medical primary care encounter. Commun Res 1992; 19: 370-3&I. f3Q] Gekoski WL, Knox VJ. Ageism or healtbism? Perceptions based on age and health status. J Aging Health 1990,2: 115-127. [31] Gerteis M, Edgman-Levitan S, Dalay J, Delbanco TL. Through the patient’s eyes: understanding and promoting patient-centered care. San Francisco: Jossey Bass 1993. [32] Sofaer S. Informing and protecting consumers under managed com~tition. Health Aff Suppl1993; 12: 79-98.

Education

and Counseling

21(1996)

177-M

[33] U.S. Department of Health and Human Services. Healthy people 2ooO: national health promotion and disease prevention objectives. Boston: Jones and Bartlett 1992. f34] Rater D, Frankef R Quantitative and qualitative approaches to the evaluation of the medial dialogue. Sot Sci Mod 1992; 34: 1097-1103. 1351 McKinlay JB, McKinlay SM, Brambillia DJ. Health status and utilization behavior associated with menopause. Am J EpidemioI 1987; 12.5: 110-121. [36] Kaplan S, Greenheld S, Ware JE. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989; 27: sllO-~127. f37f Lock M, Kaufert P, Gilbert P, Cultural injection of the menopausal syndrome: the Japanese case. Maturitas 1988; lo: 317-332. f38] Skinner CS, Strecher VJ? Hospers SH. Physicians’ recommendations for mammography: do tailored messages make a difference. Am J Public Health 1994; &I: 43-49, [39] Litzelman DK, Dittus RS, Miller ME, Tiemey WM. Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols. J Gen Intern Med 1993; 8: 311-317. [40] Roter DL. Patient participation in the patient-provider interaction: the effects of patient question asking on the quality of interaction, satisfaction and compliance. Health Educ Monogr 1977; 5: 288-311. [41] Thompson SC, Nanni C, Schwankovsky L. Patient-oriented interventions to improve communications in a medical office visit. Health Psycho1 lm, 9: 390-404. [42] Fahlberg LL, Poulin AL, Girdano DA, Dusek DE, Empowerment as an emerging approach in health education. J Health Educ 1991; 22: 185-193. [43] Rene J, Weinberger M, Mazzuca SA, Brandt KD- Katz BP Reduction of joint pain in patients with knee ~teoa~h~t~ who have received monthly telephone calls from lay personnel and whose medical treatment regimens have remained stable. Arthritis Rheum 19% 35: 511-51s. [44] Wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. Telephone care as a substitute for routine clinic follow-up. J Am Med Assoc 1992; 267: 1788-1793.