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Patient Education and Counseling, 8 (1986) 407414 Elsevier Scientific Publishers Ireland Ltd.
GAINING PHYSICIAN EDUCATION
SUPPORT
FOR EFFECTIVE
PATIENT
JANE WESTBERG* National Center for,Faculty Development, (U.S.A.) (Received (Accepted
University of Miami School of Medicine, Coral Gables, FL
April 24th, 1986) September llth, 1986)
ABSTRACT
It is desirable for patient education managers and coordinators to foster physician support for and involvement in patient education. Physicians who value, understand and are skilled at patient education can enhance the quality of care they provide to their own patients. They can also make contributions to the patient education program at the institution with which they are affiliated by participating in such activities as critiquing and developing patient education materials, teaching patient education classes and serving as advocates of the patient education program. This paper is in response to a challenge to suggest strategies that patient education managers and coordinators can use to gain physician support for patient education. These strategies are based on lessons learned from working as a medical educator with responsibilities that have included helping practicing physicians, residents, and medical students develop and enhance their skills as teachers of patients. Suggested strategies include: assessing physicians’ attitudes towards and capabilities in providing patient education; helping physicians understand what patient education can do for their own patient care; publicizing successful patient education activities and the impact they have had on the institution; and inviting physicians to help create patient education materials.
Key words: Physician
support -
Medical
education
*To whom reprint requests should be sent at: 11060 Paradela St., Coral Gables, FL, 33156, U.S.A.
0738-3991/86/$03.50 0 1986 Elsevier Scientific Printed and Published in Ireland
Publishers
Ireland Ltd.
408 INTRODUCTION
Patient education coordinators and managers who want high quality patient education programs in their institution have much to gain by working actively to make physicians their allies in this endeavor. Physicians who value, understand and are skilled at patient education can enhance the quality of care that they provide to their own patients. Inui and colleagues found that physicians who were tutored in patient education skills allocated a greater percent of clinic-visit time to patient teaching than did control physicians. The physicians who received the tutoring helped their patients develop more knowledge about, and more appropriate beliefs regarding, their health problems and the therapy they needed. (1) Numerous other studies document positive outcomes achieved when physicians utilize strategies that are basic to effective patient education such as: developing trust-based relationships, assessing patients’ knowledge of and attitudes toward their problem, providing information to patients in a form and in language that is appropriate for each of them, assuring that patients understand the information that has been provided to them, and, in general, helping patients be as active as possible in their own care [2-51. Physicians who value, understand and are skilled at patient education can also make important contributions to the patient education programs at the institutions where they work. It is likely that these physicians will encourage their patients to make appropriate use of patient education programs and resources available at the institution, and these physicians are even likely to help patients get the most out of these programs, for example, by reinforcing what these patients have learned. Further, physicians who value, understand and are skilled at patient education can make more direct contributions to the overall patient education program by doing such things as teaching patient education classes and helping with the selecting of new patient education materials. In a time when there is growing competition among programs in health care institutions for space and funding, it can be important to have these physicians as advocates of the patient education program. SOME STRATEGIES
FOR GAINING PHYSICIAN
SUPPORT
AND INVOLVEMENT
What are some strategies for gaining physician support for patient education? Those of us involved in medical education at the medical school and residency level obviously need to help make patient education a valued and respected part of the curriculum. Although Abraham Flexner, in his highly influential report, acknowledged that physicians should work to prevent and treat disease ‘through measures essentially educational’, [ 61 medical schools and residency training programs have been slow to give attention to this area [7]. Progress, however, is being made. The Directory of Health Education Programs in Medical Education lists 120 courses in patient education at the medical
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school or residency levels. [8] Some specialities, such as family medicine, are giving increasing attention to patient education [%ll]. There was enough interest in and consensus about the importance of patient education in this speciality to warrant the formation of a Task Force on Training Family Physicians in Patient Education. One of the major responsibilities of the Task Force was producing a document, Patient Education: A Handbook for Teachers [ 121, that is currently being used in teaching patient education in family practice residencies. Those of us who are medical educators still have much we need to do. In particular, patient education needs to be an integral part of the curriculum, not merely the subject of an isolated course. One approach to making patient education a part of the fabric of the curriculum is helping the clinical faculty value and become skilled at patient education so that they will serve as models of these values and capabilities and so that they will foster these attributes and capabilities in their students. What are some ways that patient education managers and coordinators can gain physician support? The following are some ideas that are drawn from my own work with physicians and medical students and from many discussions with patient educators. Identify and assess physicians’ attitudes toward and capabilities in providing patient education Just as it is important in patient education and patient care to assess patients’ attitudes and capabilities before moving ahead with a treatment plan, so too it is important to assess physicians’ present attitudes and capabilities before devising strategies for gaining their support and involvement. A quick way to lose physician interest and cooperation is to attempt to teach them what they feel they already know or to ask them to do what they already think they are doing. Physicians in your institution are not likely to hold still for a formal assessment, but there are ways you can conduct an informal assessment. You can, for example, find out which of the physicians now utilize patient education resources and services, which ones serve as teachers of patient education courses and which ones discuss patient education issues when presenting patients to their colleagues. You can get some feeling for the level of sophistication and the quality of physicians’ patient education efforts by doing such things as sitting in on patient education classes taught by physicians, assessing patient education materials physicians have selected for their own use and assessing any patient education materials developed by physicians at your institution. As you do your assessment, you are likely to find a great deal of diversity among physicians in their valuing of and skills in patient education. As indicated, recent graduates are more likely than their predecessors to have had formal exposure to patient education during medical school or residency training.
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Be alert to what physicians might be learning about patient education One way of finding out what physicians might be learning about patient education is by reviewing the articles on patient and health education that are appearing with increasing frequency in widely read medical journals [ 13-141. If ypu are doing this, you probably are discovering that the articles are uneven in quality and that some of the findings of the published studies are not positive [15]. Reading these articles can give you a feeling for physicians’ likely perspectives on patient education. You will also be in a better position to discuss these articles with physicians. Help the physicians at your institution get to know you and the services you provide There are many things competing for physicians’ attention. If the physicians at your institution are to get to know you and the services you provide, you need to establish your presence. Go to the places where physicians mingle. Attend medical conferences and rounds. Wear a tag that clearly identifies your name and profession. Prepare and personally distribute a card or small pamphlet with your name, number and services you provide. If you have a resource center or similar facility, invite physicians to visit it. Use the information you are gathering as part of your needs assessment to alert individual physicians and groups of physicians to resources and services you think are appropriate to their unique interests and needs. Assure that colorful posters advertising upcoming patient education events are placed in areas where physicians congregate. Let the director of medical education know you are available to give presentations on patient education An important early step in raising doctors’ consciousness about patient education is helping the director of medical education at your institution understand what you do and what you have to offer physicians and other health professionals. It could be useful to give the director of medical education a list of sample topics you could present by yourself or in conjunction with others. Assure that the topics you suggest are relevant to the needs of the people at your institution and reflect the fact that you have done your homework and are familiar with any topics in patient education that have already been presented by others. Attempt to be a participant in team rounds and conferences In some institutions, rounds and conferences are presented by members of the health teams who have been involved in caring for particular patients. If this is a practice at your institution, try negotiating to be one of the presenters, if you are not already routinely invited to participate. .If team rounds and conferences are not offered at your institution, try to see what you can do to bring them about. Participating in team-led rounds and conferences offers an excellent opportunity to help physicians and other health professionals better
411
understand the unique and important place of patient education ity health care.
in high qual-
Participate in the training of medical students and residents, if appropriate As a medical educator, I greatly welcome the participation of patient educators in helping medical students and residents value, understand and develop capabilities in patient education. Medical students at my institution have shown great interest in patient and health education and have pursued these areas outside of the formal curriculum. For example, they have conducted health education classes for students in the public schools and for visitors at the annual health fair which they plan and carry out [16]. Kosch and Dallman report that residents they studied at four training programs in Florida identify patient education as an area in which they received little training as medical students and as a ‘high priority’ area for inclusion in their residency curriculum [ 171. Plorde-McCann and colleagues found that family practice residents’ attitudes toward patient education and toward their own skills as patient educators underwent positive changes as the result of their participation in a patient education training program [ 181. Working with medical students and residents is an investment in the future, but patient educators can find more immediate rewards. For example, medical students and residents can contribute to an institution by participating in some of the activities listed below, such as preparing instructional materials and teaching classes.
Help physicians understand what patient education can do for their own patient care An important first step with learners, be they physicians or patients, is helping them become motivated to learn. Physicians, typically, are very pragmatic people. They are likely to become interested in patient education if they understand how it can contribute to such things as patient satisfaction, patient adherence to management plans and informed consent. It can be useful to send some physicians copies of articles documenting the values of patient education.
Do not use educational jargon Using educational jargon is a fast way to lose physician interest. Do try explaining educational principles and strategies in terms that are familiar to physicians. Physicians can readily understand the need to be diagnostic, to identify problems or goals, to develop a plan of action for addressing the problems and to monitor interventions that are used. In explaining how you function as a patient educator, be specific and concrete. If you are working with some of the physicians’ patients, for instance, describe your explicit goals for those patients.
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Send physicians materials they might find useful As a way of helping physicians understand and value patient education, give them some sample materials focusing on problems or needs that their patients are likely to have. Again, use the results of your needs assessment to assure that the materials you send to each physician are maximally helpful. When appropriate, use patient referrals as an opportunity to educate physicians Working with physicians around the care of their patients offers potential opportunities for assessing the physicians’ understandings of patient education and for providing them with any needed information. When physicians first refer patients to you, for example, you can determine what these physicians would like you to do. If their expectations are not appropriate, you can help them understand the services patient educators can provide. Publicize successful patient education activities within your institution Physicians who have an investment in your institution might be interested in the results of data you have collected on the value of your program to the institution. Physicians, for example, might be inte,rested in information on how patient education activities have contributed to patient satisfaction within your institution and the extent to which classes held for the general public have contributed to people selecting your institution when they are in need of health care. Hearing about successful activities can also remind physicians of the resources available to them and their patients through the patient education program. Identify physicians who are genuinely open to learning about patient education and begin your efforts with them An important lesson from the field of organizational change is the desirability of starting new projects by focusing your initial efforts on those people who are most ready for change. This approach is far more satisfying and less frustrating than working with people who are indifferent to, or who oppose, your efforts. As the physicians you are focusing on begin to understand what you are trying to do, they can serve as advocates of patient education with those physicians who have been less positive. This strategy is particularly important with groups such as physicians, some of whom tend to feel they have little to learn from those who are not their professional peers. Invite physicians to help critique patient education materials This strategy has several positive features. Physicians can provide valuable critique regarding the medical content of the materials. The very act of critiquing these materials can give physicians a greater sense of ownership of these patient education materials. In addition, this activity provides opportunities to help physicians better understand the characteristics of effective patient education materials. For example, participating physicians can be provided with a check-list of the characteristics of effective patient eduction videotapes and asked to consider the items on this check-list when reviewing tapes.
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Invite physicians to help create materials Not many busy physicians are likely to want to create patient education materials from scratch. They might, though, be willing to provide some help, particularly as a content expert, in the creation of written or audiovisual materials. This can be a valuable service, and it can help physicians enhance their sense of ownership of the program. In addition, participating physicians can increase their understanding of the characteristics of effective patient education materials. If you are working with medical students, you might challenge them to help with this activity. We have found that some students are far better able to identify with the consumer’s needs, interests and levels of understanding than are experienced physicians. Invite select physicians to serve as teachers for patient education classes This is yet another activity that can benefit the patient education program and facilitate the physicians’ sense of ownership of the program. It can also provide opportunities for helping participating physicians enhance their skills as teachers. If appropriate, for example, the patient educator could do such things as help the physician develop an instructional plan, help him or her acquire or create audiovisuals for the session and work with him or her in rehearsing for the session and later in assessing the effectiveness of the session. Be patient Educating physicians about the value of patient education and gaining their participation and support is not unlike helping patients develop new values and habits. Some physicians will be eager to learn and will support your efforts; others, if they make progress at all, will move at a very slow pace. To the extent you can, take the long view; be patient. CONCLUSION
Gaining physician support for and involvement in patient education is desirable. Physicians who value and are skilled at patient education can provide higher quality patient care to their own patients. They can also make important contributions to the patient education program of the institution with which they are affiliated. Many of the strategies involved in helping physicians value and become skilled at patient education are parallel to the strategies involved in patient education. These strategies include assessing physicians’ attitudes and capabilities in the area of patient education, helping physicians become committed to high quality patient education, helping physicians become aware of the resources that are available to them and their patients, helping physicians feel ownership of the patient education program and providing physicians with opportunities to develop such new skills as creating patient education materials.
414 REFERENCES 1 Inui TS, Yourtee EL, Williamson JW. Improved outcomes in hypertension after physician tutorials. Ann Int Med 1976; 84: 646650. 2 Egbert LD, Battit GE, Welch CE, Bartlett MK. Reduction of postoperative pain by encouragement and instruction of patients: a study of doctor-patient rapport. N Engl J Med 1964; 270: 825827. 3 Waitzkin_ H. Doctor-patient communication: clinical implications of social scientific research. JAMA 1984; 252: 2441-2446. 4 Bartlett EE, Grayson M, Barker R, Levine DM, Golden A, Libber S. The effects of physician communication skills on patient satisfaction; recall and adherence. J Chron Dis 1984; 37: 755764. 5 Haynes RB, Taylor DW, Scakett DL eds. Compliance in Health Care. Baltimore: Johns Hop kins University Press, 1979. 6 Flexner A: Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin 4. Boston: The Merrymount Press, 1910. 7 Tosteson DC. The right to know: public education for health. J Med Educ 1975; 50: 117-123. 8 Directory of Health Education Programs in Medical Education. Birmingham: University of Alabama, 1981. 9 Plorde DS, Blossom HJ, Blaschko W. A health education curriculum for family practice residents. Fam Med 1984; 16(2): 50-53. 10 Zoller DP, Murphy-Cullen CL, Moore S, Graff A. A wellness program model for family practice residency programs. Fam Med 1985; 17(3): 93-95. 11 Jason H, Westberg J. Microcomputers in faculty development: the Florida FAC-NET Project. J Fam Pratt 1984; 19: 72-79. 12 Report of the National Task Force on Training Family Physicians in Patient Education. Patient education: A handbook for teachers. Kansas City, Missouri: The Society of Teachers of Family Medicine, 1979. 13 Levine DM, Green LW, Deed SG et al. Health education for hypertensive patients. JAMA 1979; 241: 17061703. 14 Rodnick JE, Bubb K. Patient education and multiphasic screening: it can change behavior. J Fam Pratt 1978; 6: 599607. 15 Webb PA. Effectiveness of patient education and psychosocial counseling in promoting compliance and control among hypertensive patients. J Fam Pratt 1980; 10: 1047-1055. 16 Westberg J, Schachner T, Jason H. A family practice learning resource center. Fam Med 1986; 18: 313314. 17 Kosch SG, Dallman JJ. Essential areas for behavioral science training: a needs assessment approach J Med Educ 1983; 58: 619626. 18 Plorde-McCann D, Wollitzer AO, Blossom HJ. Effects of training in patient education on attitudes and behaviors of family practice residents. 1986; 18: 8183.