A Pilot Study in Patient Education Sandra S. Smith, MSW, and William - - PDF document

The Effect of Video Tape

• n Presentations Made to Physicians:

A Pilot Study in Patient Education

Sandra S. Smith, MSW, and William L

. Roberts, MSW

T u c s o n , A r i z o n a

This paper examines the use of brief patient education in en­ couraging patients to present stress conditions as problems to physicians. Participants were patients at the Family Practice Office, University of Arizona Health Sciences Center. All 40 selected patients were visiting the Family Practice Office for the first

• time. The two groups of 20 patients were similar in age and

sex. An audio recording was made of the patient-physician en­ counter of all participants. The control group of 20 patients received no education prior to meeting the physician. The 20 patients in the experimental group observed a video tape prior to meeting the physician. The video tape, specially prepared for this project, described the relationship between stress conditions and illness. It further emphasized the physician’s need to know about these stress conditions and the patient’s responsibility for presenting them to the physician. The results of the chi-square test of association applied to the number of stress conditions presented demonstrated a highly significant difference between the two groups. The probability level was .01. This study produced strong evidence to support the hy­ pothesis that brief patient education does affect the presenta­ tion of stress conditions to physicians.

This paper examines the use of patient educa­ tion in encouraging patients to present stress con­ ditions to their physicians. It developed from the recognition of a need to legitimize stress condi­ tions as appropriate problems for patients to pre­ sent to physicians. The study was conducted at the Family Practice

Fr o m t h e D e p a r t m e n t o f F a m i l y a n d C o m m u n i t y M e d i c i n e , C o l l e g e o f M e d i c i n e , T h e U n i v e r s i t y o f A r i z o n a , T u c s o n , A r i z o n a . R e q u e s t s f o r r e p r i n t s s h o u l d b e a d d r e s s e d t o M s. S a n d r a S . S m i t h , F a m i l y P r a c t i c e O f f i c e , 1 4 5 0 N o r t h C h e r r y A v e n u e , T u c s o n , A Z 8 5 7 1 9 .

Office of the Department of Family and Commu­ nity Medicine, University of Arizona Flealth Sci­ ences Center. A philosophy of encouraging pa­ tients to assume increasing responsibility in the care of their health, and an interest in the social and emotional aspects as well as in the medical aspects of health, made the Family Practice Office an ideal setting for this study. Patients come to the Family Practice Office with a variety of problems. Those problems most frequently presented are not necessarily the pri­ mary problem the patient carries to the physician.1

T H E JO U R N A L O F F A M I L Y P R A C T I C E , V O L . 6 , N O . 1 , 1 9 7 8 9 3

VIDE OTAPE AND PRESENTATIONS TO PHYSICIANS Table 1. Results of Chi-square Test of Association Applied to Three Categories of Patient's Statements Statements Made by Patients Chi-Square Value Probability Level

S t r e s s c o n d i t i o n s 6 .5 3 .0 1 V o l u n t e e r e d li f e c h a n g e s 0 .4 0 .5 2 L i f e c h a n g e r e s p o n s e s 0 .1 0 .7 4

Often the presenting problem serves as a patient’s ticket of admission to the physician’s office: Zborowski describes social training that does not necessarily discourage use of the physician, but does imply that such use will be based on physical needs rather than on emotional concerns.2 Today, patients, as consumers of services, are seeking more from physicians than the treatment

• f diseases. Cobb suggested that patients seek not
• nly adequate medical care, but also sympathetic

emotional support from the physician.3 Mechanic found that persons who change physicians be­ cause of dissatisfaction appear to complain more about the physician’s lack of interest, caring, and motivation than about his/her medical qualifica­ tions.4 Because the physician’s role involves commu­ nication, interaction, and nurturance, Mechanic suggests that it also meets the interpersonal needs

• f patients. This is not to say that physicians are in

universal agreement over this holistic approach. Black argues that “ the doctor’s focus should be on the disease and not on the whole life of his patient

• r on some general ideal of humanness.” 5

Increasingly, however, physicians are accept­ ing stress as significant in the etiology of disease. Selye’s physiologic concept of stress has been ex­ panded to include environmental and social stres­ ses, thus legitimizing the presentation of emotional needs and changes in life situations to the physi­ cian.6 While the relationship between stress and ill­ ness is gaining wider acceptance among physi­ cians, patient education is necessary to help pa­ tients identify and accept emotional needs as legitimate and appropriate for presentation to

• physicians. This study examines the effect that

brief patient education has on the presentation of stress conditions to physicians.

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Methods

The study employed a selected sample of pa­ tients who were to see a physician at the Family Practice Office for the first time. To be selected, the patient needed to meet certain criteria. He/she (1) had to be new to the Family Practice Office, (2) had to be regarded as adult, which was designated by the Family Practice Office as 17 years or older, (3) could not be accompanied by another person during the time spent with the physician, and (4) had to indicate consent to participate in the study. A total of 20 patients was selected for the con­ trol group, and 20 patients for the experimental

• group. The ages of the control group ranged from

19 to 80 years with a mean age of 39 years. The ages of the experimental group ranged from 17 to 76 years with the mean age of 44.05 years. There were 6 males and 14 females in the con­ trol group. Likewise, there were 6 males and 14 females in the experimental group. The video tape, which was produced as the tool

• f brief patient education for the purpose of this

study, was 6 minutes and 12 seconds long and had three thrusts to its content. The brief introduction emphasized that changes occurring in the life ex­ perience require the body to make some adapta­ tion or adjustment. This need for adjustment was identified as stress, and stress was recognized as a significant factor in the etiology of disease. The body of the script referred to several pos­ sible changes or life events which the patient might have experienced. Finally, the message was di­ rected toward placing responsibility on the patient for bringing these events to the attention of the physician. In order to measure the effectiveness of the selected tool of patient education it was necessary to confine the patients in the control group to the regular office procedure. Only those patients in

T H E JO U R N A L O F F A M I L Y P R A C T I C E , V O L . 6 , N O . 1 , 1 9 7 8

VIDE OTAPE AND PRESENTATIONS TO PHYS ICIANS Table 2. Frequency and Percent Scores of Both Groups for Presentation of Stress Conditions One or More Mention of Stress Conditions Group Frequency %

C o n t r o l 1 5 E x p e r i m e n t a l 9 4 5 C o m b i n e d 1 0 2 5

the experimental group were shown the video tape before meeting the physician. The study depended heavily on the cooperation

• f residents in their second and third year of

graduate training, who would be seeing patients in the Family Practice Office. Before recording the conversations between physician and patient, ver­ bal requests to individual physicians yielded per­

• mission. The physicians had no knowledge con­

cerning the content of the video tape and were not informed which patients viewed the video tape. The only extraordinary procedure the physicians were aware of was the presence of the audio re­ corder during every patient-physician encounter involved in the study. Data were collected by means of these audio

• recordings. The audio tapes varied in length from

12 to 45 minutes. Only data from the first ten minutes were analyzed. Besides the data gathered from the audio tapes, descriptive information was collected in the form

• f responses to letters mailed to participants.

The letter mailed to control sample participants asked, “ Do you think your first visit with your doctor would have been different without the presence of a tape recorder?” The one mailed to experimental group members asked, “ Do you think the video tape influenced your conversation with your doctor? If yes, in what way?”

Results

The chi-square test of association was applied to three variables:

• 1. Number of stress conditions presented as

problems to the physician. Specific examples of problems recorded as stress conditions are “ stress, tension, feeling down, strain, and worry.”

• 2. Number of life changes volunteered by the

patient, using Holmes’ and Rahe’s Social

T H E JO U R N A L O F F A M I L Y P R A C T I C E , V O L . 6 , N O . 1 , 1 9 7 8

Readjustment Rating Scale.7 Examples of life changes included in the scale are: marriage, death

• f spouse, outstanding personal achievement,

change in financial status, change in residence, re­

• tirement. A patient’s statement regarding a life

change, not immediately preceded by a physi­ cian’s question, was recorded as volunteered. 3. Number of life changes presented in re­ sponse to the physician’s question. The patient’s statement of a life change immediately preceded by a physician’s question was recorded as a re­ sponse. No quantitative analysis was applied to the de­ scriptive information from the letters mailed to and returned by the participants. Table 1 describes the results of the chi-square test of association. No significant difference was found between the two groups based on the number of life events volunteered by the patients and the number of life events presented in re­ sponse to the physician’s questions. When applied to the number of stress condi­ tions presented as problems to physicians, the chi-square test of association indicated a highly significant difference between the two groups, with a probability level of .0106. Table 2 describes the frequency and percent scores of both groups for the presentation of stress

• conditions. Five percent of the control group

mentioned one or more stress conditions to the

• physician. Forty-five percent of the experimental

group mentioned one or more stress conditions to the physician. This score of 45 percent is signifi­ cantly higher than the score of the five percent for the control group and mean score of 25 percent for the combined groups. The results of the chi-square test of association strongly support the hypothesis that brief patient education does affect the presentation of stress conditions to physicians, and the descriptive in­ formation gathered in this study adds credibility to

9 5

VIDE OTAPE AND PRESENTATIONS TO PHYSICIANS

the interpretation of the findings. While responses from the control group indi­ cated that the presence of a tape recorder during the patient-physician encounter did not affect the visit either by inhibiting or enhancing communica­ tion, six participants in the experimental group indicated that the video tape did influence their conversation with the physician. They made the following statements:

• 1. “ I guess it made me feel more comfortable

and relaxed so I could talk to my doctor with ease.”

• 2. “ Tell all, no secrets.”
• 3. “ I told him something that had been worry­

ing me—my little girl wetting the bed. I would have kept it to myself.”

• 4. “ I was relaxed and open to considering

emotional aspects of health, but the doctor was clearly not interested and I felt a good deal of re­ sentment at his attitude—courteous but distant and closed.”

• 5. “ Better understanding.”
• 6. “ It brought home the message that before

the doctor could help me, I had to go through the painful memories again. It really triggered a de­ pressed mood.”

Discussion

As demonstrated by this study, the effect of the brief patient education was to encourage patients to present stress conditions to the physician. Be­ cause of the small size of the sample and the lim­ ited background information regarding the sample, this project should be regarded as a pilot study. Caution is urged in the interpretation of the find­ ings. The mode of patient education selected was the video tape. This was efficient to manage. It also was general enough to be presented to a variety of patients. The results of this study suggest a potential for directing the presentations made by patients toward the specific interests of the physician. For the hypothetical physician who has no interest in the patient’s emotional status, brief education could influence the presentation toward specific medical symptoms. The findings further suggest that uncertainty and anxiety over the first visit with the physician could be reduced by brief pa­ tient education. The success of the use of patient education to

9 6

encourage patients to present stress conditions to the physician will be determined in large part by the attitude of the physician. Consider the state­ ment made by one participant, “ I was relaxed and

• pen to considering emotional aspects of health,

but the doctor was clearly not interested...” Pa­ tient education can create patient awareness. This awareness requires reinforcement by the physi­ cian. This study does not presume an interest among all physicians in the psychosocial elements of the patient’s health. Some physicians argue that the economics of time do not permit a holistic ap­ proach to practice. At the very least, however, the physician must be able to recognize the problems

• f stress. The physician needs a knowledge of re­

sources in order to make appropriate referrals, or special skills if he prefers to deal with these prob­ lems himself. As patients come to expect more than technical competence from physicians, the physician needs education in the skills required for providing emotional support. The medical literature is replete with studies confirming the relationship between stress and ill­

• ness. This information has not reached the public

to the extent that it is generally supposed. Brief patient education in the form of a video tape can bring this information to the patient. Until now, patient education has focused primarily on specific medical problems. The find­ ings of this study indicate that patient education can be used effectively to prepare patients for their first encounter with the physician. The effects seemed to be (1) relaxing the patient, (2) encourag­ ing the patient to talk about stress conditions as well as medical problems, and (3) imparting a sense of caring to the patients.

References

• 1. B a l i n t M : T h e D o c t o r , H i s P a t i e n t , a n d t h e Il l n e s s .

N e w Y o r k , In t e r n a t i o n a l U n i v e r s i t i e s P r e s s , In c , 1 9 6 4 2 . Z b o r o w s k i M : C u l t u r a l c o m p o n e n t s in r e s p o n s e t o p a i n . J S o c I s s u e s 8 ( 4 ) : 1 6 , 1 9 5 2 3 . C o b b B : W h y d o p e o p l e d e t o u r t o q u a c k s ? In Ja c o EG (e d ): P a t i e n t s , P h y s i c i a n s a n d I l l n e s s . N e w Y o r k , T h e Fr e e P r e s s , 1 9 5 8 , p p 2 8 3 - 2 8 7 4 . M e c h a n i c D : T h e i n f l u e n c e o f m o t h e r s o n t h e i r c h i l ­ d r e n ' s h e a l t h a t t i t u d e s a n d b e h a v i o r . P e d i a t r i c s 3 3 :4 4 4 , 1 9 6 2 5 . B l a c k P : M u s t p h y s i c i a n s t r e a t t h e w h o l e m a n ? T h e P h a r o s 3 9 (1 ) :8 , 1 9 7 6 6 . S e l y e H : T h e S t r e s s o f L i f e . N e w Y o r k , M c G r a w - H i l l , 1 9 5 6 7 . H o l m e s T H , R a h e R H : T h e s o c i a l r e a d j u s t m e n t r a t in g s c a l e . J P s y c h o s o m R e s 1 1 :2 1 3 , 1 9 6 7 T H E JO U R N A L O F F A M I L Y P R A C T I C E , V O L . 6 , N O . 1 , 1 9 7 8