Encouraging out-patients to make the most of their first hospital appointment: to what extent can a written prompt help patients get the information they want?
Introduction
The first out-patient appointment after referral bridges primary and secondary care and has great importance for patient and health services alike. A critical component of the consultation is the exchange of information [1]. Yet a recent national survey of out-patients in the UK found that 27% of those who had attended just once would have liked to have been given more information at the consultation [2].
There are many reasons why communication between doctors and patients can be unsatisfactory; factors may be related to the organisation of the clinic, the doctor or the patient 1, 2, 3, 4, 5. One of the factors identified is the difficulty patients have in asking questions to get the information they need. During a medical consultation patients may be unwell, anxious, forgetful or feel inhibited from asking what they want. They can also find it difficult to process and respond to the new information given to them [6]. Communication difficulties for patients may well be enhanced at a first hospital out-patient appointment, as patients are not accustomed to the physician's examination style and approach and are uncertain about behavioural norms [7]. Patient anxiety and confusion may also be increased because the surroundings are unfamiliar, clinics and staff are usually busy and there can be a long wait before being seen.
A number of strategies have been used to help patients to ask questions. One approach employed in the US has been the use of advocates who coach patients to ask appropriate questions in their consultation 8, 9. These studies have demonstrated positive results in terms of increased patient participation, but the routine employment of patient advocates may not be feasible [10], and other cheaper ways of helping patients to obtain the information they want must to be found. One method used successfully in the primary care setting has been the use of written materials to increase patient involvement and question asking 5, 6, 11, 12, 13.
This paper describes the results of a survey of new out-patients who attended the Royal Free Hospital, London. The respondents took part in a randomised controlled study in which we piloted a `help card' and explanatory letter. These written materials were designed to encourage and assist out-patients to prepare, prioritise and remember questions to ask at their initial hospital consultation. The focus of this paper is the patient. The views of the participating doctors were also obtained and will be reported elsewhere. We hypothesised that:
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the help card and letter would help patients to focus on what they wanted to find out
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the help card and letter would give patients `permission' to ask questions
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the help card and letter would encourage patients to prepare questions in advance
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the help card would help patients to remember questions during the consultation
To test these hypotheses patients were sent a questionnaire after the consultation which asked about their information requirements and expectations before the visit, whether they had prepared questions beforehand, whether their questions were raised during the consultation, whether they had thought of additional questions since the visit and what they would have liked to have discussed further. Patients who were sent the help card were asked additional questions about its usefulness. The impact of the help card on patients' expectations, preparation for and experience of their out-patient consultation are discussed. The extent to which the information needs of new patients can be addressed at the first hospital visit is also considered.
Section snippets
Development of the materials
The content of the help card and its accompanying letter were based on earlier materials 14, 15. Modifications were made after discussions with nurses, patients and colleagues and piloting. The suggested questions (see Fig. 1) were general and there was space for patients' own questions. The accompanying letter said that patients' questions would be expected by the hospital doctor, but were not obligatory. It also emphasised that the printed questions were only suggestions and advised patients
Response rate
After one reminder, adequately completed questionnaires were returned by 64% (1077/1683) patients. The response rate was associated with gender; 58% (260/449) of males responded compared with 66% (817/1233) of females (P<0.01, gender was unknown for one non-respondent) and the response rate increased with age from 53% (213/404) of those aged under 30 years to 80% (258/322) of those aged 60 or above (P<0.05). The response rate was not associated with being sent a help card (66% (315/475)
Discussion
To summarise, the help card was popular and half of the patients who were sent the card said it helped them to get more out if the consultation. Yet the analysis of the questionnaire data showed few statistically significant differences between the help card group and the control group and few differences between patients seen during the pre-intervention phase and afterwards. This may be because the help card did not make a significant difference to patient behaviour in the population studied
Conclusion and implications for practice
To conclude, our results highlight the difficulties out-patients have in asking questions and discussing topics fully at their initial consultation, even when they have thought of questions in advance. A written prompt may assist new out-patients to focus on their appointment and think of questions beforehand and this may help them to get more out of their consultation, but patients also need help and encouragement from staff during the consultation. The help card was popular with patients, but
Acknowledgements
The study was funded by North Thames Regional Health Authority (Responsive Funding Group). We thank Heather Rowley for administrative assistance, Fiona Lampe for statistical support, Ann Cartwright and Joy Windsor for advice and our colleagues at the Royal Free Hospital for their help and support. We are grateful to the patients and doctors who participated.
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