The Use of Recommended Communication Techniques by Maryland Family Physicians and Pediatricians

Background Health literacy experts and the American Medical Association have developed recommended communication techniques for healthcare providers given that effective communication has been shown to greatly improve health outcomes. The purpose of this study was to determine the number and types of communication techniques routinely used by Maryland physicians. Methods In 2010, a 30-item survey was mailed to a random sample of 1,472 Maryland family physicians and pediatricians, with 294 surveys being returned and usable. The survey contained questions about provider and practice characteristics, and 17 items related to communication techniques, including seven basic communication techniques. Physicians’ use of recommended communication techniques was analyzed using descriptive statistics, analysis of variance, and ordinary least squares regression. Results Family physicians routinely used an average of 6.6 of the 17 total techniques and 3.3 of the seven basic techniques, whereas pediatricians routinely used 6.4 and 3.2 techniques, respectively. The use of simple language was the only technique that nearly all physicians routinely utilized (Family physicians, 91%; Pediatricians, 93%). Physicians who had taken a communications course used significantly more techniques than those who had not. Physicians with a low percentage of patients on Medicaid were significantly less likely to use the recommended communication techniques compared to those providers who had high proportion of their patient population on Medicaid. Conclusions Overall, the use of recommended communication techniques was low. Additionally, many physicians were unsure of the effectiveness of several of the recommended techniques, which could suggest that physicians are unaware of valuable skills that could enhance their communication. The findings of this study suggest that communications training should be given a higher priority in the medical training process in the United States.

Introduction such as using simple language (94.7%) were commonly used; the majority of techniques recommended by health literacy experts were not routinely used by providers [11]. To further complicate this issue, medical students receive very little practical training in communication, and during residency training when most patient contact occurs, training in communication receives very low priority [2].
Understanding the use of communication techniques by family physicians and pediatricians is especially critical because these practitioners see a wide range of patients, making them a valuable resource in promoting other aspects of health, such as oral health [18]. Therefore, the overall aims of this study are to determine: 1) the number and types of communication techniques Maryland pediatricians and family practice physicians use on a routine basis 2) their perception of the effectiveness of the recommended communication techniques and 3) factors associated with their use of these techniques. This survey of Maryland physicians was part of a comprehensive, statewide assessment of oral health literacy and communication techniques that was conducted. The proposed study aims were achieved, and the results will serve as a baseline for future studies aimed at further assessing and improving provider communication in the state of Maryland.
The study sample was obtained using the membership lists of Maryland Academy of Family Physicians (MAFP) and the Maryland American Academy of Pediatrics (MDAAP). An initial mailing consisted of the full survey questionnaire along with a cover letter explaining the survey that was signed by either the President of the MAFP or MDAAP. Three weeks after the first mailing, a second complete mailing was sent to non-respondents. Approximately three weeks after the second mailing, a postcard was mailed to remaining non-respondents. The executive director of each organization was asked to send a blast email reminder to urge all members to respond to the survey.

Ethics Statement
The Institutional Review Board, University of Maryland, College Park, reviewed and approved this study. The physicians were informed that their participation in this study was completely voluntary, and passive informed consent was obtained by participants completing and returning the survey.

Data Analysis
Data was analyzed using SAS Version 9.3 (SAS Institute, Inc., Cary, NC.). Separate analyses were conducted for family physicians and pediatricians because they were from different sampling frames. The statistical analyses included distributions (frequencies and percentages) of physician characteristics, routine use of techniques, and perceived effectiveness of techniques. Additionally, the associations between all demographic variables and the mean number of communication techniques used were examined using the Analysis of Variance (ANOVA). For the ANOVA, the selected predictor variables were used as the independent variable and the mean number of communication techniques routinely used was the dependent variable. Finally, ordinary least squares regression was used to analyze the association between selected predictor variables (i.e.: provider and practice characteristics) as the independent variables, and the count of communication techniques routinely used as the dependent variable. The level of significance was set at p<0.05.

Sample results and characteristics
Of the 1,472 surveys mailed to Maryland family physicians and pediatricians, 415 were returned and of the total surveys returned, 294 were usable (consisting of 215 pediatricians and 79 family physicians) yielding an effective response rate of 20%. Table 1 displays the characteristics of the sample in total, and by family physician and pediatrician providers. The majority of respondents were white (75%), female (62%), private practitioners (67%), and practiced in a group setting (58%). These characteristics were similar for both family physicians and pediatricians. Thirty percent of pediatricians graduated prior to 1980 compared to only 12% of family physicians. Nearly half of all respondents had assessed their office to determine if it was user friendly. Additionally, about half of both family physicians and pediatricians reported to have previously taken a communications course, and a similar proportion of respondents were interested in attending a communications continuing education course. Tables 2 and 3 display the percentage distribution for each of the five possible Likert-scale responses and the mean response score for each of the 17 communications techniques grouped into five domains for family physicians and pediatricians, respectively. The first seven techniques are grouped into the "Interpersonal communication" and "Teach-back methods" domains, and are considered to be the basic communications techniques that every health provider should routinely use. Family physicians reported routinely using on average 6.6 of the 17 total techniques and 3.3 of the seven basic techniques, whereas pediatricians reported routinely using 6.4 and 3.2 techniques, respectively (data not shown). The frequency of use varied considerably across the 17 techniques and five domains. The use of simple language was the only basic technique that was routinely used (used "always" or "most of the time") by nearly all of the respondents (Family physicians, 91%; Pediatricians, 93%) and the technique with the highest mean Likert-scale score (Family physicians, 4.27; Pediatricians, 4.23). Limiting the number of concepts presented, speaking slowly, and writing or printing out instructions were other techniques routinely used by at least 60% of family physicians and pediatricians. Table 4 shows the physicians' perceived effectiveness of the communications techniques. Using simple language was the technique that both family physicians and pediatricians thought was most effective (family physicians, 81.36%; pediatricians, 85.63%). Limiting the number of concepts, asking patients to repeat back information, writing/printing out instructions, and using a translator/interpreter were techniques that approximately 70% or more family physicians and pediatricians thought were effective. Additionally, about 70% of pediatricians also thought that drawing pictures/using printed illustrations and speaking slowly were effective techniques. Physicians were most unsure about the effectiveness of using videos/DVDs (family physicians, 77.36%; pediatricians, 75%). Over half of family physicians were also unsure about the effectiveness of using models and x-rays to explain health issues and referring patients to the internet or other sources of information, while over half of pediatricians were unsure about the effectiveness of asking their patients if they would like a family member to accompany them and referring patients to the internet or other sources of information.

Variables associated with routine use of communications techniques
Bivariate analysis of the routine use of communication techniques according to provider and practice characteristics are displayed in Tables 5 and 6. Family physicians that had taken a communications course outside of medical school used significantly more of the 17 recommended communications techniques on average than those who had not (7.71 vs. 5.50; P<0.01). The mean number of 17 and seven basic techniques did not differ significantly by other provider or practice characteristics for family physicians. For pediatricians, a significant association was observed between year of graduation and the mean number of techniques used. Pediatricians that graduated prior to 1980 or after 1999 reported using significantly more of the 17 and basic techniques on average than those Finally, a significantly greater mean number of techniques were observed in pediatricians that had assessed their office for user-friendliness than those who had not (P0.001). All pediatrician practice characteristics showed a significant association with the mean number of both the 17 and the seven basic techniques used. A significantly higher mean score was observed as the percentage of pediatricians' child patients on Medicaid increased (P <0.05). Additionally, pediatricians who practiced in settings other than group or solo practices (i.e.: public health, hospital, other) and those who had an occupation other than a private practitioner reported significantly greater mean use of the 17 total and the seven basic communication techniques. Tables 7 and 8 present results from the ordinary least squares regression analysis with communication techniques as the dependent variable. The observed results were generally in-line with the associations observed in the bivariate regression analysis, with some additional information provided. As seen in the bivariate analysis, family physicians who had taken a communications course were more likely to use the 17 techniques than those who did not (P<0.01). Family physicians with less than 26% of their child patients on Medicaid were significantly less likely to use the 17 techniques and the seven basic techniques compared to those providers who had greater than 75% of their patient population on Medicaid (P<0.05).
In agreement with what was observed in the bivariate analysis, pediatricians who had taken a communications course or assessed their office for user-friendliness were more likely to use the 17 techniques and the seven basic techniques than those providers who had not. Likewise, pediatricians with less than 26% of their child patients on Medicaid were less likely to use the 17 techniques and seven basic techniques than those who had greater than 75% of their patient population on Medicaid (P0.01 and P0.001, respectively). Pediatricians in practice settings other than solo or group practices were more likely to use the recommended communications techniques than their counterparts, as were pediatricians who had an occupation other than a private practitioner.

Routine use of communication techniques
The AMA and health literacy experts have recommended 17 techniques that physicians can use to improve communication with their patients [11]. Similar to previous studies, this study found that many of these communication techniques were under-utilized by Maryland physicians [11,15,16]. Family physicians and pediatricians make up a large majority of primary care providers in the U.S., and although slight differences were observed, overall the two groups of physicians in this study were similar in their low, routine use of many of the recommended communication techniques. The use of simple language was the technique that both groups of physicians in this study used most routinely and felt was most effective. Using simple language and avoiding jargon has been previously demonstrated to have a high utility amongst physicians [11]. While it is encouraging to see that many physicians focus on using simple language, previous research has also found that physicians tend to underestimate their use of jargon during patient encounters even if unknowingly [16]. This study relied on self-report on use rather than direct observation, so there was no way to objectively determine how 'effectively' these techniques were delivered. Future studies should consider not only evaluating the use of these techniques, but also whether these communication techniques were used effectively. A concerning finding was that only approximately 30% of both family physicians and pediatricians in this study routinely used the 'teach-back methods' of asking patients to repeat back information and asking patients to tell them what they will do at home to follow instructions. This finding is important because 'teach-back methods', which assess patients' understanding of information received by having them repeat it, are strategies that the Institute for Healthcare Improvement and health literacy experts recommend all healthcare providers use [22]. The low routine use comes in spite of the fact that over 60% of physicians in the sample felt that these teach-back techniques were effective. Additionally, many physicians were unsure of the effectiveness of several of the recommended techniques, which could suggest that physicians are unaware of valuable skills that could enhance their communication. Taken together, these findings suggest that provider communication skills should receive a higher priority in the medical and residency training process, including continuing medical education course offerings; so that physicians have the opportunity to more regularly utilize and refine these skills over the course of their careers, thereby making them more likely to use them in practice settings.

Factors affecting use of communication techniques
Both pediatricians and family physicians in this study who had taken a communications course used more communications techniques than their counterparts. This finding provides additional support for increasing physicians' exposure to communications training as a way to increase their utilization of communication techniques. The physicians with a high percentage of patients on Medicaid were also more likely to use the recommended communications techniques (total and seven basic) than those physicians with a low percentage of patients on Medicaid. Additionally, pediatricians who served in non-private practice settings (i.e. public health centers, hospitals) were more likely to use recommended communication techniques than their counterparts. This is a positive finding given that health literacy has been observed to be lower amongst underserved individuals [3]. Physicians may naturally place a greater emphasis on communicating effectively with underserved populations, however, it is important for physicians to realize how pervasive low health literacy is for many different segments of the population [3]. If physicians were more aware of the preponderance of low health literacy in the population and its effects on patient outcomes, they may be more motivated to utilize effective communication techniques for all patients as a regular part of their practice. As part of communications training, physicians should also be made aware of the prevalence of low health literacy in the population and its negative effects on health outcomes [5][6][7][8][9].

Study limitations
There are important limitations in this study. Although the 20% response rate in this study is typical of many mailed surveys to healthcare providers [23], it likely introduced some selection bias into the study, where participating physicians' responses may not reflect the views of nonresponders. Providers who participated in this study were likely to be more interested in the study topic than those who did not, and information on the characteristics of non-responders could not be obtained. Another limitation of this study was the use of a self-reported questionnaire to determine physicians' communication practices as opposed to using direct observation to validate communication. Although physicians may over-estimate their use of recommended communications techniques, using a validated survey allowed for greater study efficiency and the analysis of a larger sample size. Despite the limitations, this study provides strong baseline data that can be used to develop and implement educational interventions and policies in Maryland aimed at enhancing provider communication.

Conclusions
The purpose of this study was to determine the use of recommended communication techniques by family physicians and pediatricians in Maryland. Overall, and in agreement with previous studies, the use of communication techniques by physicians in the study sample was low [11,15,16], however, those physicians with additional communications training (i.e. those who had taken a communications course) used more techniques than those who had not. The benefits of effective communication have been well documented [12][13][14]. Additionally, because of the wide range of patients that family physicians and pediatricians see, these providers have the opportunity to communicate and promote other aspects of their patients' health such as oral health, making their effective communication especially important [18,19].
One way to help achieve the Healthy People 2020 objective of increasing satisfactory communication by providers, would be to increase the priority of communications training in the medical education process [2]. Potential ways to incorporate more communications training could include: having trained faculty provide more observation and feedback of medical students' communication with patients during their clinical years (years 3 and 4); having a greater focus on the Accreditation Council for Graduate Medical Education (ACGME)-required interpersonal and communication competency during residency training through the use of patient and faculty feedback; and incorporating required continuing medical education in communication as part of the maintenance of certification [2]. As the focus on patient-centered care in the U.S. increases, the need for effective provider communication will become even more essential. Incorporating this skill into the life-long learning process of physicians and other health care providers will help to ensure that they are properly trained in this important aspect of patient care.
Supporting Information S1 Document. Physician Survey. This is a modified questionnaire that was used to survey the Family physicians and Pediatricians in this study on their communication practices. This survey also captures Provider and Practice demographic information. Because this survey was used for a larger study that included dental caries prevention, only the questions pertaining to provider communication are included (the questions related to dental caries prevention have been removed). Each question corresponds to a variable in the databases. Both Family physicians and Pediatricians used the exact same questionnaire in this study. (DOCX) S1 Dataset. Family Physicians Dataset. This is the dataset that contains the data collected from Family physicians using the Physician Survey. The variables in the dataset begin with a Q followed by a number, which corresponds to the specific question in the Physician survey. Some questions contain sub-questions, and these corresponding variables contain an underscore after the question number followed by a number/letter to denote the sub-question. Furthermore, for Question 12 on the Physician Survey, participants answered a) How often they use communication techniques, and b) Do they think it is effective, which are denoted by an "a" or "b" in the variable. The values of the variables in the dataset correspond to the numbers listed next to the answer choices on the Physician Survey. (XLS) S2 Dataset. Pediatricians Dataset. This is the dataset that contains the data collected from Pediatrician using the Physician Survey. The variables in the dataset begin with a Q followed by a number, which corresponds to the specific question in the Physician Survey. Some questions contain sub-questions, and these corresponding variables contain an underscore after the question number followed by a number/letter to denote the sub-question. Furthermore, for Question 12 on the Physician Survey, participants answered a) How often they use communication techniques, and b) Do they think it is effective, which are denoted by an "a" or "b" in the variable. The values of the variables in the dataset correspond to the numbers listed next to the answer choices on the Physician Survey. (XLS)