Patient Barriers

Most patients want to avoid the discomfort and costs associated with chronic disease, yet providers struggle to get patients to follow their advice on how to prevent or effectively manage these disorders. Motivation is a determining factor in the successful implementation of patient education and a health care plan. Some patients receive the teaching that is provided and implement it successfully; however, many do not. It is common for providers to seek innovative ways to inspire and motivate patients. In the past, fear tactics were used as the primary tool to motivate patients. Fear works for some people, but for many, it isn’t enough to inspire action. Fear can lead patients to develop attitudes of denial, avoidance, or hopelessness.

Motivation is an intrinsic quality that is difficult to influence. The stages of change model developed by Feldman allows the provider to assess where the patient is in her willingness to implement a change in behavior. Using this model allows providers to identify which patients are ready and motivated to make a change and which patients need more information and encouragement.

Feldman’s stages are precontemplation, contemplation, preparation, maintenance, and relapse. These stages can be applied in any situation during which a provider is asking a patient to make a behavioral change. Smoking cessation counseling is used as an example here.

A patient in the precontemplation stage is aware that smoking is bad for him or her but will either dismiss the problem or deny it. This patient might resist change by using an example of someone he or she knows who smoked his or her whole life and never became unwell. This patient is not motivated or willing to make a change yet.

In the contemplation stage , the patient is more aware of the problem, may begin to articulate a desire to quit smoking, and understands some of the benefits of doing so. This patient will weigh the desire to change against the perceived benefits of continuing to smoke. A patient in the contemplation stage might make a few attempts at change, but these efforts are often inconsistent and short-lived.

During the preparation stage , the patient is ready to commit to making a change. In this stage, the patient who smokes is willing to set a quit date. The patient has not yet implemented any changes but exhibits a willingness to do so.

Patients in the action stage are actively engaged in executing behavioral change. The patient has reached his or her preestablished quit date and is using a provider-recommended plan of action to successfully avoid smoking. This stage requires daily effort to maintain the change to avoid smoking.

When the patient reaches the maintenance stage, the implemented behavioral change has become a habit. The patient may not need to use daily strategies to feel like he or she is able to maintain a smoke-free life. During this stage, the change begins to feel more integrated into normal life. The final stage is relapse , which is exactly as it sounds. This is when the patient begins to smoke again after a period of success. Not all patients will relapse. Feldman’s model, however, encourages both patients and providers to anticipate and plan for what will happen if relapse occurs.

Physician assistants who take the time to assess where the patient’s willingness to change can tailor the message to the patient in a way that encourages him to move toward the action and maintenance stages. For example, if a patient is solidly in the precontemplation stage, the provider should not see the task as impossible and avoid the conversation with the patient about smoking cessation. Conversely, it would be premature for the provider to attempt to engage the patient in a plan of action for smoking cessation because the patient is not yet ready for this step. Instead, the PA should engage the patient in a conversation targeted at moving the patient from the precontemplation stage to the contemplation stage. The provider should use the time to understand the patient’s concerns and correct any misperceptions the patient might have. The provider should always encourage the patient to let the provider know when he might want to talk about making a change. Similar provider strategies exist for each stage, which are designed to increase and encourage patient readiness for change ( Table 23.1 ).

Patients give many reasons for their previous failed attempts to change behavior or their current unwillingness to attempt change. Common reasons include lack of time, lack of family support, level of difficulty, cost, time of high stress, and lack of resources. If two similar patients want to start an exercise program, both of whom are in the preparation stage but have similar barriers such as stressful jobs, lack of time, and no gym access, why is one successful and the other unsuccessful? Patients have belief systems that influence their faith in their ability to overcome obstacles. These barrier-beliefs create rationalizations and excuses that undermine a patient’s ability to succeed. Ultimately, if these rationalizations and excuses are not managed by the health care provider and the patient together, the patient will give up on change. Barrier beliefs are created by the patient’s past experiences and perceptions and can be divided into three distinct categories: attributions, self-efficacy, and negative outcome expectations. For a provider to successfully encourage patients to adhere to treatment plans, these three elements should be considered.

Attributions are the reasons a patient uses to explain her lack of success in implementing a change or a strategy. It is human nature to ascribe meaning and reasoning to an undesirable behavior or outcome. These attributions can be factual, interpreted, and even implausible. For example, if a patient is asked to take a medication for hypertension every day, he or she may use the following attributions to explain why he or she is unable to do so. Factual: “I cannot afford the medication.” Interpreted: “Taking medication every day will be too many chemicals for my body to handle.” Implausible (or misinformed): “Lowering my blood pressure will make my heart have to work harder to get blood to my feet, so it will wear out my heart if I take this medication.” The type of attribution used by the patient will direct the PA’s response.

Self-efficacy is the patient’s belief that she is capable of completing an action or meeting a goal. Self-efficacy is often the decisive factor in determining success or failure. If one patient believes he or she can exercise on a regular basis, then that patient will overcome her busy schedule and lack of gym membership. However, if the patient does not believe she is capable of exercising on a regular basis, the barriers will prevent the patient from achieving her goal. Many factors influence a person’s self-efficacy: previous failures or successes, other people’s failures or successes, other people’s opinions regarding their ability to succeed, low self-esteem, or knowledge about the steps needed to achieve the goal.

Negative outcome experiences are beliefs that implementing change will precipitate an undesirable outcome. These outcomes could be social, physical, or monetary. For example, dieters may have one of the following reasons for not dieting. Social: “My family won’t eat the healthy food I make, and it is important that we eat the same foods.” Physical: “I feel tired in the afternoons when I eat healthy so I have to eat more.” Monetary: “Healthy food is really expensive, and the food spoils so quickly. I can’t afford to do this.”

Health care providers must consider these dynamics when counseling their patients. If the provider does not account for a patient’s willingness to change and the patient’s belief in his or her ability to make a change, the provider cannot tailor the message to the patient to give the greatest opportunity for long-term success. Without tailored education, the patient is less likely to succeed.

Provider Barriers

Physician assistants may also encounter personal barriers that can limit the potential for effective patient education. One of the most frequently cited barriers for providers is a lack of time. Providers are asked to accomplish much in the brief span of an office visit. Health information is complex. When faced with limited time, PAs may provide partial information, rush the delivery of information, or choose not to provide the information at all. PAs may eliminate patient education as a part of a patient encounter because of a developed sense that education is a waste of time and does not result in appreciable change. Providers who do not develop the skills to overcome patient education barriers will find patient education frustrating and perhaps even pointless.

Some PAs may think that they are not qualified to teach patients. Although PAs spend much of their education learning clinical medicine, the training they receive tailored specifically to teaching and educating patients is less extensive. PAs may believe they lack detailed knowledge of rarer diagnoses and feel inadequate to teach the patient about these diseases and their management. Providers should develop a set of readily available resources to overcome this barrier.

Another barrier to effective patient communication is the tendency by some providers to speak in medical jargon. Patients often feel uncomfortable interrupting a provider to say that he or she did not understand a term or phrase. Patients often simply nod and agree with the provider to hide their lack of understanding. Patients feel frustrated that they were not able to get the information they so badly need out of the encounter. Providers should monitor their own speech and ensure they are using lay terms when speaking with patients. Asking the patient to explain the concept back to the provider is an effective way to assess the patient’s understanding of the information given during the encounter.

Providers are often frustrated by the difficulties patients have in recalling crucial health information provided at the visit. Even if the provider has accounted for the potential barriers to communication, research suggests that a patient will only remember a maximum of seven new pieces of information from each visit. Providers commonly err by giving too much information during a single patient encounter. Less is more. Too much information overwhelms the patient, which inhibits both understanding and recall. Providers must develop the ability to prioritize information and structure the presentation of new information logically to help the patient retain the most crucial messages from the visit.

Health Literacy

Health literacy is the degree to which a patient has the ability to obtain, communicate, process, and understand health information and services to make informed health decisions. Improving health literacy should begin with identifying the barriers to effective communication with a particular patient. Common health literacy barriers include:

• 1.
  

  The patient does not speak English.

  
  
• 2.
  

  The patient has never learned to read or reads poorly in any language.

  
  
• 3.
  

  The patient does not have sufficient numeracy to be able to manage medications or complete self-management charts.

  
  
• 4.
  

  The patient does not know the basics of how the body works.

  
  
• 5.
  

  The patient has limited education and does not understand how the scientific process is applied to diagnosis and treatment in medicine.

  
  
• 6.
  

  The patient does not understand statistics, probability, or the concepts of risk that are used in medical decision making.

  
  
• 7.
  

  The patient does not have access to a computer or does not know how to use a computer.

As PAs, it is our job to identify patients who may have health literacy struggles and provide them the information in a way that is accessible to them. Effective strategies to overcome health literacy barriers include:

• 1.
  

  Choose the essential information that the patient must have today, and discuss only those topics. Schedule the patient for another visit soon to give them further information. The more information you give the patient, the less likely he or she is to retain any of it. Dole it out in small pieces for easy digestion.

  
  
• 2.
  

  Use translators and translated materials with non–English-speaking patients. Translators (or use of a phone translation line) are required by law in the United States. Although providers occasionally use an adult friend or family member to help clarify the discussion with a limited English speaker, it is never appropriate to use a child for translation or clarification.

  
  
• 3.
  

  Write all patient handouts at the third grade level or below. Most commercially available word processing software includes tools for assessing the grade level of the handout. Even better educated people benefit from simple and clearly written health information.

  
  
• 4.
  

  Always use pictures that demonstrate the proper way to do something. Never use pictures that demonstrate the improper way to perform a skill. Patients who cannot read may confuse the two.

  
  
• 5.
  

  If possible, schedule a double appointment for patients who struggle with one or more health literacy challenges to allow you more time for your discussion. Use this extra time to ask the patient to explain what you have just said back to you to assess their level of comprehension.

  
  
• 6.
  

  Explain concepts of risk with drawings. For example, show patients what 1 in 10 means by drawing 9 people with a blue marker and one person with a red marker.

  
  
• 7.
  

  Ask patients if they have a computer, if they know how to use a computer, or if they have a tech-savvy friend to help them with a computer before you refer them to online education or self-management resources. Giving a URL to patients who do not have or cannot access a computer is the same as giving them no information at all.