The Physician’s Role in Educating Patients: A Comparison of Mailed Versus Physician-Delivered Patient Education

Patients appear to be most satisfied when they consider the physician a partner in the exchange of information rather than an authority who controls the relationship.¹ Also, patient satisfaction is strongly associated with the quantity and quality of the educational information provided by physicians.^2-5 In a study of the relationship between patient satisfaction and health education, patients were significantly more likely to be satisfied with their physician if the physician had discussed one or more health education topics with them in the past 3 years.²

Patients’ needs for health education, however, continue to be unmet.⁶ A primary complaint of those dissatisfied with care is the inadequate level of information provided by their physicians.⁷ Indeed, there are documented discrepancies between what patients value and what physicians think is important during routine office visits.^8-10 We examined whether an increased physician role in educating patients is an effective means of improving patient satisfaction.

Advising physicians that their patients prefer more education and counseling will not increase the likelihood that they will provide such information.^11,12 A recent study concerning the physician’s role in patient education illustrates a gap between physician and patient expectations. Laine and colleagues10 demonstrated that although physicians’ and patients’ opinions were similar in describing the importance of many aspects of care, they were dissimilar in their evaluation of the importance of the communication of health-related information. Patients ranked the importance of receiving information much higher than did the physicians.

Self-care education programs have traditionally been delivered directly to patients as a way to offer standardized consumer information about the self-management of common health problems.^13-16 Because self-care education programs bypass the physician, little is known about the effect of self-care education on patient satisfaction and physician-patient communications.^17-19 Most studies of self-care education focus on use rather than patient satisfaction.^20-26 Relatively little is known about the value of the self-care education that is provided by the physician or any subsequent effect on patient satisfaction with physician-patient communication.^27-29

The purpose of our study was to compare patient satisfaction with the self-care information delivered by traditional direct-mail approaches with that provided by physicians during routine office visits. These 2 approaches to information distribution were compared with a control group of patients receiving usual care.

The selected self-care book, Well-Advised: A Practical Guide to Everyday Health Decisions,³⁰ includes more than 100 topics and provides home remedies, advice for dealing with children’s symptoms, and information about when to call the physician. It was written by health educators in cooperation with professional writers. It was reviewed and approved by more than 150 physicians from family practice, internal medicine, pediatrics, and other specialties.

We hypothesized that patients receiving self-care education from their physicians would be more satisfied with their physician-patient communication than those who either received the education materials in the mail or experienced only usual care. In addition, we believed patients receiving self-care education during their office visits would be more satisfied with the information than with those who received it in the mail.

Methods

Setting

We conducted this study at the Park Nicollet Clinic, HealthSystem Minnesota, an outpatient multispecialty clinic within a vertically integrated health care system, from November to December 1997. The Park Nicollet Clinic employs more than 400 physicians and has 15 clinic sites that provide primary care in Minneapolis and its suburbs. For our study, we selected 4 clinic sites according to patient volume and demographic characteristics. Those selected included an inner city primary care site with a diverse population and 3 suburban sites with busy primary care practices and relatively homogeneous white middle-class patient populations.

Sample

Using data from a survey for assessing patient satisfaction with their physicians,³¹ we calculated that a sample size of 1000 patients per group would be needed to detect a difference of 2 points on a summary satisfaction scale (a=0.05; power=0.80).

We used an automated scheduling system to identify eligible patients who arranged an office visit with a physician in family practice or general internal medicine. In the 3 clinics that have both internal medicine and family practice physicians, we stratified the sample so there was an equal distribution between the 2 specialties. The fourth clinic had internal medicine physicians only. The sample population resides primarily in the first and second ring suburban communities of a major metropolitan area. People in these communities are predominantly white, well-educated, employed, and have health insurance.

Patients were assigned to 1 of 3 groups, depending on the week that they had an office visit to a particular clinic. The patients in the physician-delivered information group received the Well-Advised book from their physicians during an office visit. Physicians were instructed to explain to patients that the book was based on medical guidelines approved by Park Nicollet Clinic and that using it could prevent unnecessary clinic visits. The physicians encouraged patients to use the book for taking care of common health problems. The patients in the consumer-direct group received Well-Advised at home through the mail, with a letter encouraging them to use the book and the nurse health information telephone line. The patients in the usual-care group did not receive Well-Advised and served as a control group.

Training

Before initiating any interventions, physicians were instructed to introduce the book Well-Advised as an opportunity for patients to play an active role in medical decision making. Health educators introduced our study at staff meetings and provided a written recommended script for physicians to use when offering the self-care book to their patients. Physicians who could not attend the self-care in-service meetings were given the written script by their department’s administrator or head nurse.

Study Design

The research design was a nonrandomized controlled study with 2 intervention groups. We used a postintervention questionnaire to test group differences. The 4 test clinics comprised 3 study sites. We considered the 2 smaller clinics one site for purposes of rotating the interventions. For each study period, we designated patients from one site as the physician-delivered self-care education group, a second site as the direct-mail group, and the third site as the usual-care group. The intervention at each site rotated so that each clinic participated in both interventions and the control. The goal was to enroll 1000 patients per study site. The intervention period lasted 1 to 3 weeks depending on site size, with a 1-week break between interventions.

Within 2 weeks of the patients’ visits, questionnaires were mailed to patients’ homes to assess general satisfaction with provider communication and specific satisfaction with the self-care materials. The questionnaire was designed to compare the level of satisfaction with variables such as provision of information, physician listening, question answering, explaining, and reviewing of educational materials. Patients were also asked about the value and utility of the Well-Advised book, and their intentions to use it. We combined questionnaire items for the analysis of findings. For categorical variables, we used chisquare to test for significant differences between groups. For continuous variables, we used analysis of variance (ANOVA) to test for differences between groups. Scales that summarized comparable items were developed that combined items related to satisfaction with the physician into one category and satisfaction with the self-care book into another category.

Results

We enrolled a total of 2954 patients in our study. Of these, 2140 (72.4%) returned surveys. Table 1 shows the demographics of respondents compared with nonrespondents. As is typical for patient satisfaction surveys, respondents were more likely to be women and older. Younger men were underrepresented. There were no significant differences in response rates across study sites or between departments.

Patients who received self-care information from their physicians were significantly more satisfied with their care and with their physician-patient communication experience than those in either the direct-mail group or the control group. There were no significant differences between the control group and the direct-mail group. The physician-delivered information group also rated the overall quality of care significantly higher than the other groups. In the majority of measures, the physician-delivered information group was significantly more satisfied with the clinical visit. Using a 5-point scale (where 1=strongly disagree; 5=strongly agree), respondents in the physician-delivered information group were significantly more likely to agree that the physician spent enough time with them, explained things clearly, and listened to what they were saying. Those in the physician-delivered information group were also significantly more likely to agree that the physician provided information so they could make decisions about their own care. Receiving the book from the physician also increased patients’ perception that the physician answered their questions and was concerned about them as patients. Not surprisingly, this group was significantly more likely to agree that the physician reviewed educational material with them. Table 2 shows individual comparisons of patient satisfaction with the physician interaction. There was no significant difference among the groups as to whether the patients believed the Well-Advised book offered a credible resource for making health decisions; the large majority agreed that the book was a credible source.

Discussion

Our study suggests that providing a self-care book during routine office visits substantially enhances satisfaction with physician-patient communication. The more commonly used approach of sending self-care education materials directly to consumers misses the opportunity to use self-care education to improve the physician-patient relationship.

Patients want to participate in their own health care more actively with their physicians. Ninety percent of patients want to receive written educational materials from their medical providers, and most read and save them.²⁵ When patients are expected to pay a greater share of costs in the future, they will expect greater value from each visit, and educational materials can play a role in increasing such value. Although the Well-Advised book increased satisfaction with physician communications, having the physician distribute the book did not increase the value of the book to the patient. This observation is pertinent, given recent evidence that medical self-care books are a primary source of health information across communities.³² Using the physician as a self-care educator increases the value of the physician visit and complements the value of such books already used in the community.

Limitations

Our study has 2 noteworthy limitations. First, because our intervention was directed at patients visiting the physician, we can draw no conclusions about the value of self-care education to the general population. It is fair to speculate, however, that self-care information is as important for other patients who visit their physicians. Second, we did not try to assess a Hawthorne effect from book distribution by offering the control group a comparable intervention. It is possible that increased satisfaction was related to receiving a nice new book at the visit rather than to the educational aspects of the intervention. We cannot assess the extent to which book distribution merely served as a prompt for increased attention by the physician to the educational needs presented by the patient. There are any number of non–education-related prompts that could trigger increased physician-patient communication.

Conclusions

Since our physician-distributed intervention group showed significantly higher satisfaction than either the control group or direct-mail distribution group, it is unlikely that the book alone explains increased satisfaction. Other studies have established a link between patient satisfaction with care and patient education.^3,4,6,33 In our study, it is difficult to separate the benefits of receiving the book from the patient education about self care delivered by the physician. It may be instructive to compare the effects of physician-delivered self-care education with satisfaction with physician messages that are not related to self-care. For example, a study could compare self-care education with information that helps the patients review their medical bills. In addition, a planned analysis of patient utilization practices during the year following this intervention should provide relevant information about the impact of the book on subsequent self-care related visits—whether delivered with or without physician education.

Our findings lend support to the growing evidence that informed patients are more satisfied with their care. Patient satisfaction is related to adherence to therapy and, consequently, better treatment results.^24,25,34,35 The simple, relatively inexpensive practice of educating patients is an effective but underused method of improving physician-patient communication. Further research is needed to understand the barriers to physician-based patient education and to assess the effectiveness of using other health care providers to provide patient information.

Acknowledgements

Our research was partially funded through a grant from The Institute for Research and Education, HealthSystem Minnesola. The authors thank Jinnet Fowles, PHD; Elizabeth Kind, MS, RN; Amy Lennartson; and Susan Adlis, MS, for their assitance in editing and reviewing this paper.

Patients appear to be most satisfied when they consider the physician a partner in the exchange of information rather than an authority who controls the relationship.¹ Also, patient satisfaction is strongly associated with the quantity and quality of the educational information provided by physicians.^2-5 In a study of the relationship between patient satisfaction and health education, patients were significantly more likely to be satisfied with their physician if the physician had discussed one or more health education topics with them in the past 3 years.²

Patients’ needs for health education, however, continue to be unmet.⁶ A primary complaint of those dissatisfied with care is the inadequate level of information provided by their physicians.⁷ Indeed, there are documented discrepancies between what patients value and what physicians think is important during routine office visits.^8-10 We examined whether an increased physician role in educating patients is an effective means of improving patient satisfaction.

Advising physicians that their patients prefer more education and counseling will not increase the likelihood that they will provide such information.^11,12 A recent study concerning the physician’s role in patient education illustrates a gap between physician and patient expectations. Laine and colleagues10 demonstrated that although physicians’ and patients’ opinions were similar in describing the importance of many aspects of care, they were dissimilar in their evaluation of the importance of the communication of health-related information. Patients ranked the importance of receiving information much higher than did the physicians.

Self-care education programs have traditionally been delivered directly to patients as a way to offer standardized consumer information about the self-management of common health problems.^13-16 Because self-care education programs bypass the physician, little is known about the effect of self-care education on patient satisfaction and physician-patient communications.^17-19 Most studies of self-care education focus on use rather than patient satisfaction.^20-26 Relatively little is known about the value of the self-care education that is provided by the physician or any subsequent effect on patient satisfaction with physician-patient communication.^27-29

The purpose of our study was to compare patient satisfaction with the self-care information delivered by traditional direct-mail approaches with that provided by physicians during routine office visits. These 2 approaches to information distribution were compared with a control group of patients receiving usual care.

The selected self-care book, Well-Advised: A Practical Guide to Everyday Health Decisions,³⁰ includes more than 100 topics and provides home remedies, advice for dealing with children’s symptoms, and information about when to call the physician. It was written by health educators in cooperation with professional writers. It was reviewed and approved by more than 150 physicians from family practice, internal medicine, pediatrics, and other specialties.

We hypothesized that patients receiving self-care education from their physicians would be more satisfied with their physician-patient communication than those who either received the education materials in the mail or experienced only usual care. In addition, we believed patients receiving self-care education during their office visits would be more satisfied with the information than with those who received it in the mail.

Methods

Setting

We conducted this study at the Park Nicollet Clinic, HealthSystem Minnesota, an outpatient multispecialty clinic within a vertically integrated health care system, from November to December 1997. The Park Nicollet Clinic employs more than 400 physicians and has 15 clinic sites that provide primary care in Minneapolis and its suburbs. For our study, we selected 4 clinic sites according to patient volume and demographic characteristics. Those selected included an inner city primary care site with a diverse population and 3 suburban sites with busy primary care practices and relatively homogeneous white middle-class patient populations.

Sample

Using data from a survey for assessing patient satisfaction with their physicians,³¹ we calculated that a sample size of 1000 patients per group would be needed to detect a difference of 2 points on a summary satisfaction scale (a=0.05; power=0.80).

We used an automated scheduling system to identify eligible patients who arranged an office visit with a physician in family practice or general internal medicine. In the 3 clinics that have both internal medicine and family practice physicians, we stratified the sample so there was an equal distribution between the 2 specialties. The fourth clinic had internal medicine physicians only. The sample population resides primarily in the first and second ring suburban communities of a major metropolitan area. People in these communities are predominantly white, well-educated, employed, and have health insurance.

Patients were assigned to 1 of 3 groups, depending on the week that they had an office visit to a particular clinic. The patients in the physician-delivered information group received the Well-Advised book from their physicians during an office visit. Physicians were instructed to explain to patients that the book was based on medical guidelines approved by Park Nicollet Clinic and that using it could prevent unnecessary clinic visits. The physicians encouraged patients to use the book for taking care of common health problems. The patients in the consumer-direct group received Well-Advised at home through the mail, with a letter encouraging them to use the book and the nurse health information telephone line. The patients in the usual-care group did not receive Well-Advised and served as a control group.

Training

Before initiating any interventions, physicians were instructed to introduce the book Well-Advised as an opportunity for patients to play an active role in medical decision making. Health educators introduced our study at staff meetings and provided a written recommended script for physicians to use when offering the self-care book to their patients. Physicians who could not attend the self-care in-service meetings were given the written script by their department’s administrator or head nurse.

Study Design

The research design was a nonrandomized controlled study with 2 intervention groups. We used a postintervention questionnaire to test group differences. The 4 test clinics comprised 3 study sites. We considered the 2 smaller clinics one site for purposes of rotating the interventions. For each study period, we designated patients from one site as the physician-delivered self-care education group, a second site as the direct-mail group, and the third site as the usual-care group. The intervention at each site rotated so that each clinic participated in both interventions and the control. The goal was to enroll 1000 patients per study site. The intervention period lasted 1 to 3 weeks depending on site size, with a 1-week break between interventions.

Within 2 weeks of the patients’ visits, questionnaires were mailed to patients’ homes to assess general satisfaction with provider communication and specific satisfaction with the self-care materials. The questionnaire was designed to compare the level of satisfaction with variables such as provision of information, physician listening, question answering, explaining, and reviewing of educational materials. Patients were also asked about the value and utility of the Well-Advised book, and their intentions to use it. We combined questionnaire items for the analysis of findings. For categorical variables, we used chisquare to test for significant differences between groups. For continuous variables, we used analysis of variance (ANOVA) to test for differences between groups. Scales that summarized comparable items were developed that combined items related to satisfaction with the physician into one category and satisfaction with the self-care book into another category.

Results

We enrolled a total of 2954 patients in our study. Of these, 2140 (72.4%) returned surveys. Table 1 shows the demographics of respondents compared with nonrespondents. As is typical for patient satisfaction surveys, respondents were more likely to be women and older. Younger men were underrepresented. There were no significant differences in response rates across study sites or between departments.

Patients who received self-care information from their physicians were significantly more satisfied with their care and with their physician-patient communication experience than those in either the direct-mail group or the control group. There were no significant differences between the control group and the direct-mail group. The physician-delivered information group also rated the overall quality of care significantly higher than the other groups. In the majority of measures, the physician-delivered information group was significantly more satisfied with the clinical visit. Using a 5-point scale (where 1=strongly disagree; 5=strongly agree), respondents in the physician-delivered information group were significantly more likely to agree that the physician spent enough time with them, explained things clearly, and listened to what they were saying. Those in the physician-delivered information group were also significantly more likely to agree that the physician provided information so they could make decisions about their own care. Receiving the book from the physician also increased patients’ perception that the physician answered their questions and was concerned about them as patients. Not surprisingly, this group was significantly more likely to agree that the physician reviewed educational material with them. Table 2 shows individual comparisons of patient satisfaction with the physician interaction. There was no significant difference among the groups as to whether the patients believed the Well-Advised book offered a credible resource for making health decisions; the large majority agreed that the book was a credible source.

Discussion

Our study suggests that providing a self-care book during routine office visits substantially enhances satisfaction with physician-patient communication. The more commonly used approach of sending self-care education materials directly to consumers misses the opportunity to use self-care education to improve the physician-patient relationship.

Patients want to participate in their own health care more actively with their physicians. Ninety percent of patients want to receive written educational materials from their medical providers, and most read and save them.²⁵ When patients are expected to pay a greater share of costs in the future, they will expect greater value from each visit, and educational materials can play a role in increasing such value. Although the Well-Advised book increased satisfaction with physician communications, having the physician distribute the book did not increase the value of the book to the patient. This observation is pertinent, given recent evidence that medical self-care books are a primary source of health information across communities.³² Using the physician as a self-care educator increases the value of the physician visit and complements the value of such books already used in the community.

Limitations

Our study has 2 noteworthy limitations. First, because our intervention was directed at patients visiting the physician, we can draw no conclusions about the value of self-care education to the general population. It is fair to speculate, however, that self-care information is as important for other patients who visit their physicians. Second, we did not try to assess a Hawthorne effect from book distribution by offering the control group a comparable intervention. It is possible that increased satisfaction was related to receiving a nice new book at the visit rather than to the educational aspects of the intervention. We cannot assess the extent to which book distribution merely served as a prompt for increased attention by the physician to the educational needs presented by the patient. There are any number of non–education-related prompts that could trigger increased physician-patient communication.

Conclusions

Since our physician-distributed intervention group showed significantly higher satisfaction than either the control group or direct-mail distribution group, it is unlikely that the book alone explains increased satisfaction. Other studies have established a link between patient satisfaction with care and patient education.^3,4,6,33 In our study, it is difficult to separate the benefits of receiving the book from the patient education about self care delivered by the physician. It may be instructive to compare the effects of physician-delivered self-care education with satisfaction with physician messages that are not related to self-care. For example, a study could compare self-care education with information that helps the patients review their medical bills. In addition, a planned analysis of patient utilization practices during the year following this intervention should provide relevant information about the impact of the book on subsequent self-care related visits—whether delivered with or without physician education.

Our findings lend support to the growing evidence that informed patients are more satisfied with their care. Patient satisfaction is related to adherence to therapy and, consequently, better treatment results.^24,25,34,35 The simple, relatively inexpensive practice of educating patients is an effective but underused method of improving physician-patient communication. Further research is needed to understand the barriers to physician-based patient education and to assess the effectiveness of using other health care providers to provide patient information.

Acknowledgements

Our research was partially funded through a grant from The Institute for Research and Education, HealthSystem Minnesola. The authors thank Jinnet Fowles, PHD; Elizabeth Kind, MS, RN; Amy Lennartson; and Susan Adlis, MS, for their assitance in editing and reviewing this paper.

Patients appear to be most satisfied when they consider the physician a partner in the exchange of information rather than an authority who controls the relationship.¹ Also, patient satisfaction is strongly associated with the quantity and quality of the educational information provided by physicians.^2-5 In a study of the relationship between patient satisfaction and health education, patients were significantly more likely to be satisfied with their physician if the physician had discussed one or more health education topics with them in the past 3 years.²

Patients’ needs for health education, however, continue to be unmet.⁶ A primary complaint of those dissatisfied with care is the inadequate level of information provided by their physicians.⁷ Indeed, there are documented discrepancies between what patients value and what physicians think is important during routine office visits.^8-10 We examined whether an increased physician role in educating patients is an effective means of improving patient satisfaction.

Advising physicians that their patients prefer more education and counseling will not increase the likelihood that they will provide such information.^11,12 A recent study concerning the physician’s role in patient education illustrates a gap between physician and patient expectations. Laine and colleagues10 demonstrated that although physicians’ and patients’ opinions were similar in describing the importance of many aspects of care, they were dissimilar in their evaluation of the importance of the communication of health-related information. Patients ranked the importance of receiving information much higher than did the physicians.

Self-care education programs have traditionally been delivered directly to patients as a way to offer standardized consumer information about the self-management of common health problems.^13-16 Because self-care education programs bypass the physician, little is known about the effect of self-care education on patient satisfaction and physician-patient communications.^17-19 Most studies of self-care education focus on use rather than patient satisfaction.^20-26 Relatively little is known about the value of the self-care education that is provided by the physician or any subsequent effect on patient satisfaction with physician-patient communication.^27-29

The purpose of our study was to compare patient satisfaction with the self-care information delivered by traditional direct-mail approaches with that provided by physicians during routine office visits. These 2 approaches to information distribution were compared with a control group of patients receiving usual care.

The selected self-care book, Well-Advised: A Practical Guide to Everyday Health Decisions,³⁰ includes more than 100 topics and provides home remedies, advice for dealing with children’s symptoms, and information about when to call the physician. It was written by health educators in cooperation with professional writers. It was reviewed and approved by more than 150 physicians from family practice, internal medicine, pediatrics, and other specialties.

We hypothesized that patients receiving self-care education from their physicians would be more satisfied with their physician-patient communication than those who either received the education materials in the mail or experienced only usual care. In addition, we believed patients receiving self-care education during their office visits would be more satisfied with the information than with those who received it in the mail.

Methods

Setting

We conducted this study at the Park Nicollet Clinic, HealthSystem Minnesota, an outpatient multispecialty clinic within a vertically integrated health care system, from November to December 1997. The Park Nicollet Clinic employs more than 400 physicians and has 15 clinic sites that provide primary care in Minneapolis and its suburbs. For our study, we selected 4 clinic sites according to patient volume and demographic characteristics. Those selected included an inner city primary care site with a diverse population and 3 suburban sites with busy primary care practices and relatively homogeneous white middle-class patient populations.

Sample

Using data from a survey for assessing patient satisfaction with their physicians,³¹ we calculated that a sample size of 1000 patients per group would be needed to detect a difference of 2 points on a summary satisfaction scale (a=0.05; power=0.80).

We used an automated scheduling system to identify eligible patients who arranged an office visit with a physician in family practice or general internal medicine. In the 3 clinics that have both internal medicine and family practice physicians, we stratified the sample so there was an equal distribution between the 2 specialties. The fourth clinic had internal medicine physicians only. The sample population resides primarily in the first and second ring suburban communities of a major metropolitan area. People in these communities are predominantly white, well-educated, employed, and have health insurance.

Patients were assigned to 1 of 3 groups, depending on the week that they had an office visit to a particular clinic. The patients in the physician-delivered information group received the Well-Advised book from their physicians during an office visit. Physicians were instructed to explain to patients that the book was based on medical guidelines approved by Park Nicollet Clinic and that using it could prevent unnecessary clinic visits. The physicians encouraged patients to use the book for taking care of common health problems. The patients in the consumer-direct group received Well-Advised at home through the mail, with a letter encouraging them to use the book and the nurse health information telephone line. The patients in the usual-care group did not receive Well-Advised and served as a control group.

Training

Before initiating any interventions, physicians were instructed to introduce the book Well-Advised as an opportunity for patients to play an active role in medical decision making. Health educators introduced our study at staff meetings and provided a written recommended script for physicians to use when offering the self-care book to their patients. Physicians who could not attend the self-care in-service meetings were given the written script by their department’s administrator or head nurse.

Study Design

The research design was a nonrandomized controlled study with 2 intervention groups. We used a postintervention questionnaire to test group differences. The 4 test clinics comprised 3 study sites. We considered the 2 smaller clinics one site for purposes of rotating the interventions. For each study period, we designated patients from one site as the physician-delivered self-care education group, a second site as the direct-mail group, and the third site as the usual-care group. The intervention at each site rotated so that each clinic participated in both interventions and the control. The goal was to enroll 1000 patients per study site. The intervention period lasted 1 to 3 weeks depending on site size, with a 1-week break between interventions.

Within 2 weeks of the patients’ visits, questionnaires were mailed to patients’ homes to assess general satisfaction with provider communication and specific satisfaction with the self-care materials. The questionnaire was designed to compare the level of satisfaction with variables such as provision of information, physician listening, question answering, explaining, and reviewing of educational materials. Patients were also asked about the value and utility of the Well-Advised book, and their intentions to use it. We combined questionnaire items for the analysis of findings. For categorical variables, we used chisquare to test for significant differences between groups. For continuous variables, we used analysis of variance (ANOVA) to test for differences between groups. Scales that summarized comparable items were developed that combined items related to satisfaction with the physician into one category and satisfaction with the self-care book into another category.

Results

We enrolled a total of 2954 patients in our study. Of these, 2140 (72.4%) returned surveys. Table 1 shows the demographics of respondents compared with nonrespondents. As is typical for patient satisfaction surveys, respondents were more likely to be women and older. Younger men were underrepresented. There were no significant differences in response rates across study sites or between departments.

Patients who received self-care information from their physicians were significantly more satisfied with their care and with their physician-patient communication experience than those in either the direct-mail group or the control group. There were no significant differences between the control group and the direct-mail group. The physician-delivered information group also rated the overall quality of care significantly higher than the other groups. In the majority of measures, the physician-delivered information group was significantly more satisfied with the clinical visit. Using a 5-point scale (where 1=strongly disagree; 5=strongly agree), respondents in the physician-delivered information group were significantly more likely to agree that the physician spent enough time with them, explained things clearly, and listened to what they were saying. Those in the physician-delivered information group were also significantly more likely to agree that the physician provided information so they could make decisions about their own care. Receiving the book from the physician also increased patients’ perception that the physician answered their questions and was concerned about them as patients. Not surprisingly, this group was significantly more likely to agree that the physician reviewed educational material with them. Table 2 shows individual comparisons of patient satisfaction with the physician interaction. There was no significant difference among the groups as to whether the patients believed the Well-Advised book offered a credible resource for making health decisions; the large majority agreed that the book was a credible source.

Discussion

Our study suggests that providing a self-care book during routine office visits substantially enhances satisfaction with physician-patient communication. The more commonly used approach of sending self-care education materials directly to consumers misses the opportunity to use self-care education to improve the physician-patient relationship.

Patients want to participate in their own health care more actively with their physicians. Ninety percent of patients want to receive written educational materials from their medical providers, and most read and save them.²⁵ When patients are expected to pay a greater share of costs in the future, they will expect greater value from each visit, and educational materials can play a role in increasing such value. Although the Well-Advised book increased satisfaction with physician communications, having the physician distribute the book did not increase the value of the book to the patient. This observation is pertinent, given recent evidence that medical self-care books are a primary source of health information across communities.³² Using the physician as a self-care educator increases the value of the physician visit and complements the value of such books already used in the community.

Limitations

Our study has 2 noteworthy limitations. First, because our intervention was directed at patients visiting the physician, we can draw no conclusions about the value of self-care education to the general population. It is fair to speculate, however, that self-care information is as important for other patients who visit their physicians. Second, we did not try to assess a Hawthorne effect from book distribution by offering the control group a comparable intervention. It is possible that increased satisfaction was related to receiving a nice new book at the visit rather than to the educational aspects of the intervention. We cannot assess the extent to which book distribution merely served as a prompt for increased attention by the physician to the educational needs presented by the patient. There are any number of non–education-related prompts that could trigger increased physician-patient communication.

Conclusions

Since our physician-distributed intervention group showed significantly higher satisfaction than either the control group or direct-mail distribution group, it is unlikely that the book alone explains increased satisfaction. Other studies have established a link between patient satisfaction with care and patient education.^3,4,6,33 In our study, it is difficult to separate the benefits of receiving the book from the patient education about self care delivered by the physician. It may be instructive to compare the effects of physician-delivered self-care education with satisfaction with physician messages that are not related to self-care. For example, a study could compare self-care education with information that helps the patients review their medical bills. In addition, a planned analysis of patient utilization practices during the year following this intervention should provide relevant information about the impact of the book on subsequent self-care related visits—whether delivered with or without physician education.

Our findings lend support to the growing evidence that informed patients are more satisfied with their care. Patient satisfaction is related to adherence to therapy and, consequently, better treatment results.^24,25,34,35 The simple, relatively inexpensive practice of educating patients is an effective but underused method of improving physician-patient communication. Further research is needed to understand the barriers to physician-based patient education and to assess the effectiveness of using other health care providers to provide patient information.

Acknowledgements

Our research was partially funded through a grant from The Institute for Research and Education, HealthSystem Minnesola. The authors thank Jinnet Fowles, PHD; Elizabeth Kind, MS, RN; Amy Lennartson; and Susan Adlis, MS, for their assitance in editing and reviewing this paper.