August 2001 Bulletin

‘Virtual’ visit tests communication skills

‘Standardized’ patient, Internet used to educate physicians in informed decision-making

The discomfort in her hip started about 10 years ago, the gray-haired woman said quietly and paused, waiting for the physician to respond. He encouraged her to continue. "I have stiffness if I sit too long and I ache when I walk a few blocks," she explained. "The pain has become worse in the last year."

The orthopaedic surgeon continued probing, posing questions in the conversational manner of someone genuinely interested in learning how the pain affected her life. "I used to take walks with my grandchildren, but I can’t do that again," she responded, sadly.

No wonder she had pain. Her X-ray showed no joint space in her right hip. The orthopaedist knew she had mild tenderness over her anterior right hip and pain with flexion beyond 100 degrees. Internal rotation was limited by pain beyond 5 degrees, and external rotation was limited by pain beyond 15 degrees.

So there she was, referred by her primary care physician, talking to an orthopaedic surgeon about the possibility of total hip replacement.

But it wasn’t your usual office visit. The woman was a "standardized" patient—someone trained to accurately represent a real patient with a history and symptoms—and the orthopaedist was a trauma surgeon who rarely performs total hip replacements.

What’s more, the patient was in Philadelphia and the orthopaedic surgeon was in the Orthopaedic Learning Center in Rosemont, Ill. They communicated via video over the Internet in what was dubbed a "virtual" office visit.

It was a pilot test to determine if this setting can be used to educate physicians about communication skills—in this case informed decision-making. The project is cosponsored by the AAOS, University of Chicago and MCP-Hahnemann School of Medicine. Developed by Sarah Clever, MD; and Wendy Levinson, MD, a nationally-known expert in patient-physician communications, both of the University of Chicago, the pilot test is one element in the AAOS’s priority efforts to help orthopaedic surgeons improve their communication skills.

The program developed out of a study by Dr. Levinson and colleagues who reviewed audiotapes of physician-patient discussions to determine if the conversations contained elements of informed decision-making, explained Dr. Clever, a Robert Wood Johnson Clinical Scholar. They found a low level of informed decision-making in the physicians’ practices. And while surgeons ranked higher than primary care physicians did, the surgeons’ ranking was still low.

The AAOS has taken up the challenge of helping orthopaedic surgeons improve their skills in engaging patients in a conversation to help the patients make a well-informed decision. The goal of the "virtual" office visit is to measure and give feedback to the physician about his or her informed decision-making skills.

Alan Jones, MD, a 40-year-old trauma orthopaedist at Shock Trauma Hospital, Baltimore, was one of four volunteers taking part in the "virtual" office visit during a recent OLC course. He reviewed slides presenting a brief medical history and the results of a physical examination that Dr. Jones would have done if this were a real office visit. He was asked to spend as much time as he would have with a real patient and to ask the same questions.

Sitting before a TV monitor with a video camera on top, he saw the image of the patient peering back at him. The woman was one of the "standardized" patients who are part of the Hahnemann School of Medicine’s Objective Structured Clinical Experience (OSCE) program to train and test students.

Dr. Jones asked about the background of the patient’s condition, medication and family history. He described hip replacement surgery as one option to treat her pain.

He spoke about recovery and rehabilitation, pointing out that it would take several months for full rehabilitation. He seemed pleased to learn her husband would be home to help her during rehabilitation.

Dr. Jones told her about the upside results—the pain relief—and the downside risks. "This is major surgery and there is a potential for nerve damage and certain risks of anesthesia," he said. "This is not a decision to be made lightly."

He pulled no punches about the outcome. If gardening were her passion in the past, she would not be able to sit on a low seat as she tended her flowers. And she may not be able to resume some of the activities with her grandchildren.

Several times during the visit, Dr. Jones stopped the discussion to ask if the patient understood what he was saying.

When the visit was completed, the patient offered a positive critique. "You told me the decision was up to me and not to rush into surgery," the patient said. "You said this was not an emergency; the surgery could be done later. You told me about the surgery and recovery."

She praised Dr. Jones for being realistic about what she could do after the surgery, especially concerning gardening and activities with her grandchildren. "You didn’t offer any false hopes," she said.

"You made sure I understood everything and spoke in an easy conversational manner. There was no medical jargon and you didn’t talk down to me."

But she admonished Dr. Jones for not telling her how long she would be in surgery. Dr. Jones admitted the oversight and laughingly added, "every patient wants to know that. I don’t know why."

Dr. Jones also was faulted for not telling her that one of the risks of surgery was death. He agreed, but explained that this was their first meeting and that the patient hadn’t decided to have the surgery. At this juncture he didn’t want to frighten the patient. If the patient later decided to have the surgery, Dr. Jones said he would have told her about that consequence.

Dr. Clever, who was present at the session, pointed out that it’s important to let patients know this risk before they make the decision, because it’s harder to change one’s mind once a decision has been made. Dr. Jones agreed.

So far, six orthopaedic surgeons have participated in the "virtual" office visits. Dr. Clever said the goal is to have 25 encounters and then to prepare a report on the program for the AAOS. They are actively seeking participants.

Dr. Clever acknowledged that at this stage of the pilot program there is not yet a mechanism to validate the program will be a successful teaching tool for all orthopaedists, though they plan to design one. "Those who sign up for the program are motivated to improve their skills," Dr. Clever observed. The program also doesn’t include a mechanism to reinforce the lessons learned, but that issue will be addressed later.

Editor’s Note: One month after the pilot program Dr. Jones said, "It was a good exercise in the informed decision-making process. It made me think differently in the way I talk to patients."

Communicate welcomes suggestions about future topics for the column on patient-physician communications. Send your suggestions to the Bulletin at AAOS, 6300 N. River Rd., Rosemont, Ill. 60018.

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