To our knowledge, this is the first study to examine the effects of notifying physicians of their patients' HL skills. Physicians notified of their patients' limited HL were more likely to use management strategies recommended to improve communication with these patients, but felt less satisfied and perceived themselves as marginally less effective than control physicians. While patients in this study considered HL screening to be useful, the increased intensity of physician management did not result in improved patient self-efficacy, at least in the short term.
The increased management intensity of physicians in the intervention group demonstrates that physicians are receptive to HL screening and recognize HL's importance in chronic disease management. Lower satisfaction rates in these physicians, despite their actively engaging in strategies to overcome this communication barrier, suggest that physicians lack appropriate training, evidence-based recommendations, and/or systematic support to best respond. A similar phenomenon has been reported in education research. Teachers who work with students who have barriers to learning are less satisfied than general education teachers,55
particularly when adequate training for teachers and system support for students are lacking.56
Similarly, in studies of screening for other complex, psychosocial issues such as depression, alcoholism, and domestic violence, physician satisfaction has been achieved by linking screening results with specific educational interventions and structural supports.57–60
We measured patients' self-efficacy because of the conflicting hypotheses regarding the effects of HL screening. On the one hand, HL screening could enhance self-efficacy by enabling physicians to employ tailored communication strategies and more realistic goal-setting; on the other hand, it could lower self-efficacy by eliciting feelings of shame in patients. The lack of a difference in self-efficacy scores between the intervention and control group patients suggests that the management strategies physicians employed need to be reinforced over a number of patient visits, had effects that could not be detected with the measures we used, or were not particularly effective.61
The low rate at which physicians discussed screening results with their patients suggests that physicians felt unprepared to address the subject or were concerned about stigmatizing patients. Physician detection of communication barriers without open acknowledgement and mutual problem-solving with patients is unlikely to improve outcomes,36
and may partially explain our negative patient outcomes. Since patients in our study considered HL measurement to be potentially useful, and intervention group patients did not report lower self-efficacy, physicians should feel less reluctant to discuss this barrier with their patients. Without a more robust measure of patient stigma, however, we cannot definitively determine whether patients who reported the screening to be useful nonetheless may have felt stigmatized.
The lack of patient benefits may illustrate the need to refine our understanding of the mechanisms whereby physician notification of patients' limited HL could lead to improved health outcomes.60,62,63
In the case of biomedical conditions, acceptable screening tests must detect diseases for which effective treatments exist.64
With regard to screening for HL deficits, this prerequisite suggests that widespread screening will not be warranted until rigorous trials identify specific actions clinicians can take to change the trajectory of patients' disease.63
Our study has several limitations. Because we made only a single assessment of many outcomes, we could not determine whether observed differences in physician behaviors between the intervention and control groups were related to unmeasured baseline differences or were sustained over time; whether intervention group patients' self-efficacy scores would have improved over a longer observation period; or whether the screening test itself may have lowered self-efficacy scores in both groups. Second, we relied on physician self-report of management strategies, rather than objective assessment. Prior research, however, has demonstrated a high correlation between physician reports of their counseling strategies and direct observation.65
Third, while our study may have overestimated the management strategies of physicians because they were aware they were enrolled in a study, this bias may have disproportionately affected intervention physicians insofar as control physicians did not receive a “control notification.”
Fourth, because some patients may have refused study participation because of misgivings related to HL testing, we may have overestimated the degree to which HL screening is acceptable to patients. Assuming the most conservative scenario, in which all 30 patients who refused participation had limited HL and would have found the screening stigmatizing, 83% of patients would still have found screening to be useful. Fifth, our negative results with regard to glycemic control should be considered inconclusive since our study was underpowered for this outcome and our follow-up time was brief. Finally, our results may not generalize to patients without diabetes, private practice settings, or non-primary care relationships.
The increased attention to HL1,5
and the evolution of shorter screening instruments25,27,28
has increased interest in developing screening programs in the clinical context. This trial suggests we exercise caution before implementing such programs. While it is encouraging that physicians respond to the notification of their patients' limited HL skills, and reassuring that patients report screening to be useful, system-wide training programs and/or support for physicians and patients may be essential to an effective screening program. Future research should explore the ways in which health care providers and systems can more effectively engage patients with limited HL. Without this step, HL screening and notification of physicians of their patients' HL deficits is unlikely to be a powerful tool in improving diabetes outcomes.