People diagnosed with a serious illness such as cancer usually face complex decisions regarding treatment. Visit preparation interventions are designed to help patients get ready to discuss treatment decisions with their providers. Visit preparation interventions range from low-cost prompt sheets and proformas to more intensive preparatory sessions that include coaching. Studies have found visit preparation to have modestly positive effects, such as improving the number and quality of questions asked, especially about sensitive topics such as prognosis [1
]. A systematic review suggests that the early evidence about this new class of interventions consists of 'a series of tantalizing but disconnected and unconfirmed results.' The authors conclude that visit preparation may be worth implementing for other reasons [13
'In terms of practice there are strong justifications unrelated to evidence-based medicine for adopting a collaborative approach to the medical encounter, such as, for example, patient preferences and moral imperatives.'
Another recent systematic review, 'Interventions before consultations for helping patients address their information needs,' concurs about the modest positive effects of visit preparation interventions, and then states:
'Despite these apparent benefits, we know of no routine implementation of strategies to help patients address their information needs' [14
Our team has been associated with a routinely implemented form of visit preparation, an intervention called consultation planning (CP), which has been in use at a university breast cancer center since 1998. One of the authors (JB) developed CP as part of his doctoral research, advised by one of the present co-authors (LE) and assisted by another (KS) [15
]. In CP, a trained facilitator or consultation planner helps newly diagnosed patients brainstorm and write down questions and concerns for their doctor [16
]. The consultation planner uses a prompt sheet or template (see Appendix 1 for the most recent edition) to survey the patient for questions and concerns, and then documents these in a consultation plan, or patient agenda for the upcoming visit. Copies of the consultation plan are printed out for the patient, family members, and physicians to use as a visual aid during the appointment. (See Appendix 2, a real case with all patient identifiers modified or suppressed.) Consultation planners are trained not to provide advice or information, but rather to focus on eliciting and documenting patient questions and concerns.
Based on our studies of CP showing reduced communication barriers and enhanced patient and physician satisfaction [17
], and other studies showing benefits of visit preparation [1
], we integrated CP into routine clinical care at the University of California, San Francisco (UCSF) Breast Care Center in 1999. Since then, the service has been offered free of charge to newly diagnosed patients thanks to government and foundation grants as well as faculty discretionary funds. We have previously published reports on our UCSF experience [19
In 2000, 2001, and 2002, we responded to ad hoc, word-of-mouth expressions of interest in CP by individuals affiliated with resource centers and clinics in our region. For the purposes of this report, we define our region as the nine counties of the San Francisco Bay Area plus two North Coast Counties (Mendocino and Humboldt), comprising over seven million people and over 14,000 square miles. We define clinics as organizations that provide medical services to patients in exchange for fees or private or public insurance reimbursements. We define resource centers as organizations that provide non-medical supportive services (such as information and emotional support) at no financial cost to patients, financed either by charitable contributions or by budgetary contributions from a parent organization such as a medical center.
We opened our internal workshops, conducted annually to train personnel at our university breast cancer center, to all self-referred individuals who heard about the training through informal networking among regional clinics and resource centers. The trainees' organizations paid for print materials, transportation, meals, and lodging while our institution, UCSF, donated the space and instructor time.
The CP training workshops included lectures, structured role playing, and group discussion sessions. The training handouts included templates, checklists, and reference materials summarizing lecture topics. It is important to note that consultation planners are trained to avoid providing medical advice or information. Rather, they learn how to elicit, paraphrase, summarize, and document patient questions and concerns in accordance with our SCOPED model of decision making [22
The significance of the present report is that while evidence is suggestive about the effectiveness of visit preparation in academic settings, and there are ethical and patient-centered reasons to implement visit preparation, little is known about efforts to disseminate such interventions. We sought to learn whether our training workshops were leading to uptake of CP in our region, and if so, learn more about the implementation experience.