The 5A’s tasks can be reliably documented by examining audio recordings and transcripts of primary care encounters. Efforts to develop an accurate and efficient method for identifying the 5A’s tasks showed that an exclusive focus on the activities of physicians would lead to a mischaracterization of the 5A’s tasks actually accomplished during the encounter. The 5A-DOC flexibly codes both physician and patient completion of the 5A’s tasks, which allows an important social convention of conversation to be included in the analysis. It is well documented19
that it is socially inappropriate to ask questions in an interaction when the answer has already been established during that conversation. For example, a clinician would be very unlikely to Ask a patient if they smoke when the patient’s smoking status had already been established by a statement made by the patient earlier in the visit. Thus, the importance of the patient’s role in accomplishing the 5A’s tasks is clear, as patients’ statements may effectively preempt a clinician’s question or statement that would accomplish a 5A’s task.
Identifying possible associations between patients accomplishing the 5A’s tasks and their subsequent smoking-cessation outcomes is an empirical issue that merits further investigation. A reliable observation tool such as the 5A-DOC could be used as a standard against which less-resource-intensive methods such as patient report, clinician checklists, and medical-record review might be evaluated. For example, the degree to which other assessment methods capture tasks accomplished by the patient is unclear. Multimethod studies including observational methods could greatly enhance our understanding of the degree and nature of documentation biases and could be used to further guide the refinement of items on surveys and checklists.15
Evaluation of the completion of the 5A’s indicated that adequate advice occurred in only 27% of visits with smokers in which smoking was discussed. If the recommendation that smoking should be addressed at every visit were followed,4
then only 16% of visits would be considered adequate. However, it has been shown20
that competing priorities can reasonably override the importance of addressing smoking cessation in about one quarter of primary care visits. Even after accounting for this fact, the observed rates of adequate advice fall short of expectations. In particular, the 5A-DOC showed physicians rarely completing Arrange, even when willing patients had been Assisted in their cessation plans. Multimethod research using the 5A-DOC along with other data collection methods could examine the factors that encourage or discourage Arranging follow-up visits for smoking cessation. Additionally, clinician training might emphasize this underutilized task to further support patients in their cessation efforts.
The delivery of the 5A’s in this study is comparable to other reports that use direct observation methods in primary care settings. For example, using field notes about primary care visits with smokers, it was found20
that 12 of 91 (13%) smokers received adequate counseling; another 7 of 91 (8%) received “good but deficient” counseling, because their readiness to stop smoking was not assessed. In another study21
that used a direct observation checklist during primary care visits with 244 smokers, it was reported that the following counseling elements were addressed: Advise (55%); Assess (37%); and Assist (38%).
This study also provides evidence that the sequence of the 5A’s is important and thus may be necessary to evaluate the effectiveness of the 5A’s in practice. This sample provided examples of difficulties that were encountered when physicians continued to offer specific options for cessation Assistance in cases in which patients had not expressed readiness to change. Others have indicated that the failure of clinicians and patients to mutually establish readiness for change may result in patient resistance,22,23
inefficient time usage, and a straining of the clinician–patient relationship.24,25
An implication for future work is that the sequence and response patterns observed for the tasks of Assess and Assist may be important when researching the effectiveness of the 5A’s. If further inquiry supports the observation that patient resistance is engendered when Assist occurs without an Assessment of readiness, efforts to train clinicians may need to emphasize the Assess task and its timing.
This study does have limitations. First, the samples of physicians and their adult patients were limited to primary care practices in one geographic region. Data generated from a larger and more geographically varied pool of clinicians would add to the generalizability of these findings. Second, study participants were not completely blinded to the research process; therefore, it is possible that the presence of the observer and audio recorder may have caused the participants to interact differently than they would have in a typical visit. However, when surveyed after their visit, the overwhelming majority of patients reported no effect or very minimal effect from being observed. Additionally, patients and physicians were made aware of only the general aim of the study, namely the investigation of physician–patient communication in routine healthcare visits.
Third, the development phase was conducted with only 46 cases, which may have limited exposure to some of the possible variation in the range of utterances and discussions that could accomplish the 5A’s tasks. Yet this sample size was adequate to reach a point of developmental saturation, with new cases no longer introducing material beyond the scope of the coding rules. Additionally, the application of the 5A-DOC to a second sample of 131 encounters with smokers that were drawn from the patients of 28 primary care physicians strengthens the assessment that the 5A-DOC is capable of accurately capturing specific aspects of smoking discussions across a wide range of physician and patient communication styles.
Fourth, inter-rater reliability for Assess was modest (kappa=0.58). An examination of disagreements between coders rating Assess indicates that difficulty arose during the interpretation of ambiguous patient statements about readiness to change. Efforts are currently underway to further refine coding rules for Assess. This refinement may be particularly important given that proper application of the 5A’s depends on an accurate Assessment of a patient’s readiness to change. An improved coding instrument could better examine this crucial task. Finally, the 5A-DOC is a resource-intensive protocol, and therefore the range of its possible applications may be limited.
The strength of the 5A-DOC is its ability to fill a significant gap in the research tools available for analyzing the prevalence and delivery of this widely disseminated model for discussing smoking cessation. By attending to interactive features of smoking discussions, the 5A-DOC captures all of the goals of the 5A’s that are accomplished, not just those performed by clinicians; completion of 5A’s by patients may be unaccounted for in self-reported data.
Highlighting the variety of utterances and exchanges that could accomplish the operationalized goals of each of the 5A’s tasks is a significant contribution to the adequate evaluation of the extent to which the goals of the 5A’s model are being achieved in actual practice. Additional evaluation of the 5A-DOC tool is necessary to assess its reliability across a wider range of clinicians, patients, and clinical settings. If additional findings are robust, the 5A-DOC could be used as a benchmark against which other methods currently used to document the 5A’s might be compared.