Some examples:
Discovering the reasons for the patient’s attendance
Some problems:
- 54 per cent of patients’ complaints and 45 per cent of their concerns are not elicited. (Stewart et al 1979)
- In 50 per cent of visits patient and doctor did not agree on the nature of the main presenting problem (Starfield 1981)
- Doctors frequently interrupt patients before they had completed their opening statement, after a mean time of 23.1 seconds (Marvel 1999)
Some solutions:
- The longer the doctor waits before interrupting the interview, the more likely he or she will discover the full spread of issues the patient wants to discuss and the less likely will it be that new complaints arise at the end (Beckman and Frankel 1984)
- In a tertiary physician centre (difficult patients with complex histories) patient mean spontaneous talking time was 92 seconds
- Screening for problems (identifying at an early stage all the issues the patient wants to discuss) helps reduce uncertainty in the patient’s mind, reducing distraction and allowing effective communication. (Korsch 1968), it allows for:
- Agenda-setting: physicians who were taught to elicit the patient’s full concerns and negotiate an agreed agenda, could discover more of their patients’ concerns, but with no increase in length of visits.
Gathering information
Some problems:
- Doctors using a high control style and premature focus on medical problems (in hospital internal medicine in the USA) can lead to an over-narrow approach to hypothesis generation, and to limitation of the patient’s ability to communicate their concerns. This leads to inaccurate consultations (Platt and McMath 1979)
- Levinson et al (2000) found that patients gave verbal and non-verbal cues throughout the interview, but that physicians only responded positively to patient cues in 38% of cases in surgery and 21% of cases in primary care
- Kuhl (2002) demonstrated that doctors who trivialise or disregard patients’ views, or fail to take account of patients’ concerns, might inadvertently cause what he terms iatrogenic suffering.
Some solutions:
- Stiles et al(1979) have shown that patients at a hospital based Medical walk-in clinic were more satisfied with the information gathering phase of the interview if allowed to express themselves in their own words rather than provide yes/no answers to closed questions
- Levinson (2000) showed that picking up and responding to cues shortens visits
- Stewart et al (2000) showed that patient-centred communication in primary care, as judged by patients’ perceptions of patient-centredness, was associated with better recovery from discomfort and concerns, better emotional health two months later and fewer diagnostic tests and referrals.
Building the relationship
Some problems:
- Considerable reports in media of patient dissatisfaction with doctor-patient relationship: articles comment on the doctors’ lack of understanding of the patient as a person with individual concerns and wishes
- BMJ personal view
- Korsch et al (1968) studied 800 visits to a paediatric walk-in clinic in Los Angeles. Physicians showing lack of warmth and friendliness was one of the most important variables related to poor levels of patient satisfaction and compliance
Some solutions:
- Di Matteo et al (1986): Physicians non-verbal communication (eye-contact, posture, nods, distance, communication of emotion through the voice and face) is positively related to patients satisfaction
- Wasserman (1984) analysed effects of supportive statements made to mothers during paediatric visits. They found that empathic statements led to increased satisfaction and a reduction in maternal concerns. Encouragement (eg acknowledging coping efforts and appropriate self care) led to increased satisfaction and higher opinions of clinicians
Explanation and planning
i) Problems with the amount of information that doctors give:
Makoul et al (1995): doctors in UK general practice underestimated the extent with which they: discussed risks in medication, discussed the patient’s ability to follow the treatment plan and elicited the patient’s opinion about medication prescribed
ii) Problems with the type of information:
Kindelan and Kent (1987): UK general practice: patients place highest value on information about prognosis, diagnosis and causation of their condition, while doctors overestimate their patients’ desire for information concerning treatment and drug therapy
iii) Problems with recall:
Ley’s original studies showed only 50 to 60% of information given is recalled. Later studies show that in fact much more is remembered: the real difficulty is that patients do not always understand the meaning of key messages nor are they necessarily committed to the doctors view.
iv) Involvement in decision-making:
Degner (1997) studied women with confirmed diagnosis of breast cancer attending oncology clinics and found that 22% wanted to select their own cancer treatment, 44% wanted to select their treatment in collaboration with their doctors, and 34% wanted to delegate this decision making to their doctors. Only 42% of women believe that they had achieved their preferred level of control in decision-making.
v) Compliance to plans:
Average of 50% of patients prescribed drugs do not take their medicine at all, or take it incorrectly.
Some solutions:
- Hall et al (1988): patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors (very consistent finding)
- Patient recall is increased by categorisation, signposting, summarising, repetition, clarity and use of diagrams (Ley 1988)
- Asking patients to repeat in their own words what they understood of the information they have just been given increases their retention of information by 30% (Bertakis 1977)
- Eisenthal (1979) demonstrated that higher levels of negotiation and participation in the decision-making process are associated with both increased adherence and greater satisfaction.
From Silverman, Kurtz and Draper: Skills for communicating with patients 2005