Do our talks with patients meet their expectations?

,; ,; ,

Original Research

Do our talks with patients meet their expectations?

J Fam Pract. 2007 July;56(7):559-568

By

Atie Van Den Brink-Muinen, PhD

Hans P. Jung, MD, PhD

Jozien M. Bensing, MD, PhD

Yes, for the most part they do. Results of this study, however, reveal specific areas that require greater attention.

PDF Download

References

1. Haidet P. Jazz and the ‘Art’ of Medicine: Improvisation in the Medical Encounter. Ann Fam Med 2007;5:164-169.

2. Jung HP, Baerveldt C, Olesen F, Grol R, Wensing M. Patient characteristics as predictors of primary health care p: a systematic literature analysis. Health Expect 2003;6:160-181.

3. Bartholomew L, Schneiderman LJ. Attitudes of patients towards family care in a family practice group. J Fam Pract 1982;15:477-481.

4. Wetzels R, Geest TA, Wensing M, Lopes Ferreira P, Grol R, Baker R. GPs’ views on involvement of older patients: a European qualitative study. Pat Educ Couns 2004;53:183-188.

5. Brink-Muinen A, Verhaak PFM, Bensing JM, et al. Doctor-patient communication in different European health care systems: relevance and performance from the patients’ perspective. Pat Educ Counsel 2000;39:115-127.

6. Bensing JM, Dronkers J. Instrumental and affective aspects of physician behaviour. Med Care 1992;30:283-

7. Little P, Everitt H, Williamson I, et al. observational study of effect of patient centeredness and positive approach on outcomes of general practice. BMJ 2001;323:908-911.

8. Roter DL, Hall JA. Doctors Talking with Patients/Patients Talking with Doctors: Improving Communication in Medical Visits Westport/London: Auburn House; 1992.

9. Roter DL, Stewart M, Putnam SM, Lipkin M, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA 1997;277:350-356.

10. Sixma H, Spreeuwenberg P, Pasch M van der. Patient satisfaction with the general practitioner: a two-level analysis. Med Care 1998;2:212-229.

11. Dulmen AM van, Bensing JM. The Effect of Context in Health Care: A Programming Study The Hague: RGO; 2001.

12. Wensing M, Baker R. Patient involvement in general practice care: a pragmatic framework. Eur J Gen Pract 2003;9:62-65.

13. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000;49:796-804.

14. Bensing JM, Langewitz W. Die ärztliche Konsultation. In: Uexkull: Psychosomatische Medizin. 2002:415-424.

15. Brown J, Stewart M, Ryan B. Assessing communication between patients and physicians: the measure of patient-centred communication (MPCC). London, Ontario, Canada: Centre for Studies in Family Medicine, 2001.

16. Sullivan M. The new subjective medicine: taking the patients’ view on health care and health. Soc Sci Med 2003;56:1995-1604.

17. Mead N, Bower P. Patient-centeredness: a conceptual framework and review of the empirical literature. Soc Sci Med 2000;51:1087-1110.

18. Jung HP, Wensing M, Grol R. What makes a good general practitioner: do patients and doctors have different views? Br J Gen Pract 1997;47:805—809.

19. Wensing M, Jung HP, Mainz J, Olesen F, Grol R. A systematic review of the literature in patient priorities for general practice care. Part 1: description of the research domain. Soc Sci Med 1998;47:1573-1588.

20. Thorsen H, Witt K, Hollnagel H, Malterud K. The purpose of the general practice consultation from the patients’ perspective—theoretical aspects. Fam Pract 2001;18:638-643.

21. Brink-Muinen A, Verhaak PFM, Bensing JM, et al. Communication in general practice: differences between European countries. Fam Pract 2003;20:478-485.

22. Schellevis FG, Westert GP, Bakker DH de, Groenewegen PP, Zee J van der, Bensing JM. De tweede Nationale studie naar ziekten en verrichtingen in de huisartsenpraktijk: aanleiding en methoden [Second Dutch National Survey of general practice: background and methods]. H&W 2003;46:7-12.

23. Lamberts H, Wood M (eds). International Classification of Primary Care Oxford: Oxford University Press; 1987.

24. Weel C van, König-Zahn C, Touw-Otten FWMM, Duijn NP van, Meyboom-de Jong B. Measuring Functional Health Status with the COOP/WONCA Charts. A Manual WoNCA, ERGHo, NCH, university of Groningen, Netherlands; 1995.

25. Sixma HJ, Kerssens JJ, Campen C van, Peters L. Quality of care from the patients’ perspective: from theoretical concept to a new measurement instrument. Health Expect 1998;1:82-95.

26. Roter DL. The Roter Method of Interaction Process Analysis Baltimore, Md: Johns Hopkins University; 2001.

27. Noldus LP, Trienes RJ, Hendriksen AH, Janden H, Jansen RG. The observer video-Pro: new software for the collection, management and presentation of time-structured data from videotapes and digital media films. Behavioral Research Methods, Instruments & Computers 2000;32:197-206.

28. Leyland AH, Groenewegen PP. Multilevel modelling and public health policy. Scand J Public Health 2003;31:267-274

29. Jung HP, Horne F van, Wensing M, Hearnshaw H, Grol R. Which aspects of general practitioners’ behaviour determine patients’ evaluations of care? Soc Sci Med 1998;47:1077-1087.

30. Swenson SL, Buell S, Zettler P, White M, Ruston DC, Lo B. Patient-centred communication: do patients really prefer it? J Gen Intern Med 2004;19:1069-1079.

31. Epstein RM, Campbell TL, Cohen-Cole SA, MaWhinney IR, Smilkstein G. Perspectives on patient-doctor communication. J Fam Pract 1993;37:377-388.

Practice recommendations

Patients want an attentive, friendly, frank and empathic doctor who listens well.
To enhance quality of health care, consider asking patients at the end of a visit whether their communication preferences were met.

One physician has written that good patient-doctor communication, like jazz, calls for improvisation.¹ We agree. And improvise we must when patients’ expectations for how we will communicate with them vary between visits and individuals.

For example, those who are ill may prefer that their doctor communicate with them in a way that is less important to those who are healthy. Patients with biomedical problems may have different preferences than persons with psychosocial problems. And older individuals may have communication desires that differ from those who are younger.^2-4

Do patients want cure or care, or both?

Depending on the reason for a visit—eg, biomedical or psychosocial—patient preferences may fit either the cure or the care dimension.

Cure dimension. On one hand, patients expect their doctor to be task-oriented and to find a cure for what ails them. They want an explanation of what is wrong and advice about possible treatments, and they want the doctor to do whatever is needed to get answers.⁵

Care dimension. On the other hand, patients may feel anxious and want reassurance. They expect the doctor to listen to their story and encourage them to disclose all health problems, concerns, and worries. They also expect friendliness and empathy. They want to be taken seriously. The extent to which the doctor shows this affect-oriented (and patient-centered) behavior will determine how fulfilled patients feel in their preference for care.^6,7

Why does it matter? Good communication serves a patient’s need to understand and to be understood.^6,8,9 And communication aimed at matching patient preferences enhances satisfaction with care, compliance with medical instructions, and health status.^10-13

How well do we assess patients’ communication preferences?

Patient-centered behavior is a necessary tool for discovering and fulfilling patients’ task-oriented (cure dimension) and affect-oriented (care dimension) communication preferences.^14-17 It’s important to know how well primary-care physicians interpret patients’ preferences for clinical encounters and if they respond in a manner that satisfies those expectations.

FAST TRACK

Communication that matches patient preferences enhances satisfaction with care and compliance with medical instructions

Reassuringly, patients indicate on surveys that their physicians do a fairly good job of interpreting their communication preferences and acting accordingly.^18-20 They also report that their desires and expectations from consultations are increasingly met.

There is always the worry, though, that physicians in certain positions—eg, non-gatekeeper roles or positions involving only part-time clinical responsibilities—would be challenged to assess patient preferences as accurately as others.²¹

The aim of our study

While it’s encouraging that physicians by and large understand their patients and communicate with them meaningfully, we wondered whether communication could improve further. Our purpose in this study was to gain detailed insight into patients’ preferences in physician communication and, through patients’ subjective perspectives and observed real practice consultations, learn how well physicians communicate according to those preferences.

Methods

Design

We derived physician data from the Second Dutch National Survey of General Practice (2001). This study was carried out in practices representative of Dutch general practice.²² We asked patients for permission to videotape consultations with the general practitioner (GP), and asked them to sign a consent form. Collected data were kept private as per regulations.

We videotaped consultations of 142 GPs (76.1% male) and 2784 patients (41.2% male). The number of patients cared for by each GP ranged between 17 and 21 (mean=19.6). Each patient was videotaped just once. We rated roughly 15 patient-consultations per GP (13–15, mean=14.8), excluding the first 3 to correct for possible bias because of the video camera. Before and immediately after the consultation, patients 18 years of age and older answered a questionnaire. We used data from 1787 patient consultations.

Patients rate their communication preferences

The patient questionnaire covered demographic characteristics (gender, age, education); health problems (psychosocial or not [ICPC-coded]);²³ overall health during the past 2 weeks (1=excellent, 2=very good, 3=good, 4=fair, 5=poor); and depressive feelings during the past 2 weeks (1=not at all, 2=slightly, 3=moderately, 4=quite a bit, 5=extremely) (COOP-WONCA charts²⁴).

We defined communication preferences as “the extent of importance patients attach to communication aspects.”²⁵ Patients’ preferences and the actual performance by the GP were measured using the conceptual framework of the QUOTE scale (quality of care through the patient’s eyes).^5,25

Before consultation, patients recorded how important they considered different aspects of communication for the coming visit (1=not important, 2=rather important, 3=important, 4=utmost important). Following consultation, they rated the GP’s performance in meeting their expectations for these aspects (1=not, 2=really not, 3=really yes, 4=yes).