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Are there problems in communication between doctors and patients?

 

INITIATING THE SESSION - reasons for the patient’s attendance

 1.      how many problems do people bring:

in a variety of settings including primary care, paediatrics and internal medicine, the mean number of concerns ranged from 1.2 to 3.9 in both new and return visits

2.      how many discovered:

50% see below

3.      which is the most important, which one do doctors assume to be the most important:

order unrelated to importance yet  doctors very often assume erroneously that the first complaint mentioned is the only one that the patient has brought (Beckman and Frankel 1984 in internal medicine residents and physicians in primary care)

4.      when do doctors interrupt:

18 secs,

the earlier the interruption the less likely to hear more than one complaint and the more likely  to have late arising complaints and to miss important complaints

only 23% of patients completed their opening statement

in only 1 out of 51 interrupted statements was the patient allowed to complete their opening statement later

94% of all interruptions concluded with the doctor obtaining the floor

the longer the doctor waited before interruption, the more complaints were elicited

allowing the patient to complete the opening statement led to a significant reduction in late arising problems

in 34 out of 51 visits, the doctor interrupted the patient after the initial concern, apparently assuming that the first complaint was the chief one

patients who were allowed to complete their opening statement without interruption mostly took less than 60 seconds and none took longer than 150 seconds even when encouraged to continue.

 

GATHERING INFORMATION - EXPLORATION OF PROBLEMS

 

1.      what happens to hypothesis generation if doctors use closed questioning (relying on those questions and methods that we were often taught at medical school)

poor hypothesis generation, poor problem solving

both 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 patients’ ability to communicate their concerns. These in turn lead to inaccurate consultations (Platt and McMath 1979)

Maguire and Rutter (1976) showed serious deficiencies in senior medical students’ information gathering skills: few students managed to discover the patient’s main problem, to clarify the exact nature of the problem and explore ambiguous statements, to clarify with precision, to elicit the impact of the problem on daily life, to respond to verbal cues, to cover more personal topics or to use facilitation. Most used closed, lengthy multiple and repetitive questions.

 Gathering information - UNDERSTANDING ThE PATIENT’S PERSPECTIVE 

1.    how often do doctors make a deliberate effort to elicit their patients’ ideas and concerns?

doctors rarely ask their patients to volunteer their ideas (6%) and in fact, doctors often evade their patients’ ideas and inhibit their expression if they do spontaneously bring them up (only 7% then encourage). Yet if discordance between doctors’ and patients’ ideas and beliefs about the illness remains unrecognised, poor understanding, adherence, satisfaction and outcome are likely to ensue (Tuckett et al 1985)

 

EXPLANATION AND PLANNING

1.      in what percentage of consultations do we underestimate our patients desire for info

Waitzkin (1984) showed that in 65% of encounters, internists underestimated their particular patient’s desire for information; in only 6% did they overestimate.

Many studies have shown that patients can be divided into seekers (80%) and avoiders (20%) concerning information, with seekers coping better with more information and avoiders with less (Miller and Mangan 1983, Deber 1994)

2.      how many minutes spent in info giving

one minute in 20  minute intrview, not 9 minutes as they thought (now shown in British GP as well by Makoul 1995)

3.      what type of information do patients want; what do doctors give

patients and doctors disagree over the relative importance of imparting different types of medical information; patients place the highest value on information about prognosis, diagnosis and causation of their condition while doctors overestimate their patient’s desire for information concerning treatment and drug therapy (Kindelan and Kent in British general practice 1987)

4.      how much do patients remember

It is clear that patients do not recall all that we impart nor do they make sense of difficult messages. As we shall see later, original studies showed that only 50 to 60% of information given is recalled. Later studies have suggested that in fact much more is remembered and that the real difficulty is that patients do not always understand the meaning of key messages nor are they necessarily committed to the doctor’s view.

5.      percentage who do not adhere

50%

 

medicolegal complaints

1.     medicolegal complaints related to communication

70%

 

Lack of empathy and understanding

1.      numerous reports of patient dissatisfaction with the doctor-patient relationship appear in the media. Many articles comment on doctors’ lack of understanding of the patient as a person with individual concerns and wishes.

2.      there are significant problems in medical education in the development of relationship building skills: it is not correct to assume that doctors either have the ability to communicate empathically with their patients or that they will acquire this ability during their medical training (Sanson-Fisher and Poole 1978).

3.      Korsch et al’s seminal study in 1968 of 800 visits to a paediatric walk-in outpatients in Los Angeles was the first research to tackle the doctor-patient interaction using rigorous methods. Physician lack of warmth and friendliness was one of the most important variables related to poor levels of patient satisfaction and compliance.

 

Discovering the reasons for the patient’s attendance

·        54% of patients’ complaints and 45% of their concerns are not elicited (Stewart et al 1979)

·        in 50% of visits, the patient and the doctor do not agree on the nature of the main presenting problem (Starfield et al 1981)

·        patients and doctors agreed on the chief complaint in only 76% of somatic problems and in only 6% of psychosocial problems (Burack and Carpenter 1983)

·        doctors frequently interrupt patients so soon after they begin their opening statement  - after a mean time of only 18 seconds! - that patients fail to disclose significant concerns (Beckman and Frankel 1984)

·        doctors often interrupt patients after the initial concern, apparently assuming that the first complaint is the chief one, yet the order in which patients present their problems is not related to their clinical importance (Beckman and Frankel 1984)

·        interviews were particularly likely to become dysfunctional if there were shortcomings in that part of the consultation relating to “discovering the reason for the patient’s attendance” (Byrne and Long 1976)

 

Gathering information

·        doctors often pursue a “doctor-centred”, closed approach to information gathering that discourages patients from telling their story or voicing their concerns (Byrne and Long 1976)

·        both 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 patients’ ability to communicate their concerns. These in turn lead to inaccurate consultations (Platt and McMath 1979)

·        doctors rarely ask their patients to volunteer their ideas and in fact, doctors often evade their patients’ ideas and inhibit their expression if they do spontaneously bring them up. Yet if discordance between doctors’ and patients’ ideas and beliefs about the illness remains unrecognised, poor understanding, adherence, satisfaction and outcome are likely to ensue (Tuckett et al 1985)

·        Maguire and Rutter (1976) showed serious deficiencies in senior medical students’ information gathering skills: few students managed to discover the patient’s main problem, to clarify the exact nature of the problem and explore ambiguous statements, to clarify with precision, to elicit the impact of the problem on daily life, to respond to verbal cues, to cover more personal topics or to use facilitation. Most used closed, lengthy multiple and repetitive questions.

 

Explanation and planning

·        in general, physicians give sparse information to their patients, with most patients wanting their doctors to provide more information than they do (Waitzkin 1984, Pinder 1990, Beisecker and Beisecker 1990)

·        Waitzkin (1984) has demonstrated that American internists devoted little more than one minute on average to the task of information giving in interviews lasting 20 minutes and overestimated the amount of time that they spent on this task by a factor of nine

·        Makoul et al (1995) found that doctors in British general practice overestimated the extent to which they accomplished the following key tasks in explanation and planning: discussing the risks of medication, discussing the patient’s ability to follow the treatment plan and eliciting the patient’s opinion about medication prescribed.

·        patients and doctors disagree over the relative importance of imparting different types of medical information; patients place the highest value on information about prognosis, diagnosis and causation of their condition while doctors overestimate their patient’s desire for information concerning treatment and drug therapy (Kindelan and Kent 1987)

·        doctors consistently use jargon that patients do not understand (Svarstad 1974, Hadlow and Pitts 1991)

·        Korsch et al (1968) found that paediatricians’ use of technical language (e.g. “oedema”) and medical shorthand (e.g. “history”) was a barrier to communication in more than half of the 800 visits studied. Mothers were confused by the terms used by doctors yet rarely asked for clarification of unfamiliar terms.

·        Svarstad (1974) suggested that doctors and patients engage in a “communication conspiracy”. In only 15% of visits where unfamiliar terms were used did the patient admit that they did not understand. Doctors in turn seemed to speak as if their patients understood all that they said. Physicians deliberately used highly technical language to control communication and to limit patient questions - such behaviour occurred twice as often when doctors were under pressure of time!

·        McKinlay (1975) in a study of British obstetricians and gynaecologists showed that physicians were well aware of the difficulties patients had in understanding doctors in general. Despite this, in their interviews with patients physicians continued to use terms which they had previously identified were the very ones that they would not expect their patients to understand.

·        there are significant problems with patients’ recall and understand of the information that doctors impart (Tuckett et al 1985). It is clear that patients do not recall all that we impart nor do they make sense of difficult messages. As we shall see later, original studies showed that only 50 to 60% of information given is recalled. Later studies have suggested that in fact much more is remembered and that the real difficulty is that patients do not always understand the meaning of key messages nor are they necessarily committed to the doctor’s view.

 

Patient adherence

·        patients do not comply or adhere to the plans that doctors make: on average 50% do not take their medicine at all or take it incorrectly (Meichenbaum and Turk 1987, Butler et al 1996)

·        non-compliance is enormously expensive. Walton et al in 1980 estimated that the cost of such wasted drugs per year in the UK was in the order of £300 million; estimates of the overall costs of non-compliance (including extra visits to physicians, laboratory tests, additional medications, hospital and nursing home admissions, lost productivity and premature death) are CAN$7-9 billion in Canada (Coambs et al 1995) and US$100 billion plus in the US (Berg et al 1993).

 

Medico-legal issues

·        breakdown in communication between patients and physicians is a critical factor leading to malpractice litigation (Levinson 1994). Lawyers identified physicians’ communication and attitudes as the primary reason for patients pursuing a malpractice suit in 70% of cases (Avery 1986). Beckman et al (1994) showed that the following four communication problems were present in over 70% of malpractice depositions: deserting the patient, devaluing patients’ views, delivering information poorly and failing to understand patients’ perspectives.

·        in several states of the USA, malpractice insurance companies award premium discounts of 3 to 10% annually to their insured physicians who attend a communication skills workshop (Carroll 1996).

 

Lack of empathy and understanding

·        numerous reports of patient dissatisfaction with the doctor-patient relationship appear in the media. Many articles comment on doctors’ lack of understanding of the patient as a person with individual concerns and wishes.

·        there are significant problems in medical education in the development of relationship building skills: it is not correct to assume that doctors either have the ability to communicate empathically with their patients or that they will acquire this ability during their medical training (Sanson-Fisher and Poole 1978).

·        Korsch et al’s seminal study in 1968 of 800 visits to a paediatric walk-in outpatients in Los Angeles was the first research to tackle the doctor-patient interaction using rigorous methods. Physician lack of warmth and friendliness was one of the most important variables related to poor levels of patient satisfaction and compliance.

 

is there evidence that communication skills can overcome these problems and make a difference to Patients, doctors and outcomes of care ?

 

Many studies over the last 25 years have demonstrated that communication skills can make a difference in all of the following objective measurements of medical care - it is not just subjective

 

INITIATING THE SESSION

 

Process of the interview

·        what are the consequences if doctors deliberately wait before interrupting at the beginning of the interview until the patient has stopped and only facilitate the patient to go on?

the longer the doctor waits before interrupting at the beginning of the interview, the more likely she is to discover the full spread of issues that the patient wants to discuss and the less likely will it be that new complaints arise at the end of the interview (Beckman and Frankel 1984)

int medicine residents and physicians taught these skills and those of agenda setting elicited more of the patients’ concerns and allowed more patient talking time without an increase in the length of the visit (Joos et al 1996, Putnam 1988)

·        at the beginning of the interview, interrupters include echoing and facilitation

 GATHERING INFORMATION - EXPLORATION OF PROBLEMS

 Process of the interview

·        how does the use of open and closed questions influence information gathering in the interview: how do you maximise accurate and efficient information gathering?

Roter and Hall (1987) investigated the association between primary care physician’s interviewing styles and the medical information that they obtained during consultations with simulated patients. They found that physicians on average elicited only 50% of the medical information considered important by expert consensus, with a worrying range of 9-85%! They found that the amount of information elicited was related to the use of both appropriate open and closed questions. However, open questions prompted the revelation of substantially more relevant information than closed questions.

the use of open rather than closed questions and the use of attentive listening leads to greater disclosure of patients’ significant concerns (cancer patients), increased talkativeness and expression of both concerns and emotions (child psychiatry) and disclosure of psychosocial problems (paediatrics) (Cox 1989, Maguire et al 1996, Wissow et al 1994). Similarly need for open to closed cone and loss of significant (often negative) information without closed questions

·        what happens to medical students’ interviews if you teach them these information gathering skills

Evans et al (1991) have also shown that medical students who learned key interviewing skills were diagnostically more efficient and effective in interviewing medical and surgical patients (i.e. that the improved behaviours and skills developed in training led to an increase in clinical proficiency) and yet took no more time with interviews than untrained students.

Gathering information - UNDERSTANDING ThE PATIENT’S PERSPECTIVE

 

Process of the interview

·        which of these statements produces a bigger trawl of patient concerns?

asking “what worries you about this problem” is not as effective a question as “what concerns you about this problem” in discovering unrecognised concerns (Bass and Cohen 1982)

 

but why bother to discover the patient’s perspective?

Patient satisfaction

·        we know that:

greater “patient centredness” in the interview leads to greater patient satisfaction (Stewart 1984, Arborelius and Bromberg 1992)

discovering and acknowledging patients’ expectations improves patient satisfaction (Korsch et al 1968 - paediatrics, Eisenthal and Lazare 1976, Eisenthal et al 1990 - psychiatry)

 

Patient recall and understanding

·        perhaps the most important of all the work about patient understanding:
there is decreased understanding of information given if the patient’s and doctor’s explanatory frameworks are at odds and if this is not discovered and addressed during the interview (Tuckett et al 1985)

 

Adherence

·        what happens to compliance if you discover a patient’s expectations for help early on in the interview but don’t actually meet the expectations, compared to never finding out at all?

discovering patients’ expectations leads to greater patient adherence to plans made whether or not those expectations are met by the doctor (Eisenthal and Lazare 1976, Eisenthal et al 1990)

 

·        what is the most likely cause of uncontrolled hypertension of patients followed up in hypertension clinics?

doctors can increase adherence to treatment regimens by explicitly asking patients about knowledge, beliefs, concerns and attitudes to their own illness (Inui et al 1976, Maiman et al 1988). Innui: 2 hour session: importance of compliance in poor control, importance of discussing patient knowledge, attitudes and beliefs re BP rather than seeking complications, linking pt and dr knowledge and beliefs and looking for barriers

 

Outcome

symptom resolution

·        what is the most important thing you can do in the management of chronic headache to enable resolution of the symptoms?

one year prospective study of Canadian family medicine in 272 patients to describe the natural history of chronic headache in primary care, not done with this intention: resolution of symptoms of chronic headache is more related to the patient’s feeling that they were able to discuss their headache and problems fully at the initial visit with their doctor than to diagnosis (except organic), investigation, prescription or referral. (The Headache Study Group 1986) (3.4 times more likely compared to 3.2 times for organic v. Non-organic)

·        recovery speed in URTI relaed to discusion of concerns about illness rather than inv, Rx, exam, culture) (Brody and Miller 1988)

 

physiological outcome

·        giving the patient the opportunity to discuss their health concerns rather than simply answer closed questions leads to better control of hypertension (Orth et al 1987)

·        Innui 1976 also showed better BP control - see above

 

 

Building the RELATIONSHIP

 

Process of the interview

·        Goldberg et al (1983) demonstrated that family practice residents who established eye contact were more likely to detect emotional distress in their patients.

·        training primary care doctors in problem-defining and emotion-handling skills leads to improvements in the detection of psychosocial problems (Roter et al 1995)

 

Patient satisfaction

physician non-verbal communication (eye-contact, posture, nods, distance, communication of emotion though face and voice) is positively related to patient satisfaction (DiMatteo et al 1986, Weinberger et al 1981, Larsen and Smith 1981)

 

Outcome

 

symptom resolution

 

·        training doctors in problem-defining and emotion-handling skills not only leads to improvements in the detection of psychosocial problems but also to a reduction in patient’s emotional distress up to six months later (Roter et al 1995)

 

 

EXPLANATION AND PLANNING

 

Process of the interview

·        the more questions patients are allowed to ask of the doctor, the more information they obtain but incresed negative affect (Tuckett et al 1985)

 

Patient satisfaction

·        but what aspect of communication skills most correlates with patient satisfaction?

patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors (Hall et al 1988): highly consistent finding

 

Patient recall and understanding

·        patient recall is increased by categorisation, signposting, summarising, repetition, clarity and use of diagrams (Ley 1988)

·        when you have finished giving information to the patient, what one thing can you do to increase the patients’ recall by 30%?

asking patients to repeat in their own words what they understand of the information they have just been given increases their retention of that information by 30% (61 to 83% of info retained) (Bertakis 1977)

 

Adherence

·        patients who are viewed as partners, informed of treatment rationales and helped in understanding their disease are more adherent to plans made (Schulman 1979)

 

Outcome

physiological outcome

·        decreased need for analgesia after myocardial infarction is related to information giving and discussion with the patient (Mumford et al 1982)

·        what happens to patients with breast cancer who are offered choice in the type of surgery that they face? And if technically no choice is available?

providing an atmosphere in which the patient can be involved in choices if they are available leads to less anxiety and depression after breast cancer surgery (Fallowfield et al 1990)

·        what happens to hypertension and diabetic and rheumatoid patients of doctors with a more participatory and less controlling style?

they developed better physiological outcome in hypertension, diabetes and rheumatoid athritis: furthermore, in RCTs, patients who are coached in asking questions of and negotiating with their doctor not only obtain more information and reprt better health but actually achieve better BP control in hypertension and improved blood sugar control in diabetes and in ulcer control (Kaplan et al 1989, Rost et al 1991)

·        Stewart et al (1997) have shown that interviews where patients perceived that the doctor and patient found common ground in the decision-making process (involving a mutual discussion of treatment options and goals and roles in management, checking for feedback etc.) were associated with significantly less referrals and investigations over the following two months. This suggests that a collaborative approach can reduce demands on the health care system.  

 Better doctor satisfaction and decreased conflict

·        The use of appropriate communication skills not only increases patients’ satisfaction with their doctors but also helps doctors to feel less frustrated and more satisfied in their work (Levinson et al 1993). Appropriate communication reduces conflict by preventing the misunderstanding which is so often the source of difficulties between doctors and patients.

 

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