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Maximising effectiveness doctor/patient communication

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Most complaints from patients about their doctor are not regarding the clinical competence of the doctor in question, but rather the communication problems encountered during doctor-patient consultations (Meryn, 1998). Good communication between doctors and patients is important for patients’ well-being. Several reviews examining communication in medical consultations demonstrated the beneficial effects good communication has on patients’ mental and physical health. Ong, De Haes, Hoos and Lammes (1995) found that positive consultations resulted in higher patient satisfaction, with Stewart (1995) suggesting that good doctor-patient communication may not only improve emotional health, but can also have a positive effect on the physiological status of the patient.

However, despite these obvious benefits of good communication, early research examining doctor-patient consultations revealed problems in the consulting relationship. Korsch, Gozzi & Francis, (1968) reported that their doctors lacked general warmth and friendliness. In order to maximise the consultation experience for a patient and leave them more satisfied, it may be suggested that doctors could use better nonverbal communication, in order to create a friendly, inviting atmosphere. Beck, Dautridge & Slone (2002) note the lack of recent empirical research into patient satisfaction outcomes, however early research indicates that use of non verbal cues such as eye-contact, posture, nods, distance and communication of emotion though face and voice has a positive outcome on patient satisfaction (e.g. DiMatteo et al., 1986; Larsen & Smith, 1981).

Other early research found that doctors interrupted patients only a few seconds into describing their symptoms and did not allow them to say everything they wanted to (Beckman & Frankel, 1984). This was surprising, as this experiment incorporated videotaping the interactions, which may have been an incentive for doctors to seem like they were doing a better job, so the real situation may be even worse. The finding that doctors tend to interrupt patients may help to explain findings from Barry et al. (2000) and Levenstein et al. (1986) who found that many of patients’ ‘agendas’ of why they came to visit a doctor were unvoiced. These findings coupled together may indicate that patients may want to fully describe their symptoms and feelings to enable the doctor to provide them with the information they require, and make a more accurate diagnosis, but are maybe unable to due to doctors interrupting, and therefore do not provide sufficient information.

Effective provision of information and clear explanations of symptoms and treatment is an important aspect of a doctor-patient consultation which can maximise the experience for a patient, and have an impact on the patient after leaving the consultation including symptom reduction, and effective anxiety and pain management (Stewart, 1995).  Many studies have highlighted how doctors use jargon and technical language during consultations that many patients cannot understand (e.g. Hadlow & Pitts, 1991), and these numbers increase when in an emergency hospital situation with younger, poorly educated patients (Lerner et al., 2000). This would suggest that patients may not fully understand their symptoms and/or treatment. It has also been consistently demonstrated that many patients express dissatisfaction at the amount of information they receive from their doctors, and was subsequently found that high numbers of patients wished to be provided with as much information as possible whether it was good or bad, unless they directly specify otherwise (Fallowfield, Ford & Lewis, 2007). It has also been demonstrated that diagnostic and prognostic information provided by doctors is associated with a greater improvement in symptoms and health status 2 weeks after a consultation (Jackson & Kroenke, 2001). However, when informing patients about their diseases, doctors may define information objectively, and such provide patients with medical information, and feel that they have given enough precise information, and patients may feel like they need information relating to the personal relevance of the disease (Ong et al., 1995). This is therefore a conflict of interests which must be addressed.

A technique which has been demonstrated to have beneficial effects on encouraging patients to say all they wanted, and enable them to ask more questions and therefore provide them with more information and leaving them patient more satisfied is doctors using an ‘interviewing’ technique. It has been found that doctors who were trained in interviewing skills scored higher when patients scored their satisfaction of a consultation, and this was utilised as evidence that this training produced a considerable difference in the quality of communication (Kaplan et al., 1996; Roter et al, 1995). However it can be noted that when doctors enable pateitns to fully express what is on their minds and ask as many questions as they wish, consulkations only last an average of six seconds longer than average (Marvel et al., 1999). This may suggest that patients do not require as much information as previously suggested.

Doctors attempting to use techniques such as the aforementioned interviewing style was signatory of a ‘shift’ in the last few decades which has been argued to occur (Bensing, 2000). This shift saw the style of doctor consultation evolving from the more traditional ‘doctor-centred’ or paternalistic approach to medical consultations (Stewart & Roter, 1989) to a more ‘patient centred’ approach to increase patient satisfaction. This may be due to many reviews highlighting the negative effects poor communication in consultations has on patients (e.g. Ong et al., 1995; Stewart, 1995). There may of course be problems with such reviews that suggest that good communication is beneficial to psychological and physiological health, as they may display a publication bias. This may therefore exaggerate the effects that have been described to an inflated level, and they may not be as dramatic as assumed. However, some authors (e.g. Stewart, 1995) explain how they attempt to control for this bias by using unpublished research. There is also discrepancy regarding the effectiveness of using patient satisfaction as a measure of evaluation of healthcare (Avis, Bond & Arthur, 1997). This may be due to patients having distorted expectations of healthcare, and it is not clear whether the patient is evaluating the processes or outcomes of the consultation. However, the measure of satisfaction continues to be the main measure of the effectiveness of a consultation, and even if the effects of good doctor-patient communication are not as excessive as described, it is clear that effective communication plays some part in satisfying a patient, and may therefore have been the focus of a shift in approaches to medical consultations (Bensing, 2000).

The changes in healthcare consultations to become more patient centred attempted to enable patients to play an active role in their healthcare decisions and be more involved in deciding their treatments etc. The NHS even developed new strategies to attempt to make consultations less focussed on doctors and more on patients (NHS Executive, 1996). This involves the patient being provided with maximum information, and being encouraged to ask questions if they require. These strategies also encourage patients to become more involved in healthcare decisions.

Techniques such as the patient centred interviewing technique helped to enable the doctor to respond to the patient effectively. The showing of concern and empathy is a way of fully maximising the consultation so that patient fully disclose their emotions and talk about their real concerns and worries, and has been shown to effectively reduce patients’ long term emotional distress (Roter et al., 1995; Roter, 2000). There is also evidence to suggest that doctors engaging patients in social conversation contributes to patient satisfaction, to give patients the impression that they represent more than just an illness, which may help promote greater satisfaction and compliance and may therefore have an indirect effect on patient health (Hall et al., 1998).

The introduction of the aforementioned healthcare strategies may have had an impact on the amount of information being offered by a doctor, and the input patients have in treatment decisions. It was demonstrated that many patients didwanted to discuss their treatment options and share their opinions with their doctors, and personally clarify advantages and disadvantages of various options (Levinson et al., 2005). However, Levinson et al. (2005) also found that half of patients preferred to leave final treatment decisions up to their doctor. This was consistent with other findings that the majority of patients wanted doctors to do the ‘problem solving’ tasks of utilising information to make a diagnosis and treatment decisions (e.g. Deber, Kraetschmer & Irvine, 1996). The interaction and discussion of options as preferred by many patients may have encouraged such a high volume of patients to leave the decision up to the doctor as they trusted that their doctor would make a decision which is correct in terms of the patients’ personal desires and circumstances.

Other research has suggested that not all patients want to play such an active role in healthcare decisions. Lee et al. (2002) reported that only 9% of breast cancer and 2% of stem cell transplant patients wanted to alone decide their healthcare treatments. Arora and McHorney (2000) also reported that 69% of suffers of chronic disease preferred to leave medical decisions to the doctor. However, the patients who did want to be involved in their medical decisions were more likely to be women or older patients. This was consistent with Levinson et al.’s (2005) findings where this was also the case. Levinson et al. (2005) suggested that this may be due to women being more likely to prepare themselves before visiting the doctor with information from sources such as the internet, and therefore wanting active involvement decision making.

Other evidence to suggest that the shift in consultation styles to enhance patient satisfaction may not be as prevalent as assumed. Bensing et al. (2006) conducted a comparison study between consultations in 1986 and 2002. It was reported that the patient involvement in the consultation did not increase in the later study as expected. The main observed change in consultation style saw a greater volume of information giving in the later observation, but a lower level of personal relationship building. It can of course be suggested that patients did not have to have as much input into the consultation as the previous observation as due to the rise in information giving, they received all information required without extra questioning. It may also be suggested that as hypertension patients make regular trips and have regular engagement with healthcare professionals that they already had all the information that they required.

Therefore, it has been indicated some patients may want to be active in discussing options, and only some patients may want to ultimately make a decision on treatments. Therefore to maximise consultations and enable patients who want to get involved to do so and vice versa, doctors should offer patients the opportunity to get involved in discussion, and actively engage the patient in a decision making process so that they can eventually do as they feel comfortable.

Overall, it may be concluded that healthcare consultation patterns have shifted from doctor-centred to more patient centred approaches to attempt to maximise the effectiveness of these consultations and increase patient compliance and outcomes. This may be due to the publication of reviews highlighting the positive effects effective communication during a consultation has on patients. There are problems with such reviews including discrepancy over the reliability of the measure of patient satisfaction (Avis, Bond & Arthur, 1997) and the possibility of publication bias (Stewart, 1995), but overall, good doctor-patient communication has been seen to be beneficial to patients’ physical and mental health and wellbeing (e.g. Ong et al., 1995; Stewart, 1995). This has been reflected in the development of new strategies by the National Health Service (NHS Executive, 1996), and the use of techniques by doctors such as interviewing techniques, social engagement and, increased information giving and patient involvement in decisions.


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