Doctor-patient communication in general practice consultations.

Detailed study of a series of tape-recorded interviews enabled the author to carry out a critical self-audit of his consultations. The analysis of categories of verbal interaction in doctor-patient consultations proved to be a practical and reliable method of studying the doctor-patient relationship. The methods and techniques used in this research could, with advantage, be employed in the fields of undergraduate and postgraduate teaching. Since a satisfactory doctor-patient relationship is of great value, study in depth of the verbal interaction between doctor and patient in general practice consultations can provide guide lines to those who seek an improvement in doctor-patient communication.     

Doctor-patient communication in the e-health era

ABSTRACT: The digital revolution will have a profound impact on how physicians and health care delivery organizations interact with patients and the community at-large. Over the coming decades, face-to-face patient/doctor contacts will become less common and exchanges between consumers and providers will increasingly be mediated by electronic devices.In highly developed health care systems like those in Israel, the United States, and Europe, most aspects of the health care and consumer health experience are becoming supported by a wide array of technology such as electronic and personal health records (EHRs and PHRs), biometric & telemedicine devices, and consumer-focused wireless and wired Internet applications.In an article in this issue, Peleg and Nazarenko report on a survey they fielded within Israel's largest integrated delivery system regarding patient views on the use of electronic communication with their doctors via direct-access mobile phones and e-mail. A previous complementary paper describes the parallel perspectives of the physician staff at the same organization. These two surveys offer useful insights to clinicians, managers, researchers, and policymakers on how best to integrate e-mail and direct-to-doctor mobile phones into their practice settings. These papers, along with several other recent Israeli studies on e-health, also provide an opportunity to step back and take stock of the dramatic impact that information & communication technology (ICT) and health information technology (HIT) will have on clinician/patient communication moving forward.The main goals of this commentary are to describe the scope of this issue and to offer a framework for understanding the potential impact that e-health tools will have on provider/patient communication. It will be essential that clinicians, managers, policymakers, and researchers gain an increased understanding of this trend so that health care systems around the globe can adapt, adopt, and embrace these rapidly evolving digital technologies.     

Doctor-patient communication and outcomes among diabetic patients

This study reports on 242 diabetic patients from the practices of 42 physicians. Communication from physician to patient was studied to determine the effect of communication on subsequent patient outcomes. Patients and physicians were questioned on instructions provided for diabetic management and self-care. The average level of effective communication for all patients in the study was 67 percent. Insulin-dependent diabetics had the best communication scores, those controlled on diet alone the poorest, while oral medication patients were intermediate.Although overall communication scores showed to significant correlation with diabetic control status, patient satisfaction, compliance in taking prescribed medication, or frequency of hospitalization, specific communication items were highly correlated with corresponding behavioral outcomes.Dr. Hulka is Associate Professor, Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina 27514. Dr. Kupper is Assistant Professor, Department of Biostatistics, University of North Carolina, and Dr. Cassel is Professor and Chairman, Department of Epidemiology, University of North Carolina. Dr. Mayo is Professor and Chairman, Department of Family Practice, Medical College of Virginia/Virginia Commonwealth University. The project upon which this paper is based was performed persuant to Grant No. HS00026-03 between the National Center for Health Services Research and Development and the Department of Epidemiology, University of North Carolina.     

Doctor-patient communication and the quality of care

In this article a comparison is made between three independent sources of assessment of medical consultations. A panel of 12 experienced general practitioners rated 103 consultations with hypertensive patients on the quality of psychosocial care. There was a wide consensus between the judges, resulting in a high reliability score. Two contrasting groups were formed: consultations that were rated high and those rated low in quality of psychosocial care. A comparison was made between this general assessment of the quality of psychosocial care and a more detailed assessment of the same consultations on nine much used communication variables made by trained psychologists. Knowledge about doctor-patient communication proved to predict very well as to which quality group the consultations belonged. A very high percentage (95%) was predicted accurately, solely on the basis of these nine communication variables. Affective behaviour, and especially nonverbal affective behaviour had the strongest predictive power. In the last part of the study a third source of assessment, i.e. patients' satisfaction was compared with both other sources. Much lower relationships were found, although most were in the predicted direction. Affective behavior seems to be the most important in determining patient's satisfaction. The implications of these findings are discussed.     

Doctor-patient communication: a social and micro-political performance

In the United States the medical relationship is asymmetrical. Doctors not only control medical knowledge, they also have an institutionally based authority which allows them to act as gatekeepers, providing options to some while denying them to others. This study, conducted in a model family practice clinic of a teaching hospital, examines how decisions to do, or not to do, Pap smears are negotiated as residents and a potentially high-risk group of patients communicate. Decision-making occurs in layered phases--opening, medical history, physical examination, and closing. Each phase expresses the doctor's control and the patient's trust. Doctors initiate phases, develop topics and make key choices. They decide when patients undress--a choice which shapes the later Pap smear decision. Decisions to undress patients and to perform Pap smears or decisions not to undress patients and not to perform Pap smears produce no conflict. When there is a conflict, avoidance strategies--bowing to higher-level specialists, selling and unselling, and letting silence speak--are used negotiating devices. The doctor's choice and the patient's agreement produce a specific and a more general outcome--managing the presenting complaint and providing medically adequate health care, respectively. Although interactionally accomplished, these outcomes are institutionally constrained, and, thus are both a social and a micro-political performance.     

Doctor-patient communication: a study of junior house officers

This study evaluates junior house officers' perceptions of their communication skills with cancer patients; the usefulness of their undergraduate communication skills training; and their sources of emotional support. All 42 junior house officers employed at Guy's and Lewisham Hospitals in August 1994 were interviewed using a study-specific, semi-structured interview. Sixty-seven per cent of junior house officers felt they had adequate communication skills in relation to medical issues, but only 36% felt they had adequate skills in relation to psychological issues. Thirty-one per cent of doctors reported that they never, or nearly never, enquired about the emotional adjustment of dying patients. Lack of time was the most commonly reported reason for avoiding asking about psychological problems (62% of junior house officers), followed by wishing to avoid awkward questions (51%) and inadequacy of skills to deal with such issues (44%). Ninety-eight per cent of junior house officers had attended the 1-week undergraduate communication skills course at Guy's and St Thomas's Hospital Medical School (UMDS). Sixty-seven per cent of those who had attended found the course helpful and 62% felt they would benefit from further training as junior house officers. Seventy-four per cent felt they could discuss their work-related concerns with colleagues and 95% felt they could talk to friends. In contrast only about 9% felt they could, if needed, talk to a counsellor. Although the majority of the junior house officers reported benefit from their communication skills training, the course does not appear to be meeting all their communication training needs. Junior house officers require further training opportunities at the undergraduate and postgraduate levels. Traditional counselling services for junior house officers may not be meeting their support needs.     

Doctor-patient communication: a comparison of the USA and Japan

BACKGROUND: Little is known about the differences and similarities between doctor-patient communication patterns in different cultures. OBJECTIVES: The aim of this study was to examine communication patterns of doctor-patient consultations in two different cultures, namely the USA and Japan, and to elucidate linguistic differences and similarities in communication. METHODS: This cross-sectional study used quantitative discourse analysis from linguistics to compare 40 doctor-patient consultations: 20 out-patient consultations of five physicians in the USA and 20 out-patient consultations of four physicians in Japan. The main outcomes measured were time spent in each phase of the encounter, number of categorized speech acts, distribution of question types and frequencies of back-channel responses and interruptions. RESULTS: The average length of doctor-patient encounters was 668.7 s in the USA and 505 s in Japan. US physicians spent relatively more time on treatment and follow-up talk (31%) and social talk (12%), whereas the Japanese had longer physical examinations (28%) and diagnosis or consideration talk (15%). Japanese doctor-patient conversations included more silence (30%) than those in the USA (8.2%). The doctor-patient ratios of total speech acts were similar (USA 55% versus 45%; Japan 59% versus 41%). Physicians in both countries controlled communication during encounters by asking more questions than the patients (75% in the USA; 78% in Japan). The Japanese physicians and patients used back-channel responses and interruptions more often than those in the USA. CONCLUSIONS: While doctor-patient communication differed between the USA and Japan in the proportion of time spent in each phase of the encounter, length of pauses and the use of back-channel responses and interruptions, physician versus patient ratios of questions and other speech acts were similar. The variations may reflect cultural differences, whereas the similarities may reflect professional specificity stemming from the shared needs to fill the information gap between physician and patient. Adequate awareness of these differences and similarities could be used to educate clinicians about the best approaches to patients from particular cultural backgrounds.     

Doctor-patient communication with people with intellectual disability - a qualitative study

Background

Patients' priorities and views on quality care are well-documented in Western countries but there is a dearth of research in this area in the East. The aim of the present study was to explore Chinese patients' views on quality of primary care consultations in Hong Kong and to compare these with the items in the CARE measure (a process measure of consultation quality widely used in the UK) in order to assess the potential utility of the CARE measure in a Chinese population.

Methods

Individual semi-structured interviews were conducted on 21 adult patients from 3 different primary care clinics (a public primary healthcare clinic, a University health centre, and a private family physician's clinic). Topics discussed included expectations, experiences, and views about quality of medical consultations. Interviews were typed verbatim, and a thematic approach was taken to identify key issues. These identified issues were then compared with the ten CARE measure items, using a CARE framework: Connecting (Care Measure items 1–3), Assessing (item 4), Responding (items 5,6), and Empowering (items 7–10).

Results

Patients judged doctors in terms of both the process of the consultation and the perceived outcomes. Themes identified that related to the interpersonal process of the consultation fitted well under the CARE framework; Connecting and communicating (18/21 patients), Assessing holistically (10/21 patients), Responding (18/21 patients) and Empowering (19/21 patients). Patients from the public clinic, who were generally of lower socio-economic status, were least likely to expect holistic care or empowerment. Two-thirds of patients also judged doctors on whether they performed an adequate physical examination, and three-quarters on the later outcomes of consultation (in terms of relief or cure and/or side-effects of prescribed drugs).

Conclusion

These findings suggest that Chinese patients in Hong Kong value engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and the attitudes and values that underpin them, as well as on the perceived outcomes of treatment. The match between themes relating to consultation process and the CARE Measure items suggests utility of this measure in this population, but further quantitative validation is required.     

Doctor-patient communication about drugs: the evidence for shared decision making

The traditional paternalistic model of medical decision-making, in which doctors make decisions on behalf of their patients, has increasingly come to be seen as outdated. Moreover, the role of the patient in the consultation has been emphasised, notably through the adoption of 'patient-centred' strategies. Models that promote patients' active involvement in the decision-making process about treatment have been developed. We examine one particular model of shared decision making [Charles, C., Gafni, A., Whelan, T, 1997. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science & Medicine 44, 681-692.]. The model has four main characteristics. These are that (1) both the patient and the doctor are involved, (2) both parties share information, (3) both parties take steps to build a consensus about the preferred treatment and (4) an agreement is reached on the treatment to implement. Focusing on the first two of the four characteristics of the model, we use the findings from a study of 62 consultations, together with interviews conducted with patients and general practitioners, to consider participation in the consultation in terms of sharing information about, and views of, medicines. We found little evidence that doctors and patients both participate in the consultation in this way. As a consequence there was no basis upon which to build a consensus about the preferred treatment and reach an agreement on which treatment to implement. Thus even the first two of the four conditions said to be necessary for shared decision making were not generally present in the consultations we studied. These findings were presented in feedback sessions with participating GPs, who identified a number of barriers to shared decision making, as well as expressing an interest in developing strategies to overcome these barriers.     

临床实习生医患沟通能力培养及教学改革研究

为探讨临床实习生医患沟通中存在的问题及解决方法,作者问卷调查浙江省两所医院实习的多所医学院校学生,了解其医患沟通现状及存在问题,并针对医患沟通的课程设置、课程体系、教学内容和教学方法等方面进行教学改革。对临床实习生加强医患沟通培训迫在眉睫,医患沟通课程的教学改革应尽快实施。     

Doctor-patient relationships in global society. Informed consent in dentistry

The concept for initiation of treatment only after the explicit consent of the patient, based on preliminary information, is the most important element determining the relationship between patient and doctor nowadays. The application of this concept in dentistry and its inclusion in the professional documents regulating these relationships needs more comprehensive and modern conditions-relevant analysis of ethical, legal and professional aspects of the problem. The purpose of the study was to define the modern view of informed consent and its application in dentistry in different social environment. The general and specific features of the evolution of the problem and the social practice in Bulgaria, The European Community and Northern America are discussed in the context of the global tendency for free movement of patients and mutual recognition of professional qualification. The results suggest that despite the different degree of social and economical development in different countries the interest in the problem grows significantly and harmonization of legislation for health protection is based on the new social decree in the construction of doctor-patient relationships. It is expected that the comparative studies in this field will promote the improvement of dentists' training and improvement of scientific and expert exchange in solving problems of patents' rights and professional ethics.     

医患纠纷的多重性研究与思考

分析了目前医患纠纷产生的成因、特点、危害、制约因素等,提出了医患纠纷的防范对策及建议:由国家为主导从制度层而上进行防范,完善医疗事故处理法规,建立健全第三方调解机制;以医院为核心从诊疗的环节上进行防范,建立正确的医患关系、狠抓规章制度的落实、提高医疗技术水平和提高处理医患纠纷的能力,从而构建和谐的医患关系.     

执业药师的人文关怀

构建和谐医患关系是促进医院健康发展的基础,倡导人文关怀是架起医患关系的桥梁。执业药师通过沟通、理解、信任等方面拉近医患之间的距离,从而提高患者用药的依从性,促进临床合理用药。     

我国医患关系研究现状

近年来,我国医患关系较为紧张,医患矛盾频发,这不仅使患者及家属感到不满,也对医院正常秩序和医生执业环境形成不良影响,更是阻碍医学发展、人民健康水平提高的社会问题。针对文献研究的焦点问题,如医患关系的概念、现状、影响因素和改善对策等进行整理和总结,并提出其存在的问题及今后可能的研究方向。     

医患关系研究进展综述

国内关于医患关系成因、表现形式和对策的研究己涉及社会学、医疗技术、医疗信息、医疗法律制度、医疗卫生体制、舆论监督等多个方面。从医技、医价、医药、医风和医疗制度等方面全面、系统地认识、研究医患关系,是构建和谐医患关系的关键。