Archives of Medicine

Keywords

Doctor patient communication, Patient centeredness, Patients expectations, Doctors perceptions

Introduction

Effective communication is an essential component of delivery of healthcare. Training could enhance efficacy, effectiveness and supportiveness of communication [1]. Efficacy, the ability to gather information within the limited time available is a useful attribute for doctors practicing with over loaded patients. Effectiveness is the accuracy and comprehensiveness of information. Supportiveness will look after the psychosocioeconomic considerations of the patient [1].

Patient-centeredness, an attitude possess by doctors as well as patients indicates readiness to share information and planning care collaboratively in doctor patient encounters. Whereas doctor-centeredness indicates doctors taking the lead in handling information and planning care [2]. Patient-centeredness results in patient satisfaction and efficacy in data gathering in doctor patient encounters. It is beneficial for both patients and doctors to have similar attitudes [3].

Competency in communication is essential and trainable for any doctor along with other competencies like knowledge, clinical skills, and interpretation skills [4]. The requirement for teaching and training communication skills in undergraduate and postgraduate training is well established in developed countries and it is gaining popularity in the rest of the world [5,6]. Teaching and training communication skills needs priority as any doctor will perform more than 200 000 consultations in their life time [1]. Advantages of good communication like patient satisfaction, treatment adherence, therapeutic efficacy, cost effectiveness in care, doctors satisfaction and less chances of vicarious trauma has been documented [7]. Disadvantages of poor communication such as patient dissatisfaction, poor treatment adherence, conflicts and lesser therapeutic efficacy are also documented [7,8].

Teaching communication skills involves imparting knowledge, skills and attitude [4] to achieve a desired change of the behaviour of learners. This inescapable challenge cannot be achieved by traditional methods of teaching. Well-planned cognitive input, demonstrations and role modelling should be facilitated with experiential learning. Barriers for desired change in behaviour includes non-acceptance of the model by senior colleagues and poor role modelling by teachers. Doctors perception about patient expectation is also an important consideration that will have major influence on acceptance of concepts by learners. This study will explore patient expectations and doctors perceptions about patient expectations during doctor patient encounters.

Material and Methods

A pretested and validated questionnaire was administered to 700 consecutive patients attending the out-patients clinics and all the doctors in a tertiary care hospital. The questionnaire had 26 close-ended questions with likert scale indicating totally agree, agree to some extent, disagree and totally disagree. Perceptions of the respondents in relations to some question were further explored by open-ended question.

Developing the questionnaire

Items suitable for self-reporting questionnaire to evaluate patient expectations in doctor-patient communication were developed by literature survey and expert opinion. Developing more items as suggested by patients in focus group discussions helped to further modify the questionnaire. Out of 32 items developed only 26 items were selected after pretesting with a group of 10 patients. The 26-item questionnaire with likert scale of totally agree, agree, disagree and totally disagree was developed and was discussed with another group of patients to evaluate its intelligibility and validity. Items were rephrased to evaluate doctors perceptions about patient’s communication expectations. Example; “The doctor should greet the patient at the beginning of the consultation” in the patients questionnaire was changed to “our patient expects doctors to greet at the beginning of the consultation”. Doctors questionnaire also had similar likert scale. At the end of each item space was provided to express free opinion and such data collected was analysed in a separate study.

Sample and administration of the questionnaire

All the doctors working in two teaching hospitals were invited to participate in this study and two research assistants distributed the questionnaire and requested to return them after one week. All patients waiting in the Out-patient Department of one of the teaching hospital were given the patients questionnaire after explaining their right to refuse to complete the questionnaire. All the results were analysed using simple proportions.

Results

Ninety-one doctors (36%) and 655 patients (93%) have responded to the questionnaire. Patient’s expectations and doctors perceptions are presented parallel in the same Table 1. Responses expressed only as totally agree and somewhat agree were amalgamated and presented as percentages. Missing responses were not presented in this Table 1.

		‘Totally” or “some what” agree
		Patients	Doctors
1.1	The doctor should greet the patient at the beginning of the consultation.	88.9	96.7
1.2	The doctor should welcome the patients with a smile at the initiation of the consultation	96.8	96.7
1.3	The doctor should invite the patient to sit down at the beginning of the consultation.	91.3	97.8
1.4	Doctors need not introduce themselves to their patients at the beginning of the consultation.	60.6	57.2
1.5	Doctors should get engaged in a small talk with the patients before starting the consultation	38	78.1
2	Our doctors use language and word that is familiar to their patients.	88.1	86.9
3	Our patients would like to have precise instructions instead of explaining about the disease and the treatment	65	66
4.1	The doctor need not ask about the patient’s views and opinions about the disease.	30.7	35.2
4.2	The doctor should not consider the patient’s views and opinions in deciding treatment	35.4	17.6
5	The doctor should discuss about his/her personal experiences with the patient.	37	48.4
6	The doctor should decide the most appropriate treatment modality instead of discussing the available treatment options with the patient.	83.8	55
7	The doctor should not involve the patient’s relatives in the treatment of the patient’s disease.	44.8	27.5
8.1	Patient should take enough time to express their opinions and the views about the disease	84	90.2
8.2	The doctor should ask specific question rather than broad questions so that the patient can give short and accurate information.	74	73.7
8.3	Allowing the patient to express their views and opinions about the disease is not useful.	15.8	16.5
9	It is not necessary to thank the patient following examination of the patient.	53.6	35.2
10	Doctors do not entertain the patient’s points of views and ideas about the disease.	29	51.7
11	Patients will appreciate doctors understanding about their problems if they repeat what they said back to them.	66.2	73.7
12	The doctor should avoid expression of his/her feelings when they come across emotional situations regarding their patients.	54.9	67.1
13.1	Some doctor’s work considering patient’s problem as their problem.	72.8	72.5
13.2	Doctors should not get emotionally involved about their patients’ problems.	57.2	70.4
13.3	Doctors who empathize their patients are better at treating their patients.	82.3	71.5
14	Sri Lankan patients are usually contented about their encounter with the doctor during the consultation.	77.7	61.6
15	Doctors spend adequate time with each patient during their consultation.	80.1	39.6
16	Doctors do not pay respect to their patients’ points of views and opinions.	33	49.5
17	Doctors should involve the patients when deciding the management of the patient’s illness.	82.8	52.6

Table 1: Patient’s expectations and doctors perceptions.

Discussion

Items in the questionnaire reflect social niceties (items 1.1-1.5 and 2) doctor-centred attitudes (items 3, 4.1, 4.2, 6, 7, 8.2, 8.3, 9, 10, 12, 13.2 and 16) and patient-centred attitudes (5, 8.1, 11, 13, 13. 3, 14,15, 17).

Involving patients in deciding the management was supported only by 83% while “not exploring patient’s ideas” and “not involving patients in management” (items 4.1, 4.2. 8.3, 10) was supported by almost one third of patients indicating significant doctors centred attitude in the society. Doctors also perceive this expectation of the society. The majority of patients have supported decision-making by doctors (item 6). Nevertheless similar majority has supported patient’s involvement in decisionmaking (item 17). Only 50% of doctors have realized this need. When a significant proportion of patients (29%) feel that doctors do not entertain patient’s point of view only half of the doctors perceive this opinion of patients.

Majority of patients indicated their expectations for social niceties such as greeting, social smile, using simple language and offering a seat. Doctors also perceive this expectation of our patients. Doctors introducing themselves were need by only 60% of patients and doctors also seem to perceive this expectation. Doctors engaging in small talk was a need for only 38% of patients but 78% doctors seems to believe that our patient expect that.

Majority of patients supported doctor-centred attitudes such as asking instructions rather than explanations, unilateral decision making and closed ended questions and doctors perceive this expectation of patients. Doctors sharing their experiences with patients and involving relatives in planning care was a need of patients. Over 80% of patients indicated that they need time to talk, and doctors seem to understand this need.

The majority of patients need doctors empathy, understanding and paraphrasing, and doctors seem to have recognized this need. Only half of the patients supported doctors expression of emotions and feelings, but the majority of doctors thought that our patient expects that.

The needs of our patients regarding doctor patient communication indicate predominantly doctors-centred attitudes. Predominance of doctor centred attitudes of the general public in this country has been demonstrated [9]. Doctors seem to perceive these attitudes of their patients correctly.

However in our society with over 95% literacy rate [10] we should expect more and more patient-centred attitudes like sharing information with doctors and developing partnership with doctors. The willingness has been expressed but surpassed by the expression of allowing doctors to decide. Such empowered patients are likely to get more benefits from health care rather than doctors-centred less empowered patients. Doctors as well as patients seem to lay more emphasis on patient satisfaction. However patient empowerment is a more important and valuable achievement in doctor-patient encounters [11,12].

Limitations- lengthy questionnaire and repeated questions would have caused confusions in some items. Therefore only general analysis was done rather than an exploratory evaluation of data.

Conclusion

Doctors need to understand that the majority of patients like to contribute their opinion and get involve in decision making even though they wanted doctors to make decisions. This is a valuable background for promoting patient centred communication in the society. Patients wish for doctors to decide should not be misinterpreted as patient’s dislike to express opinion or being involve in decision-making. Patients expect doctor empathy, understanding and paraphrasing. However in contrast to the perception of the majority of doctors, majority of our patients do not expect doctors to express their feelings. Emphasis on social niceties should be supported and patient empowerment should be promoted. Information gathered in this study would be valuable in training doctors and students on doctor patient communication.

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References

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