How physicians experience patient consultations at on orthopaedic out-patient clinic: a qualitative study
Introduction
The present study at an orthopaedic outpatient clinic in a university hospital in Stockholm, Sweden, was initiated because of changes concerning the profile of patients, new financial directives and the need for quality safeguards. This and criticism from patients have brought about this study. The overall goal of the study is to pinpoint decisive factors in the physician–patient encounter, i.e. factors in the physician’s as well as the patient’s behaviour which can facilitate or hinder communication, and to pass on the findings of this study to orthopaedics in order to improve the care of patients. The first part of the study describes patients’ experiences of communication with their physicians, after the patients observed and commented on their own video-recorded consultations [1].
It has been stated that “the medical profession has traditionally been granted an attitude to the patient characterised by a biomedical organ/disease orientation based on a paradigm of scientific knowledge” [2]. According to this paradigm, the physician is motivated in encounters with patients “mainly by an interest in diseases … and by an ambition to try to solve the existing and clearly defined problem” [2]. A conflict may arise between the physician’s two-fold obligation to provide health care of a diagnostic/technical/scientific nature and that of showing caring concern for the individual [1]. Several studies about the experiences and attitudes of physicians point to conflicts within this area. Laine et al. [3] showed that doctors and patients had widely differing views on what they consider to be the most important aspect of a consultation. Major discrepancies emerged on a number of issues, especially concerning health-related information, i.e. patients regarded such information as more significant than the physicians did.
An earlier paper from the present study [1] showed that the negative comments of patients described various difficulties with communication. Such difficulties included the patients’ failure to understand what the physicians were inquiring about, or what they said or did; also that the physician seemed inadequately prepared for the consultation. Other difficulties experienced by the patients were that some physicians questioned the judgement of others, or showed a lack of understanding for the patient. In one study by Eggly et al. [4] using video-recordings, it emerged that physicians in specialist training programs displayed incompetence when it came to giving the patient negative information. Furthermore, a Swedish study described [5] general practitioners’ comments on video-recorded consultations where the subjects broached included difficulties in understanding the patient, how they should manage the consultation, and how to understand the actual content of the consultation.
One researcher, Tähkä [6], who has studied physician–patient relationships, states that the “increasing number of patient complaints about doctors are in many cases a result of the physicians’ one-sided emphasis on the scientific side”; however, he has also stated that it “is a mistake to think that physicians should study the psychosocial framework primarily in order to create a more pleasant atmosphere in their contacts with patients.” The psychosocial factors are of even greater importance from a medical point of view, since these factors clearly give rise to physical ailments/illnesses. In another article Tähkä [7] states that “the medical interview has, however, therapeutic importance, both for the short-term and long-term perspective. The interview should lay the groundwork for a patient–physician relationship which motivates the patient to actively co-operate with the physician.” (authors’ translation.) In contrast to Täkhä’s reasoning, which is often theoretical, one can emphasise instead Emanuel et al. [8], [9], [10], who provide concrete advice as to how the patient–physician relationship can be improved, based primarily on various models and behavioural patterns.
Three American studies present the patient–physician relationship as being greatly influenced by contextual areas such as power and financial aspects. In his book, Waitzkin [11] addresses the issue of power, introducing concepts such as micro- and macro-levels, where micro-levels are to be found in medical encounters such as “processes that involve the interaction of individuals”. The “interpersonal processes … occur in a social context, which is shaped by ‘macro-level’ structures in society”. Levinson et al. [12] maintains that “physicians most often attributed communication problems to the patient rather than to their own limitations”, examining in a article [13] patients’ disagreement which arises from their financial circumstances. Here, Levinson et al. particularly stress the “importance of excellent communication”. Brinkler et al. [14] investigate orthopaedic patients’ satisfaction from a similar perspective to that of Levinson, i.e. limited financial circumstances. Their findings reveal that the use of a gatekeeper significantly lowers patient satisfaction compared with situations where gatekeepers are not used and, consequently, the patients can more easily gain access to specialists.
The most important conclusions to be derived from the studies referred to above are that difficulties and obstacles in the patient–physician relationship are attributable in part to a scientific approach by the physician. Such an approach leads to the patient and physician having different opinions about what is important and enables structural factors, including financial circumstances, to influence the consultation. The majority of studies treating patient–physician relationships have investigated general practitioners and their patients. But during the recent years studies concerning hospital specialists and their patients are more and more usual [15], [16], [17], [18], [19], [20], [21]. Six of these studies [16], [17], [18], [19], [20], [21] used the Roter Interaction Analysis System (RIAS) to analyse doctor–patient communication.
The aim of the present study is to describe physicians’ experiences in their encounters with patients by allowing the physicians to observe and comment on their own video-recorded medical consultations.
Section snippets
Methods
Studies of visits to general practitioners [22] have demonstrated that by using a particular video-recording method, informative material can be obtained which sheds light upon key factors in the physician–patient encounter. One method [23] has proved successful in providing helpful information about the experiences of both physicians and patients. The method consists of the physician and patient independently observing the recorded medical consultation and commenting spontaneously on it. The
Results
The physicians’ views make up 203 comments. Slightly more than 15% (32 comments per 15 physicians) did not pertain to the study, because they did not describe the physicians assessment of communication. Comments and views which emerged while watching the filmed consultation were categorised into six different groups (Table 1).
Discussion
Most comments (3/4) deal with the fact that the physicians adapt the way they communicate to the patients’ situation and that when physicians see the recorded consultations, they reflect on, and question, their demeanour towards the patients. Furthermore, the results show that when the physicians were shown the recorded consultations, they commented spontaneously on such things as having to work under unfavourable conditions, the need to explain things to the patients, the experience of having
Acknowledgements
This study has been carried out with the financial support of the Orthopaedic Clinic’s FoUU-grant for medical research at Karolinska Hospital, the Board of Research for Health and Caring Sciences, Karolinska Institute as well as contributions from the Red Cross University College of Nursing, Stockholm, Sweden.
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