Patient-centred communication: videotaped consultations

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Abstract

The aim of this study is to analyse the way in which orthopaedic physicians manage consultations, and to identify those factors associated with patient-experienced satisfaction/dissatisfaction. This was explored both using a descriptive method and by analysing comments from patients. Consultations were videotaped; 18 physicians and 18 patients participated. Approximately 1 week after the consultation, the patient was shown the video recording and asked for his/her points of view and spontaneous reactions. Each time, the patient wished to say something, the video was stopped and the comments recorded. According to the patients’ comments of the videotaped consultations four consultations were mainly positive, seven negative and seven neither completely positive nor completely negative. We analysed the positive and negative consultations using the Consultation Map (CM) method. The pattern in the positive consultations shows a greater flexibility. Statements regarding initial history and aetiology often move to and fro between other items, and the consultation as a whole was often characterised by this rapid change between items. The pattern in the negative consultations seems to indicate a slower motion; with longer time spent with few items and fewer items covered. The positive consultations were characterised by a greater prevalence of the items ‘Sharing Understanding’ and ‘Involving the Patient in Management’. On the other hand, the negative consultations were characterised by more time spent with the items ‘History of problems’, and ‘Patient Ideas’. This might be due to the patient having tried to express him/herself in order to present his/her views but the physician not following them up. In this study, the CM has been helpful in clarifying the difference between encounters experienced as satisfactory or dissatisfactory.

Introduction

It is essential to study the communication between physicians and patients because of the importance of patient satisfaction and its consequences regarding compliance, outcome, and other effects concerning efficacy. In spite of financial cutbacks in the health care system, quality and effectiveness must be maintained or even improved. These factors, as well as criticism from patients, have initiated this study. Orthopaedic surgeons have rarely been studied from the point of view of communication. Most studies in this field have concerned general practitioners (GPs). The aim of the first part of the three studies [1] was to describe the patients’ experience of communication with their orthopaedic surgeons. The aim of the second study [2] was to describe orthopaedic surgeons’ experience of encounters with patients by allowing them to observe and comment on their own videotaped medical consultations. The main results were that, surprisingly often, patients did not understand what the physicians were talking about, but also that the physicians felt that it was difficult to help certain patients. Consequently, the aim of this study—the third part—is to analyse the way in which orthopaedic surgeons manage consultations, and to identify factors possibly associated with patient-experienced satisfaction/dissatisfaction.

Many studies have focused on patient satisfaction with the consultation regarding an association with compliance, symptom alleviation, and other positive effects [3], [4], [5]. In the study by Ong et al. [6] patients’ satisfaction was best predicted by information-giving by their physician. Hall et al. [7] showed that healthier patients were more satisfied with their care and that patients were more satisfied with visits to female than male physicians. Waghorn and McKee [8] found that the majority of patients (78%) at a surgical outpatient clinic did not have a preference with regard to the gender of the physician. Among those who expressed a preference, males preferred being attended by males and females by females. One study from the orthopaedic field [9] shows that patient satisfaction can be an important determinant of outcome. Patient-centredness is a concept often mentioned in the literature; including that the physician is paying attention, among other things, to the patient’s health beliefs, i.e. ideas about health, illness and management [10].

Orthopaedics is the medical speciality devoted to the diagnosis, treatment, rehabilitation and prevention of injuries and diseases of the body’s musculoskeletal system. This complex system includes bones, joints, ligaments, tendons, muscles and nerves which allow us to move, work and be active. As part of the surgical specialities, orthopaedics have a tradition of being much disease-oriented than GPs, for instance.

Section snippets

Sample and procedure

Eighteen orthopaedic consultations were videotaped at an orthopaedic outpatient clinic. Nine of the consultations were first-time visits and an equal number were follow-up consultations. In each videotaped consultation, an orthopaedic surgeon and a patient took part; thus a total of 18 physicians, 17 male, 1 female (years of age 33–63, years as specialist 1–36) and 18 patients, 10 male, 8 female (years of age 27–74) participated. All of the orthopaedic surgeons working at the clinic in question

Assessments of the four positive and seven negative consultations using the CM

According to the researchers’ assessment using the CM, four consultations were rated as positive, seven as negative, and seven were neither completely positive nor completely negative. This was in accordance with the comments of the patients.

The four positive consultations (Fig. 1) were characterised by a greater prevalence of the items ‘Sharing Understanding’ and ‘Involving’, in contrast with the seven negative consultations (Fig. 2).

On the other hand, the negative consultations (Fig. 2) were

Discussion and conclusion

The present study showed an association between satisfied patients and that the physician involves the patient in the consultation. There was also an association when the physician and patient arrive at a mutual understanding, i.e. the more ‘Sharing Understanding’ the less the patients are dissatisfied. A similar pattern was observed with regard to ‘Involving the patient’. Other studies [25] have shown that a key factor in the communication difficulties appears to be the difficulty for the

Acknowledgements

The authors are grateful to Professor Töres Theorell MD and Hans Peter Søndergaard PhD, MD for their valuable comments. This study has been financed by the Board of Research for Health and Caring Sciences, Karolinska Institutet, Stockholm, Sweden and the FoUU grant at the Orthopaedic Clinic at the Karolinska Hospital. The study has been approved by the Research Ethics Committee at Karolinska Hospital, Stockholm, Sweden.

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