How patients perceive a doctor's caring attitude

Abstract

Objective

Caring is closely associated with reduced malpractice litigation, adherence to treatment and even symptom relief. Caring also is included in pay for performance formulas as well as widely utilized for quality improvement purposes. Our objective in this prospective qualitative study was to define caring behaviors associated with three challenging encounters: discussing the transition from curative to palliative care, delivering bad news (cancer), and discussing a medical error (misplaced test result). The purpose was to lay the groundwork for the creation of a ‘patient-centered’ caring attitude checklist that could help the healthcare provider understand and ultimately enhance the patient's experience of care.

Methods

Groups of randomly selected lay people, henceforth referred to as patients: (1) engaged in ‘think aloud’ exercises to help create a 15-item caring behavior checklist; (2) used the checklist to rate videotapes of simulated challenging encounters conducted by twenty primary care physicians (total of 600 ratings sets); and (3) participated in 12 separate 1.5 h focus groups discussing the caring (and non-caring) behaviors exhibited in videotapes of the highest and lowest rated encounters.

Results

Thirteen behaviors emerged as focal for describing a doctor's caring attitude but with disagreement as to whether specific examples of these behaviors were ‘caring’ or ‘uncaring.’ For example, although the concept of empathic inquiry was considered important by most patients, the physician question, “Is there someone you can call or talk with” (about a cancer diagnosis) was interpreted by one patient as ‘very caring’ while another was ‘impressed with how uncaring’ the statement appeared.

Conclusion

At the conceptual level there is a set of behaviors that represent caring, however, the manifestation of these behaviors is ‘in the eye of the beholder.’ The most important element of caring may not be the set of behaviors but a set of underlying abilities that include taking the patient's perspective and reflecting on the patient's responses.

Practice implications

Medical education must focus on the underlying abilities of caring.

Introduction

Why study caring? On the one hand, there is mounting evidence that it is closely associated with many critically important patient outcomes in medicine including reduced malpractice litigation, adherence to treatment and even symptom relief [1], [2], [3]. Caring also is integral to patient satisfaction which is often included in pay for performance formulas and is widely utilized for marketing and quality improvement purposes [4].

Caring is increasingly recognized as central to the practice of medicine, and yet it remains an elusive concept for practitioners and educators alike. Branch uses attributes such as honesty, respect, compassion and trustworthiness to describe “an orientation to caring [5].” On the surface all of these descriptors appear intangible and open to interpretation.

Specific behaviors that convey caring would seem more helpful in ensuring adoption. However, there is evidence that even at the behavioral level, differences in perception prevail. For example, patients vary widely in their beliefs as to how much informing constitutes caring behavior [6]. Fully informing the patient about his serious diagnosis could be interpreted as uncaring by some patients or family members despite the most caring of intentions [3].

Rather than focus on the use of specific caring behaviors that are open to interpretation by patients, a better approach would be to focus on each patient's unique perspective of caring. Suchman et al suggest the importance of these underlying abilities when they refer to the “… clinician's intrinsic capacity and motivation, respectively, to attend to the emotional experiences of others;” and more importantly in their eyes; “… the accurate understanding of the patient's feelings …” (p. 679) [7]. As Back et al state: “These communication skills are not the ‘medical interviewing’ skills most physicians learned in medical school, which focused on taking a complete medical, social, and family history” but rather “second order skills that address difficult situations.” (p. 164) [3]. These skills are referred to as metacognitive in that they involve thinking about one's own thoughts and feelings as well as the patient's [8]. They include the abilities to anticipate, reflect, self-assess and plan the interaction accordingly [8]. It has been suggested that these abilities can be fostered in the clinical teaching environment using techniques such as role-modeling, review of seminal events and focusing on the hidden curricula [9].

We designed this study primarily to define caring from the perspective of patients (lay people chosen randomly from the community). We chose to focus on medical situations in which caring is likely to be challenged, specifically when making a transition from curative to palliative care, delivering bad news in the form of telling a patient that they likely have cancer, and in communicating a medical error about a test result. The findings could be used for teaching and to develop a caring attitude checklist that integrated perspective with behaviors to serve as the basis for further understanding patients’ experiences of healthcare.