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1.  Changes in the quality of doctor–patient communication between 1982 and 2001: an observational study on hypertension care as perceived by patients and general practitioners 
BMJ Open  2011;1(1):e000203.
The rise of evidence-based medicine may have implications for the doctor–patient interaction. In recent decades, a shift towards a more task-oriented approach in general practice indicates a development towards more standardised healthcare.
To examine whether this shift is accompanied by changes in perceived quality of doctor–patient communication.
GP observers and patient observers performed quality assessments of Dutch General Practice consultations on hypertension videotaped in 1982–1984 and 2000–2001. In the first cohort (1982–1984) 81 patients were recorded by 23 GPs and in the second cohort (2000–2001) 108 patients were recorded by 108 GPs. The GP observers and patient observers rated the consultations on a scale from 1 to 10 on three quality dimensions: medical technical quality, psychosocial quality and quality of interpersonal behaviour. Multilevel regression analyses were used to test whether a change occurred over time.
The findings showed a significant improvement over time on all three dimensions. There was no difference between the quality assessments of GP observers and patient observers. The three different dimensions were moderately to highly correlated and the assessments of GP observers showed less variability in the second cohort.
Hypertension consultations in general practice in the Netherlands received higher quality assessments by general practitioners and patients on medical technical quality, psychosocial quality and the quality of interpersonal behaviour in 2000–2001 as compared with the 1980s. The shift towards a more task-oriented approach in hypertension consultations does not seem to detract from individual attention for the patient. In addition, there is less variation between general practitioners in the quality assessments of more recent consultations. The next step in this line of research is to unravel the factors that determine patients' quality assessments of doctor–patient communication.
Article summary
Article focus
Doctor–patient communication in hypertension consultations has become more business-like and task-oriented in the past few decades.
Shifts in communication styles in general practice may have produced changes in quality assessments of doctor–patient communication by general practitioners and patients.
Key messages
Compared with 20 years earlier (1982–1984), hypertension consultations recorded in 2000–2001 received higher quality assessments by GP observers and patient observers on three distinct quality dimensions: medical technical quality, psychosocial quality and the quality of interpersonal behaviour.
There was less variation between general practitioners in the quality assessments of more recent consultations.
Strengths and limitations of this study
Videotaped real-life general practice consultations from two distinct periods were analysed, which means that the findings refer to actual behaviour in general practice.
The quality assessments were made according to the same protocol in both periods.
Assessments of the GPs were executed by contemporary peers, while the assessments of patients were performed retrospectively. However, the concurrence of assessments of patient observers and GP observers in their different contexts reinforces our conclusions.
The generalisability of the findings is restricted to hypertension consultations, which involve a high proportion of repeat visits.
PMCID: PMC3191582  PMID: 22021787
2.  Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped General Practice consultations with hypertension patients 
BMC Family Practice  2006;7:62.
Departing from the hypotheses that over the past decades patients have become more active participants and physicians have become more task-oriented, this study tries to identify shifts in GP and patient communication patterns between 1986 and 2002.
A repeated cross-sectional observation study was carried out in 1986 and 2002, using the same methodology. From two existing datasets of videotaped routine General Practice consultations, a selection was made of consultations with hypertension patients (102 in 1986; 108 in 2002). GP and patient communication was coded with RIAS (Roter Interaction Analysis System). The data were analysed, using multilevel techniques.
No gender or age differences were found between the patient groups in either study period. Contrary to expectations, patients were less active in recent consultations, talking less, asking fewer questions and showing less concerns or worries. GPs provided more medical information, but expressed also less often their concern about the patients' medical conditions. In addition, they were less involved in process-oriented behaviour and partnership building. Overall, these results suggest that consultations in 2002 were more task-oriented and businesslike than sixteen years earlier.
The existence of a more equal relationship in General Practice, with patients as active and critical consumers, is not reflected in this sample of hypertension patients. The most important shift that could be observed over the years was a shift towards a more businesslike, task-oriented GP communication pattern, reflecting the recent emphasis on evidence-based medicine and protocolized care. The entrance of the computer in the consultation room could play a role. Some concerns may be raised about the effectiveness of modern medicine in helping patients to voice their worries.
PMCID: PMC1630692  PMID: 17064407
3.  Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views 
Quality & safety in health care  2005;14(4):290-294.
Background: The current orthodoxy within patient safety research and policy is characterised by a faith in rules based systems which limit the capacity for individual discretion, and hence fallibility. However, guidelines have been seen as stifling innovation and eroding trust. Our objectives were to explore the attitudes towards guidelines of doctors and nurses working together in surgical teams and to examine the extent to which trusting relationships are maintained in a context governed by explicit rules.
Methods: Fourteen consultant grade surgeons of mixed specialty, 12 consultant anaesthetists, and 15 nurses were selected to reflect a range of roles. Participant observation was combined with semi-structured interviews.
Results: Doctors' views about the contribution of guidelines to safety and to clinical practice differed from those of nurses. Doctors rejected written rules, instead adhering to the unwritten rules of what constitutes acceptable behaviour for members of the medical profession. In contrast, nurses viewed guideline adherence as synonymous with professionalism and criticised doctors for failing to comply with guidelines.
Conclusions: While the creation of a "safety culture" requires a shared set of beliefs, attitudes and norms in relation to what is seen as safe clinical practice, differences of opinion on these issues exist which cannot be easily reconciled since they reflect deeply ingrained beliefs about what constitutes professional conduct. While advocates of standardisation (such as nurses) view doctors as rule breakers, doctors may not necessarily regard guidelines as legitimate or identify with the rules written for them by members of other social groups. Future safety research and policy should attempt to understand the unwritten rules which govern clinical behaviour and examine the ways in which such rules are produced, maintained, and accepted as legitimate.
PMCID: PMC1744048  PMID: 16076795
4.  Effective improvement of doctor–patient communication: a randomised controlled trial 
Doctor–patient communication is an essential component of general practice. Improvement of GPs' communication patterns is an important target of training programmes. Available studies have so far failed to provide conclusive evidence of the effectiveness of educational interventions to improve doctor–patient communication.
To examine the effectiveness of a learner-centred approach that focuses on actual needs, to improve GPs' communication with patients.
Design of study
Randomised controlled trial.
One hundred volunteer GPs in the Netherlands.
The intervention identified individual GPs' deficiencies in communication skills by observing authentic consultations in their own surgery. This performance assessment was followed by structured activities in small group meetings, aimed at remedying the identified shortcomings. Outcomes were measured using videotaped consultations in the GPs' own surgery before and after the intervention. Communication skills were rated using the MAAS-Global, a validated checklist.
The scores in the intervention group demonstrated a significant improvement compared with those of the control group (95% confidence interval = 0.04 to 0.75). The effect size was moderate to large (d-value = 0.66). The level of participation significantly contributed to the effectiveness. Largest improvement was found on patient-centred communication skills.
The approach of structured individual improvement activities based on performance assessment is more effective in improving communication skills than current educational activities.
PMCID: PMC1874521  PMID: 16882375
communication; continuing medical education; physician–patient relations; task performance; analysis
5.  Calling the Doctor: A Qualitative Study of Patient-Initiated Physician Consultation among rural older adults 
Journal of aging and health  2011;23(5):782-805.
Guided by Leventhal’s Self-regulatory Model and Cockerham’s theory of health lifestyles, we explore 2 questions regarding physician consultation among elderly rural adults: What symptom characteristics prompt patient-initiated physician consultation? Do participants’ accounts of responses to symptoms, including the decision to consult a physician, incorporate descriptions of change over time?
We analyze data from semi-structured in-depth interviews with 62 older rural adults.
Accounts of decisions to initiate contact with physicians support prior research. Some symptoms encouraged immediate consultation; others prompted periods of monitoring and lay management. Physicians were most often contacted if changes were new, unusually severe, persisted or worsened, or failed to respond to lay treatment.
We characterize participants’ responses to symptoms as bricolages to highlight their construction from available materials. Incorporating the integrating concept of bricolage and Cockerham’s emphasis on both general dispositions and symptom-specific responses represents an important extension of Leventhal’s conceptualization of illness behavior, including patient-initiated physician consultation.
PMCID: PMC3130826  PMID: 21311048
Utilization of Medical Care; Illness Behavior; Rural Aging
6.  Eliciting patients' concerns: a randomised controlled trial of different approaches by the doctor 
Background: Although a ‘patient-centred’ approach to general practice consultation is widely advocated, there is mixed evidence of its benefits.
Aim: To measure the costs and benefits of using a prompt to elicit patients' concerns when they consult for minor illness.
Design of study: An open randomised controlled trial.
Setting: Four training semi-rural general practices in the south-east of the United Kingdom.
Method: Patients identified during the first part of the consultation as having a self-limiting illness were randomised to a second part of the consultation that was conducted ‘as usual’ or involved a written prompt to elicit the patient's concerns. After each consultation the doctor noted the diagnosis and the consultation length and the patient self-completed a questionnaire containing measures of satisfaction, enablement and anxiety.
Results: One hundred and ten patients were studied. Patients in the elicitation group reported a small but significant increase in the ‘professional care’ score of the consultation satisfaction questionnaire (88.2 versus 80.9, mean difference = 7.3, 95% confidence interval = 2.0 to 12.6) but no other benefits were detected. Consultations in the elicitation group, however, were longer by about a minute.
Conclusion: Given the pressures on consultation time in general practice there must be questions about the practical value of eliciting patients' concerns if the benefit of doing so is small and the cost large.
PMCID: PMC1326066  PMID: 15353051
consultation; general practice; patient concern; patient satisfaction; self-limiting illness; time
7.  Is personal continuity of care compatible with free choice of doctor? Patients' views on seeing the same doctor. 
While much has been written about the benefits of personal continuity of care there has been little research about the views of patients. In this cross sectional study 111 patients from three group practices (one of which ran a personal list system) were interviewed at home within a week of consulting a general practitioner. Patients were selected randomly from a systematic series of consulting sessions and a semi-structured interview was administered. Patients receiving more personal continuity of care were likely to be older, to have booked their most recent appointment further in advance, to desire personal continuity of care, to have an external health locus of control and to have a lower extroversion score. In the practice with a personal list, patients had a high level of continuity of care, were satisfied and showed little interest in having a choice of doctor. In the combined list practices patients valued their choice of doctor but often could not exercise it enough and they were more critical. They made more suggestions for change than those in the practice with a personal list system, mostly about receptionists and appointments. It is concluded that most patients like to see the same doctor, but they may not be willing to wait two days for this if there is a quicker option. It may be difficult to deliver both personal continuity of care and choice in group practice.
PMCID: PMC1372612  PMID: 8312019
8.  Conflicts in the Doctor/Patient Relationship: A Short Research Report 
Canadian Family Physician  1975;21(9):67-69.
The data for this paper come from the study initiated by the Lay Advisory and Research Committees of the British Columbia Chapter, College of Family Physicians of Canada. It recognizes that the practice of family medicine cannot exist without clients and that those clients will often have markedly different ideas about what they want and expect from those supposedly held by the professionals they consult. Thus a system operates in which representatives of the medical profession practice in local communities of prospective clients.1 Practitioners claim that their skills are so esoteric that the patient is in no position to evaluate them; this is described as the prerogative of his peers. But the practitioner will be evaluated by the patient, albeit on an unprofessional basis with non-professional criteria. Hence, practice may consist of an interaction between two different and sometimes conflicting sets of norms.2 A full report, “Family Medicine in a Consumer Age”, pp. 245 is available from the author for $7.50 (prepaid). This present paper summarizes a small portion of the major report.
PMCID: PMC2274690
9.  Does burnout among doctors affect their involvement in patients' mental health problems? A study of videotaped consultations 
BMC Family Practice  2009;10:60.
General practitioners' (GPs') feelings of burnout or dissatisfaction may affect their patient care negatively, but it is unknown if these negative feelings also affect their mental health care. GPs' available time, together with specific communication tools, are important conditions for providing mental health care. We investigated if GPs who feel burnt out or dissatisfied with the time available for their patients, are less inclined to encourage their patients to disclose their distress, and have shorter consultations, in order to gain time and energy. This may result in less psychological evaluations of patients' complaints.
We used 1890 videotaped consultations from a nationally representative sample of 126 Dutch GPs to analyse GPs' communication and the duration of their consultations. Burnout was subdivided into emotional exhaustion, depersonalisation and reduced accomplishment. Multilevel regression analyses were used to investigate which subgroups of GPs differed significantly.
GPs with feelings of exhaustion or dissatisfaction with the available time have longer consultations compared to GPs without these feelings. Exhausted GPs, and GPs with feelings of depersonalisation, talk more about psychological or social topics in their consultations. GPs with feelings of reduced accomplishment are an exception: they communicate less affectively, are less patient-centred and have less eye contact with their patients compared to GPs without reduced accomplishment.
We found no relationship between GPs' feelings of burnout or dissatisfaction with the available time and their psychological evaluations of patients' problems.
GPs' feelings of burnout or dissatisfaction with the time available for their patients do not obstruct their diagnosis and awareness of patients' psychological problems. On the contrary, GPs with high levels of exhaustion or depersonalisation, and GPs who are dissatisfied with the available time, sometimes provide more opportunities to discuss mental health problems. This increases the chance that appropriate care will be found for patients with mental health problems. On the other hand, these GPs are themselves more likely to retire, or risk burnout, because of their dissatisfaction. Therefore these GPs may benefit from training or personal coaching to decrease the chance that the process of burnout will get out of hand.
PMCID: PMC2754435  PMID: 19706200
10.  Do doctors and patients agree on cardiovascular-risk management recommendations post-consultation? The INTERMEDE study 
The British Journal of General Practice  2011;61(584):e105-e111.
Understanding interactions between patients and GPs may be important for optimising communication during consultations and improving health promotion, notably in the management of cardiovascular risk factors.
To explore the agreement between physicians and patients on the management of cardiovascular risk factors, and whether potential disagreement is linked to the patient's educational level.
Design of study
INTERMEDE is a cross-sectional study with data collection occurring at GPs' offices over a 2-week period in October 2007 in France.
Data were collected from both patients and doctors respectively via pre- and post-consultation questionnaires that were ‘mirrored’, meaning that GPs and patients were presented with the same questions.
The sample consisted of 585 eligible patients (61% females) and 27 GPs. Agreement between patients and GPs was better for tangible aspects of the consultation, such as measuring blood pressure (κ = 0.84, standard deviation [SD] = 0.04), compared to abstract elements, like advising the patient on nutrition (κ = 0.36, SD = 0.04), and on exercise (κ = 0.56, SD = 0.04). Patients' age was closely related to level of education: half of those without any qualification were older than 65 years. The statistical association between education and agreement between physicians and patients disappeared after adjustment for age, but a trend remained.
This study reveals misunderstandings between patients and GPs on the content of the consultation, especially for health-promotion outcomes. Taking patients' social characteristics into account, notably age and educational level, could improve mutual understanding between patients and GPs, and therefore, the quality of care.
PMCID: PMC3047342  PMID: 21375892
cardiovascular diseases; communication; counselling; healthcare disparities; education; patients; physician–patient relations; physicians; socioeconomic factors
11.  “Patient-Time,” “Doctor-Time,” and “Institution-Time”: Perceptions and Definitions of Time Among Doctors Who Become Patients 
Patient education and counseling  2006;66(2):147-155.
To examine views and experiences of conflicts concerning time in healthcare, from the perspective of physicians who have become patients.
We conducted two in-depth semi-structured two-hour interviews concerning experiences of being health care workers, and becoming a patient, with each of 50 doctors who had serious illnesses.
These doctor-patients often came to realize as they had not before how patients experience time differently, and how “patient-time,” “doctor-time,” and “institution-time” exist and can conflict. Differences arose in both long and short term, regarding historical time (prior eras/decades in medicine), prognosis (months/years), scheduling delays (days/weeks), daily medical events and tasks (hours), and periods in waiting rooms (minutes/hours). Definitions of periods of time (e.g., “fast,” “slow,” “plenty,” and “soon”) also varied widely, and could clash. Professional socialization had heretofore impeded awareness of these differences. Physicians tried to address these conflicts in several ways (e.g., trying to provide test results promptly), though full resolution remained difficult.
Doctors who became patients often now realized how physicians and patients differ in subjective experiences of time. Medical education and research have not adequately considered these issues, which can affect patient satisfaction, doctor-patient relationships and communication, and care.
Practice Implications
Physicians need to be more sensitive to how their definitions, perceptions, and experiences concerning time can differ from those of patients.
PMCID: PMC2950119  PMID: 17125956
Doctor-patient relationships; doctor-patient communication; medical education; patient satisfaction; medical ethics; medical socialization; health care delivery
12.  The Validity of Using Analogue Patients in Practitioner–Patient Communication Research: Systematic Review and Meta-Analysis 
Journal of General Internal Medicine  2012;27(11):1528-1543.
When studying the patient perspective on communication, some studies rely on analogue patients (patients and healthy subjects) who rate videotaped medical consultations while putting themselves in the shoes of the video-patient. To describe the rationales, methodology, and outcomes of studies using video-vignette designs in which videotaped medical consultations are watched and judged by analogue patients. Pubmed, Embase, Psychinfo and CINAHL databases were systematically searched up to February 2012. Data was extracted on: study characteristics and quality, design, rationales, internal and external validity, limitations and analogue patients’ perceptions of studied communication. A meta-analysis was conducted on the distribution of analogue patients’ evaluations of communication. Thirty-four studies were included, comprising both scripted and clinical studies, of average-to-superior quality. Studies provided unspecific, ethical as well as methodological rationales for conducting video-vignette studies with analogue patients. Scripted studies provided the most specific methodological rationales and tried the most to increase and test internal validity (e.g. by performing manipulation checks) and external validity (e.g. by determining identification with video-patient). Analogue patients’ perceptions of communication largely overlap with clinical patients’ perceptions. The meta-analysis revealed that analogue patients’ evaluations of practitioners’ communication are not subject to ceiling effects. Analogue patients’ evaluations of communication equaled clinical patients’ perceptions, while overcoming ceiling effects. This implies that analogue patients can be included as proxies for clinical patients in studies on communication, taken some described precautions into account. Insights from this review may ease decisions about including analogue patients in video-vignette studies, improve the quality of these studies and increase knowledge on communication from the patient perspective.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2111-8) contains supplementary material, which is available to authorized users.
PMCID: PMC3475831  PMID: 22700392
communication; patient preferences; research design; doctor–patient relationships; systematic reviews
13.  The Effect of Videotaping Students' Interviews with Patients for Interview Skill Education 
The importance of communication between patients and physicians has been proven in many previous studies. The authors analyzed the effect of interview skill education through videotapes which recorded students' interviews with real patients in the outpatient department of family medicine.
This study was conducted with all students who chose the elective course of family medicine and one randomly selected student every week from an 'infectious internal medicine' class at Dongguk University Ilsan Hospital during the period from December 2008 to March 2011. All students performed a preliminary examination of a new patient at the outpatient department of family medicine. All consultations were videotaped. Feedback to the student was given on the same day by viewing the videotape together. After feedback, all students performed another preliminary examination of one new patient at the department of family medicine the same week. Three family medicine residents scored all videotapes using 10-item interview skill checklists. Many parts of the checklists were modified using the Arizona Clinical Interview Rating Scales.
Thirty-three students participated. Of 10 items, nine showed increased scores after feedback. There was a significant change in four items after feedback: 'type of question' (before 2.36 ± 0.60, after 2.73 ± 0.72), 'timeline' (before 2.82 ± 0.68, after 3.18 ± 0.73), 'positive verbal reinforcement' (before 2.24 ± 0.56, after 2.61 ± 0.90), and the total score (before 21.70 ± 2.62, after 23.39 ± 3.13) (P < 0.05).
Giving feedback to medical school students on medical interview skills using videotapes of students' preliminary consultations with real patients in outpatient settings, was effective in improving the interview areas of 'type of question,' 'timeline,' 'positive verbal reinforcement,' and the total interview scores.
PMCID: PMC3611108  PMID: 23560207
Medical Schools; Undergraduate Education; Outpatients; Communication; Videotape Recording
14.  Doctor-initiated consultations: a study of communication between general practitioners and patients about the need for reattendance. 
It has been suggested that general practitioners have the potential to regulate a large percentage of their workload through their control of 'doctor-initiated' consultations. A survey was made of 300 consecutive consultations in a group practice. After their consultation patients completed a questionnaire asking what advice the doctor had given them on the need to reattend. At the same time the general practitioner completed a similar questionnaire about the need for reattendance and the advice given. The general practitioners judged that 74% of patients definitely or possibly needed to reattend, and only 26% definitely did not need to reattend. The coefficient of agreement between patients' and doctors' views on whether reattendance had been recommended was only 0.41. Thus the room for control of doctor-initiated consultations is limited by both clinical considerations and the apparent difficulty of accurately communicating the doctor's advice on reattendance to the patient.
PMCID: PMC1371110  PMID: 2117947
15.  Patients' choice of general practitioner: importance of patients' and doctors' sex and ethnicity. 
The relative importance of sex and ethnicity in patients' choice of doctor is not known. A total of 1633 consultations at a health centre in Bradford, with a mixed ethnic list, were examined over a four week period to test the relative importance of these variables. Patients had the choice to consult any one of: a male Asian, a male white or a female white doctor. Asian patients, irrespective of sex, were significantly (P less than 0.001) more likely to consult the Asian doctor then either of the other two doctors, though a greater proportion of Asian women than men consulted the female white doctor. Although the sex of the doctor was important in patients' choice, for Asian patients the doctor's culture and language were more important.
PMCID: PMC1371756  PMID: 1777278
16.  Touch in primary care consultations: qualitative investigation of doctors’ and patients’ perceptions 
The British Journal of General Practice  2013;63(609):e283-e290.
Good communication skills are integral to successful doctor–patient relationships. Communication may be verbal or non-verbal, and touch is a significant component, which has received little attention in the primary care literature. Touch may be procedural (part of a clinical task) or expressive (contact unrelated to a procedure/examination).
To explore GPs’ and patients’ experiences of using touch in consultations.
Design and setting
Qualitative study in urban and semi-rural areas of north-west England.
Participating GPs recruited registered patients with whom they felt they had an ongoing relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.
All participants described the importance of verbal and non-verbal communication in developing relationships. Expressive touch was suggested to improve communication quality by most GPs and all patients. GPs reported a lower threshold for using touch with older patients or those who were bereaved, and with patients of the same sex as themselves. All patient responders felt touch on the hand or forearm was appropriate. GPs described limits to using touch, with some responders rarely using anything other than procedural touch. In contrast, most patient responders believed expressive touch was acceptable, especially in situations of distress. All GP responders feared misinterpretation in their use of touch, but patients were keen that these concerns should not prevent doctors using expressive touch in consultations.
Expressive touch improves interactions between GPs and patients. Increased educational emphasis on the conscious use of expressive touch would enhance clinical communication and, hence, perhaps patient wellbeing and care.
PMCID: PMC3609476  PMID: 23540485
communication skills; consultations; non-verbal communication; primary health care; qualitative research; touch
17.  Is networking different with doctors working part-time? Differences in social networks of part-time and full-time doctors 
Part-time working is a growing phenomenon in medicine, which is expected to influence informal networks at work differently compared to full-time working. The opportunity to meet and build up social capital at work has offered a basis for theoretical arguments.
Twenty-eight teams of medical specialists in the Netherlands, including 226 individuals participated in this study. Interviews with team representatives and individual questionnaires were used. Data were gathered on three types of networks: relationships of consulting, communication and trust. For analyses, network and multilevel applications were used. Differences between individual doctors and between teams were both analysed, taking the dependency structure of the data into account, because networks of individual doctors are not independent. Teams were divided into teams with and without doctors working part-time.
Results and Discussion
Contrary to expectations we found no impact of part-time working on the size of personal networks, neither at the individual nor at the team level. The same was found regarding efficient reachability. Whereas we expected part-time doctors to choose their relations as efficiently as possible, we even found the opposite in intended relationships of trust, implying that efficiency in reaching each other was higher for full-time doctors. But we found as expected that in mixed teams with part-time doctors the frequency of regular communication was less compared to full-time teams. Furthermore, as expected the strength of the intended relationships of trust of part-time and full-time doctors was equally high.
From these findings we can conclude that part-time doctors are not aiming at efficiency by limiting the size of networks or by efficient reachability, because they want to contact their colleagues directly in order to prevent from communication errors. On the other hand, together with the growth of teams, we found this strategy, focussed on reaching all colleagues, was diminishing. And our data confirmed that formalisation was increasing together with the growth of teams.
PMCID: PMC2583974  PMID: 18834545
18.  Bone densitometry at a district general hospital: evaluation of service by doctors and patients. 
Quality in Health Care  1996;5(1):36-43.
OBJECTIVE--To assess doctors' and patients' views about a district general hospital bone densitometry service and to examine existing practice to influence future provision. DESIGN--Three postal surveys: (a) of doctors potentially using the service, (b) of patients undergoing a bone densitometry test during a six month period, and (c) of the referring doctors of the patients undergoing the test. SETTING--Bone densitometry service at South Cleveland Hospital, Middlesbrough and two district health authorities: South Tees and Northallerton. SUBJECTS--All general practitioners (n=201) and hospital consultants in general medicine, rheumatology, obstetrics and gynaecology, orthopaedics, radio therapy and oncology, haematology, and radiology (n=61); all patients undergoing an initial bone densitometry test (n=309) during a six month period; and their referring doctors. MAIN MEASURES--Service awareness and use, knowledge of clinical indications, test results, influence of test results on patient management, satisfaction with the service and its future provision. RESULTS--The overall response rates for the three surveys were 87%, 70%, and 61%. There was a high awareness of the service among doctors and patients; 219(84%) doctors were aware and 155 of them (71%) had used it, and patients often (40%) suggested the test to their doctor. The test was used for a range of reasons including screening although the general use was consistent with current guidelines. Two hundred (65%) bone densitometry measurements were normal, 71(23%) were low normal, and 38(12%) were low. Although doctors reported that management of patients had been influenced by the test results, the algorithm for decision making was unclear. Patients and doctors were satisfied with the service and most (n=146, 68%) doctors wanted referral guidelines for the service. CONCLUSIONS--There was a high awareness of, use of, and satisfaction with the service. Patients were being referred for a range of reasons and a few of these could not be justified, many tests were normal, and clinical decision making was not always influenced by the test result. It is concluded that bone densitometry services should be provided but only for patients whose management will be influenced by test results and subject to guidelines to ensure appropriate use of the technology.
PMCID: PMC1055352  PMID: 10157271
19.  Doctor's perception of doctor-patient relationships in emergency departments: What roles do gender and ethnicity play? 
Emergency departments continuously provide medical treatment on a walk-in basis. Several studies investigated the patient's perception of the doctor-patient relationship, but few have asked doctors about their views. Furthermore, the influence of the patient's ethnicity and gender on the doctor's perception remains largely unanswered.
Based on data collated in three gynaecology (GYN)/internal medicine (INT) emergency departments in Berlin, Germany, we evaluated the impact of the patient's gender and ethnicity on the doctors' satisfaction with the course of the treatment they provided. Information was gathered from 2.429 short questionnaires completed by doctors and the medical records of the corresponding patients.
The patient's ethnicity had a significant impact on the doctors' satisfaction with the doctor-patient relationship. Logistic regression analysis showed that the odds ratio (OR) for physician satisfaction was significantly lower for patients of Turkish origin (OR = 2.6 INT and 5.5 GYN) than for those of German origin. The main reasons stated were problems with communication and a perceived lack of urgency for emergency treatment. The odds ratios for dissatisfaction due to a lack of language skills were 4.48 (INT) and 6.22 (GYN), and those due to perceived lack of urgency for emergency treatment were 0.75 (INT) and 0.63 (GYN). Sex differences caused minor variation.
The results show that good communication despite language barriers is crucial in providing medical care that is satisfactory to both patient and doctors, especially in emergency situations. Therefore the use of professional interpreters for improved communication and the training of medical staff for improved intercultural competence are essential for the provision of adequate health care in a multicultural setting.
PMCID: PMC2329628  PMID: 18405351
20.  Doctor-Patient Communication: A Review 
The Ochsner Journal  2010;10(1):38-43.
Effective doctor-patient communication is a central clinical function in building a therapeutic doctor-patient relationship, which is the heart and art of medicine. This is important in the delivery of high-quality health care. Much patient dissatisfaction and many complaints are due to breakdown in the doctor-patient relationship. However, many doctors tend to overestimate their ability in communication. Over the years, much has been published in the literature on this important topic. We review the literature on doctor-patient communication.
PMCID: PMC3096184  PMID: 21603354
Benefits; communication; doctor-patient relationship; review; strategies
21.  Herbal medicine: women's views, knowledge and interaction with doctors: a qualitative study 
There is growing concern that serious interactions are occurring between prescribed/over the counter and herbal medicines and that there is a lack of disclosure of herbal use by patients to doctors. This study explores women's perspectives about the safety of herbal remedies, herb-drug interactions and communication with doctors about herbal medicines.
Qualitative, cross-sectional study, with purposive sampling which took place in Cheshire, UK. Eighteen in depth semi-structured interviews were conducted with female herbal medicine users aged 18 years and above.
The large majority did not inform their GPs of their use of herbal medicines. This was due to lack of physician enquiry, perception of importance and fear of a negative response. Several women were not aware that herbal remedies could interact with prescribed or over the counter medicines. Of the women who had experienced adverse effects none had reported them, believing them of low importance.
The women had little knowledge about herb-drug interactions and rarely disclosed use of herbal medicines to their doctor. Doctors' communication and openness regarding herbal medicines needs to improve and there should be increased access to accurate information on herbal medicines in the public and health care domain.
PMCID: PMC1702550  PMID: 17156416
22.  Management of patient adherence to medications: protocol for an online survey of doctors, pharmacists and nurses in Europe 
BMJ Open  2011;1(1):e000355.
It is widely recognised that many patients do not take prescribed medicines as advised. Research in this field has commonly focused on the role of the patient in non-adherence; however, healthcare professionals can also have a major influence on patient behaviour in taking medicines. This study examines the perceptions, beliefs and behaviours of healthcare professionals—doctors, pharmacists and nurses—about patient medication adherence.
Methods and analysis
This paper describes the study protocol and online questionnaire used in a cross-sectional survey of healthcare professionals in Europe. The participating countries include Austria, Belgium, France, Greece, The Netherlands, Germany, Poland, Portugal, Switzerland, Hungary, Italy and England. The study population comprises primary care and community-based doctors, pharmacists and nurses involved in the care of adult patients taking prescribed medicines for chronic and acute illnesses.
Knowledge of the nature, extent and variability of the practices of healthcare professionals to support medication adherence could inform future service design, healthcare professional education, policy and research.
Article summary
Article focus
A protocol for a cross-sectional survey of healthcare professionals in Europe to examine the perceptions, beliefs and behaviours of healthcare professionals—doctors, pharmacists and nurses—about patient medication adherence.
The questionnaire used in the survey of healthcare professionals is described in detail.
Key messages
There is an acute need for evidence regarding healthcare professionals' beliefs, perceptions and behaviour with regard to patient non-adherence to medicines.
This protocol describes a study to address this need.
The results of this study could guide healthcare professionals as they support patients with taking medicine in their day-to-day clinical practice.
Strengths and limitations of this study
The survey is the largest cross-national survey of healthcare professionals' approach to medication adherence.
Reliance on self-report data may raise concerns regarding the validity of the findings.
PMCID: PMC3276023  PMID: 22080529
23.  Courteous but not curious: how doctors' politeness masks their existential neglect. A qualitative study of video-recorded patient consultations 
Journal of Medical Ethics  2011;37(11):650-654.
To study how doctors care for their patients, both medically and as fellow humans, through observing their conduct in patient–doctor encounters.
Qualitative study in which 101 videotaped consultations were observed and analysed using a Grounded Theory approach, generating explanatory categories through a hermeneutical analysis of the taped consultations.
A 500-bed general teaching hospital in Norway.
71 doctors working in clinical non-psychiatric departments and their patients.
The doctors were concerned about their patients' health and how their medical knowledge could be of service. This medical focus often over-rode other important aspects of the consultations, especially existential elements. The doctors actively directed the focus away from their patients' existential concerns onto medical facts and rarely addressed the personal aspects of a patient's condition, treating them in a biomechanical manner. At the same time, however, the doctors attended to their patients with courteousness, displaying a polite and friendly attitude and emphasising the relationship between them.
The study suggests that the main failing of patient–doctor encounters is not a lack of courteous manners, but the moral offence patients experience when existential concerns are ignored. Improving doctors' social and communication skills cannot resolve this moral problem, which appears to be intrinsically bound to modern medical practice. Acknowledging this moral offence would, however, be the first step towards minimising the effects thereof.
PMCID: PMC3198010  PMID: 21610269
Applied and professional ethics; philosophy of medicine; professional—professional relationship
24.  The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data 
Literature on difficult doctor-patient relationships has focused on the "difficult patient." Our objective was to determine physician and practice characteristics associated with greater physician-reported frustration with patients.
We conducted a secondary analysis of the Physicians Worklife Survey, which surveyed a random national sample of physicians. Participants were 1391 family medicine, general internal medicine, and medicine subspecialty physicians. The survey assessed physician and practice characteristics, including stress, depression and anxiety symptoms, practice setting, work hours, case-mix, and control over administrative and clinical practice. Physicians estimated the percentage of their patients who were "generally frustrating to deal with." We categorized physicians by quartile of reported frustrating patients and compared characteristics of physicians in the top quartile to those in the other three quartiles. We used logistic regression to model physician characteristics associated with greater frustration.
In unadjusted analyses, physicians who reported high frustration with patients were younger (p < 0.001); worked more hours per week (p = 0.041); and had more symptoms of depression, stress, and anxiety (p < 0.004 for all). In the final model, factors independently associated with high frustration included age < 40 years, work hours > 55 per week, higher stress, practice in a medicine subspeciality, and greater number of patients with psychosocial problems or substance abuse.
Personal and practice characteristics of physicians who report high frustration with patients differ from those of other physicians. Understanding factors contributing to physician frustration with patients may allow us to improve the quality of patient-physician relationships.
PMCID: PMC1617099  PMID: 17026762
25.  Information from the Internet and the doctor-patient relationship: the patient perspective – a qualitative study 
BMC Family Practice  2007;8:47.
Both doctors and patients may perceive the Internet as a potential challenge to existing therapeutic relationships. Here we examine patients' views of the effect of the Internet on their relationship with doctors.
We ran 8 disease specific focus groups of between 2 and 8 respondents comprising adult patients with diabetes mellitus, ischaemic heart disease or hepatitis C.
Data are presented on (i) the perceived benefits and (ii) limitations of the Internet in the context of the doctor-patient relationship, (iii) views on sharing information with doctors, and (iv) the potential of the Internet for the future. Information from the Internet was particularly valued in relation to experiential knowledge.
Despite evidence of increasing patient activism in seeking information and the potential to challenge the position of the doctor, the accounts here do not in any way suggest a desire to disrupt the existing balance of power, or roles, in the consultation. Patients appear to see the Internet as an additional resource to support existing and valued relationships with their doctors. Doctors therefore need not feel challenged or threatened when patients bring health information from the Internet to a consultation, rather they should see it as an attempt on the part of the patient to work with the doctor and respond positively.
PMCID: PMC2041946  PMID: 17705836

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