Doctorpatient communication

There is now considerable evidence not only of patient dissatisfaction with medical communication but also of widespread non-compliance with subsequent treatment recommendations.(64) Early research revealed that patient dissatisfaction was often associated with receiving insufficient information, poor understanding of the medical advice, and subsequent reluctance or inability to follow recommended treatment or advice.(65) Another source of patients' dissatisfaction is the perception that the doctor lacks interest and empathy, and is unwilling to involve them in decision making during the consultation. Thus, an overview of research in this area (66) revealed that patient satisfaction was higher following consultations in which the doctor engaged in more social conversation, positive verbal and non-verbal behaviour, and partnership building.

In order to develop an adequate understanding of doctor-patient communication, it is first necessary to assess what it is that the doctor and the patient bring to the consultation (input factors). An increasing number of studies have revealed significant attitudinal and belief differences between doctors, which can have a general influence on their clinical practice, including their consulting styles. (67) Moreover, consultation and clinical decision-making processes can be affected by shorter-term factors such as context and mood.(68) Similarly, many studies have demonstrated that patients vary considerably in their health beliefs, (4) illness perceptions,(5) and in their expectations prior to the consultation.(51)

A range of frameworks have been developed for describing the process of the consultation. Similarly various methods have been devised for analysing the interactional processes which occur during the consultation, using audiotape, videotape, or transcripts based on these. (66) Recently Roter et al.(69) have used these analyses to propose five distinct patterns of communication in doctors:

• narrowly biomedical, characterized by closed-ended medical questions and biomedical talk

• expanded biomedical, similar to the narrowly biomedical but with moderate levels of psychosocial discussion

• bio-psychosocial, reflecting a balance of psychosocial and biomedical topics

• psychosocial, characterized by psychosocial exchange

• consumerist, characterized by patient questions and information giving by the doctor.

The highest levels of patient satisfaction were found with those who had seen doctors using the psychosocial communication pattern, whereas the lowest satisfaction scores were recorded in those who had experienced either of the two biomedical patterns.(69)

An alternative and broader distinction has been made between consultations which are described as patient centred and those which are doctor centred, reflecting the extent to which the doctor or patient determines what is discussed. Doctor-centred consultations are ones in which closed questions are used more often and the direction is determined by the doctor, typically with a primary focus on medical problems. In contrast, patient-centred encounters involve more open-ended questions with greater scope for patients to raise their own concerns and agendas. Related to this are consistent differences in the extent to which the doctor responds to the emotional agendas and the non-verbal cues of the patient.(66) Although there has been a tendency to consider the more patient-centred/emotion-focused approach as preferable, what appears to be more important is for doctor and patient to be in agreement over the nature of the problem and the best course of action. (70) Moreover, there is some evidence that a more patient-centred approach may not necessarily result in the best clinical outcomes. (71)

These various ways of conceptualizing and analysing the consultation process have been related to various outcomes such as patient satisfaction (2) or adherence to treatment (see below). Patient satisfaction, understanding, and beliefs can play a major role in influencing adherence with treatment or advice as well as other outcomes including health and well being. A number of studies have demonstrated beneficial effects on patients' health and well being arising from positive experiences in medical consultations/72 These have focused on psychological states such as anxiety as well as changes in specific physical variables such as blood pressure and blood glucose control. Some of the most impressive findings here have been found in the patient-intervention studies, which are described below.

One important spin-off from the findings in this area has been the development of communication skills training packages for medical undergraduates (73) and for experienced clinicians, particularly for improving skills in difficult areas of communication such as giving 'bad news'. (74) There have also been a number of interesting interventions aimed at patients. Generally these have involved interventions for patients prior to a consultation in order to increase their level of participation, particularly to ensure that their own concerns are dealt with and that information provided by the doctor is clearly understood. Greenfield et al.(75) used a preconsultation intervention of this type with hospital outpatients who were helped to identify their main questions and encouraged to ask these in the consultation. Compared with control patients, these patients participated more actively in the consultation and this was also associated with better long-term health outcomes, including lowered blood pressure in hypertensives and better glycaemic control in diabetic patients.

Break Free From Passive Aggression

Break Free From Passive Aggression

This guide is meant to be of use for anyone who is keen on developing a better understanding of PAB, to help/support concerned people to discover various methods for helping others, also, to serve passive aggressive people as a tool for self-help.

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