There are a number of issues that lead to problems. First, here are at some general ones and some that lead to difficulties at the beginning of consultations.
- How many problems do people bring?In a variety of settings including primary care, paediatrics and internal medicine, the mean number of concerns ranged from 1.2 to 3.9 in both new and return visits
- How many are discovered?Approx 50% (Stewart, 1979 54% of patients complaints and 45 % of their concerns elicited)
- Which is the most important?Order of presentation is unrelated to importance yet doctors very often assume erroneously that the first complaint mentioned is the only one that the patient has brought
- What about doctors interruptions?Work by Beckman and Frankel (1984) shed important light:
- Doctors frequently interrupt – mean time l8 seconds.
- The earlier the interruption the less likely to hear more than one complaint and the more likely to have late arising complaints and to miss important complaints. Only 23% of patients completed their opening statement. In only 1 out of 51 interrupted statements was the patient allowed to complete their opening statement later. 94% of all interruptions concluded with the doctor obtaining the floor. The longer the doctor waited before the interruption, the more complaints were elicited. Allowing the patient to complete the opening statement led to a significant reduction in late arising problems.
- In 34 out of 51 visits, the doctor interrupted the patient after the initial concern, apparently assuming that the first complaint was the chief one.
- The serial order in which the patients presented their problems was not related to their clinical importance. Patients who were allowed to complete their opening statement without interruption mostly took less than 60 seconds and none took longer than 150 seconds even when encouraged to continue.
- What happens if doctors use closed questioning to hypothesis generation? Poor hypothesis generation, poor problem-solving issues
- In what percentage of consultations do we underestimate our patients desire for information? Waitzkin (1984) showed that in 65% of encounters, internists underestimated their particular patients desire for information, in only 6% did they overestimate. Many studies have shown that patients can be divided into information seekers (80%) and avoiders (20%), with seekers coping better with more information, and avoiders better with less (Miller and Maugan 1983, Deber 1994)
- How many minutes spent in information giving?On average only one minute in 20-minute interview, not 9 minutes as doctors thought (Waitzkiu and Stoekel, 1972).
- What proportion adhere to treatment?Figures depend on the context, eg new problem as opposed to a chronic one. On average 50% adhere.
- Medicolegal complaints are related to communication difficultiesPhysicians attitudes and communication were identified by lawyers as the primary reasons for malpractice litigation in 70% of complaints.
There are problems in other areas too:
Discovering the reasons for the patients attendance:
- 54% of patient complaints and45% Of their concerns are not elicited (Stewart et al 1979)
- In 50% of visits, the patient and the doctor do not agree on the nature of the main presenting problem (Starfield et at, 1981)
- Patients and doctors agreed on the chief complaint in only 76% of somatic problems and in only 6% of psychosocial problems (Burack and Carpenter, 1983).
- Doctors frequently interrupt patients so soon after they begin their opening statement – after a mean time of only 18 seconds! – that patients fail to disclose significant concerns (Beckman and Frankel, 1984).
- Doctors often interrupt patients after the initial concern, apparently assuming that the first complaint is the chief one, yet the order in which patients present their problems is not related to their clinical importance (Beckman and Frankel, 1984).
- Interviews were particularly likely to become dysfunctional if there were shortcomings in that part of the consultation relating to discovering the reason for the patients attendance (Byrne and Long, 1976).
- Doctors often pursue a doctor-centred, dosed approach to information gathering that discourages patients from telling their story or voicing their concerns (Byrne and Long, 1976).
- Both a high control style and premature focus on medical problems can lead to an over-narrow approach to hypothesis generation and to the limitation of the patient’s ability to communicate their concerns. These, in turn, lead to inaccurate consultations (Platt and McMath, 1979)
- Doctors rarely ask their patients to volunteer their ideas and in fact, doctors often evade their patients ideas and inhibit their expression. Yet, if discordance between doctors and patients ideas and beliefs about the illness remains unrecognised, poor understanding, adherence, satisfaction and outcome are likely to ensue (Tuckett et al 1985.)
- Maguire and Rutter, (1976) showed serious deficiencies in senior medical students information gathering skills: few students managed to discover the patients main problem, to clarify the exact nature of the problem and explore ambiguous statements, to clarify with precision, to elicit the impact of the problem on daily life, to respond to verbal cues, to cover more personal topics or to use facilitation. Most used closed, lengthy, multiple and repetitive questions.
Explanation and Planning
- In general, physicians give sparse information to their patients, with most patients wanting their doctors to provide more information than they do (Waitzkin 1984, Pinder 1990, Beisecker and Beisecker 1990).
- Waitzkin (1984) has demonstrated that American internists devoted little more than one minute on average to the task of information giving in interviews lasting 20 minutes and overestimated the amount of time that they spent on this task by a factor of nine.
- Makoul et al (1995) found that doctors in British general practice overestimated the extent to which they accomplished the following key tasks in explanation and planning: discussing the risks of medication, discussing the patients ability to follow the treatment plan and eliciting the patients opinion about the medication prescribed.
- Patients and doctors disagree over the relative importance of imparting different types of medical Information; patients place the highest value on information about prognosis, diagnosis and causation of their condition while doctors overestimate their patients desire for information concerning treatment and drug therapy (Kindelan and Kent 1987).
- Doctors consistently use jargon that patients do not understand (Svarstad 1974, Hadlow and Pitts 1991)
- Korsch et al (1968) found that paediatricians use of technical language (eg, oedema) and medical shorthand (e.g. history) was a barrier to communication in more than half of the 800 visits studied. Mothers were confused by the terms used by doctors yet rarely asked for clarification of unfamiliar terms.
- Svarstad (1974) suggested that doctors and patients engage in a communication conspiracy. In only 15% of visits where unfamiliar terms were used did the patient admit that they did not understand. Doctors in turn seemed to speak as if their patients understood all that they said. Physicians deliberately used highly technical language to control communication and to limit patient questions – such behaviour occurred twice as often when doctors were under pressure of time!
- McKintay (1975) in a study of British obstetricians and gynaecologists showed that physicians were well aware of the difficulties patients had in understanding doctors in general. Despite this, in their interviews with patients physicians continued to use terms which they had previously identified as the very ones that they would not expect their patients to understand.
There are significant problems with patients recall and understanding of the information that doctors impart (Tuckett et al 1985). It is clear that patients do not recall all that we impart nor do they make sense of difficult messages. Original studies have shown that only 50 to 60% of the information given is recalled. Later studies have suggested that in fact much more is remembered and that the real difficulty is that patients do not always understand the meaning of key messages nor are they necessarily commuted to the doctors view.
Patients do not comply or adhere to the plans that doctors make: on average 50% do not take their medicine at all or take it incorrectly (Meichenhaum and Turk 1987, Butler et al 1996)
Non-compliance is enormously expensive. Walton et al in 1980 estimated that the cost of such wasted drugs per year in the UK was in the order of £300 million; estimates of the overall costs of non (including extra visits to physicians, laboratory tests, additional medication; hospital and nursing home admission; lost productivity and premature death) are CAN$7-9 billion in Canada (Coambs et al 1995) and US$100 billion-plus in the US (Berg et al 1993)
Breakdown in communication between patients and physicians is a critical factor leading to malpractice litigation (Levinson 1994). Lawyers identified physicians communication and attitudes as the primary reason for patients pursuing a malpractice suit in 70% of cases. (Avery 1936). Beckman et al(1994) showed that the following four communication problems were present in over 70% of malpractice depositions: deserting the patient, devaluing patients views, delivering information poorly and failing to understand patient perspectives
In several states of the USA, malpractice insurance companies award premium discounts of 3% to 10% annually to their insured physicians who attend a communication skills workshop (Carroll 1996).
Lack of empathy and understanding
Numerous reports of patient dissatisfaction with the doctor-patient relationship appear in the media. Many articles comment on doctors lack of understanding of the patient as a person with individual concerns and wishes.
There are significant problems in medical education in the development of relationship-building skills: it is not correct to assume that doctors either have the ability to communicate empathically with their patients or that they will acquire this ability during their medical training (Sanson-Fisher and Poole 1978).