Patient-Centredness in the Consultation. 2: Does it Really Make a Difference?

Transcription

1 Family Practice Oxford University Press 1990 Vol. 7, No. 1 Printed in Great Britain Patient-Centredness in the Consultation. 2: Does it Really Make a Difference? RONALD J HENBEST AND MORIA STEWART* Henbest RJ and Stewart M. Patient-centredness in the consultation. 2: does it really make a difference? Family Practice 1990; 7: The major purpose of this study was to test the hypothesis that patient-centredness in the consultation was associated with improved patient outcomes. Patient-centred care was defined as care in which the doctor responded to the patient in such a way as to allow the patient to express all of his or her reasons for coming, including: symptoms, thoughts, feelings and expectations. The study took place in the offices of six family doctors. All consultations were audiotaped and the patients completed a questionnaire and two structured interviews with the investigator: one immediately following the consultation and the other two weeks later. Patient-centredness was found to be associated with the doctor having ascertained the patient's reasons for coming and with resolution of the patient's concerns. It was also associated with the patient feeling understood and resolution of the patient's symptoms until confounding variables were controlled. The results of the multivariate analysis suggested that the impact of a patient-centred approach may be part of a package of care, consisting of a doctor whose overall practice allows for the development of personal relationships with patients over time through continuity of care. The concept of patient-centredness can be seen as a shift from thinking about patient care in terms of disease and pathology towards thinking in terms of people and their problems. This shift is still in process and has taken the major part of this century. In 1927, Sir Francis Peabody made the following declaration: 'The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases, both diagnosis and treatment depend directly upon it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of patients'.' Increasingly, especially since 1950, there has been research on the interpersonal aspects of care, 2 " 4 and the need to demonstrate a relationship between process and outcomes has been emphasized. 3 This study was designed to assess the personal relationship of doctors and patients and to test its effectiveness. We postulated that patient-centredness Department of Family Medicine, The Medical University of Southern Africa (MEDUNSA). 4 Department of Family Medicine, The University of Western Ontario, London, Canada. Correspondence to: Dr R J Henbest, The University of Alberta Family Clinic, Royal Alexandra Hospital, Kingsway Avenue, Edmonton, Alberta, Canada T5H3V9. 28 would be positively associated with: (1) the doctor's ascertainment of the patient's reasons for attendance, (2) doctor-patient agreement about the patient's problem, (3) the patient feeling understood by the doctor, (4) patient satisfaction with the consultation, (5) resolution of the patient's symptoms, and (6) resolution of the patient's concerns. METHOD Setting and Patients The setting for the study was the consultation rooms of six experienced family doctors, including both parttime teachers of family medicine and non-teaching doctors practising in small towns and cities in southwestern Ontario. Eligible patients were those aged 16 years or older whose presentation included a new symptom. Those patients who were either too ill, or in some way incompetent to complete a self-administered questionnaire and an interview were excluded, as were those whose sole reason for attendance was for ongoing counselling for a chronic emotional or social problem. Study Design The design of the study was that of a prospective follow-up (or cohort) study. The entire consultation (index visit) was audiotaped and later scored for

2 patient-centredness by an independent rater. Immediately after the consultation patients completed a selfadministered satisfaction questionnaire (the medical interview satisfaction scale ) followed by a structured interview with the study investigator. Finally, a telephone interview was carried out two weeks after the index visit. For the purpose of this study, patient-centred care was denned as care in which the doctor responded to the patient in such a way as to allow the patient to express all of his or her reasons for coming to the doctor, including symptoms, expectations, thoughts and feelings. Patient-centredness was measured from the audiotape of the consultation in terms of the doctor's responses to the patients' offers. The doctor's response was scored as 0 if the doctor ignored the offer altogether, as 1 if closed responses were used, as 2 if openended responses were given, and as 3 if expression of the patient's expectations, thoughts, or feelings were specifically facilitated. This method for measuring patient-centredness has been tested and found to be valid, sensitive, reliable and practical. 7 An attempt was made to reduce observer bias in the study in the following ways: first, the study investigator conducting the post-consultation and follow-up interviews did not observe or listen to the tapes of the consultation and was blind to the scoring of the tapes for patient-centredness; secondly, the rater of the audiotapes for patient-centred care was blind to the study hypotheses; and thirdly the rater of the audiotapes was blind to the identity of the doctors and the patients. In addition, the doctors were unaware of the hypotheses of the study so that they were not influenced to direct their behaviour in any particular way. Surveillance bias was controlled by providing the same amount of attention by the investigator to all subjects, and by documenting at the follow-up interview any further contact that the patient had had with the doctor or any other sources of care. Hypotheses The first hypothesis was that following a patientcentred consultation, the doctor would be more likely to have ascertained all of the patient's reasons for coming than if the consultation had not been patientcentred. Four aspects of ascertainment were determined from the post-consultation interview: whether the reason came up at all, the degree to which it was discussed, the degree to which the patient felt the doctor had understood its importance, and whether the doctor knew (after the consultation) that this was one of the reasons for which the patient had come. The second hypothesis was that patient-centred care would be positively associated with doctor-patient agreement about the nature of the patient's problem. This was tested at the post-consultation interview by asking the patient, 'What did the doctor say the problem was?' and, 'Did you agree with what the doctor said?' PATIENT-CENTRED CARE IN THE CONSULTATION 29 The third hypothesis was that patient-centred care would be positively associated with the degree to which patients felt understood by the doctor. This was tested by having the patient respond to the statement, 'I really felt understood by this doctor', on a five point scale as part of the self-administered patient satisfaction questionnaire. The fourth hypotheses was that patients who had experienced patient-centred consultations would report greater satisfaction. Patient satisfaction was measured at two points in time. The main measure of patient satisfaction, the self-administered questionnaire, was used to assess satisfaction immediately following the consultation. The second measure of patient satisfaction was a single question that was asked during the follow-up telephone interview. The final two hypotheses concerned the relationship between patient-centredness and patient recovery. The amount of discomfort caused by the patient's main symptom was ascertained at the time of the consultation and again two weeks later. The level of the patients' concerns both before and after talking to the doctor were determined at the postconsultation interview. The concerns inquired about were: the seriousness of the symptoms, expectations of what might need to be done, specific thoughts or fears of what the problem might be, and any problems of living. In addition, the patient's concern about the seriousness of the main symptom was re-ascertained at the two week follow-up interview. Control of Variables and Analysis of Data The study was carefully controlled for the following variables: patient variables (age, sex, occupation, level of education, socioeconomic and marital status), doctor variables (the doctor himself and the doctor's technical or medical competence), problem variables (type and severity of the problem), and practice variables (length of consultation, who originated the appointment, frequency of contact, whether it was the patient's regular doctor and duration of relationship). The data obtained from this study were either nominal or ordinal in nature, and thus were analysed using non-parametric statistics including the chi-squared test, the Mann-Whitney U test, the Kruskal-Wallis one way analysis of variance, and the Spearman rank correlation coefficient. 8 A multiple regression model and logistic analysis were used to control for the confounding variables. RESULTS Demographic and Background Data Seventy-three patients completed the entire data collection, giving a response rate of 76.8%. The sex and age of the non-participants did not differ significantly from that of the participants (x 2 = 0.31, df=l, P = 0.9 for sex; x 2 = 5.3, df = 3, P = 0.1 for age). All of the patients who completed the post-consultation interview also completed the follow-up interview. All

3 30 FAMILY PRACTICE AN INTERNATIONAL JOURNAL ages of patients were represented, two-thirds were female, and two-thirds were married. Patients of all levels of education and socioeconomic status took part in the study with the lower levels of both education and socioeconomic status being well represented. More than 80% of appointments were initiated by the patient (rather than the doctor), probably as a result of the study requirement for new symptoms. The length of the consultation ranged from three to 32 minutes with a mean length of 12 minutes. The distribution of the patient-centred scores approximated a normal distribution with a slight skew to the right. The scores ranged from 0.58 to 1.92 (out of a total possible of 3.0) with a median of 1.00, 25th and 75th percentiles of 0.88 and 1.25 and a mode of This was in keeping with the observation that the commonest doctor response to a patient offer was a closed response (scored as 1 on the score sheet). Tests of the Six Hypotheses 1. Ascertainment of patient's reasons for attendance For 82% of patients all of their reasons for going to the doctor 'came up' during the consultation but only 25% reported that their reasons were 'very well understood', and only 7% stated that all of their reasons had been 'completely discussed'. Table 1 shows the relationships between the patientcentred score for the consultation and each of the four aspects of ascertainment for all reasons for coming to the doctor combined. The patients who had experienced a patient-centred consultation were significantly more likely to report that their reasons for coming had been discussed completely, the importance of each reason had been understood by the doctor and that if asked after the consultation, the doctor would know the reasons for which the patient had come. The relationship between patient-centredness and the first two of these three aspects of ascertainment remained significant after controlling for the confounding factors. In addition, although there was no relationship of patient-centred score with 'known by the doctor' after controlling for confounding variables, the entire group of variables together did demonstrate a significant relationship with this aspect of ascertainment as shown in Table 2 (overall F = 2.3, P = 0.05). TABLE 1 Relationship between patient-centred score and ascertainment of patient's reasons for coming Patient-centred score and: The reason having been brought up for discussion The degree to which the reason was discussed The degree to which the doctor understood the importance of the reason to the patient The doctor knowing that this was a reason for coming r$ = Spearman rank correlation coefficient Correlation (r$) P TABLE 2 Multiple regression model for correlates of 'known by the doctor' Factors F P Patient-centred score Individual physician Appointment origin Frequency of contact Regular doctor Overall F R 2 =0.l Doctor-patient agreement about problem. The percentage of patients who agreed 'completely' with the doctor's assessment of their main symptom was 75.6%, an additional 19.4% agreed 'mostly' only 4.8% agreed 'a little', and none said that they agreed 'not at all'. No association was found between doctorpatient agreement and patient-centredness (X 2 = 3.172, df = 3, P = 0.4). 3. Patient's feeling understood. All patients either agreed (53.4%) or strongly agreed (46.6%) with the statement 'I really felt understood by this doctor'. Of note, 61% of patients that had experienced patient-centred consultations agreed strongly that they felt understood by the doctor compared with 36% who had experienced a consultation that was not patient-centred (Mann-Whitney U = 431.0, P = 0.009). However, this result became non-significant after controlling for confounding variables. 4. Patient satisfaction. The mean scores on the medical interview satisfaction scale ranged from 3.23 to 4.92 out of a possible total of 5.00, the median score was 4.20 with 25th and 75th percentiles of 3.95 and 4.52 respectively. During the follow-up telephone interview 90% of patients were at least 'quite satisfied' with the consultation, but only 50% were 'very satisfied'. There was a significant, positive association between patient satisfaction immediately after the consultation and at the follow-up interview (x 2 = 11.07, df = 3, P = 0.01). No significant association was found between the patient-centred score and either the immediate postconsultation or the follow-up measures of patient satisfaction (Spearman rank correlation rs = 0.059, P = 0.3 for immediate satisfaction; Mann-Whitney U = 6.37, P = 0.8 for follow-up satisfaction), or in the multiple regression which included confounding variables. However, the consultations with patient-centred scores in the highest quartile had the greatest percentage of patients highly satisified (46%), in marked contrast to those consultations with patient-centred scores in the lowest quartile (15%) although the differences were not significant (Table 3). 5. Symptom resolution All but two patients initially reported at least some discomfort from their main symptom and almost half

4 TABLE 3 Relationship between patient-centred score and patient satisfaction Patient centred score (by quartile) 1st (lowest) 2nd 3rd 4th (highest) No. 4.77, of patients df = 3, P = PATIENT-CENTRED CARE IN THE CONSULTATION 31 Percentage who were highly satisfied complained of a great deal of discomfort. Fifty per cent of the patients had had their main symptom resolve completely by two weeks. Of those whose symptom was still present at two weeks, two-thirds were improved (that is their symptom was less severe) and one third were unchanged or worse. No significant association was found between the patient-centred score and symptom resolution at two weeks (Mann- Whitney U = 597.5, P = 0.4). However, in view of the fact that the patient-centred score reflected the doctor's combined response to all of the patient's reasons for coming and not specifically his response to the patient's main symptom, it was decided to test the relationship between the doctor's response to the patient's main symptom (main symptom score) and symptom resolution as well. As shown in Table 4, patients who had received the most patient-centred response to their main symptom were more likely to have that symptom resolve at two weeks than those who had received less patient-centred responses (75% versus 54%) although the difference did not achieve statistical significance. This difference disappeared when confounding variables were entered into a logistic regression equation. 6. Concern resolution Over half of the patients were at least a 'fair amount' concerned about their symptom initially. More than one third of patients still had some concern about their symptom two weeks after the consultation. Seventyone per cent of patients had a decrease in concern immediately after the consultation, but 21% of the patients that expressed initial concern, did not report any decrease in their concern even two weeks later. It was thought that the severity of the symptom might influence the patient's level of concern at the TABLE 4 Relationship between main symptom score and symptom resolution Symptom score No. of patients Percentage with main symptom resolved time of the consultation, but such an association was not found (x 2 = 2.00, df = 3, P = 0.6). There was however, a significant relationship between level of discomfort and patient concern at two weeks, in that the greater the level of discomfort present, the greater was the degree of concern (x = 12.38, df = 6, P = 0.02). Resolution of concern about the seriousness of the main symptom was found to be associated with the main symptom score. Table 5 shows that patients who had received the highest level of patient-centred response to their main symptom were significantly more likely to have decreased concern about that symptom immediately after the consultation than patients who had experienced less patient-centred responses (87.5% versus 65.2%, P=0.03). This association remained after controlling for confounding factors. Four of the confounding factors were highly associated with each other: one doctor variable (the doctor himself) and three practice variables (who originated the appointment, frequency of contact and whether it was the patient's regular doctor) (Table 6). DISCUSSION The positive and significant association found between resolution of patients concern and patient-centredness in the consultation was gratifying because to 'comfort always' has often been stated as a physician's highest calling. The fact that concern resolution (regarding the seriousness of the main symptom) was more strongly associated with the main symptom score than the overall patient-centred score suggests that the relationship between the doctor's behaviour and the patient's outcome was specific. The importance of finding a significant association between patient-centredness and the patient's perception that the doctor had ascertained their reasons for coming is reinforced by the work of Byrne and Long 3 who found that failure to ascertain the patient's reasons for coming was more likely to lead to a dysfunctional consultation. As noted by Starfield and colleagues: 'all other processes (diagnosis, management, reassessment) depend upon an accurate perception of the underlying reason for the visit'. 9 Hodson also declares its importance when he states that 'perhaps, the most highly developed, most rewarding and difficult art of which the experienced general practitioner is TABLE 5 Relationship between main symptom score and immediate resolution of patient concern after the consultation Percentage with Main symptom decreased concern score No. of patients after consultation Low 1 Medium 2 High 3 X 2 = 4.92, df = 3, P = Low 1 Middle 2 High 3 X 2 = 7.303, df = 2, P =

5 32 FAMILY PRACTICE AN INTERNATIONAL JOURNAL TABLE 6 Relationship among the confounding factors Physician Appointment origin Regular doctor Frequency of contact Appointment Regular Physician origin doctor NB: The values in the table are P values, indicating the significance of the interrelationships of the above variables. The tests performed in the analysis were the chi-squared, the Mann-Whitney U, and the Kruslcal-Wallis one-way analysis of variance. capable, is that of discovering the real reasons why the patient came to consult him in the first place.' 10 The failure to find an association between patientcentredness and the degree to which the patient agreed with the doctor's diagnosis of the problem may be because patient-centered interactions allow patients to question and even to disagree with their doctor's opinions. Patients in this study presented with new symptoms and may have needed more time than a single consultation for the mutual working through of differences of opinions (in the few instances where these differences existed). The finding that there was no relationship between patient-centredness and patient satisfaction was somewhat unexpected, particularly in view of the studies 4 that have found associations between various aspects of the interpersonal process and patient satisfaction. The factor that in other studies has most frequently been found to be associated with satisfaction is that of communication of information; this has been measured by determining the extent to which a patient recalls information and instructions given by the doctor, 11 ' 12 by asking the patient how well the doctor explained information, and by categorizing the doctor's consultation behaviour. 14 ' As no discrimination was made in these studies as to the manner in which that information was given, it would be reasonable to assume that at least a portion of the doctor behaviour reflected in these measures would have scored on the lower end of our patient-centred scale (that is as closed responses). It is perhaps important to note that communication of information in itself has not been identified or assessed as part of the concept of patient-centred care. It is possible that the physician who is behaving in a disease-centred or doctor-centred manner may spell out information and instructions just as clearly as the physician who is exhibiting patientcentred behaviour. However, in view of the large difference between the population of patients highly satisfied with the most and least patient-centred consultations, a more likely explanation for the lack of statistical significance may be the small number of highly patient-centred consultations involved in the sample. The small number of highly patient centred consultations may also account for the lack of significance in the relationship between patient-centredness and symptom resolution. One of the striking results was the decrease in the outcome measures when the patient-centred scores were intermediate. The first thing considered was whether there was another factor operating at this point, but our study was carefully controlled for all the potentially confounding factors which have so far been reported in the literature (including for example, the likelihood of the symptom resolving after two weeks), and the same pattern held. We acknowledge that the scoring method for patient-centredness is biased in favour of open-ended interviewing techniques in that the scoring places 'open' responses of doctors higher than 'closed' responses but we found the outcomes poorer after the open-ended responses. It is possible that this distinction between closed and open styles is not as central as the facilitative role of the response. As we define it a factilitating response is when the doctor actively helps the patient express thoughts, feelings and expectations about the offer (our score of 3). These responses were consistently associated with the best outcomes. An alternative explanation is that patient-centredness is in part a skill, that becomes effective only after a certain level of proficiency is achieved and may even lead to poorer results if inadequately performed. This would be analogous to our experience with other skills, such as those used in surgery. Our contention, based on the results of the multivariate analysis is that the patient-centred approach may best be seen as part of a package of care, consisting of a physician whose overall practice of medicine allows for the development of personal relationships with patients over time through continuity of care, which includes care by one's regular doctor, and conscientious follow-up (as reflected by doctor-initiated appointments, and frequency of contact). Strengthening this conviction was thefindingfor one aspect of the variable ascertainment of reasons for coming. Although the patient-centred score and the four practice variables were associated with 'the doctor knowing the reason for coming' prior to controlling for the confounding variables, none of these variables retained its individual association when each was controlled for the others. Significantly though, the package itself showed an association with this aspect of ascertainment of reasons for coming. CONCLUSIONS The results of this study suggest that a patient-centred approach really does make a difference. Patientcentredness was found to be associated with the doctor having ascertained the patient's reasons for coming and with resolution of the patient's concerns. It would seem that doctors are more likely to be of help to their patients if they facilitate the expression of patients' thoughts, feelings and expectations about their problems. It would also seem that a patientcentred approach is not just a matter of behaving in a

6 patient-centred way during a consultation, but is also a matter of the way in which the doctor conducts his or her overall medical practice. Further research with larger numbers of patients is necessary before any conclusions can be made about the relationship between a patient-centred approach and satisfaction, but at this point it would seem that a patient-centred approach to care is at least as satisfying, and more effective than one that is not. Also of note, is the observation that it was only once a high level of patient-centredness was achieved that patientcentred care was related to outcomes. REFERENCES 1 Peabody FW. The care of the patient. JAMA 1927;88: Balint M. The doctor, his patient and the illness. (2nd edn.) London: Pitman Medical, Byrne PS, Long BEL. Doctors talking to patients: a study of the verbal behaviour of general practitioners consulting in their surgeries. London: HMSO, 'Henbest RJ. A study of the patient-centred approach in family practice (thesis). London, Ontario: University of Western Ontario, Bass MJ, Buck C, Turner L. Primary care physician actions influencing patients outcomes. Final report OM 697 to the Ontario Ministry of Health. London, Ontario: University of Western Ontario, Wolf MH, Putman SM, James SA, Stiles WB. The medical interview satisfaction scale: development of a scale to PATIENT-CENTRED CARE IN THE CONSULTATION 33 measure patient perceptions of physician behaviour. J Behav Mcd 1978;l: Henbest RJ, Stewart MA. Patient-centredness in the consultation. 1: a method for measurement. Fam Pract 1989;6: Snedecor GW, Cochran WG. Statistical methods. (6th edn.) Ames, Iowa: Iowa State University Press, ' Starfield B, Wray C, Hess K,, etal. The influence of patientpractitioner agreement on outcome of care. Am J Public Health 1981 ;71:127. m Hodson M. Doctors and patients: a relationship examined. London: Hodder and Stoughton, 1967: Romm FJ, Hulka BS. Care process and patient outcome in diabetes mellitus. Med Care 1979;17: a Smith CK, Polis E, Hadac R. Characteristics of the initial medical interview associated with patient satisfaction and understanding. / Fam Pract 1981;12: Bertakis KD. The communication of information from physician to patient: a method for increasing patient retention and satisfaction. J Fam Pract 1977; 5: Stiles WB, Putman SM, James SA, Wolf MH. Dimension of patient and physician roles in medical screening interviews. Soc Sci Med 1979;13: Comstock LM, Hooper EM, Goodwin JM, Goodwin JS. Physician behaviours that correlate with patient satisfaction. / Med Educ 1982;57: Eisenthal S, Koopman C, Lazare A. Process analysis of two dimensions of the negotiated approach in relation to satisfaction in the initial interview. J Nerv Ment Dis 1983;171:49-54.