Patientsʼ Satisfaction with Their Family Physiciansʼ Communication Skills

In order to assess patients' satisfaction with their family physicians' communication skills, a random sample of 204 adults in Nova Scotia (NS) was interviewed by telephone to determine how satisfied they were with their family physicians' communication skills during the medical interview and with their medical care generally. Patient—doctor communication is now considered a core clinical skill at the heart of health care delivery.1 Because most doctors will perform approximately 200,000 consultations in a professional lifetime, it is essential to understand the dynamics of good patient—doctor communication and achieve competency in those skills.2 The consequences are far-reaching because good patient—doctor communication has been shown to have positive influences on patients' recall and understanding, adherence, symptom resolution, and physiologic outcomes, patients' and physicians' satisfaction, and the frequency of malpractice claims.3,4 Many factors contribute to patients' satisfaction with the medical consultation. One is the approach a physician takes to the medical interview. Some physicians may be more doctor-centered, where the focus is on disease and less on the patient's perspective. Others are more patient-centered, where the focus is not only on disease, but also on the patient's experience of the illness. This approach also encourages patient participation. Research reveals that greater patient-centeredness in the interview leads to greater patient satisfaction.5,6 In other words, discovering and acknowledging patients' perspectives and expectations and involving them in treatment plans improve patients' satisfaction. These behaviors, which build the relationship, include following the patient's lead, asking for the patient's opinion, asking for suggestions, and responding to the patient's suggestions.7 Patients' satisfaction has been found to be directly related to the amount of information that patients perceive their doctors have given them. Patients consistently express an interest in receiving information from their physicians and are more satisfied with visits in which more information is given.7 Studies have shown that concerning information acquisition, patients can be divided into seekers (80%) and avoiders (20%), with seekers coping better with more information and avoiders with less.8,9 Although most patients desire medical information, explanation of the medical problem and planning for its treatment continue to be the weakest part of the medical consultation. When Maguire et al10 examined the information-giving skills of recently qualified physicians who had graduated from Manchester Medical School in the 1980s, they found that between 63% and 90% made no attempt to discover the patient's views and expectations, encourage questions, check understanding, categorize information, or negotiate a treatment plan. In a more recent study involving over 1,000 encounters between physicians and patients, it was found that nine out of ten patients do not receive good explanations of proposed treatments or tests.11,12 Despite this, physicians tend to overestimate the time they devote to explanation and planning in the medical interview by up to 900%.13,14 In order to examine the dynamics of patient—doctor communication, it is necessary to have a structural framework for the medical interview. One excellent example is the Calgary—Cambridge Observation Guide, a communication model that focuses on the structure of the medical interview, the skills involved, and the evidence that these skills make a difference in patient—doctor communication.1,2 This guide, which takes a patient-centered and collaborative approach to the medical interview, divides the interview into five major tasks: Initiating the session [including establishing initial rapport and identifying the reason(s) for the consultation] Gathering information (including exploration of problems, understanding the patient's perspective, and providing structure to the consultation) Building the relationship (including developing rapport and involving the patient) Explanation and planning (including providing the correct amount and type of information, aiding accurate recall and understanding, achieving a shared understanding that incorporates the patient's perspective, and planning that involves shared decision making) Closing the session Our study sought to determine whether NS patients were generally satisfied with their medical care and, more specifically, whether they were satisfied with their family physicians' communication skills during the medical interview. The Calgary—Cambridge Observation Guide was used to assess the results, using the first four categories described above. Method Participants. Participants in the study consisted of a randomized sample of 204 adults, evenly distributed across the province of NS using telephone database listings. The target sample of 200 was chosen for a combination of statistical and financial reasons. Participants were required to be 18 years of age or older, to live in the province, and to have a family physician. Twelve hundred people were called in order to reach the target sample of 200. Survey. The survey consisted of two parts. The first part asked for personal background information, including age, sex, number of years with the family physician, number of visits per year, other family members, and information about illnesses. The second part consisted of 25 questions, adapted from other instruments,15–17 using a five-point Likert scale (1 = strongly disagree to 5 = strongly agree). Twenty-four statements focused on patients' satisfaction with their family physicians' communication skills, and one statement asked about satisfaction with their medical care. Participants were surveyed by telephone using a commercial survey research company, contracted by the medical school. Analysis. Completed questionnaires were coded and data were analyzed tabulating frequencies, means, t-tests, analyses of variance (ANOVAs), and chi-squares. Data analysis was carried out using a statistical software program. Calgary—Cambridge guide. Two experts independently rated the items in the survey to correspond to items in the Calgary—Cambridge guide. The distribution of questions was as follows: initiating the session (two items); gathering information (six items); building the relationship (eight items); and explanation and planning (eight items). Results The results are shown in Table 1.TABLE 1: Results of Interviews with 204 NS Patients Concerning Their Family Physicians' Communication Skills, 1998*Participants. With respect to gender distribution, 51.0% of the respondents were women and 49.0% were men. In terms of age distribution, 21.1% were between 18 and 35 years of age, 22.1% between 36 and 45 years, 24.0% between 46 and 55 years, 19.1% between 56 and 65 years, 4.9% between 65 and 70 years, and 8.8% over 70 years. Slightly over a third (35%) of the 204 participants were from an urban center. These distributions are representative of the general NS population, indicating that randomization had been effective. One fourth (25%) had chronic illnesses, and 40% had visited their family doctors more than four times during the preceding year. Patient satisfaction. There was no significant difference by age, gender, length of time with the family doctor, or number of visits relative to the total survey mean score. The only significant finding was that the overall mean score was significantly higher for patients who had small children or other family members who accompanied them to the doctor's office for visits [mean score = 3.94 (.72) versus 3.72 (.55); t = 2.33, p = .02]. Overall, the respondents were satisfied both with their medical care and with their family physicians' communication skills. However, they were less satisfied with their physicians' communication skills (mean score = 3.78 out of a possible five) than with their medical care (mean score = 4.11 out of a possible five). Physician communication skills. Examination of the distribution of mean communication skill scores for all items indicates that seven items were clearly more positive (an upper outlier group) and seven items were clearly less positive (a lower outlier group) than the larger middle group of items. The seven items rated highest in communication (4.05 or higher) included two of two items in initiating the session, two of six items in gathering information, two of eight items in building the relationship, and one of eight items in explanation and planning. The seven items rated lowest in communication (3.56 or less) included three of six items in gathering information and four of eight items in explanation and planning. Under “gathering information,” the items rated highest related to an exploration of the problems that had precipitated the visit, whereas items rated lowest related to the more general context of patients' lives. Discussion The patients responding to this survey appear to have been satisfied with their medical care, suggesting that they had confidence in their physicians' medical competence and expertise. The significantly higher rating of satisfaction by patients accompanying children or accompanied by other family members when they saw their family physicians is interesting. Possible reasons for this may be the opportunity for the doctor to gather more information and build a better relationship through contact and familiarity with other family members. In terms of specific patient—doctor interviewing skills as outlined in the Calgary—Cambridge guide, the NS family physicians seen by our patient sample appear to have done very well at initiating sessions by putting their patients at ease and showing a genuine interest in their patients' problems. In terms of gathering information, they also appear to have been proficient at identifying the reason or reasons for the consultation by providing their patients ample opportunity to discuss all their concerns. This is a valuable skill, because research has shown that a patient's initial presenting problem is not necessarily the most important one. If they are not encouraged at the outset to raise all their concerns, patients may not get the opportunity to do so until much later in the consultation, if at all.18 The respondents also reported that their family physicians had good rapport-building skills. Factors identified included physicians' respectful attitudes, their kindness and consideration of their patients' feelings, and their ability not to make their patients feel rushed. In terms of explanation and planning, most physicians explained clearly to their patients what was wrong before offering treatment. Because length of time with the family physician was not a significant factor, this suggests that NS family doctors appear adept at putting both old and new patients at ease and building good relationships with them. They are also adept at gathering the medical information they need to treat their patients effectively, as further evidenced by the patients' satisfaction with their medical care. Finally, they are careful to explain what is wrong to their patients before introducing treatment options. Results of the survey also suggest specific areas in communication that may need improvement. In terms of gathering information, these NS family physicians appear to have been less likely to solicit information about their patients' lives that was not directly related medical treatment, suggesting a more doctor-centered approach to the medical interview. Yet, as research has shown, understanding the broader context of patients' lives is an important component of the patient—physician encounter. Understanding the ways in which patients perceive, experience, and cope with their illnesses facilitates adherence, support, and empathy; helps to build the relationship between patient and physician; aids diagnosis; and makes for more effective and efficient interviews.1,2,5 Consistent with studies elsewhere, the respondents in our survey appeared to be seekers rather than avoiders of medical information. They reported that they would have preferred more information from their family physicians. Areas included more information about the presenting complaints, how the illness would affect their future health, and prescriptions that their doctor recommended. Nor did the family physicians appear to encourage shared decision making in planning for their medical care. Yet, from a health-promotion perspective, it has been shown that patients are better able to exercise appropriate control over their health when they can obtain information about their situations and participate in decisions about treatment.14 Thus, information exchange and shared decision making about treatment are key components of effective health care. If physicians are to share medical information effectively with patients, they need to do so in language that is clear, concise, and understandable, avoiding medical jargon wherever possible and, where not, explaining the meanings of the terms. Research suggests that not only do doctors use language that patients do not understand, but they also use medical language as a way of limiting their patients' involvement in the interview.2 In addition, communication is more effective if medical information is presented in small pieces or “chunks,” with the physician pausing and checking as often as necessary to ensure that the patient has understood.1 These skills, as well as skills that are designed to encourage patients' involvement in treatment options and plans, are all teachable, and with sufficient practice and feedback, will enhance physicians' communication with their patients and lead to better health care. A limitation of this study is that it provides only one perspective of the patient—doctor interviews. It would have been valuable to assess the physicians' perceptions of the patient—doctor interviews to see whether they concurred with their patients' perceptions. A further study that pairs patient—physician ratings would be useful in assessing perceived similarities and differences between the two. Conclusion Results of our survey suggest that patients in NS are satisfied with the care provided by their family physicians. They also appear satisfied with some of their doctors' communication skills, such as ability to put them at ease, listen to their complaints, and create good rapport. However, survey results also suggest areas in which family physicians might benefit from further training in communication skills. These include moving from a physician-centered to a more patient-centered perspective, providing more information to their patients about the presenting medical complaint, and actively involving patients in plans for treatment. The results support the value of involving patients in a needs assessment of patient—doctor communication in order to identify future needs in continuing medical education. Further research might include a comparison of patients' and physicians' ratings of physicians' communication skills, using the Calgary—Cambridge Observation Guide as the framework.

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