Are there problems in communication between doctors and patients?
OUTLINE FOR EXPLANATION AND PLANNING
1. In what percentage of consultations do we underestimate our patients desire for info and involvement
· Waitzkin (1984) showed that in 65% of encounters, internists underestimated their particular patient’s desire for information; in only 6% did they overestimate.
· Many studies have shown that patients can be divided into seekers (80%) and avoiders (20%) concerning information, with seekers coping better with more information and avoiders with less (Miller and Mangan 1983, Deber 1994)
· In Degner et al’s (1997) study of 1012 women with a confirmed diagnosis of breast cancer attending hospital oncology clinics, 22% wanted to select their own cancer treatment, 44% wanted to select their treatment collaboratively with their doctors, and 34% wanted to delegate this decision making to their doctors. Only 42% of women believed they had achieved their preferred level of control in decision making
2. how many minutes spent in info giving
· one minute in 20 minute intrview, not 9 minutes as they thought (now shown in British GP as well by Makoul 1995)
3. what type of information do patients want; what do doctors give
· 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 patient’s desire for information concerning treatment and drug therapy (Kindelan and Kent in British general practice 1987)
4. how much do patients remember
· it is clear that patients do not recall all that we impart nor do they make sense of difficult messages. As we shall see later, original studies showed that only 50 to 60% of 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 committed to the doctor’s view.
5. percentage who do not adhere
More DETAIL FOR EXPLANATION AND PLANNING
Are there problems with the amount of information that doctors give?
Many studies show that in general physicians give sparse information to their patients:
· 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 patient’s ability to follow the treatment plan and eliciting the patient’s opinion about medication prescribed.
· Boreham and Gibson (1978) in a study in Australian general practice showed that despite a lack of basic knowledge prior to the consultation and a strongly expressed desire to gain information concerning their illness, the majority of patients did not obtain even basic information concerning the diagnosis, prognosis, causation or treatment of their condition.
· Svarstad (1974) studied doctors’ instructions to patients when prescribing drugs and found no discussion at all in 20% of cases, no information about the name or purpose of the drug in 30%, no mention of the frequency of doses in 80% or the length of the course in 90%.
Are there problems with the type of information that doctors give?
We also know that patients and doctors disagree over the relative importance of different types of medical information:
· Kindelan and Kent (1987) in a study in British general practice showed that patients placed the highest value on information about diagnosis, prognosis and causation of their condition. Doctors however greatly underestimated their patients’ desire for information about prognosis and causation and overestimated their desire for information concerning treatment and drug therapy. Patients’ individual information needs were not elicited.
Can patients understand the language that doctors use?
Many studies have shown that doctors not only use language that patients do not understand but also appear to use it to control their patients’ involvement in the interview:
· Korsch et al (1968) found that paediatricians’ use of technical language (e.g. “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!
· McKinlay (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 were the very ones that they would not expect their patients to understand.
Do patients recall and understand the information that we give?
There are significant problems with patients’ recall and understand 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. As we shall see later, original studies showed that only 50 to 60% of 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 committed to the doctor’s view.
Do patients comply or adhere to the plans that we make?
Here the research is clear-cut and salutary:
· Studies have consistently shown that between 10 and 90% of patients prescribed drugs by their doctors (with an average of 50%) do not take their medicine at all or take it incorrectly.
· Many studies show that patients do not follow their doctors’ recommendations, with 20-30% non-adherence in medications for acute illness, 30-40% in medications for illness prevention, 50% for long-term medications and 72% for diet.
· Yet surprisingly, doctors have a tendency not to consider non-compliance as a possible cause of poor outcome
· Non-compliance is enormously expensive to the nation. 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-compliance (including extra visits to physicians, laboratory tests, additional medications, hospital and nursing home admissions, 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).
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