Introduction
The doctor–patient
encounter has attracted growing interest in the current literature. It is now
well documented and widely accepted that one of the keys to successful
treatment of the patient is a good working relationship with the doctor. [i]-[ii]
In General Practice/Family Medicine (GP/FM), furthermore, where the
relationship between doctor and patient is more personal and long lasting,
effective communication seems to be vital in establishing rapport with the
patient and enhancing the doctor’s effectiveness; however, further study is
needed in this direction. Despite the above, doctor–patient issues have received
little attention in certain Southern European countries, including Greece.[iii]-[iv] This can be partly explained by the absence
of relevant training courses in Medical Schools.
In Greece, specifically, the
Medical Faculty of the University of Crete is the only academic
institute in the country, which offers an undergraduate course to medical
students and teaches them communication skills (http://vml.med.uoc.gr-doctor-patient).
Furthermore, as a result of close collaboration with the Institute of Social Sciences, University of Leiden, the Netherlands, this Medical School experiences the
important contribution of Medical Anthropology in teaching medical students the
concept of illness and health behavior and implementing certain theoretical
models into research in the utilization of health care services.[v]-[vi]
In the present paper, we
draw on the above experience to discuss the doctor-patient relationship with
the aim to highlight some of its most important determinants. According to
Silverman et al (2005)1 , the
type of relationship established between a doctor and his/her patient seems to
be a complex issue which involves a number of parameters, including: the type
of partnership between doctor and patient, the type of skills acquired by the
doctor, the type of patient, the type of setting where the medical encounter is
performed and the medical interview. Teaching the doctor-patient relationship
issues to medical students within the Mediterranean setting is a difficult
task, since contemporary evidence is lacking. Thus, a clear objective of this
paper is to examine each of the above parameters in more detail drawing
specifically from our experience of the Southern European and Mediterranean settings.
Towards an effective communication between patient and
doctor
Type or partnership
The type of partnership between doctor and
patient has undergone major changes through time.5-[vii]
From a type of paternalistic relationship, which was exercised by the doctor
towards the patient and the decisions were solely the responsibility of the
former, we have moved towards relationships of mutuality and processes of
joined decision making.[viii]-[ix]
Patient rights have come to the centre of attention of institutions and bodies
involved in health care, and various models of involvement of the patients in
the management of their health have been implemented across the globe, such as
the Patient and Public Involvement Forum in the U.K. (http://www.cppih.org).
Furthermore, as the
principle of autonomy and involvement assumes central role in health care the
role of family and caregivers in the therapeutic process is enhanced. The
doctor not only needs to enter into a collaborative partnership with the
individual patient, but also to take into account the familial and social
background of the patient. In general practice and primary care, whose object
is to a large degree the management and treatment of chronic conditions, the
role of the family and caregivers is prominent. The discussion on the burden of
the family in cases of chronicity provides further confirmation of the family’s
role.[x]
In addition, the role of family and caregivers is particularly enhanced in
cases of patients whose ability to communicate is limited. It follows from the
above that the shared decision model of partnership often involves not only the
patient as an individual, but a nexus of relationships (family and caregivers).
The practice of family consultation may be more complicated as it involves
multiple networks of relationships, and is therefore more time consuming, but
it is rewarding in that it provides a holistic perspective. GP/FM in Europe is still focused on an
individualistic type of partnership, although the new European definition of
GP/FM makes a strong reference to the concepts of family and community
(http://www.woncaeurope.org).
In the Southern European
setting the transition to an autonomous patient role has not been made and the
paternalistic model still seems to hold strong.[xi]
In rural Crete, despite the severe burden they experience, informal caregivers
of patients with major mental disorders did not seek care from their primary
care doctor.10 More research is needed in order for the existing
situation to be depicted, future tendencies to be deciphered and policies to be
designed.
Type of acquired doctor’s skills (the doctor’s side in the
communication process)
Communication with the
patient is a demanding situation, which requires a range of skills from the
doctor. In order for the encounter to be successful, the doctor must be
empathetic towards the patient and alert to both verbal and non-verbal messages
in the communication process. Communication skills, however, do not constitute
a natural gift endowed the doctor, but are acquired through education1
and, hence, communication is included in the curricula of numerous medical
schools. Furthermore, the type of communication and the expectations held from
their encounter, by both patient and doctor, are culture specific. As Harrison[xii] has shown, patients in
the Emirates evaluate their communication with the doctor differently from
patients elsewhere. In Greece, patients tend to
express their gratitude to the doctor through the offer of homemade tidbits or
products such as house wine.11 It is therefore very important that the doctor
is aware of the cultural characteristics of the patients. This needs an active
effort on the part of the doctor to get familiar with the patients’ culture. In
rural Crete, the constitution of a list of disease names in local
dialect facilitated both research and clinical practice.[xiii]
In all situations of
communication with the patient Silverman et al., identify the skills required
as follows: content skills, process skills and perceptual skills.1
As the authors explain, the doctor must know both what to say, and how to say
it to the patient. Equally important, the doctor must be alert to the feelings
and thoughts generated by the situation both within himself and within the
patient. Those feelings and thoughts must be taken into account and addressed
by the doctor when consulting with the patient. The above form is indissoluble
and equally important aspects of the doctor-patient encounter.
Non verbal communication
also seems to have an important role in the doctor-patient relationship,
especially within the Mediterranean setting, as a consensus report in Reggio
Emilia, Italy underlined.3 Further research is needed to explore
this important issue especially during the patient’s first encounter with
his/her general practitioner.
Type of patient (the patient’s side in the doctor – patient
relationship)
In a type of partnership
where responsibility is shared between doctor and patient, the role of patient
in the relationship is accentuated. The doctor should acquire and make best use
of all
information on the patient’s background. Different cultural and social
characteristics greatly determine the way in which the patient relates to the
doctor, accepts treatment and complies or not with the doctor’s instructions.
Suchman[xiv]
introduced a model, which proposes five stages of illness and medical care: the
symptom experience, the assumption of the sick role, the medical care contact,
the dependent patient role and recovery/rehabilitation. By making general
practitioners aware of the above five stages, medical anthropology provides a
satisfactory explanatory theory of patient behavior and thus helps doctors
better understand their patients’ behavior. With such knowledge a course of
action which might appear unreasonable to the doctor, such as non-compliance or
seeking medical advise at a late stage when medical services are no longer
capable of stopping the natural course of the disease, might make sense and be
dealt with. Furthermore, knowledge of patient behavior can help eliminate
feelings of anger or frustration in the doctor.
A last issue to be
mentioned is that the patient comes to the doctor with specific beliefs and
concerns on his/her condition, with feelings of hope, fear or despair and
carrying particular expectations from the doctor. All the above often
constitute a mute background to the doctor–patient relationship, which can
prove either facilitating or hindering to the encounter. The doctor must be
aware of the existence of hidden agendas in the encounter with the patient and
aim towards bringing hidden worries, fear, doubts to the fore. It is only then
that tensions generated by such feelings can be resolved and the relationship
with the patient can be productive. This part of the doctor-patient encounter
is not only important for the establishment of a good and effective
relationship, but provides a major contribution in the success of health
promotion programs in primary care and especially in the ones which focus on
behavior modification. GP/FMs should be aware of the principles of the Theory
of Planned Behavior[xv]
and be well trained in translating it into research and clinical practice. There is little experience from the
translation of this theory into practice. Attempts have been undertaken at the
Department of Social Medicine, School of Medicine, University of Crete to explore the
possibility of the implementation of this theory into intervention programs
which aimed at reducing the use of over-the-counter medicines.
Type of setting
The doctor’s office and
its capacity in both technologies and staff critically influence the
doctor–patient encounter. Both the waiting area and the doctor’s office must
offer a calm and reassuring environment for the patient. It is important that
the patient is welcomed by the appropriate personnel and informed on issues
such as, processes that must be followed, waiting time, possible delay and
reasons of delay. The office itself must be provided with all the appropriate
technological and medical equipment, which will enable the doctor to provide
the proper treatment. The appropriate setting in terms both of human and of
technological capacities, can induce a feeling of trust in the patient, and can
greatly reduce anxiety and uncertainty.
Despite the discussion of the setting in modern industrialized societies
and among certain European and Australian colleagues,[xvi]
the issue is still not sufficiently resolved in Southern Europe, where a conventional
arrangement of the doctor’s office, reflecting the paternalistic type of relationship
is still predominant. Advances in
electronic technology make possible the communication between patient and
doctor without face-to-face consultation. The introduction of telemedicine has
an impact on the new skills and training programs needed for the improvement of
doctor-patient communication in such a setting.[xvii]
The medical interview
The medical interview is
the time par excellence where the
communication between doctor and patient is performed and worked out. Taking
the patient’s history and performing a medical interview are among the skills
acquired through the years of medical education. However, a problem which has
been identified is the rigid adherence of many doctors on what is meant to be a
rough guide for the acquisition of a patient’s medical history. The enhanced
Calgary-Cambridge guide1 addresses the shortcomings of a typified medical interview
and provides clues towards an interview which will be flexible and allow the
patient to provide richer information on his/her condition and background. The
Calgary-Cambridge guide provides detailed and useful guidelines for every phase
of the medical interview: initiating the session, gathering information,
physical examination, explanation and planning and closing the session. The
anticipated result is one where both the patient leaves the doctor’s office
reassured, with a clear plan to follow, and the doctor is in hold of all the
useful information needed for a successful rapport with the patient and
treatment plan. The translation of this model within the Mediterranean and southern European
settings and discussion of its key elements remains to be studied.
Conclusion
In conclusion, it is a
fact that the patient-centered, or relationship-centered approach to the
medical work, requires more time than the traditional paternalistic approach
which seems to be preferred by many Southern European practitioners. However,
the benefits from the former model are undoubtedly worth the time investment.
The factors, which have an impact on the quality of the consultation are wide
ranging. Establishing a good, working relationship with the patient is a
complex issue, yet vital for the successful outcome. Further research is needed
in order to determine and quantify, where possible, the different factors affecting
consultation. A discussion of physician’s skills with emphasis on verbal and
non verbal communication, awareness of the patient’s background, the symptom
experience and sick role, remain to be explored within the Southern European
and Mediterranean setting. Towards the above direction, a collaborative study
among Southern European countries could usefully highlight particular key
issues for an effective partnership between doctor and patient. Previous
country-to-country collaborations should be led towards this goal.[xviii]
References:
[i] Silverman J, Kurtz S,
Draper J. Skills for communicating with patients. Oxford: Radcliff Publishing,
2005.
[ii] Stewart MA. Effective
physician–patient communication and health outcomes: a review. Can Med Assoc J
1995;152:1423-1433.
[iii] Lionis C, Grassi E, Bellos
G, Chiari C. Doctor-patient communication in Mediterranean countries: the
Reggio Emilia consensus. Eur J Gen Pract 1996;2:36-37.
[iv]
Compare with, Teutsch
C. Patient–doctor communication. Med Clin North Am 2003;87:1115-1145.
[v] Slikkerveer LJ. Plural
medical systems in the horn of Africa: the legacy of ‘Sheikh’
Hippocrates. London: Kegan Paul
International, 1990.
[vi] Chatziarsenis M, Makri E,
Sapouna – Chatziarseni W, Fioretos M, Faresjo T, Trell E, Lionis C. Care
preferences in a Cretan community with integrated hospital/general practice
services. Int J Health Care Qual Assur 2001;14:189-192.
[vii] Balint J, Shelton W.
Regaining the initiative: forging a new model of the patient – physician
relationship. JAMA 1996;275:887-891.
[viii]
Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does
it mean? (Or it takes at least two to tango). Soc Sci Med
1997;44:681-692.
[ix]
Kravitz RL, Melnikow J. Engaging patients in medical decision making. BMJ 2001;323:584-585.
[x] Sapouna V. Burden
(consequences) for family members and other individuals who care for patients
with mental disorders in Crete. Unpublished M.Ph. thesis: University of Crete, 2005.
[xi] Liangas G, Lionis C.
General practice in Greece: A student’s and a
supervisor’s perspective. Aust J Rural Health 2004;12:112-114.
[xii] Harrison A. Patients’
evaluation of their consultations with primary health clinic doctors in the United Arab Emirates. Fam Pract 1996;13:59-66.
[xiii] Lionis C, van Beelen N, Slikkerveer
JL. Making doctor-patients communication more effective: disease names (terms)
in the local dialect of a primary health care area in rural Grete, Greece. Patient Educ Couns
1998;34(Suppl.1):S77.
[xiv] Suchman EA.
Stages of illness and medical care. J Health Hum Behav 1965;6:114-128.
[xv] Ajzen I. The
theory of planned behavior. Organizational Behavior and Human Decision
Processes 1991;50:179-211.
[xvii] Liu X, Sawada Y, Takizawa T, Sato H, Sato M,
Sakamoto H, et al. Doctor-patient communication: a comparison between
telemedicine consultation and face-to-face consultation. Int Med 2007;227-232.
[xviii] Lionis C,
Dagdeviren N, Merkouris B-P, Caylan A, Symeonidis A, Topsever P, et al. Greek –
Turkish collaboration in general practice/family medicine: an example of
country-to-country collaboration. Eur J Gen Pract 2005;11:131-132.
