Health promotion in primary care: Physician-patient communication and decision making about prescription medications

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Pergamon

Soc. Sci. Med. Vol. 41, No. 9, pp. 1241-1254, 1995

0277-9536(95)00061-5

Copyright X" 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/95 $9.50 + 0.00

HEALTH PROMOTION IN PRIMARY CARE: PHYSICIAN-PATIENT COMMUNICATION A N D DECISION M A K I N G ABOUT PRESCRIPTION MEDICATIONS GREGORY

M A K O U L , 1'2 P A U L A R N T S O N 2 a n d T H E O S C H O F I E L D ~

~Department of Medicine, Northwestern University Medical School, Chicago, Illinois, U.S.A., -'Department of Communication Studies, Northwestern University, Evanston, Illinois, U.S.A. and 3Department of Community Medicine and General Practice, Oxford University Medical School, Oxford, England

Abstract--To examine health promotion in a primary-care context, we studied perceived and actual communication in 271 consultations between general practitioners and patients in Oxford (England). Although health promotion is a term usually reserved for public-health or wellness programs, a health promotion perspective enriches the examination of communication in physician-patient interactions by emphasizing issues of empowerment, competence and control. Accordingly, we are interested in how communication during medical encounters can improve patients" abilities to exercise appropriate control over their health. A major factor in enabling patients to increase control over their health involves developing their competencies for making decisions and enacting behaviors that can lead to desired, and attainable, health outcomes. This report focuses on communication and decision making about prescription medications, since whether and how to use medications are among the most common and important decisions in which patients can participate. Five instruments were employed to collect data about physicians, patients and their consultations: a Video Analysis, which allowed assessment of actual communication behavior; a Patient Questionnaire designed to gauge perceptions of the encounter and collect demographic information; a Medical-Record Review, which provided information on utilization, diagnosis and treatment; a Telep~one Interview, conducted 14 days after the consultation to obtain follow-up information (e.g. experience with the prescribed medication); and a Doctor Questionnaire that focused on attitudes toward consultations and patients. With respect to communication about prescription medications, physicians most frequently mentioned product name (78.2% of consultations) and instructions for use (86.7% of consultations). Patients were extremely passive, rarely offering their opinion or initiating discussion about any aspect of the treatment. We suggest that improving patients' decision-making competencies may require more discussion of benefits and risks, as well as discussion of patients' opinions about the prescribed medications and their abilities to follow through with the treatment plans. The research design proved useful in highlighting discrepancies between perceived and actual communication. Physicians tended to overestimate the extent to which they discussed patients" ability to follow the treatment plan, elicited patients' opinion about the prescribed medication and discussed risks of the medication. And, 24.3 % of the patients left the consultation with an "illusion of competence', a belief that important topics had been discussed when, in fact, they had not been mentioned at all. The pattern of results illustrates the complexity of health promotion in primary care, and underscores the importance of attending to both perceived and actual communication in medical encounters. Key words--health promotion, control, competence, communication

T h e W o r l d H e a l t h O r g a n i z a t i o n defines health p r o m o t i o n as " t h e process of enabling people to increase control over, a n d to improve, their h e a l t h " [1] (p. 1). Peterson a n d S t u n k a r d also linked health p r o m o t i o n a n d control, suggesting that the concept o f personal control can serve as the f o u n d a t i o n for a theory of health p r o m o t i o n [2]. A l t h o u g h health p r o m o t i o n is a term usually reserved for public-health or wellness programs, a h e a l t h - p r o m o t i o n perspective enriches the e x a m i n a t i o n of c o m m u n i c a t i o n in p h y s i c i a n - p a t i e n t interactions by emphasizing issues of e m p o w e r m e n t , competence, a n d control [3]. A great n u m b e r of studies attest to the health benefits of perceived control (see Refs [4-6] for reviews), Accordingly, we are interested in h o w c o m m u n i c a t i o n d u r i n g medical encounters can improve patients' abilities to exercise a p p r o p r i a t e control over their health.

People are constantly m a k i n g decisions a b o u t their health (e.g. whether or not to see their physician a b o u t a health problem; what to bring up during the consultation; w h e t h e r or not to follow the physician's advice; whether or not to seek out o t h e r advice or information). A m a j o r factor in enabling patients to increase control over their health involves developing their competencies for m a k i n g decisions a n d enacting behaviors that can lead to desired, a n d attainable, health outcomes. With regard to the consultation, patients can m a i n t a i n control by o b t a i n i n g inform a t i o n a b o u t their situation a n d participating in decisions a b o u t t r e a t m e n t [7]. G i v e n the fact t h a t whether a n d h o w to use prescription medications are a m o n g the most c o m m o n a n d i m p o r t a n t decisions in which patients can participate [8, 9], we analyzed c o m m u n i c a t i o n a b o u t

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medications as a first step toward studying the development of patients' decision-making competence. A necessary, but not sufficient, component of decision-making competence is "usable information through which uncertainty can be reduced and decisions can be made" [10] (p. 30). Since physicians can invest patients with a sense of control by providing information relevant to decision making (see Ref. [11] for more on this point), the content of communication between physicians and patients is of great interest. Tuckett, Boulton, Olson and Williams [12] noted that "research on consultations and their outcomes has been almost exclusively preoccupied with matters of style: it has been about how patients and doctors 'related' to each other as opposed to what they said" (p. 13). In contrast, our study deliberately focused on what physicians and patients said: it was designed to elicit specific information about how they discuss health problems and solutions, how they perceive this process and the level of congruence between perceived and actual communication. Research questions and hypotheses. This paper is structured around five questions regarding the kind of information exchange that can help patients exercise appropriate control over their health. This set of questions is accompanied by hypotheses that serve to focus the presentation and discussion of data*. Note that the context for each question and hypothesis is communication and decision making about prescription medications. I. Where Do Patients Get Most o f Their Information About Prescription Medications? We argued that physicians are in a unique position to help patients develop decision-making competencies, in large part through the provision of information relevant to a health decision. Studies conducted in the United States indicate that a marked majority of people consider physicians to be important sources of information about medications [13], health and fitness [14, 15]. Our argument will be strengthened if the English patients in our study also report getting most of their information about medications from physicians. Accordingly: HI: A majority of patients will report that they get most of their information about medications from physicians. H. How Do Physicians Rate the Importance o f Communication About Prescription Medications? The content of communication is likely to be determined, at least in part, by physician and patient *See Ref. [11] for an extensive treatment of additional hypotheses and data regarding physician and patient attitudes, perceptions and actual communication. J'The task approach focuses attention on discrete areas of the consultation and facilitates the assessment of congruence between interactants' perceptions and actual communication (see Refs [11, 16]).

attitudes toward communication and participation in the medical encounter. More specifically, the likelihood that a physician will provide patients with information about risks, side-effects, benefits and instructions is a function of his/her perception of the relative importance of these communication taskst. Given our focus on decision-making competence, we will assess how physicians rate the importance of four additional tasks: involving patients in deciding upon a treatment plan, providing patients with enough information to be able to make their own treatment choice, eliciting patients' opinions about the prescribed treatment and discussing their ability to follow the treatment plan. The first two tasks reflect a willingness to have patients participate in decisions; the latter two focus on information that can improve the quality of decisions by uncovering obstacles to adopting a particular treatment plan. III. What are Physicians' Estimates o f the Extent to Which They Communicate with Patients About Prescription Medications? Waitzkin [17, 18] reported that physicians tend to overestimate the amount of time they spend giving information to patients. Time is a rather ambiguous measure of communication (i.e. one can provide a tremendous amount of information within a short time-span or very little information over a long period of time). Thus, our analysis of perceived communication focuses on the same content for which importance ratings were assessed: instructions, benefits, risks, side-effects, patients' opinion about the prescribed medication and their ability to follow the treatment plan, as well as the more general tasks of involving patients in decision making and giving them enough information to make a decision. On one level, physicians' estimates regarding communication about different topics can serve as a validity check for their importance ratings. That is, the frequency estimates should roughly parallel physicians' ratings of topic importance. In addition, the estimates reflect how these physicians characterize the communicative content of their interactions. However, one must remember that the estimates do not necessarily reflect actual communication. Along these lines, Folger, Hewes and: Poole [19] noted that "[communication] journals are replete with studies of the relationships among self-reports of communicative behaviors...but all too seldom do we explore the content and function of the actual messages" (p. 116). The next research question attempts to redress this situation in the physician-patient context. IV. To What Extent Do Physicians and Patients Actually Communicate About Prescription Medications? Clearly, this is a fundamental question. Here, the kind of information exchanged during the

Health promotion in primary care consultation, as recorded on videotape, is assessed. Observations include communication about the medication's name, instructions for use, benefits, mode of action, risks, side-effects and precautions, as well as discussion of patients' opinions of the medication and their ability to follow the treatment plan. Given Waitzkin's work [17, 18], we expect to find differences between physicians' estimates of information exchange and actual communication, but offer no hypothesis because the measures of perceived and actual information exchange are not isomorphic (see Methods section). While all of the topics mentioned above aid in decision making, one is central to the discussion of competence: adverse reactions associated with the prescribed medication. From a decision-analysis perspective, risk-oriented information is integral to informed choice [20, 21]. Morris [9] noted a number of health-care, medico-legal and practice-management reasons for discussing possible adverse reactions. Of course, not all prescription medications have the same adverse-reaction profiles. Since it might not always be equally appropriate to discuss side-effects, risks or precautions, it is likely that distinct classes of prescription medications (i.e. those indicated for different health problems) will generate different patterns of communication: H2: Different classes of medications will be associated with varying levels of communication about side-effects, risks or precautions. We do not mean to suggest, however, that adverse-reaction information will always be communicated when it might be appropriate. The research design facilitates evaluation of whether or not patients who actually experienced side-effects after taking the prescribed medication knew that the adverse reaction was a possibility. Each patient who reported a side-effect, but was not advised of its likelihood, represents another argument for providing this information during consultations. V. How Do Patients Perceive Communication About Prescription Medications?

This question will bring the analysis full-circle. Actual exchange of information about prescription medications is a prerequisite for developing patients' decision-making competence; another important determinant is how patients perceive this process. Retaining the focus on prescription medications, we will gauge patients' perceptions about whether the physician asked them to choose a treatment, gave them enough information to make a decision, fully explained risks, fully explained benefits and asked their opinion. Regarding information about risk, we expect patient perceptions to roughly parallel actual mention of adverse reactions. Yet, the focus on competence requires going beyond the surface of a simple pattern analysis. We noted above that some patients who experience side-effects might well be unaware of the

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possibility. If physicians' reluctance to discuss adverse reactions [9, 22] is interpreted by patients as an indication that there are none, patients can leave the consultation with an 'illusion of competence' (i.e. a false belief that they had an adequate knowledge base for making a decision). As the research design allows investigation of this phenomenon, we posit: H3: Patients will tend to overestimate the extent to which their doctors discuss adverse reactions associated with the prescribed medications. Data supporting this hypothesis would illustrate the complex nature of decision-making competence, as well as underscore the importance of assessing both actual and perceived communication when studying human interaction. METHODS In the Fall of 1989, we conducted an investigation of physician-patient communication and decision making within the Oxford Regional Health Authority. We ran the study in Oxford for three reasons: it was the site of our previous work on doctor-patient communication [23]; setting the stage for a cross-cultural analysis of physician-patient communication was especially timely, given the burgeoning debate regarding national health insurance in the United States; the organization that provided our primary research grant was interested in the state of general practitioner-patient interaction in England. Design

Although it was clear from the outset that a fairly large sample of consultations within the Oxford region would be required in order to represent the diversity of general practitioner-patient interactions, the actual target number of consultations to be included in the study was derived from a statistical power analysis [24]. Since one important focus of the overall research project was communication and decision making about prescription medications, the first step was to establish the approximate proportion of patients who would receive a new prescription during their consultation. The decision to select this subsample, in which new medications were prescribed, was based on a desire to eliminate past communication about prescribed medications (e.g. refills) that could confound interpretation of results. Estimates derived from experience in a Shipston-onStour practice indicated that one-third to one-half of the total number of patient visits would result in a new prescription. We conducted a pilot test in two practices, one in Shipston-on-Stour and the other in Chipping Norton, to cheek this estimate, as well as to pretest our procedures and instrumentation. Of the 36 patients who participated in the pilot test, 17 (47.2%) received a new prescription during their consultation.

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Given these values, the total target sample size was calculated by first conservatively estimating that 33% of consultations would result in new prescriptions and then consulting power tables to determine new-prescription sample size requirements. In terms of correlation, Cohen described small effects as r = 0.10 and medium effects as r = 0.30 [24]. Based on our previous research [23], the minimum effect sizes of theoretical interest were expected to lie somewhere in between (i.e. r = 0.20). To reach a power level of 0.80 for detecting small to medium effect sizes at a relatively conservative alpha level (e.g. 0.01), 250-300 patients were required in the new-prescription sample*. In determining the total number of consultations required, it seemed prudent to use the larger value, which yielded a total target sample size of 900 (i.e. 300 x 3, since the new-prescription estimate was set at 33% of all consultations). Accordingly, the goal was to enlist the cooperation of a purposive sample of 40 general practitioners (GPs) and monitor their interactions with an opportunity sample of 25 patients each, for a total of 1000 consultationst. Even if we were unable to secure the full level of GP or patient participation, this sampling plan was expected to yield the desired number of consultations for analysis. Subject recruitment. During the recruiting phase of the study, GPs were told that we were conducting a study of physician-patient communication, which is not an unusual occurrence in Oxford [16]. After asking if a research assistant could videotape their consultations with patients, as well as review corresponding medical records, we were able to secure the participation of 39 GPs in 22 different group practices. The research assistant collected data on an average of 23 patients per GP, which yielded 903 consultations. All of these patients read and signed a consent form that described the investigation as a 'study of communication between doctors and patients' and outlined the ways in which we would obtain data about their consultation. Instrumentation. There were five points at which data about the consultations were collected, each of *Both the power and alpha level chosen lend considerable confidenceto results, whether tests are one- or two-tailed [24]. The conservative alpha level was chosen because of the interaction between sample size and statistical conclusion validity [25]. tWe employed a similar sampling design in our earlier study [23] as well, because we believe that it offers the best balance betweenKish's four designcriteria: compatibility with research objectives, measurability, practicality and economy [26]. Although only probability samples yield theoretically valid estimates of sampling variability (i.e. measurability), our design captures consultations in 'real time'. :~Fullinstrumentation and technical appendices are available from the first author. §Percent agreement, though it does not correct for chance agreement between coders [27], was considered a useful sign of coder preparedness (i.e. it marked a threshold at which the initial training period could end).

which was pilot tested and refined in the months preceding this study. Below, we provide a general description of each one:~. Video Analysis All consultations were videotaped to allow assessment of the actual form and content of interaction through use of a fairly elaborate coding system to collect information on the process of communication, as well as a checklist to flag events. Only checklist results will be reported in this paper. The checklist was designed to allow coders to record mention of a particular topic (e.g. risk, benefit), as well as who initiated discussion of the topic (i.e. physician or patient). This nominal coding system was chosen because the research objective was to implement a comprehensive, yet reliable, analysis. Thus, no effort was made to judge the quality or quantity of discussion; that was left for physicians and patients to do in their respective questionnaires. Two groups of 20 Northwestern University students were trained, for a period of four weeks each, in the use of the video coding schemes. Weekly training sessions were held to discuss coding rules, work through hypothetical cases, code videotapes, review coding sheets and resolve questions or disputes. By the end of the training period, coders reached an acceptable level of agreement on all items when coding by themselves (85% agreement)§. During the subsequent coding period, students worked in rotating pairs, each of which coded four to six of the videotaped consultations per week. Spot-checks were conducted throughout the coding period. In addition, coders participated in ongoing weekly training sessions and reliability checks. The spot-check, rotating-pair, training-session and reliability-check procedures were designed to reduce coder bias, fatigue and drift [19], as well as to create an incentive for attention to the task and instantaneous double-checking of consultations and coding rules. Two supplementary procedures were implemented in order to ensure accuracy and determine actual coding reliability among pairs: (1) All consultations during which topic mentions were flagged by coding pairs were rechecked; (2) Videotapes, checklists and coding sheets for all consultations involving new prescriptions were reviewed by the first author (i.e. coding was cross-checked). The combination of a simple coding scheme, an intensive training period and rigorous spot-checking was intended to enhance intercoder agreement. To assess reliability, a random sample of 10% of the checklists generated by coder pairs were compared to corresponding 'standard' checklists (i.e. those generated by the author). Reliability analyses were run on this sample using Ko, an intercoder agreement index

Health promotion in primary care that uses 1/n as a definition of chance agreement [28], as well as the more commonly used agreement index, K, which incorporates marginal proportions in its definition of chance agreement [27]. The difference between the two indices is that Kn assumes that one or both marginals are free (i.e. coders have no marginal restrictions), while K assumes that they are both fixed a priori. Overall, the average intercoder reliability coefficient was quite high (aveKn = 0.97, range = 0.92-1.00; aveK = 0.94, range = 0.70-1.00).

Patient Questionnaire Immediately after the consultation, our research assistant asked patients to complete a five-page questionnaire. The questionnaire consisted of four sections, arranged such that all patients began with a question on their preferred source of information about prescription medications, proceeded to items regarding their perceptions of the medical encounter and personal health-beliefs, then moved on to report concern about their health problem, sociodemographic information and outcome of the visit. Only patients who were prescribed a new medication during the visit were instructed to complete the final section, which is the main source of data regarding patient perceptions of communication and decision making about medications.

Medical-record Review Our research assistant reviewed the medical record of each patient after their consultation to capture age and gender information, as well as to note utilization and continuity-of-care patterns. The medical-record review also covered diagnosis [29] and treatment information, which included type of drug [30], number of pills or applications in prescription, number to be taken each day and whether the drug had been previously prescribed for that particular patient.

Telephone Interview Two weeks after the consultation, every patient who received a new prescription--and had a phone--was called to assess a number of issues. These included: whether or not the patient took the medication as prescribed, experience with side-effects and information seeking regarding the medication. Calls were made on the 14th day after the consultation in order to allow a reasonable period of experience with the medication. All of the questions were asked in an open-ended form, which allowed respondents to express themselves in language that was comfortable, and meaningful, for them [31].

Doctor Questionnaire After all of the consultations were taped, we distributed a five-page questionnaire to each participating GP by mail. Items in the doctor questionnaire *This methodology has been used successfully in the Oxford Regional Health Authority since 1984 [32].

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asked the GPs about their patients in general (i.e. they did not focus on individual participants in this study). This single-wave approach was adopted so physicians who participated in the later weeks of the study would not hear of the foci from those who had been observed earlier. In other words, we attempted to preclude contamination of results. In Section One, GPs were asked to rate the importance of accomplishing 22 specific, randomly ordered, consultation tasks on a scale of 0-10, where 0 = not at all important to accomplish and 10 = crucially important to accomplish*. The GPs were also asked to estimate the percentage of consultations in which they actually accomplish those tasks, again on a scale of 0-10; here, 0 = none of the consultations and 10 = 100% of the consultations. Where applicable, the information-exchange items employed the same modifiers as did those used in the patient questionnaire. In Section Two, the GPs were asked to rate the desirability of 26 specific, randomly ordered, patient characteristics on a scale of 0-10, where 0 = not at all desirable and 10 = highly desirable. Physicians were also asked to use a 0-10 scale to estimate the proportion of their patients who seem to possess each of these characteristics; in this case, 0 = none of their patients and 10 = 100% of their patients. Information on the physicians" communication style and comfort with taking risks was obtained in Section Three. In Section Four, we asked for descriptive information about the doctors and their practices: age, sex, years in practice, exposure to communication-skill training, scheduled appointment length and arrangements for seeing patients (e.g. registered list or open list system). Procedure jbr matching records. Data from the video checklists, patient questionnaires, medicalrecord reviews, telephone interviews and doctor questionnaires were coded, entered into computer files and thoroughly checked for accuracy. The data obtained from each instrument was sorted by doctor and patient identification numbers and merged within the SPSS/PC + v4.0 environment [33], which allowed linkage of all data sources. This design enabled determination of the level of congruence between what was said during the consultations (via videotape coding) and interactants' perceptions of communication (via questionnaires). This study employs an exact matching procedure and a full record-check design (see Ref. [34]). Since many studies of dyadic communication rely on self-reports of what transpired during interactions, the design of this investigation should prove important if there is evidence of marked discrepancies between actual communication and the self-reports.

Sample Between October and December of 1989, we worked with 39 GPs and the 1105 patients who visited them on the days our research assistant spent in their practices.

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Gregory Makoul et al. 1105 PATIENTS WERE SEEN BY GPs IN THE STUDY - - 1 5 6 refused to participate --26 not asked 923 PATIENTS WERE VIDEOTAPED --20 left before getting survey 903 PATIENTS COMPLETED SURVEY --48 eliminated to reduce bias 855 PATIENTS MET RESEARCH CRITERIA --343 received no prescription --224 received refill/repeat 288 PATIENTS RECEIVED A NEW PRESCRIPTION --17 video could not be coded 271 PATIENTS YIELDED COMPLETE VIDEO AND SURVEY DATA Fig. 1. Patient sampling summary.

Patients. O f the 1105 patients, 156 (14.1%) refused to participate in the study and 26 (2.4%) were not asked to participate*. This left 923 patients, or 83.5% of the total number of patients seen by the GPs while we were observing their practices. Our research assistant was able to collect data on 903 (97.8%) of these patients; the remaining 20 left the office before she could render the questionnaire. As this study was conducted within a general practice environment, we saw a wide range of both health problems and patients. In an attempt to eliminate probable sources of bias in the data set [25], we established three criteria for including patients in the analysis. First, they could be no more than 87 years old (after Ref. [14]), which eliminated three outliers. Second, only those patients who had seen their doctors no more than 26 times in the two years prior to the observed consultation were selected for analysis. Eliminating patients who had seen their physician, on average, more than once every four weeks disqualified another 40 patients, most of w h o m made more than twice as many visits as did patients in the criterion group. Third, the person whose problem was addressed during the consultation had to be present,

*Consistent with our earlier study [23], the most frequent reasons for refusing to participate were 'too busy" and ~no time '. The research assistant did not ask people to participate for the following reasons: She was unable to request consent before the patient went in to see the doctor (n = 10); The patient's English was poor (n = 10); The type of visit (e.g. cervical smear) was not appropriate for this study (n = 3); The patient appeared 'too unwell' (n = 3). #We were able to code videotapes for 816 of the 855 consultations that met the criteria for data analysis (95.4%). The 39 unusable tapes break down as follows: 22 were cut offduring the consultation, 11 were not on the tape and six were inaudible. This yielded complete data on 271 of the 288 consultations in which patients reported receiving a new prescription (94.1%). SMost patients under 15 years old were accompanied by a parent during their consultation. In these cases, the parent was considered to be the primary decision-maker (i.e. the parent is an agent of care for, and thus able to answer for, the patient). In fact, GPs usually directed their communication toward the parents, not the younger patients.

which excluded the five people who came to talk about someone else's problem. This yielded a net sample of 855 patients for data analysis; of these, 288 (33.7%) reported receiving a new prescription medication, 224 (26.2%) received a refill prescription and 343 (40.1%) received no prescription at all during the consultation. Given the focus on communication and decision making about new prescription medications, the sample will be limited to 271 of the 288 patients who received a new prescription, and for whom we have complete data#. Figure 1 summarizes the progression from the total number of patients seen by physicians during the research period and the final patient sample. Consistent with our previous research [23], a majority of these patients were female (60.1%). Patients' age ranged from 0 to 87 years, with a mean of 37.5 (SD = 22.5) and median of 365. On average, these patients had been with the practice for 12.4 years (SD = 12.1); the median was 8.3 years; the mode was zero. Patients made an average of 10.4 visits to the practice under study (SD = 8.3), with a median and mode of 8 visits. They saw the G P who participated in the study an average of 4.2 times in the two years prior to the consultation under study (SD = 5.1); the median number of visits was 2; the mode was zero. Regarding follow-up interviews, the research assistant was able to reach 212 (78.2%) of the 271 patients by telephone on the 14th day after their consultation. Of the 59 patients we were unable to contact for follow-up interviews, 34 (58%) had no telephone and two (3 %) told the research assistant that they would be away from home at the follow-up point. Despite repeated attempts to contact the remaining 23 patients on their follow-up date, we had no success. Physicians. Thirty-seven (94.9%) of the 39 GPs returned the doctor questionnaire, one of whom prescribed no new medications during the study. Thus, the following description of the physician sample is limited to the 36 GPs who returned the questionnaire and participated in interactions that resulted in new prescriptions. These GPs ranged in age from 33 to 60 years, with a mean of 44.9 (SD = 7.3), median of 44 and mode of 40 years; only two were female. These

Health promotion in primary care G P s h a d been in practice between 1 a n d 30 years. T h e m e a n time in practice was 14.2 years (SD = 8.0); the m e d i a n was 13 a n d the m o d e was 10 years. Exactly 50% of the G P s h a d participated in a communication-skills training course (see Ref. [16]). A p p o i n t m e n t s were scheduled every 7-10 min, with ameanof9.4 min(SD = 1.0);two-thirdsoftherespondents b o o k e d their a p p o i n t m e n t s in 10 rain intervals. Seventy-five percent o f the physicians (n = 27) were involved with practices t h a t employ a system in which patients are encouraged to see their usual d o c t o r w h e n e v e r possible, b u t are free to change doctors, The r e m a i n i n g doctors were fairly equally divided between practices t h a t either expect patients to see the G P with w h o m they are registered (n = 4) or allow patients to see whichever d o c t o r is available (n = 5). Interactions. F o r the 36 G P s w h o r e t u r n e d their questionnaire a n d participated in interactions t h a t resulted in new prescriptions, the m e a n n u m b e r of patients per physician was 7.0 (SD = 2.5); the range was 3-14, a n d the median a n d m o d a l n u m b e r of patients was 6. The average d u r a t i o n o f these c o n s u l t a t i o n s is estimated to be 7.5 min (SD = 3.5), as measured by the checklist coders*. The consultations ranged from 2.2 to 21.2 m i n in length, with a m e d i a n d u r a t i o n of 6.8 min a n d a m o d e o f 6.0 min. These estimates are consistent with the average interval at which a p p o i n t m e n t s were scheduled (i.e. 9.4 min). RESULTS O u r experience with this type o f research [23] suggests t h a t there will be a considerable a m o u n t o f 'noise' in the data set. Beisecker [35] offered a n u m b e r of situational factors that m i g h t cause the p h y s i c i a n patient interaction to vary, including: reason for visit, length of interaction, presence o f a c o m p a n i o n , familiarity with the d o c t o r a n d physical features o f the office. M a n y of these are likely to be operating in this study, given its focus on G P s a n d their diverse patient population.

*The measure of consultation duration must be considered an estimate, since coders were not provided with a standard measurement device (e.g. a stopwatch). tThe patient data (i.e. that derived from individual consultations, patient questionnaires, telephone interviews and medical-record checks) offers the relatively strong statistical power associated with n > 200, even at these conservative alpha levels. :~The computing formula for Z2 is Z ( O - E ) 2 / E or, equivalently, ~,02/E - N, where O is the observed frequency and E is the expected frequency. Siegel and Castellan [36] state that "the sum of frequencies should be N, the number of independent observations" (p. 50), by which they mean the number of cases in the sample. Since we asked patients to indicate two information sources, we feel it is logically justified to use the number of sources selected, rather than the number of subjects in our sample, as the N when calculating X:. In light of this modification, these statistical tests are probably best regarded as secondary confirmation of the obvious differences between frequencies with which sources were selected. SSM 4U9--D

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Table 1. Sources of information about prescription medications' Source nb %c Doctors 232 85.6"** Chemists/pharmacists 90 33.2 Family and friends 61 22.5 Newspapers and magazines 34 12.5 Labels on packages 28 10.3 Leaflets in packages 18 6.6 Nurses 10 3.7 Other~ 14 5.2 •Data from patient questionnaire (n = 271). bPatients were asked to indicate the two (2) sources from which they get most of their information about prescription drugs. Thus, the total number of possible responses is 2 x 271 = 542. However, 55 patients (20.3%) selected only one source. Of these, 44 chose doctors (80.0%), 3 chose chemists/pharmacists, 3 chose family and friends, 3 chose labels and 2 chose other. Accordingly,values in this column sum to 542 - 55 = 487. ~This column displays the percentage of our 271 patients who indicated each source. As each patient bad the opportunity to select two sources, the values sum to more than 100%. d'Other' was provided as a response option. The 14 responses break down as follows: television (4), medical literature (4), radio (I), school (1), health visitor (1), consultant (I), health shop (1) and MIMMS (1). • **;(: for Goodness-of-fit, P < 0.001 (across all sources and when compared to chemists/pharmacists).

While this state o f affairs p o r t e n d s fairly small effect sizes [24], it also serves as an a r g u m e n t t h a t m e d i u m to large effect sizes o u g h t to be t a k e n quite seriously. T h a t is, a difference or relationship between variables t h a t emerges clearly from the clutter can be considered a robust difference or relationship. In a n effort to emphasize such results, relatively conservative significance criteria (i.e. ~ = 0.01 a n d 0.001) are applied to the hypothesis testst. Results are presented in a sequence parallel to the research questions.

I. Where Do Patients Get Most o f Their Information About Prescription Medications? In order to assess the premise t h a t physicians are patients' primary source of i n f o r m a t i o n a b o u t medications, the patient questionnaire asked patients to indicate the two sources from which they get most of their i n f o r m a t i o n a b o u t prescription drugs. Table 1 illustrates t h a t an overwhelming majority (85.6%) indicated t h a t they get most of their i n f o r m a t i o n from Doctors. C h e m i s t s / P h a r m a c i s t s were the next most frequently selected source (33.2%), followed by Family a n d Friends (22.5%). Thus, the d a t a strongly s u p p o r t Hypothesis 1: A m a r k e d majority o f patients reported t h a t they get m o s t o f their i n f o r m a t i o n a b o u t medications from physicians. W h e n the null hypothesis was equiprobability across all sources, Z2 for Goodness-ofFit = 633.41 (n -- 487, expected frequency = 60.88, df=7, P<0.001). M o r e specifically, w h e n the frequency with which D o c t o r s were selected was c o m p a r e d to t h a t with which C h e m i s t s / P h a r m a c i s t s were selected, ~(2= 62.62 (n = 322, expected frequency = 161, d f = 1, P < 0.001)~.

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Table 2. Information-seekingafter the consultation" Print source n % None 168 79.2 Label on package 21 9.9 Leaflet in package 16 7.5 Medical literature 7 3.3 Interpersonal source n % Nobody 164 77.4 Family and friends 34 16.0 Person on same prescription 5 2.4 Chemist/pharmacist 5 2.4 Nurse 4 1.9 ~Data from telephone interviews(n = 212/271).

Table 2 reinforces the primacy of physicians as information sources. Two weeks after their consultation, patients were asked if they read anything or talked to anyone about the medication they were prescribed. More than three-quarters of the patients reported that they did not, which suggests that, for most people, a physician was the sole source of information. This combination of results, representing self-reports of general information-seeking and specific post-consultation behavior, reinforces the value of information exchange during the medical encounter.

H. How Do Physicians Rate the Importance of Communication About Prescription Medications? Given that physicians seem to be the primary source of information about prescription medications, their perspectives regarding relevant communication tasks will largely determine the type, and amount, of information patients get. The Importance column of Table 3 summarizes how the sample of physicians rated the importance of accomplishing the communication tasks presented to them in the doctor questionnaire. The GPs were asked to rate each task on a scale of 0-10, where 0 = not at all important to accomplish and 1 0 = c r u c i a l l y important to accomplish. The mean G P ratings ranged from a high of 8.25 (SD = 1.92) for 'provide complete instructions for taking the medication' to a low of 5.94 (SD = 2.60) for 'explain fully all possible side-effects of the medi-

cation'. In fact, the three tasks rated least important involved communicating information about attributes of the prescribed medication (i.e. benefits, risks, side-effects).

IlL What are Physicians' Estimates of the Extent to Which They Communicate with Patients About Prescription Medications? We also assessed physicians' estimates of the extent to which they accomplish each of these communication tasks. Their perceptions are summarized in the Accomplish column of Table 3. Note the rough parallel between task-importance ratings and task-accomplishment estimates, which serves as a validity check of sorts: GPs reported a greater incidence of accomplishing the tasks they consider most important; or to put it another way, they rated as most important the tasks they think they accomplish most frequently. In the next section, actual information exchange is reported for purposes of description and comparison.

IV. To What Extent Do Physicians and Patients Actually Communicate About Prescription Medications? In contrast to the doctor and patient questionnaires, in which adverbial intensifiers (e.g. 'fully explained') were employed when asking respondents about communication tasks, the video checklist coded for mere mention of a topic. The checklist results reveal discrepancies between physicians' perceptions of information exchange with patients in general and their actual communication with the patients in this sample. F o r each task listed in Table 4, the GP Estimate column provides the same values found under the Accomplish column of Table 3, and the Videotape column reports the average percentage of each GPs consultations in which a topic was mentioned, whether discussion was initiated by physician or patient. While it is tempting to make direct comparisons between physician perceptions and actual communication, it is more appropriate to view any differences as preliminary indications of incongruence, since the checklist results are not derived from a strictly random sample of each physician's patients.

Table 3. Physician perceptions of consultation tasks~ Task Importance~ Accomplish ~ Provide complete instructions for taking the medication 8.25 (1.92) 61.9%(21.8%) Involve patients in deciding upon a treatment plan 8.03 (1.80) 63.9%(16.6%) Provide patients with enough information to make a choice 7.61 (1.89) 58.3%(19.0%) Discuss patients' ability to follow the treatment plan 7.11 (2.51) 49.2%(22.0%) Find out what patients think about the medication 6.97 (2.21) 48.9%(20.3%) Explain all the benefits of the medication 6.53 (2.55) 47.8%(24.6%) Explain all the risks of any medication 6.00 (2.59) 42.2%(23.4%) Explain fully all possible side-effectsof the medication 5.94 (2.60) 39.4%(24.0%) ~Data from Doctor Questionnaire, n = 36. bThe GPs were asked to rate the importance of each task on a scale of 0 (not at all important to accomplish) to 10 (crucially important to accomplish). Data are summarized as means and (standard deviations). eThe GPs were asked to indicate the overall percentage of their consultations in which they actually accomplish each of these tasks. Again, data are summarized as means and (standard deviations).

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Table 4. Comparison between physician estimates regarding communication and actual discourse Task GP Estimate (%)' Videotape(%)b Provide instructions for taking the medication 61.9 (21.8) 87.0 (18.9) Discuss patients' ability to follow treatment plan 49.2 (22.0) 7.9 (12.0) Find out what patients think about the medication 48.9 (20.3) 33.9 (20.4) Discuss benefits of the medication 47.8 (24.6) 56.0 (23.0) Discuss risks of the medication 42.2 (23.4) 3.1 (6.2) Discuss side-effects of the medication 39.4 (24.0) 30.7 (18.2) ~From Doctor Questionnaire, n = 36. Data are summarized as means and (standard deviations). These are the same values found under the 'Accomplish' column of Table 3 (i.e. GPs were asked to estimate the overall percentage of consultations in which they fully or completely accomplish each task). bFrom Video Checklist. Data are again summarized as means and (standard deviations). Here, n = 36, representing the average percentage of each GP's consultations in which a topic was mentioned, whether discussion was initiated by physician or patient. As the matching procedure omits the 20 patients who saw GPs that did not return a Doctor Questionnaire, values differ slightly from a sum of the columns displayed in Table 5. Table 4 suggests t h a t G P s m a y overestimate the extent to which they accomplish i m p o r t a n t c o m m u n i cation tasks, especially discussing patients' abilities to follow the suggested t r e a t m e n t plan, finding o u t w h a t patients t h i n k a b o u t the prescribed medications a n d explaining all the risks o f any prescribed medication*. R e g a r d i n g actual c o m m u n i c a t i o n behavior, Table 5 indicates that, consistent with the i m p o r t a n c e ratings reported in Table 3, physicians initiated discussion o f instructions m o r e often t h a n they did any o t h e r topic (86.7%). They also referred to the medication by n a m e in a large p r o p o r t i o n o f the interactions ( 7 8 . 2 % ) t . In fact, the prescription of medications in most c o n s u l t a t i o n s can be characterized by statements such as, ' T a k e this antibiotic four times a day for two weeks'. O t h e r t h a n benefits, which were m e n t i o n e d in just over half of the consultations, attributes of the m e d i c a t i o n were not discussed very m u c h at all. Since n o t all medications have the same adversereaction profiles, we hypothesized t h a t medications for different indications (i.e. different classes o f medication) would be associated with varying levels of c o m m u n i c a t i o n a b o u t side-effects, risks or precautions (Hypothesis 2). In order to test this hypothesis, the measures of c o m m u n i c a t i o n a b o u t side-effects, precautions a n d risks were collapsed to form a d i c h o t o m o u s indicator of overall adverse-reaction i n f o r m a t i o n exchange, termed A N Y R I S K . This procedure manifests some discussion o f side-effects, precautions or risks, w h e t h e r initiated by physician or *Table 4 might suggest to some that GPs underestimated the extent to which they discussed instructions and, to a lesser extent, benefits. However, such a conclusion is unwarranted because GPs were asked to estimate the percentage of consultations in which they provided 'complete instructions for taking the medication', whereas the checklist coding of actual communication recorded mere mention of instructions (i.e. mentions are not necessarily complete instructions). The same logic holds for discussion of benefits. ?Coders were instructed to consider any term that might help patients label a medication to be a 'name'. That is, drug classifications (e.g. ulcer medicine), generic names (e.g. ranitidine) and proprietary names (e.g. Zantac) were coded as mentions, but global referents (e.g. pills) were not. :~We emphasize that these are self-reports (i.e. patient perceptions of adverse-reaction experience).

patient, in 32.5% of the consultations. By definition, neither side-effects, precautions n o r risks were mentioned, by either physician or patient, in 67.5% o f the interactions. Table 6, which reports A N Y R I S K m e n t i o n s associated with the five m o s t frequent indications, clearly illustrates t h a t Hypothesis 2 was supported (X2 = 104.83, df= 4, P < 0.001). Side-effects, risks or precautions were m e n t i o n e d most often w h e n central nervous system (CNS) medications were prescribed (75.0%) a n d least often when dermatologic (Skin) drugs were prescribed (5.0%). This is n o t to say that the G P s always c o m m u n i c a t e d adverse-reaction i n f o r m a t i o n when it m i g h t have been appropriate. Fifty-one (24.1%) of the 212 patients with w h o m we were able to c o n d u c t telephone interviews reported t h a t they experienced a side-effect from the prescribed medication (see Table 7)~. As s h o w n in Table 8, 25 (49.0%) of these 51 patients reported t h a t they were u n a w a r e the side-effect was a possibility. Those patients w h o said they were aware of the possibility were asked how they knew; the lower p o r t i o n o f Table 8 reveals t h a t fewer t h a n half of these patients learned a b o u t possible side-effects from their doctors. O n average, consultations d u r i n g which A N Y R I S K was m e n t i o n e d took approx. 8 . 5 m i n (SD = 3.9), while those in which there was no m e n t i o n of A N Y R I S K lasted a b o u t 7.0 m i n (SD = 3.2). Since Table 5. Actual communication about prescription medications~ Discussion initiated by: Topic mentioned GP(%) Patient (%) Instructions for use 86.7 1.1 Name of medication 78.2 4.4 Intended benefits 53.9 1.5 Mode of action 23.6 0.0 Possible side-effectsb 22.1 5.2 Precautionsb 6.6 0.4 Possible risksb 1.8 1.5 Patient's opinion about reed 15.1 18.5 Patient's ability to follow the treatment plan 4.8 3.0 'Data from Video Checklist (n = 271). bThe measures of communication about side-effects, precautions or risks were collapsed to create an indicator of adverse-reaction information exchange, termed ANYRISK. This indicator is dichotomous: NO ~ no discussion of side-effects, precautions or risks; YES = any mention, whether initiated by physician or patient, of side-effects, precautions or risks.

Gregory Makoul et al.

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Table 6. Differential mention of any risk information Drug Indication (n)" Mentioned (%)b.***

Table 7. Patient reports of side-effects" Adverse reaction n

CNS (16) 75.0 Muscle/Joint (27) 44.4 Respiratory (22) 31.8 Infection (88) 18.2 Skin (20) 5.0 "Data from Medical Record Review. These are the five indications for which medications were prescribed most frequently. The n associated with each indication represents the number of consultations in which only one new medication was prescribed. bData from Video Checklist. These percentages reflect the number of consultations during which ANYRISK (i.e. risks, side-effectsor precautions) was mentioned, whether discussion was initiated by physician or patient, ***There is a statistically reliable difference, between indications, in the extent to which risks, side-effects or precautions were discussed (;~2for Goodness-of-Fit = 104.83, df= 4, P < 0.001).

None Weak/tired/drowsy Stomach pain/indigestion Diarrhea Nausea Headache Rash Thrush/oral sores Faint/dizzy Other¢

several o t h e r factors (e.g. severity of disease, discussion o f o t h e r topics) could c o n t r i b u t e to the 1.5 m i n time differential, this estimate m i g h t well be considered a n u p p e r b o u n d of the additional time required for risk c o m m u n i c a t i o n ,

V. How Do Patients Perceive Communication About Prescription Medications? F r o m a c o m m u n i c a t i o n studies s t a n d p o i n t , perception, n o t 'reality', is the basis o f action. Thus, patient perceptions o f c o m m u n i c a t i o n a n d decision m a k i n g are considered to be i m p o r t a n t d e t e r m i n a n t s of p o s t - c o n s u l t a t i o n beliefs a n d behavior. T a b l e 9 provides a n indication o f h o w patients in this study perceived seven c o n s u l t a t i o n tasks. W h e n responding to items in the patient questionnaire, they agreed most strongly t h a t their physician gave t h e m all the i n f o r m a t i o n they needed a b o u t their health p r o b l e m (mean = 5.49, SD = 1.01, n = 271) a n d disagreed almost equally as strongly t h a t their d o c t o r asked t h e m to choose a t r e a t m e n t for their health p r o b l e m ( m e a n = 1.95, SD = 1.58, n = 263). T h e m e a n patient response to 'The d o c t o r fully explained the risks o f the medicine he/she prescribed' was almost exactly at the m i d - p o i n t o f the six-point scale ( m e a n = 3.56, SD = 2.12, n = 264). However, when detailed by type o f medication, the p a t t e r n o f results parallels actual discussion o f risk i n f o r m a t i o n , as reported in Table 6: Patients w h o were prescribed a C N S medication m o s t strongly agreed t h a t their G P fully explained risk (mean = 4.47, S D = 1.96,n = 15), while those w h o received a Skin medication m o s t strongly disagreed ( m e a n = 2.75, S D = 2.02, n = 20). As n o t e d earlier, the focus on decision-making competence requires going b e y o n d the surface o f this simple p a t t e r n analysis. We argued t h a t some patients m i g h t interpret lack o f risk c o m m u n i c a t i o n as a n indication t h a t there are n o adverse reactions associated

with

the

prescribed

medication.

The

*This decision rule omits patients who either slightly agreed or slightly disagreed with the statement in order to compare subjects whose responses suggested that they were relatively sure.

161 16 7 5 4 4 3 3 3 6

%b 75.9 7.5 3.3 2.4 1.9 1.9 1.4 1.4 1.4 2.8

~Datafrom Telephone Interviews (n = 212). ~Columnpercentages do not sum to 100% due to rounding. c'Other' includes: kept awake, urinated more frequently, felt depressed/down,eyes hurt, increased appetite, did not specify.

telephone-interview results presented in Table 8 suggest t h a t such patients would be misinterpreting this lack o f c o m m u n i c a t i o n , since only 12 of the 51 patients w h o reported experiencing a side effect were advised of this possibility by their physician. Thus, patients could leave the c o n s u l t a t i o n with a n 'illusion o f competence' (i.e. a false belief that they h a d a n a d e q u a t e knowledge base for m a k i n g a decision a b o u t treatment). We examined this illusion o f competence in the context o f Hypothesis 3, which stated that patients will tend to overestimate the extent to which their doctors discuss adverse reactions associated with the prescribed medications. T o test this hypothesis, we ran a cross-tabulation between patient perceptions a n d actual discourse regarding risk c o m m u n i c a t i o n . Patients' responses to the statement 'The d o c t o r fully explained the risks o f the medication he/she prescribed' were split as follows: N O = patients w h o very strongly or moderately disagreed t h a t their G P fully explained risks o f the medication; YES = patients w h o very strongly or moderately agreed t h a t their G P fully explained the risks.* Recall t h a t the measures o f c o m m u n i c a t i o n a b o u t side effects, precautions or risks were collapsed to create a n i n d i c a t o r of adverse-reaction i n f o r m a t i o n exchange. This indicator, termed A N Y R I S K , is

Table 8. Patient awareness of side-effects~ Know of possibilityb n % Yes 26 51.0 No 25 49.0 Sourceof informationc n % Who knew Doctord 12 46.2 Had similar Rx before 4 15.4 Label on package 4 15.4 Leaflet in package 2 7.7 Medicalliterature I 3.8 Chemist/pharmacist I 3.8 Don't know 2 7.7 "Data from telephone interviews, for people who reported experiencing side-effects(n = 51, or 24.1%, of the 212 patients we were able toreachbytelephone). bPatients who reported experiencing a side-effect were asked if they knew the side-effect was a possibility. CPatientswho said they were aware that the side-effectwas a possibility (n = 26) were asked how they knew. dThe number of consultations during which doctors and patients discussedside-effects was verified by cross-referencing records from the video checklist.

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Health promotion in primary care Table 9. Patient perceptions of consultation tasks~ Mean

Taskb

SD

Skew

n

The doctor gave me responsibility for deciding how to deal with my health problem 3.99 1.96 -0.44 ~ 268 The doctor asked me to choose a treatment for my health problem 1.95 1.58 1.58 263 The doctor gave me enough information to make my own decision about treatment 3.36 2.06 0.06' 262 The doctor gave me all the information I needed about my health problem 5.49 1.01 -2.72 271 The doctor fully explained the benefits of the medicine he/she prescribed 5.11 1.44 - 1.68 266 The doctor fully explained the risks of the medicine he/she prescribed 3.56 2.12 -0.03 ~ 263 The doctor did not ask my opinion about taking the medicine he/she prescribed 3.08 2.00 0.3 I' 266 *Data from Patient Questionnaire. Since not all patients answered all questions in this section, a separate n is listed for each item. bPatientswere asked to indicate how strongly they agreed or disagreedwith these statements regarding specificconsultation tasks. They registered their level of agreement on a six-point scale, where Very Strongly Disagree was coded as I and Very Strongly Agree was coded as 6. Thus, higher mean scores reflect more agreement with the particular statement. ~Bimodal (U-shaped) distribution.

d i c h o t o m o u s : N O = n o discussion o f side effects, precautions or risks by either physician or patient; YES = any m e n t i o n , w h e t h e r initiated by physician or patient, of side effects, p r e c a u t i o n s or risks. Results of this c r o s s - t a b u l a t i o n are presented in Table 10. T h e n u m b e r of patients w h o moderately or very strongly disagreed t h a t their d o c t o r fully explained risk i n f o r m a t i o n (n = 112) was nearly equal to the n u m b e r w h o moderately or very strongly agreed that risk i n f o r m a t i o n was fully explained (n = 114). R e g a r d i n g c o n s u l t a t i o n s of the 112 patients w h o disagreed, coders f o u n d no m e n t i o n of A N Y R I S K (i.e. risks, side effects or precautions) in 93 cases (83.0%), b u t did find some m e n t i o n of A N Y R . I S K in 19 cases (17.0%). W e do not consider patients in this latter g r o u p to be in error; mere m e n t i o n of risk m a y n o t have met their criteria for full explanation. The videotaped consultations o f patients w h o agreed t h a t risks were fully explained are the focus o f Hypothesis 3. W h e n reviewing videotapes o f these 114 subjects, coders f o u n d some m e n t i o n o f A N Y R I S K in 59 cases (51.8%). But they could detect n o m e n t i o n o f A N Y R I S K in 55 cases (48.2%). Neither was any m e n t i o n of side effects, risks or precautions detected w h e n these videotaped consultations were transcribed. It is i m p o r t a n t to note that this cell represents a conservative measure of incongruity, since coders were looking for any mention o f risks, side effects or precautions, while patients were rating the extent to which risks were fully explained. Still, 24.3% o f the 226 patients in this analysis clearly over-reported the extent to which risk i n f o r m a t i o n was discussed, lending s u p p o r t to the Hypothesis 3.* In addition, there is a statistically reliable difference between observed frequencies a n d the null hypothesis of equiprobability in this cross-tabulation (Z 2 for G o o d n e s s - o f - F i t = 31.61, d f = 1, P < 0.001). DISCUSSION The fact t h a t we focused o n general p r a c t i t i o n e r patient consultations in E n g l a n d should be kept in m i n d w h e n considering the implications o f o u r data. One could certainly expect different p a t t e r n s o f results *More formally [34], the proportion of over-report is 37.2% (i.e. false positives/true negatives = 55/93 + 55).

to emerge if the study included specialists r a t h e r t h a n general practitioners, or if the investigation was r u n in countries with different health-care systems. Here, o u r aim was to examine the relationship between c o m m u n i c a t i o n a n d health p r o m o t i o n in a primarycare context. W e offered a detailed description o f h o w o u r sample of physicians a n d patients discussed health problems a n d solutions, h o w they perceived this process, a n d the level of congruence between perceived a n d actual c o m m u n i c a t i o n . This discussion integrates o u r observations, addressing the implications o f observed levels of i n f o r m a t i o n exchange a n d observed discrepancies between perceived a n d actual communication. The competence gap. A central theme of this investigation is the extent to which physicians can help patients increase a p p r o p r i a t e control over their h e a l t h by fostering decision-making competencies. W e suggested t h a t i n f o r m a t i o n exchange between physicians a n d patients is a key to this process (see R.efs [7, 10, 11]), The i m p o r t a n c e of i n f o r m a t i o n exchange d u r i n g medical encounters is highlighted by our o b s e r v a t i o n t h a t patients identified physicians as their m a i n source of i n f o r m a t i o n a b o u t prescription medications. The 'competence gap' concept further reinforces the need for b o t h physicians a n d patients to share information. Parsons [37] observed t h a t specialized medical training a n d knowledge creates a competence gap between physicians a n d patients. In o t h e r words,

Table 10. Relationship between patient reports and actual discourse regarding risk Were any risks discussed?~ Did patient report that risks were discussed?b No Yes No 93 55*** Yes 19 59 Total = 112 Total = 114 'Data from Video Checklist: NO = no discussion of side effects, precautions or risks by either physician or patient; YES = any mention, whether initiated by physician or patient, of side effects, precautions or risks. bData from Patient Questionnaire: NO = patients who very strongly or moderately disagreed that their GP fully explained risks of the medication; YES = patients who very strongly or moderately agreed that their GP fully explained the risks. ***There is a statistically reliable difference between observed and expected frequenciesin this cross-tabulation (;(-for Goodness-ofFit = 30.25, dr= 1, P < 0.001).

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physicians have expertise in areas that patients do not (e.g. doctors have more information about the range of treatment options). Tuckett, Boulton, Oison and Williams [12] argued persuasively that the competence gap is not unilateral, for patients are expert in areas physicians are not (e.g. the ability to follow a treatment plan). Further, with regard to attributes of prescription medications, Veatch [38] suggested that patients are probably better able than physicians to decide "whether a drug's effects will be considered beneficial or harmful and to what degree" (p. 1021). If information exchange is the primary tool for closing the competence gap, our data demonstrate that it remains very wide indeed. Recall that doctors and patients agreed to participate in this study and knew that their consultations were being videotaped. Accordingly, one might expect that subjects were on their 'best behavior' when interacting during the consultation. Still, with respect to communication about prescription medications, patients were extremely passive and physicians most frequently mentioned product name (78.2% of consultations) and instructions for use (86.7% of consultations).* These observations reflect the traditional GuidanceCooperation type of relationship [40], in which physicians are expected to give orders and patients are expected to comply. The relative lack of discussion regarding other topics (e.g. adverse reactions, patients' opinion about medications, ability to follow the treatment plan) underscores the inertia of this model. For instance, the fact that physicians initiated discussion about patients' ability to follow the treatment plan in only 4.8 % of the consultations suggests an underlying assumption that there are no obstacles to compliance. These results emphasize the two-sided nature of the competence gap. Improving patients' decision-making competencies may require more discussion of benefits and risks, as well as the criteria for making treatment decisions [20]. Achieving a concomitant increase in physicians' competence involves eliciting more information on which patients are relative experts (e.g. ability), something that physicians who adhere to the traditional Guidance-Cooperation model [40] might find difficult, if not superfluous. True health promotion in primary care requires moving toward a Mutual Participation model [40], where the patient assumes a more active role in decision making, a role facilitated by relevant

*Morris, Grossman, Barkdoll, Gordon and Soviero [39] reported obtaining a similar pattern of results in a telephone survey of 1104 adult Americans who had obtained a new prescription for themselves or a household member. tRecall that GPs were asked to estimate the overall proportion of consultations in which they accomplish these tasks (i.e. they were not asked specifically about the consultations under observation).

communication (see Refs [11, 41] for more on this point). Perception l,s 'reality'. Given that many studies of dyadic communication rely on either self reports or recorded observations of what transpired during interactions, the observed differences between perceived and actual communication have important methodological and phenomenological implications for communication research, not to mention implications for the medical encounter itself. While perception might well be considered the basis for action, it cannot, and should not, be construed as an accurate reflection of actual interaction. For instance, results indicate that physicians may have overestimated the extent to which they accomplished three specific consultation tasks: discussing patients' ability to follow the treatment plan, eliciting patients' opinion about the prescribed medication and discussing risks of the medication.t These results, obtained in England, complement Waitzkin's more general observation that a sample of American internists overestimated the amount of time they spent giving information to patients [I 7, 18]. Such discrepancies might arise because physicians think they are providing information, think they should provide the information or are responding to researchers in what they perceive to be a socially desirable manner (i.e. physicians believe that the researchers think they should provide the information). In addition, it is possible that overestimates of communication are endemic to any professionalclient context. Whatever the reason, awareness of these discrepancies should prove useful to those interested in improving communication in the medical encounter. Discrepancies are also evident between patient perceptions and actual communication. The crosstabulation between 226 patient reports and actual discourse regarding risk revealed that 24.3% of the patients either moderately or very strongly agreed that their physician fully explained risks of the prescribed medication when we could find no mention of side-effects, precautions or risks. This set of consultation videotapes was transcribed to ensure coding accuracy--nothing that could be construed as communication about adverse reactions was detected. These patients are of great interest because they might well leave the consultation with an illusion of competence. Note that the patient questionnaire was administered immediately after the consultation in an attempt to maintain saliency and reduce memory loss. Thus, it is unlikely that the patients simply forgot whether or not their physician provided the information, and guessed. It is possible that patients might have assumed that a drug was free of side-effects if their physician did not discuss the possibility. Following this reasoning, patients are likely to have agreed that risks were discussed fully, even if no mention was made during the consultation. Or, patients might have

Health promotion in primary care agreed t h a t risks were fully discussed because they, themselves, believed there were none.* T h e observed discrepancies between interactants' perceptions a n d actual c o m m u n i c a t i o n m i g h t affect two critical, a n d related, health o u t c o m e s o f the medical encounter: h e a l t h a n d decision-making competence. O n a n o t h e r level, this c o m b i n a t i o n of results clearly suggests t h a t researchers interested in studying p h y s i c i a n - p a t i e n t c o m m u n i c a t i o n should be wary of data generated solely by self-report methods. Conclusion. A t the beginning of this p a p e r we argued that, if physicians do not share i n f o r m a t i o n with their patients, it is highly unlikely t h a t patients will be able to develop decision-making competencies. In studying general practitioners' perceptions a n d behaviors regarding consultations in which new medications were prescribed, we f o u n d that physicians were neither giving n o r eliciting m u c h of the i n f o r m a t i o n t h a t might help patients m a k e optimal decisions a b o u t their treatment. In studying patients' perceptions a n d behaviors, we found that they seldom initiated discussion regarding this information. In addition, patients often left the c o n s u l t a t i o n with a n illusion of competence, t h i n k i n g they received i n f o r m a t i o n that had never been discussed. T a k e n together, these results underscore b o t h the i m p o r t a n c e a n d complexity of health p r o m o t i o n in primary care. W e hope o u r work will stimulate further clinical, c o m m u n i c a t i o n a n d ethical research o n closing the competence gap for b o t h physicians a n d patients. Acknowledgements--This research project was supported, in part, by grants from the International Medical Benefit/Risk Foundation, Geneva, Switzerland and the Institute for Modern Communications at Northwestern University, Evanston, IL, U,S.A. REFERENCES

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