Meetings between experts

BooK REVIEWS services. This is reviewed in Chap. 3. Attention is drawn to the fact that there must be a shift away from having hospital-based curative care as the cornerstone of health services. However, even countries which have this commitment find it difficult to alter the pattern of services (p. 161). The recognition of the need for primary health care services is just a beginning. Many obstacles still stand in the way of its development. These include the diversion of resources to other (often destructive) ventures, inappropriately trained western medical personnel, counter pressures from clients themselves and the lack of political commitment. Chapter 4 focuses on the need to review the training and role of health workers, the relationship between the different categories and the development of new cadres of part-time community health workers. Emphasis is placed on the types of workers who have proved successful in some locations @. 219) and the ways in which such persons have been trained @. 220). With the goal of de-emphasising hospital-oriented care, there should be an interest in learning how communities and families have been taking care of their own health in order to build on this knowledge. Thus “We need to recognise the network of caring and curing that takes place outside health units, informally, via traditional systems, in the home and by purchase of medicaments. To create more appropriate services and management which will build them up and maintain them is going to require much rethinking and planning” (p. 230). The interest in communication problems is central to the book and indeed communicating is the impetus for the project itself. Since communication is viewed as the sharing of knowledge and flow of much needed information, it is argued that for all groups of health workers, management and new patterns of communication may be more important than their specific medical skills in solving health problems. In the final chapter, the authors look to the future in terms of possible programmes and activities which they feel could make a difference to the overall negative picture painted in the earlier chapters. These include the UNICEF GOBI-FFF programme, increased breast feeding by mothers and the monitoring of child health with such items as baby weight charts. On the whole, the picture presented and messages put forth are clear. However, there may be a problem of readership. As admitted by the authors themselves, the more powerful individuals, those with assets and resources are the most likely to come across the book. And within this group, those with the real power, who can make a difference faster or sooner, are the most likely to lose patience with the simplicity of language and style of presentation. Although the authors emphasise that “health is a highly political matter” @. 199) in which control, political change and the ability to alter one’s situation are fundamental, there is little explicit discussion of the processes by which powerful institutions and corporations have operated historically to create the present situation or block the efforts of those attempting the changes advocated throughout the book. There is too little on the complexity of international relationships,and the ways in which good ideas and programmes can be stopped or co-opted by powerful interests. Again since the issue of ORT ‘packets’ and ‘selective’ PHC programmes such as GOBI are controversial, perhaps less emphasis should have been placed on them in this presentation. In Chap. 5, one would have liked to see more examples of people in the field and how problems have been confronted and overcome. It is obvious from the various discussions that the authors have a rich body of information that would be very useful to others. More could have been made of the successes of various CHILD-to-CHILD programmes, for instance. Again, there are surely many examples where traditional/indigenous health workers are being successfully used. What have made the more successful programmes so?

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Finally, one should point out that some of the messages are marred by the concepts or terminology used. For example the concept of “bush economy” (pp. 136-137) is not useful. It remains ambiguous and conceals the many and often detrimental changes which have occurred within the economies of LDCs given their form of interaction with the more developed ones since the sixteenth century. The concept of ‘bush economy’ gives a static view of these nations, although they were changing over time towards the crises depicted so well in Chaps 1 and 2. Similarly, words such as “more experienced” and “less experienced” health workers (p. 188) entrench the old views about medical personnel, especially the relationship between physicians and all others. Perhaps words like ‘more specialized’ would have been better. On the whole, the book should be useful in that it attempts to wean people away from the old ideas of how health problems in the LDCs are to be tackled. Many people in these nations, even within the local communities, have begun to understand the connections between their (health) situation and the economic straits of their communities. An important message of the project is that much of the success of medicine today will depend on social skills and commitment. The issue now is how to change the poliricoeconomic factors affecting children’s health. Department of Sociology/ Anthropology Obafetni Awolowo University uormerly fhe Universiry of I/e) Ile -Ife

TOLAOrv PEARCE

Meetings Between Experts, by D. Tuc~arr, M. MOULTON, C. OLSON and A. WILLIAMS.Tavistock Publications, New York, 1986. 289 pp. $37.50 (cloth), S16.95 (paperback). The tug between professional and consumer domination of medical practice is reaching a new phase. The strident demands of consumers in the 60s and 70s has given way to the pressures of health administrators who have subjected both providers and consumers to unwanted constraints. Because the health administrators adhere to a biomedical, doctor-centered view of illness, consumers are still the losers. Tuckett er af.‘s book, Meetings Between Experts, provides the empirical data and the theoretical underpinnings for a patient-centered view, one where the opinions of the patient have to be taken more seriously. The intention of the authors was to discover “. . . the extent to which ideas are shared (between patients and physicians) . . . and how far what is said in consultations can help patients to an understanding of what is happening to them”. The amount and complexity of the data presented by the authors make it difficult to convey the richness of this study in a brief review. The style of writing-long and contorted sentences-adds to its complexity. On the other hand, the authors use clear definitions and avoid using jargon. Noting that few studies have combined both a quantitative and qualitative approach to the study of medical interactions, the authors gathered both types of data through tape recordings of the interactions and follow-up interviews with patients. The findings are largely based upon subjective rating systems for the exchange of information. judgments were made on what information was given, how it was given, what questions were asked, what doubts were expressed, and what understanding was achieved. By working for 18 months to standardize their interpretations, the authors were able to achieve a high degree of inter-rater reliability. Furthermore, they have presented their data in enough detail to allow readers to reach their own conclusions. The careful sampling of the physician population, the adherence to explicit criteria for selecting visits, the large

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number of visits, and the random sampling used for in-depth studies of the data base make the results more generalizable than is usually the case for such detailed studies of patient-physician interactions. The study population consisted of 16 physicians within a 100 mile radius of London, half of whom were selected on the basis of their reputation as clinical teachers of the consultative process; they were senior general practitioners with teaching appointments who had attended a lengthy course on consultation skills and had a reputation as ‘good communicators’. The other half of the sample was a random selection by geographic region of general practitioners. Only two (both from the random sample of GPs) refused participation and had to be replaced by another random selection. Each practitioner picked a 2-week block in which all their consultations would be studied. Out of a total of 1470 consultations selected in this manner, 90% were successfully tape-recorded; in 7% of the consultations, either the doctor or the patient requested that the consultation not be recorded; in 3% of the consultations, the recordings were inaudible. Of those visits tape-recorded, 619 were selected for home interviews; visits were excluded if they were for administrative reasons (e.g. renewal of prescriptions), or involved minor complaints for which the physician prescribed a medicine and did not further explore the symptom (e.g. colds). (A study of 5% of the unselected visits revealed no significant differences in any of the important variables). Home visits were successfully carried out in 405 of the 619 selected visits. The study results are based on these 405 visits. In order to study how physicians shared information with patients, verbatim transcripts of the interviews and the physicians’ notes were studied. Physician information about the problem discussed during the visit was divided into four categories: (I) the diagnosis and significance of the problem; (2) its treatment; (3) preventive measures; (4) the social and emotional consequences of the problem and its treatment. While physicians conveyed information about the diagnosis and significance and treatment of problems in virtually all emotional consequences in only 31% and 12%. respectively, of the visits. In most visits, they did not express themselves clearly or give an adequate explanation of their views. In only 7% of the visits did they check patients’ understanding of their problems and in less than one-third did they invite patients to volunteer their ideas about the problems. In fact, in more than half of the visits, the physician actively discouraged patients from expressing their views of the problems. Except for ethnicity, demographic and social characteristics did not predict which patients would fare better than others in this exchange of information. In order to study how patients attempted to influence the dialog, the investigators looked for instances where patients attempted to: (1) add details about their problems that went beyond the narrow explanation of their chief complaints; (2) present their own explanations for their illnesses; (3) clarify the physician’s explanations; (4) ask for the physician’s rationales for a diagnosis, treatment or preventive measure; or (5) express doubts about the physician’s explanations. In over half of the visits, patients made overt attempts to influence the way the physician responded by using one of these strategies, but doctors ignored most of these efforts. Doctors did respond to patients’ requests for clarifications, but they were evasive in their responses when patients asked for rationales or expressed doubts about the doctor’s views. Interviewers, who had no knowledge of the content of the medical consultation, visited patients’ homes to determine just how well the patients had been able to express their own views. As expected, they found that about two-thirds of the patients did not express all their concerns to the physicians, regardless of whether the concerns were related to their biological symptoms or the social or emotional implications

of their illnesses. They also found that 76% of the patients would have liked to have asked a question or expressed their doubts about the physicians’ views, but were reluctant to do so because they felt it was not their right, or their views were not important, or they could not articulate their thoughts, or the physician would not think well of them. Patients who had had a similar problem in the past or who came from a higher socioeconomic status were more likely to try to participate in the dialog. Patients remembered 90% of the key points the physician made, though the patients often lacked a clear or correct understanding of these points. The clarity of the physician’s explanation did affect how well the patient recalled key information, but whether the physician had inhibited the patient’s ideas during the interview had a greater influence on patient recall. The most significant factor determining patient recall appeared to be the similarity between the patients’ and physicians’ explanations of the illnesses and their treatments. Similarly, the patients’ commitments to the physicians’ explanations and advice were greater when they shared the same knowledge and explanations. On the basis of these findings, the authors argue that our stereotypes of patients’ roles has to change, not only because the facts do not correspond to these stereotypes, but more importantly, our adherence to them prevents patients from coping more effectively with their health problems. Patients can no longer be regarded as passive recipients of health care. Today, not only are patients more knowledgeable about health matters, but with the increase in the proportion of chronic illness, they also have a better understanding of their own illnesses, and therefore a greater role to play in their own health care. However, the authors point out that in 50% of the visits they studied, patients lacked correct information and commitment to key points about the diagnosis, treatment, and prevention of their problems. Their data show how little information is actually exchanged: patients come into the office with their own views which, if they coincide with their physicians’, they will accept. “Thus, ‘successful’ outcomes occurred when communication was largely unnecessary; ‘unsuccessful’ outcomes occurred almost every time it was” @. 167). The failure to elicit and understand the patients’ views of their illnesses was the most important reason, in the author’s opinion, to the lack of exchange of information. I‘. . . (T)he richness and variety of the patient’s thinking is long overdue for recognition. A change in the medical ethos which so easily devalues patients’ contributions, long overdue from the day in which doctors fought to establish their status and economic power, will be one of the first steps necessary if communication between doctors and patients is to be improved” (p. 177). This is a book that teachers and investigators of the medical interview must read. However, many clinicians will also want to read it if they are disturbed by the public’s growing dissatisfaction with the medical profession and are genuinely interested in changing their behaviors in order to relate more effectively with their patients. In addition to numerous clinical vignettes that make the complicated tables more understandable, there is an interesting chapter describing the authors’ attempts to teach physicians how to make their consultations “meetings between experts”. Like the studies of Korsch et al.. 20 years ago, this carefully planned and executed study of patientphysician interactions will become a classic. (Korsch B. M., Goui E. K. and Francis V. Gaps in doctor-patient communications: doctor-patient interaction and patient satisfaction. Pediatrics 42, 855-871, 1968). Bedford VA Hospital Medical Semites Boston University Boston, Mass.. U.S.A.

SAMIZLM. PUTNAM