Exploration of doctor and patient agendas in general practice consultations

Sot. Sci. Med. Vol. 35, No. 9, pp. 1145-1155, Printed in Great Britain. All rights reserved

1992

Copyright 0

0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd

EXPLORATION OF DOCTOR AND PATIENT AGENDAS IN GENERAL PRACTICE CONSULTATIONS N. M.

BUTLER,’

P. D. CAMPION’

and A. D. Cox*

‘Department of General Practice, University of Liverpool, P.O. Box 147, Liverpool and %hild and Adolescent Psychiatry, Bloomfield Clinic, United Medical and Dental Schools, St Thomas Street, London, U.K. Abstract-A method for the interactional analysis of doctor/patient consultations is described and applied to six naturally occurring general practice interviews by three raters. the method is reliable given sufficient training and satisfies the stringent criteria for any method of analysis for medical interviews proposed by Wasserman and Inui [1: Wasserman R.C. and Inui R. S. Med. Care 21, 279, 19831. Key words-general

practice,

communication,

interaction

INTRODUCTION

centrality of the consultation in the practice of medicine can be traced back to Hippocrates, and was implicitly stated by Crookshank [2] when he observed that recent books on the diagnostic method almost completely ignored the ‘physical’ aspects of the patient. It was made explicit by James Spence [3] when he commented that all else in the practice of medicine derives from the consultation. There is evidence to suggest that identifiable components of clinician-patient interactions are related to outcome measured in terms of patient and doctor satisfaction and patient compliance [4-71. Interaction analysis is therefore one of the key tasks in the assessment of doctor-patient consultations. Moreover, since aspects of these interactions are amenable to change [&lo], such change, if applied, may lead to an improvement in the delivery of health care. In the past a number of models of the doctorpatient consultation have been described. Theoretically they may be distinguished by the extent to which a given model addresses three important dimensions: the extent to which it encourages the perspective of doctor or patient within the consultation; the extent to which it acknowledges the influence of one, either or both parties within the consultation; and the extent to which the model demonstrates an awareness of the broader psychosocial issues within which illness occurs. As the theoretical model underlying an investigation informs the methodology used in that investigation it is necessary to note the most influential. The traditional biomedical model is familiar: the objective clinician sets out to take a history, to perform examination and investigation, to make a diagnosis and to prescribe treatment. Little attention is paid to the patient’s perspective or the patient’s problem, both of which are considered to be an impediment to the diagnostic process [ll]. The patient has little influence, and the balance of power The

analysis

lies squarely with the doctor. Insofar as psychosocial issues are addressed, they relate solely to the medical presentation. The traditional model thus addresses the three dimensions listed above, but in an unbalanced way. The Health Belief Model [12, 131, in contrast, seeks to redress this imbalance by placing emphasis on patient variables such as health motivation, cues to motivation, and perceptions concerning the probable consequences of leaving an illness untreated. Although the patient’s perspective is here addressed, the balance of power within the consultation continues to rest with the doctor: rather than to encourage doctors to attend to the subjective implications of the belief systems followed by patients, its proponents have advised doctors how to manipulate patients to take action. The broader psychosocial issues within which illness occurs are not addressed in any meaningful sense, and the model subsequently has been shown to be logically flawed on at least two counts [14]. Role theory emphasizes the mutual expectations brought by two or more persons to a particular context [15, 161. What is stressed are the rights and obligations of each within a given situation [17, 181: doctors expect particular actions from their patients within the specifically medical setting. Different ‘rules’ would apply within a social function. Role theory does therefore address both the doctor’s and the patient’s perspective although that perspective is angled rather to the doctor than to the patient. The model presents problems to the concept of mutuality within the consultation. Because it focuses on the beliefs and expectations to which a patient ‘rationally’ should subscribe if he is to reach the roleprescribed end, any patient not subscribing to the relevant beliefs and attitudes may be construed as deviant in some measure [14]. Thus, although the model is concerned very much with mutual influence, it is utilitarian and restrictive. The assumption is that individuals possess ‘correct’ knowledge as to the role

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N. M. BUTLER et al.

and function of the medical consultation, or no knowledge at all. As such, role theory takes little account of the broader psychosocial issues which attend illness presentation. Pendleton [ 191 built on the Health Belief Model. He construed the doctor-patient interview in terms of an input-process-outcome approach. Insofar as the model takes account of the patient’s environment, the doctor-patient interaction itself, lay constructions of illness, the sick role and locus of control, it accommodates a much more balanced approach both to doctor and patient perspective and to mutual influence within the consultation. In essence this is a social psychological approach to the interview process which points to the importance of control as much as to the roles and perspectives of doctor and patient [20]. The model seeks to integrate and locate studies of doctor-patient communication rather than to propose a system of analysis per se. However, Pendleton’s work subsequently is influenced by this approach, and he and his colleagues do succeed in acknowledging the patient’s perspective and in redressing the balance of power within the consultation towards the patient. For example, it is the doctor’s task with the patient to choose appropriate action for each problem. The doctor should achieve a shared understanding of the problem with the patient; should aim to involve the patient in management, and should encourage him to accept responsibility in managing the problem. Tuckett et al. [14], propose the idea of the patient being an expert. Patients can have expertise in the care of their children or in the functioning of their bodies [21]. Too often this expertise is overlooked by doctors. Tuckett et al. found that in only 13% of their series of 405 consultations were doctors making an active effort to discover patients’ ideas, and in 58% no effort was made at all. They demonstrated an association between patients’ commitment to the doctors’ advice and the extent to which the doctor had accepted the patient’s ideas. The underlying philosophy of this model points to the consultation being patient led. Tuckett et al. entitle their book ‘Meeting Between Experts’, which clearly indicates the thrust of the model: both doctor and patient perspective are balanced in this approach and the model attributes considerably more power and control to the patient than the models discussed so far. Broader psychosocial issues and their salience to the presenting problem are also taken into account, and as such Tuck&t’s model can be seen to lay the foundation for the transformed medical model proposed by McWhinney [22], discussed below. Stewart and Roter [23] acknowledge the presence of the consumerist model of the doctor-patient consultation. Here the interview is redefined in terms of a market place transaction. The patient’s perspective is all important since the patient is the one who wields influence within the consultation by choosing whether or not to ‘purchase’ the medical care [24].

Engels’ [25] biopsychosocial model draws inspiration from a systems approach to the medical consultation. The model has been influential in informing the transformed medical model discussed below. Systems theory was a development in biology around 60 years ago [26]. It observes that nature is organized as an hierarchial continuum. Larger more complex units are superordinate to less complex smaller units, and each level in the hierarchy represents an organized and dynamic whole. As such each whole is itself a system of sufficient identity and persistence to be named. Each system, cell, organ, person, family has distinct characteristics and properties; each implies distinctive qualities and relationships for that level of organization. However, each system is also a component of a higher system. Thus, tissue, organ and person are simultaneously a whole and a part. Whether tissue or person every system is influenced by the system of which it is itself a component. The word ‘patient’ characterizes an individual in terms of a larger social system while identification of the patient’s name, age, marital status, occupation etc. identifies other systems of which the patient is a component. Different approaches are necessary to obtain an understanding of the rules and forces which govern the collective organ of a system [25]. The traditional biomedical model of medicine, as we have already noted, has focused on the understanding and treatment of disease to the exclusion of the patient and patient care. The effect of this is threefold. Firstly, it has forced an antithetical division between science and humanism. Secondly, it has led to a tendency within the medical profession to disregard the salience of emotional and social information in the diagnosis and treatment of disease. Lastly, insofar as discrete rules and forces govern each system, and each system requires criteria for study unique to that level, the sophisticated techniques now available to aid diagnosis have further obscured the personhood of the patient. Physicians trained in the biomedical model make decisions which have impact on the emotional and social aspect of a patient’s life, often with minimum information about the people, relationships and circumstances involved. As one physician has written, “We are interested in vision but have little interest in blindness” [27]. The biopsychosocial model proposes that the physician approaches the higher system level occurrences just mentioned with the same critical scrutiny and rigor that hitherto has been applied to the systems lower in the hierarchy such as cell, tissue, organ. The biopsychosocial model provides a conceptual framework to enable doctors’ to operate rationally in domains which have previously been regarded as excluded from rational analysis; it motivates the doctor to become more informed and skilled in psychosocial areas, and it counteracts the pursuit of what to the patient are often the more trivial determinants of illness. The biopsychosocial physician is not expected to be an expert in all disciplines, but should

Doctor and patient agendas in GP consultations have a working knowledge of the principles, language and basic facts of each [25]. Viktor Frank1 [28] and Oliver Sacks [29,30] have observed that suffering can be borne more readily if its meaning is understood [22]. Because the psychosocial model is less concerned with the doctor-patient interaction than with the wider system within which that interaction occurs, the model is less tendentious than other models in promoting the doctor or patient perspective. Unlike other models it is more concerned with the broader psychosocial issues which inform the consultation than with the balance of power within the consultation: perspective and influence are secondary to biopsychosocial system. The ‘Transformed Medical Model’ proposed by McWhinney [22], encompasses a biopsychosocial perspective. It has been endorsed by Stewart and Roter [23] and Roter [31] and researched by Levenstein et al. [32]. Here the physician’s aim is always to understand the patient’s expectations, feelings and fears. These will not always be made explicit by the patient, so the onus is on the doctor to attend the patient’s narrative with care and to be responsive to subtle cues. A reflective habit of mind, moral awareness, self-knowledge as well as an ability to listen and to empathise will be required of the doctor. The transformed medical model stresses the meaning of an illness to the patient as well as aiming to diagnose the patient’s disease. It is not less, but more rigorous than the traditional (biomedical) model. Rather than considering a single causal chain, as in the latter, the doctor must be able to analyse a complex web of relationships from several domains [23]. As such, this approach builds on the concept proposed by Tuckett et al. [14] of the patient as an expert and also on the biopsychosocial approach noted above. In these models power is something which is negotiated between doctor and patient. The ‘Transformed Medical Model’ thus addresses the three dimensions of doctor and patient perspective, mutual influence, and the psychosocial context within which illness occurs, in a balanced way. In addition to ‘models’ of consultation, there are different orientations or ways of looking at the medical encounter. The latter is concerned with the ‘direction’ from which the investigation derives its raison d’etre. Ways of looking at the consultation may be content or process orientated. The latter is concerned with quantifiable categories and assumes that information statements are equivalent in importance [33]. The former is concerned to measure the depth and meaning of information and is qualitative in its approach [34]. In their review of approaches to the systematic analysis of doctor-patient interactions, Wasserman and Inui [l] list six criteria for inclusion in any future research. The authors take ‘systematic analysis’ to mean the ‘Methodic identification, categorisation and quantification of salient features of clinician-

1147

patient communication’. They take three representative systems of interaction analysis and demonstrate how each falls short in one or more of these criteria. Those chosen as representative are Bales’ Interaction Process Analysis (together with its modification by Debra Roter), Stiles’ Verbal Response Modes, and Katz’s system of Resource Exchange Analysis. Any interaction should first be approached in terms of ‘information transfer’. In the doctor-patient consultation the transfer of information from patient to doctor and the (ideally) reciprocal transfer about treatment etc. by doctor and patient to enable a diagnosis to be made. Along the lines of Cherry [35], Wasserman and Inui take information to mean the ‘Removal of uncertainty’. Thus, to view the doctor-patient consultation in terms of information transfer is to furnish it with a dynamic and fundamental perspective. The Bales system [36, 371 of interaction analysis, which informed early studies on the impact of doctor-patient interaction, is weak in its treatment of information transfer. In this system it is difficult to categorize a statement which involves both information transfer and affective importance, and there is more to the doctor-patient encounter than giving or asking for ‘suggestion’, ‘opinion’ and ‘orientation’. Stiles [7] system, in contrast, is applicable only to language behaviour and is most functional when describing the way in which information is transferred. Verbal response mode categories are exhaustive and mutually exclusive; they examine only a single dimension of the relationship level: those relationships which are syntactically implied. An ideal system of interaction analysis must take into account the two levels upon which interaction may simultaneously occur. The first of these, the content level, contains denotation information and is usually transmitted linguistically. The second level of relationship forms a ‘metacommunication’ [38] in that it may signal information linguistically (via syntax), paralinguistically (tone of voice, pressure of talk etc.), kinesically (posture, gesture etc.) or may be derived from the situation. It also reveals something about the denotation information (the words themselves) and the communicator, about the communicators themselves or about the communicators and their environment. Wasserman and Inui [l] give as an example the scenario in which the doctor asks the patient how things are going. The patient replies, “Really well”, but in a sarcastic tone of voice which suggests the reverse. They note that, “the content level of this statement indicates one state of affairs. The relationship level, achieved through paralinguistic behaviour, conveys a message concerning the relationship between the patient and his statement (‘I do not really mean what I am saying’), and the relationship between the patient and the world (‘things are rotten’)“. In the Bales system content is not specified and the relationship categories force the coder to choose between informational and affective levels-the latter is the case with Katz’s [39] Resource

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N. M. BUTLER et al.

Exchange Analysis. The Stile’s [7] Verbal Response system does not specify content and is designed to deal only with the information implied in the syntax. The third of Wasserman and Inui’s criteria is that information must be understood in context: context can alter both the content and the relationship level of a communication. The former is illustrated when the ordinarily dangerous actions or statements of combat are exchanged between actors in play. The latter is demonstrated when the situation acts as a frame of reference for participants, as for example when a male physician asks a female patient to remove her clothes for a physical examination. The action is circumscribed by the clinical setting and the necessity for investigation. Placed in a different context a very different meaning could be inferred. Although context is implicit in the coding of communicator intent, the Bales system does not reflect context in its categories. The Stiles system similarly implies context in the ‘intent’ level of utterance coding but omits it from the ‘form’ level. Fourthly, because information transfer is accomplished through a variety of behaviours on different levels, any interaction analysis must allow for the observation of non-verbal behaviour. Written transcripts exclude information which is conveyed in tone of voice and pressure of talk etc. Audiotape recordings include the latter, but exclude the kinesic information contained in facial expression, posture, gesture etc. As such. the only observational strategies available to researchers in an ideal system are direct observations and video recordings. A recent study demonstrated that the presence of a video camera does not substantially alter the physical and verbal behaviour of doctors. Nor does it influence secondary activities of doctors accustomed to being recorded [40]. Although both the Bales and Katz systems can be applied to verbal and non-verbal behaviour and may therefore be used in the prescribed way, the Stiles system uses transcripts prepared from audiotape recordings. It therefore excludes the analysis of kinesic or paralinguistic data. Wasserman and Inui [I] note that an appreciation of interaction sequence is necessary to understand interaction process. They use the example of a clinician’s probing questions about drug abuse. These may be entirely appropriate in taking a social history but out of place during the conclusion. They point out that “a system of interaction analysis that sought to draw conclusions solely from the frequency of such probing questions may well prove deceptive” [ 1, p. 2831. Perhaps because of their focus on interaction process, sequence analysis is possible in ail of the three representative coding systems chosen by Wasserman and Inui. It is the only criterion met by all three systems. Lastly, since the rationale for analysing the doctor-patient interaction is likely to be to induce change, any system of clinician-patient interaction must be appreciable to the health care system. Any

instrument should be available for teaching and feedback and should be intellectually accessible to clinicians. Of the three representative systems of interaction analysis only the Katz system was developed with the clinical setting specifically in mind. As well as these general criteria Wasserman and Inui propose that any ideal system of interaction analysis should take account of the special nature of the doctor-patient interaction. They refer to Bloom’s [41] description of the clinician-patient relationship as a social system with often unique interactions. The socially prescribed roles, the expectations and the agendas of each are clearly identifiable and therefore influence the structure and content of their interactions. Other investigators [22, 3 I] have noted that it is the lack of an unifying structure which has hindered reform in the traditional biomedical model and which has been criticised for many years now [42]. There may be other more complex issues implicated in this lack of reform. For example Fielding and Llewelyn [43] argue that, while communication performance deficits (of nurses) and hence the need for training can be identified both by individuals and organizations. the relationship between the two levels is assumed rather than known. There may well be organizational obstacles which resist change. Such resistance has a tremendous capacity to nullify or reject the ctforts made by those wishing to change existing organizational practices, no matter how unproductive or even destructive these practices may be [44]. There is evidence which shows that no matter how good a particular training programme may be. changes in individual’s performance are rapidly reversed by rcentry to the organization [45]. It follows that, unless communication skills training is supported by the professional bodies and organizations of which the individual is a part, the training of doctors may not have lasting impact. There may be deep rooted cultural reasons for a professional resistance to change. Pickering [46] and Cassidy [47]. for example. do not see the patient’s non-medical problems as being salient to the medical consultation. Although there have been notable exceptions [e.g. 48,491 this accords with a long and traditional lint of approach and is not without it’s benefit. Models such as these provide the theoretical basis upon which the criteria for any system of interaction analysis must be built. In an extreme form, for example, patient-centredness leads to an analysis of content variables alone (discourse analysis). Equally. the traditional biomedical model can lead to a concern with information transfer and its process irrespective of what the information is about [ 141. Model is reflected in methodology. Just as previous studies have not fulfilled the necessary criteria for interaction analysis, so too they have tended to focus upon process or content variables to the exclusion of each other [I, 331. To date we are not aware of any model of interaction analysis which allows for an integrated

Doctor and patient agendas in GP consultations approach, but we believe that the method we go on to describe provides such a synthesis. The approach is grounded in the traditional medical model, builds on the transformed clinical model, and utilizes the biopsychosocial model. A problem solving perspective has been adopted. This is derived from the McMaster model of family functioning [50]. That the problem solving approach shifts to the doctor sharing the patient’s predicament and negotiating with the patient around that predicament, does not obviate the traditional model of medicine which encompasses the need for diagnosis of illness followed by treatment related to pathology. In the system described, both doctor and patient agendas are conceived as implicit or explicit problems requiring problem solving processes for their resolution. Agendas are also the content variables of our system. They depend on the relationship level of communication for their meaning. Thus, agendas are the problems (implicit or explicit) which people bring to the consultation. For the consultation to proceed, and problem solving to be conducted, these problems must be acted upon in some way or another. We therefore describe the procedures generally used within the doctor-patient encounter and conceive of these as the techniques which are brought to bear on the problem. For example, a doctor can prescribe treatment for a problem, may refer the patient’s problem to another speciality, may conduct a physical examination, or may carry out or order an investigation about the problem. Both doctor and patient have access to all procedures. Although it is not so likely, a patient may also suggest that a prescribed treatment is appropriate for his condition, may ask for referral to another specialty, or may conduct a physical examination by pointing to, and touching, a particular body part. Procedures provide a frame of reference for interview participants and form an important part of interview context. They are also significant markers in consultation sequence. The crucial link between agendas (problems) and the procedures brought to bear upon them is supplied by information processing. Information processing is itself a procedure, but it describes also how procedures are linked to problems. Either party may seek information about a problem, may give information, may discuss information or may accept information about a problem. A doctor will ask questions about the patient’s problem in order to prescribe treatment: a patient may discuss the effects of treatment previously described and so on. In measuring doctor and patient initiation of agendas, doctor and patient following of one another’s agendas, and doctor and patient returns to agendas previously raised, the system is able to address the issue of control between doctor and patient, and to assess the balance of power between parties within the consultation. It is able to assess the extent to which physical or psychosocial issues are addressed, and the extent to which problem solving strategies are brought to bear on the

Table

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1. Variables used to describe each floorholding

Floorholding No. Floorholding Duration (set) Floorholder (Doctor or Patient) Agenda(s) Procedure(s) Process(es)

different agendas. Although the detail involved in rating interviews makes the system unwieldy for rapid scoring, and reliability in coding requires careful training (see below), we describe a way of recording what people do in the interview that can be related to training. Future research will demonstrate the system’s applicability to the health care setting in terms of its sensitivity to systematic variation in doctor style and its relevant outcomes such as quality of information obtained, satisfaction and compliance. Lastly, any study of interviewing is necessarily content related so that both process and outcome are dependent on the larger systems, professional and lay, which direct and sustain both the teaching and practice of medicine. DEVELOPMENT

OF THE CODING

SYSTEM

The general practice consultation can be conceived as cornprizing a series of naturally occurring units. We refer to these units as floorholdings. These reflect the period of time when one participant is holding the conversational ground. The floorholding is a unit of linguistic sense defined as the period of time from one party in the interview commencing to speak, to the point where another party begins to speak. Naturally occurring floorholdings will vary widely in duration from periods of less than one second to several minutes. Any verbal interchange, and specifically the general practice interview, can be viewed as a succession or sequence of floorholdings. For these reasons the floorholding was chosen as the unit of analysis in the present coding system. Each floorholding is coded in terms of the content and form of the communication according to the predefined categories shown in Table 1. Operational definitions of all the categories were formulated in terms of Glaser and Strauss’ [51] ‘grounded theory’. These provided the basis of a system of rules for coding general practice interviews. Agendas are concerned with the content variables addressed within the interview, the implicit or explicit topics of concern by either party. This distinction is similar to that proposed by Levenstein et al. [32]. Ten agenda types are identified (see Table 2), through the principal agendas of interest are considered to be Physical, Emotional and Social agendas. Physical agendas refer to any verbal or non-verbal reference made by either party to what they take to be a bodily problem. Examples of non-verbal reference include pointing to parts of the body, and physical examination. Separate Physical agendas are recorded for

1150 Table 2. Agendas, Procedures

N. M. BUTLER et al. and Processes identified system

in the coding

Agendas Introduction Physical Emotional Social Open Historical Psychological Video Conversation Uncertain Conclusion Procedures Introduction Treatment Physical Examination Referral Investigation Conclusion Processes Giving Information Seeking Information (including Consulting Notes) Recordine Information Discussine Information Prescribing (or doing) Accepting Information (including Active Listening)

problems perceived by the patient to be separate (although they may in fact be related). Emotional agendas are defined as those instances when feelings are being transmitted: coding is carried out on the verbal content of the interview but an Emotional agenda must also demonstrate enough explicit reference, action or corroboration to indicate the presence of emotion. An Emotional agenda may additionally be demonstrated by non-verbal behaviours such as tone of voice or pressure of talk. In the absence of explicit verbal evidence of an Emotional agenda, at least two non-verbal behaviours must be in evidence to indicate its presence. A Social agenda is defined as the expression made by one party with the express desire of making the other aware of circumstances relating to social impact. That is, the impact of social circumstances on a problem; the impact of problems on social circumstances; the impact of physical problems on social situations, or a social problem itself. Video agendas are nontypical of the medical consultation in that they refer to those instances when either doctor or patient allude to the presence of the video camera. Agendas may occur in parallel with other agendas within the same floorholding. For example, a patient presenting to the doctor for an influenza vaccination who in the same floorholding communicates to the doctor that his business has collapsed, would be coded as having Physical and Social agendas in parallel. Procedures provide information concerning the structural and contextual aspects of the interview. Six procedures are identified, see Table 2. Each procedure will be linked to a specific agenda within the floorholding, and more than one procedure may occur in each floorholding. An example of this would be when a doctor orders an investigation and writes a prescription in the same floorholding.

Processes refer to the specific information processing strategies adopted by either party in addressing the agendas. The categories are based upon the problem solving perspective of the McMaster model of family functioning [50]. Six processes are distinguished (see Table 2). Each process will be linked with a specific agenda within the floorholding; additionally the process may be linked to a procedure. The coding categories were successively refined over time. Three interviews were coded by three raters using the first draft of the coding categories. Several problems emerged. The first draft of the coding system had ten agenda types. Originally the Mental State agenda was used to accommodate verbal expressions of emotion made without non-verbal expressions of emotion. In the final coding system the Mental State agenda was replaced by including some of its aspects into the Emotional agenda type, and other (reported) aspects into the category termed Historical Psychological. For example, it was extremely rare for current emotional statements to be unaccompanied by non-verbal expression of emotion, and this necessitated their inclusion within the Emotional agenda category. However, there were occasions when past emotion or ‘emotional’ milestones were reported by either party without the non-verbal concomitants of emotion. In these cases the Mental State agenda was transmuted into Historical Psychological. This distinction was designed to separate those situations where emotion was referred to, from situations when emotion was being expressed. It also distinguished those instances which occurred in the past and were not a focus for problem solving in the current interview. Subsequently it emerged that the category of Historical Psychological, though reliable, was not extensively used in the present sample of interviews. Also in the first version of the coding system each agenda was subscripted to denote an association with another agenda type. For example, an Emotional agenda associated with a Physical agenda but in which the Emotional agenda was presenting was coded as E,. Similarly, a Social agenda associated with an agenda that was primarily Physical was coded as P,. And so on. However, this system allowed for greater disagreement between raters since raters may or may not have adopted the same subscripts, hence E, compared to E was not counted as an agreement despite the similarity between them. To overcome this problem the system of subscripts was discontinued and the raters required to make explicit instances of parallel agendas by coding all agendas present in the floorholding. Thus E, would become E agenda in parallel with a P agenda, and P, would become P agenda in parallel with an S agenda. With regard to procedures and processes, the distinction between Treatment and Referral required further definition, since it emerged that the two categories were often confused. The definition of Referral was changed, noting that Referral is a subset

Doctor

and patient agendas in GP consultations

Table 3. Variables used to describe the interview Interview duration (min/sec) Code identifying GP GP Sex No. of Patients Patient(s) sex Patient(s) age--child or adult No. of floorholdings

1151

are found, Cohen’s kappa is a poor measure of agreement. However, with intermediate levels of OCcurrence it is the coefficient of choice since it corrects for chance levels of agreement. Values of kappa greater than 0.60 indicate satisfactory levels of agreement [53]. The sample

of Treatment, but one which requires the explicit statement of an intention to refer to another agent outside of the interview. This statement may or may not be accompanied by non-verbal behaviours such as writing a referral letter. In order to provide information concerning the interaction sequence of the consultation additional information is collected concerning the relationship between the agendas raised by one party in the interview with respect to the previous floorholdings of other parties. An Initiation refers to the inception of a new agenda by either doctor or patient, that is, an agenda which had not previously been raised in the interview. A Following refers to the adoption by one party of the same agenda used by another party in the immediately preceding floorholding. A return is said to have occurred if an agenda previously raised by either party is adopted by a party, without the other party having adopted that same agenda in the immediately preceding floorholding. Table 3 lists additional descriptive information that is gathered for each interview. This can be used to categorize the interviews in various ways, for example interviews where the consultation involves an adult alone, and those where a parent consults with their child. The coding of agendas, procedures and processes is carried out, as far as possible, without medical insight. That is, coding assumes a naive viewpoint and will be according to surface understanding. So although there may be an eyesight problem associated with diabetes, the two agendas will be coded separately since it may require medical knowledge to make the link. Additionally physically related symptoms and problems relating to anatomically related parts are coded as discrete Physical agendas, if the patient does not link them. If the doctor later makes a diagnosis which includes the separate agendas, the agendas are all coded and bracketed together on the scoresheet. ASSESSMENT

OF RELIABILITY

Method For purposes of estimating the inter-rater reliability of the coding system, a sample of six general practice consultations was gathered. In total this gave 508 floorholdings to be rated. These were then coded by three independent raters. Percentage agreement, percentage disagreement and kappa [52] were calculated as measures of inter-rater agreement. Where extremely low or extremely high rates of occurrence

Four practices were selected that were already familiar with video recording in the surgery. Three were chosen from the Mersey Region and the fourth, to provide some balance, was chosen from the southeast of England. In each practice participating doctors were videoed for one hour’s surgery. Patients were excluded if they were returning at the doctor’s request or for follow-up. As such the sample is not representative of the average general practitioner’s caseload which includes a proportion of follow-up consultation [ 141 Patients who were unwilling to take part were excluded. All participating patients signed a consent form. Patients were told that the consultation was being recorded to enable researchers to look at the way in which doctors talk to patients. This would enable problem areas to be identified and these could be addressed in training. There were 73 consultations in all [21]. Ten doctors participated, 6 male and 4 female. Of the patients, 16 were male, 33 were female, 21 were mothers with children. There was 1 father with a child and 2 consultations with 2 adults. Results The inter-rater agreement coefficients for the three raters are shown in Table 4. Levels of agreement were high in all cases when figures for percentage agreement and disagreement were calculated. However in several cases Cohen’s kappa, which represents a measure of agreement corrected for chance levels of agreement, was low. Rater 1 identified a lower rate of Social agendas in comparison to the other two raters and used this coding category infrequently. Upon reviewing the operational definitions of Social agendas this problem was acknowledged. For Video, Conversation and Uncertain agendas the value of kappa was low. This results from the very low rate of occurrence of these agendas in the six interviews sampled-all had rates of occurrence less than 1% of the floorholdings. For Emotional agendas raters 1 and 2 agreed satisfactorily. Rater 3, however, showed poor agreement with the other two raters. This was due largely to rater 3 applying overly conservative criteria for rating Emotional agendas. This problem was also acknowledged. Rater 2 showed good percentage agreement and satisfactory kappas with Rater 1 on both Physical and Emotional agendas, and showed good percentage agreement and kappas with Rater 3 for Physical and Social agendas. Raters 1 and 2 showed highly satisfactory and acceptable levels of agreement on all procedures

N. M. BUTLER et al.

1152

Agreement

Disagreement

Kappa

Agreement

Disagreement

Kappa

Agreement

D~greement

Kappa

Agendas 100.0

0.0

I .no

9x.4

I.h

0.X5

YX.4

Physical Emotional

93.3 87.1

67 I?.‘)

0.X4 O.hX

x4 x hh x

152 33 2

0 67

X3.6

I64

0.2’)

X2.7

17.3

0 46

Social

x9.x

IO 2

0.32

x7 6

124

0 4h

90.5

9s

O.hX

98 1 100.0

13 0.0

0.00 I.00

96.X 100.0

32

0 00

94.h

54

0 00

0.0

I .oo

100.0

0.0

I 00

Video

99.4

0.6

0.00

99.4

0.h

0.00

100.0

0 0

I 00

Conversation

94.6

54

0.00

99.4

0.6

0.00

95 3

47

0 IY

Uncertam

91.6

2.4

0.00

9h.4

3.h

0.00

9x.x

I?

0 00

9x.2

1.x

0.x

95.x

4.2

0.h I

97.0

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and processes calculated by percentage agreement. Kappas were good on all except Discussing Information This is a complex concept incorporating aspects of both Giving and Seeking Information. Disagreements between raters tended to occur when one rater had coded a floorholding as Discussing Information, while the other had rated the same floorholding as Seeking Information or Giving Information The definition of Discussing Information was refined to accent the distinction. Rater 3 stands out as disagreeing with the other two raters for the procedures of Referral and Investigation, and the processes of Recording Information and Prescribing. However, since high levels of percentage agreement had been met between all three raters, and because rater 2, who had been deputed to score, had reached both high levels of agreement with Rater I and satisfactory levels of agreement with rater 3 on most categories, it was decided to proceed with coding the sample of video recordings [54]. DlSCUSSlON

Many patients with psychological illness are undetected by general practitioners [55-581. Given that components in the doctor-patient interaction are able to reduce patient satisfaction [4, 59,601 and given that patients prefer doctors who have more time [6l, 621, we conclude that relevant social and emotional information is often undetected by doctors. Associated social and emotional information may be related to physical problems or may be important in its own right [63]. It need not be related to psychiatric morbidity although its presence may suggest such a possibility [56,63, 641. To substantiate this postulate requires an instrument which measures what is said

in a doctor-patient consultation (content). and how that information is conveyed (process). The instrument to be theoretically sound, must include certain criteria, should be both reliable and valid, must be related to our health care system and, ideally, should be able to be used in teaching. Using a patient centred approach, Levenstein e/ rrl. have moved some way to defining a workable procedure for their model [32]. They define the interview in terms of patient expectations, feelings, fears and prompts. Doctor behaviour is measured in terms of facilitation, acknowledgement, cut-off and return. Their method showed good inter-rater reliability and is sensitive to changes which take place during training [65,66]. Although welcome and not without utility, this instrument nevertheless has several shortcomings. Firstly, the scoring system does not include non-verbal behaviour which means that potential cues to a patient’s agenda are missed. Secondly, doctor content variables are not scored in the same way as those of the patient. Thus, while it can be argued that doctor and patient have different roles within the consultation [15], the doctor’s expectations, feelings, fears and prompts will be left out. The doctor may prompt a premature closure just as the patient may signal that not all his business has been dealt with. The fact that the interaction is a dynamic process is passed over. Similarly. as neither doctor nor patient behaviours are accessed, we do not know from the scoring system whether a doctor is prescribing, referring or doing a physical examination. All these procedures may be pertinent to the content variables being measured. Lastly, we can not be clear from the system what is happening in terms of information processing. Although we can tell if a doctor is accepting the patient’s information. we

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Doctor and patient agendas in GP consultations cannot know if either is giving information, seeking information, or negotiating around a problem. As such, mutuality in terms of problem solving is excluded from the system. In the method described here the implicit premise is that both doctor and patient will bring to Emotional and Social agendas, information that either may be hesitant to communicate. Even with Physical agendas there may be crucial Emotional or Social aspects which neither party is able to communicate about with ease. A problem solving perspective is helpful, and informs the system, since how doctor and patient access relevant Emotional and Social aspects of the interaction is fundamental to being able to identify the problem. Information gathering and asking questions can pick up on doctor or patient cues [67], and cue following may prevent premature closure of a given agenda. As McWhinney [22] points out, “Expression of emotion is the more likely to follow when the clinician has responded to some subtle cues proffered by the patient” [22, p. 331. If either party is able to be responsive then the other’s cues can be openly defined as legitimate agendas for consideration. If appropriate, problem solving strategies may be brought to bear on the agenda, which otherwise would have remained implicit. Bass et al. [68] found that the strongest association in an early resolution of a patient’s problem was agreement between doctor and patient bout the nature of the problem. This accords with McWhinney’s [22] review of the requisite skills of family medicine. However, Ort et al. [69] found that doctors were less satisfied with consultations that were predominantly psychosocial or had psychosocial components. This is at odds with studies which find strong associations between patient satisfaction and the doctor’s attention to psychosocial issues [4,70,71]. From this it can be deduced that doctor and patient expectations are often pulling in opposite directions. Such a dichotomy is not congruent to mutual agreement and negotiation. How the physician approaches the patient and the problems presented by the patient is influenced by the conceptual models against which his experience and knowledge is organized [25]. We do not believe it is beyond the bounds of doctors to address the patient’s emotional and social problems and some clearly do so. This does not mean that the doctor is always the person best placed to deal with these issues. But in identifying these agendas, problems can be acknowledged and dealt with where appropriate. Although medical schools are taking more seriously the need for communication skills training, students and young doctors are still taught in, and influenced by, the traditional biomedical model which prevails. We think that if trainees can be taught to deal with social issues and particularly emotional issues, more effective consultations will ensue. Goldberg and Huxley [72] pin-point aspects of GP style which relate accurately to case detection [see also 21,671. This includes

an empathic style sensitive to verbal and non-verbal cues. Poole and Sanson [73] suggest this skill is not usually acquired by medical students, but may be taught. Maguire [lo] shows that medical students trained in a patient centred approach demonstrate consistency over time. However, although facilitative qualities can aid the detection of cases, they do not necessarily help to solve them [74]. Mayou [75] found that medical students in a psychiatric setting, though demonstrating considerable knowledge and clinical skill, had difficulty in decision making. He shows that a problem solving approach appears to be an ideal format for the identification of these difficulties, and provides a good basis for teaching. If doctors lack basic problem’ solving skills in non-physical domains, they may feel ill equipped to deal with non-physical issues. Lack of confidence will contribute to doctor dissatisfaction and to doctors avoiding non-physical problems. Additionally, doctors who feel uneasy in the nonphysical domain are likely to communicate this to patients. Even training may take time to become second nature and some doctors will always find communication difficult. Bensing and Scuits [76] found that doctors trained to have ‘unconditional regard’ for their patients continued to maintain it three months after training. However, in spite of the doctors emphatic listening, patients did not talk more about their problems. While patients may hesitate, perhaps due to unexpected change in doctor behaviour, they may equally be resistant to divulge information in the medical setting which will not jointly be acted upon.

SUMMARY

Doctor-patient communication can be understood as the transfer of information between individuals. Doctor-patient interaction is the foundation of medicine [23, 771. Bench scientists may focus on the cell, tissue or culture, but the clinician must take account of the patient and the systems of which the patient is a part. The coding system here described is reliable and satisfies the requirements for a valid system of consultation analysis outlined by Wasserman and Inui [l]. The system is based upon the observational analysis of videotape and audiotape recordings. Operational definitions include aspects of non-verbal behaviour. Future research will address the applicability of the coding system in the health care setting, and, by using semi-structured interviews, will compare the interpretation of raters with that of consultation participants. In the absence of other standardized measures of a similar nature it is not possible at this point to assess the measure’s criterion related validity. However the system takes into account the need for an integrated model, and allows for an in-depth analysis of the content, context, and process of general practice interviews.

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Acknowledgement-The research described in this paper was supported by a generous grant from the Leverhulme Trust (Grant No. 432836).

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