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“Preparing for patients”: Preparing tomorrows doctors
Individual presentations / Patient Education and Counseling 34 (1998) S5 –S41
pharmacists and pharmacy trainers, but also to all those involved in research into communication within the health professions. Competence and job stress in general practitioners Myrra Vernooij-Dassen, Paul Ram, Wiljo Brenninkmeijer, Richard Grol. Dept. of General Practice, KUN, P.O.Box 9101, 6500 HB Nijmegen, The Netherlands. Introduction. General practice has the task to keep three balls in the air: standards, practice management and consultations. (Grundmeijer). The high demands on general practitioners’ competence make the profession challenging and complicated. The art of keeping a personal balance and coping with job stress are important for the individual general practitioner. Job stress was not strongly associated with workload. Other factors such as a self critical or perfectionist disposition working style have been noted to be more influential. Competence may also be associated with job stress, especially the degree in which general practitioners succeed in being competent in the three main tasks. The aim of our study is to explore the relationship between job stress and competence and competence in knowledge (on standards), in practice management and in communicative and medical aspects of consultations. Methods. Subjects are 63 general practitioners who are involved in the vocational training of general practitioners. These general practitioners participated in an integrated audit. Job stress is estimated by perceived workstress (NIVEL); knowledge is assessed by a knowledge test (SVUH); practice management by the Visitation method to assess Management in General Practice (VIP); and consultations by videotaped consultations of simulation patients. The communicative and medical are observed by the MAAS-GLOBAAL. MANOVA is used to estimate the relationship between job stress and competencies. Results will be presented. Improving doctor-patient communication about drugs Nick Barber, Christine Barry, Colin Bradley, Nicky Britten (a), Fiona Stevenson. (a) Department of General Practice, UMDS, 5, Lambeth Walk, London, SE116 SP, UK. Introduction. There is little knowledge about why doctors choose to prescribe or not, although some patients claim they have been prescribed drugs they do not want and some doctors claim patients demand drugs. This paper reports on a major government funded qualitative study. The multi-disciplinary study team consists of a general practitioner, a psychologist, a pharmacist and two medical sociologists. The aims of the study are: to conduct an in-depth exploration of patients expectations prior to consulting a doctor; to relate these to the perceptions and behavioursofdoctorsandpatientsintheactualconsultations; and to determine the consequences for the subsequent attitudes and medicine-taking behaviour of patients. Methods. The sample of 50 patients is drawn from 20 varied practices, in two distinct geographical areas.
S35
Patients are interviewed at home before their consultation. The consultation is audio recorded and patients and doctors are interviewed following the consultation. Results. The results presented in this paper will be based on a case-by-case analysis of the data. The current main analytical categories are: 1) Whether the whole of the patient’s agenda is covered in the consultation and if not whether this matters; 2) Whether the doctor’s agenda is shared with the patient, and if not whether this matters; 3) What mismatches or misunderstandings there are between doctor and patient; 4) What strategies are used to elicit or suppress the patient’s agenda and beliefs; 5) What are the consequences of the doctor’s strategy for the patient’s medicine taking; 6) The extent to which the doctor is aware of the the above; 7) The role of the doctor-patient relationship and 8) How might the consultation have been improved. Conclusion. The analysis will focus on discrepancies between the patient’s and doctors expectations, beliefs and behaviour with a view to designing a subsequent educational intervention. ‘‘Preparing For Patients’’: Preparing Tomorrows doctors Penny Morris (a), Ernest Dalton, Joanna Griffiths, Margaret Stanley, Reader. (a) University of Cambridge, Dept. of Pathology, Tennis Court Road, Cambridge CB2 1 QP, UK. Introduction. Our research with experienced doctors suggests that communication skills training may not be enough for effective professional-patient partnership. Unable to deal with difficult feelings, professionals stop listening to patients, in part because they feel overwhelmed with responsibility. Governments exhort doctors to be more flexible in an ever-changing health service with patients’ growing expectations while they struggle under the emotional burden of practice. Methods. ‘‘Preparing for Patients’’ is a 3 year research programme to develop ways to help undergraduate medical science students prepare for the realities of modern medicine. It aims to enable students to hear patients and share responsibility. This year’s modular course begins with audiotaped reflective interviews about each student’s vocation, personal concerns about professional development and experience of patienthood; a ‘personal pursuit’ programme, tailor-made with each student, and brief, intensive group work and patient contact. More in-depth individual and group work follows; they meet and learn from patients in their homes, specialist units and clinics. At the local hospice patients as teachers help the students understand the process of loss of health and life and about patients’ strengths as well as needs. Recordings of reflective individual and group interviews with students, patients and teachers are being collected and analysed, as well as the results of student-devised questionnaires and case studies.
S36
Individual presentations / Patient Education and Counseling 34 (1998) S5 –S41
Results. Our course builds students’ confidence and competence in communicating with patients and colleagues by reflecting individually and in groups on early patient contact and how to develop skills from that base. Their enthusiasm, and that of participating professionals and patients, has led to the commitment to make the course available to all Cambridge students (250 per year), extending its principles to later medical training. Conclusions. Professional-patient partnership entails effective preparation following the ‘maxim ‘Physician, heal thyself’. Communication techniques to use when discussing sexuality C. Gamel (a), M. Hengeveld, M. Grypdonck, B. Davis. (a) Utrecht University, Postbus 80036, 3508 TA Utrecht, The Netherlands. Introduction. This study of communication techniques was part of a larger research project designed to investigate how to provide the patient and partner with information and support which enables them to accommodate the effects of illness and disability upon sexuality within their daily living patterns. This research project focused on the effects of gynaecological cancer. This presentation is limited to the findings concerning the subquestion: how can concrete form be given to recommendations in the literature concerning the communication strategies that nurses can use when providing sexual teaching (ST)? Methods. A protocol for providing ST was developed based upon recommendations from sexology and nursing practice literature. To evaluate and refine the protocol, it was used in nursing practice and afterwards, interviews were conducted with the nurses and their patients. Underlying meaning of their perceptions was also analyzed. Two strategies were used to enhance the validity of the interpretations. The interpretations and conclusions were reviewed by a sexologist-researcher. And a different group of patients received ST according to the revised protocol. The interview data obtained from this group were evaluated to determine the accuracy of the previously made interpretations and revisions. Results. Seven recommendations specified communication strategies which decrease discomfort associated with a discussion about sexuality. Few modifications were needed for some recommen- dations, however specific implications for teaching nurses how to use the associated techniques were identified. Three recommen- dations needed modification; after that, they were maintained however the data demonstrated the complexity of the associated issues: - encouraging the patient to talk about her own sexuality, - beginning with the least (sexually) sensitive topic and - avoiding questions about sexuality before illness. To work effectively with these last three recommendations, more extensive training will be required. Conclusions. In this study, a protocol was developed in which recommendations for communication can be spe-
cific rather than vague as often is the case in nursing protocols and nursing literature. The stepwise development of the communication guidelines and the systematic examination against the perception of the communication by nurses and patients provides a better basis for practice and future research. From this study of the isolated components and their underlying assumptions, a firmer basis was developed and this is important to future testing of the protocol in a controlled study.
17
INTERNATIONAL COMPARISON
Doctor-patient communication in Eeuropean countries Atie van den Brink-Muinen, Peter F.M. Verhaak. NIVEL ( Netherlands Institute of Primary Health Care), Postbus 1568, 3500 BN Utrecht, the Netherlands. Introduction. A comparison of doctor-patient com- munication in different European countries is the main objective of the ‘Eurocommunication study’ (1996-2000). The aim is to investigate how the characteristics of various health care systems affect doctor-patient communication and patient expectations, apart from background variables. The following health care characteristics are considered relevant for doctor-patient communication: mode of access of secondary care; registration of patients with a GP; employment status of GPs; health insurance system. The selection of countries for participation in the study (Belgium, Germany, Spain, the United Kingdom, Switzerland and The Netherlands) is based on differences in these structural features. Doctor-patient communication embraces verbal and nonverbal behaviour as well as the content of the conversation. Methods. Doctor-patient communication will be assessed by observing real doctor-patient encounters. In each country 27 to 40 GPs participate in the videotaping of consultations with 15 patients per GP. The consultations are coded by three observers by means of Roter’s Interaction Analysis System to measure verbal affective and instrumental behaviour and nonverbal behaviour both of the doctor and the patient. Multilevel analyses are used to compare the countries. Moreover, the patients are asked to complete a questionnaire (before and after the consultation), among others to examine the patients’ expectations of and satisfaction about the consultation. The GPs complete both a questionnaire and registrate some consultation characteristics, amog others about the content. Results. Differences are found between countries in the conversation style (affective versus instrumental), and in biomedical versus lifestyle and psychosocial exchange. The inclusion of psychosocial factors when establishing a diagnosis also varies between the countries studied. The content of the communication differs in the symptoms discussed, medicines prescribed, referrals, instrumental treatment and diagnostics. The differences are reflected in the patients’ expectations and their satisfaction about the consultation.
pharmacists and pharmacy trainers, but also to all those involved in research into communication within the health professions. Competence and job stress in general practitioners Myrra Vernooij-Dassen, Paul Ram, Wiljo Brenninkmeijer, Richard Grol. Dept. of General Practice, KUN, P.O.Box 9101, 6500 HB Nijmegen, The Netherlands. Introduction. General practice has the task to keep three balls in the air: standards, practice management and consultations. (Grundmeijer). The high demands on general practitioners’ competence make the profession challenging and complicated. The art of keeping a personal balance and coping with job stress are important for the individual general practitioner. Job stress was not strongly associated with workload. Other factors such as a self critical or perfectionist disposition working style have been noted to be more influential. Competence may also be associated with job stress, especially the degree in which general practitioners succeed in being competent in the three main tasks. The aim of our study is to explore the relationship between job stress and competence and competence in knowledge (on standards), in practice management and in communicative and medical aspects of consultations. Methods. Subjects are 63 general practitioners who are involved in the vocational training of general practitioners. These general practitioners participated in an integrated audit. Job stress is estimated by perceived workstress (NIVEL); knowledge is assessed by a knowledge test (SVUH); practice management by the Visitation method to assess Management in General Practice (VIP); and consultations by videotaped consultations of simulation patients. The communicative and medical are observed by the MAAS-GLOBAAL. MANOVA is used to estimate the relationship between job stress and competencies. Results will be presented. Improving doctor-patient communication about drugs Nick Barber, Christine Barry, Colin Bradley, Nicky Britten (a), Fiona Stevenson. (a) Department of General Practice, UMDS, 5, Lambeth Walk, London, SE116 SP, UK. Introduction. There is little knowledge about why doctors choose to prescribe or not, although some patients claim they have been prescribed drugs they do not want and some doctors claim patients demand drugs. This paper reports on a major government funded qualitative study. The multi-disciplinary study team consists of a general practitioner, a psychologist, a pharmacist and two medical sociologists. The aims of the study are: to conduct an in-depth exploration of patients expectations prior to consulting a doctor; to relate these to the perceptions and behavioursofdoctorsandpatientsintheactualconsultations; and to determine the consequences for the subsequent attitudes and medicine-taking behaviour of patients. Methods. The sample of 50 patients is drawn from 20 varied practices, in two distinct geographical areas.
S35
Patients are interviewed at home before their consultation. The consultation is audio recorded and patients and doctors are interviewed following the consultation. Results. The results presented in this paper will be based on a case-by-case analysis of the data. The current main analytical categories are: 1) Whether the whole of the patient’s agenda is covered in the consultation and if not whether this matters; 2) Whether the doctor’s agenda is shared with the patient, and if not whether this matters; 3) What mismatches or misunderstandings there are between doctor and patient; 4) What strategies are used to elicit or suppress the patient’s agenda and beliefs; 5) What are the consequences of the doctor’s strategy for the patient’s medicine taking; 6) The extent to which the doctor is aware of the the above; 7) The role of the doctor-patient relationship and 8) How might the consultation have been improved. Conclusion. The analysis will focus on discrepancies between the patient’s and doctors expectations, beliefs and behaviour with a view to designing a subsequent educational intervention. ‘‘Preparing For Patients’’: Preparing Tomorrows doctors Penny Morris (a), Ernest Dalton, Joanna Griffiths, Margaret Stanley, Reader. (a) University of Cambridge, Dept. of Pathology, Tennis Court Road, Cambridge CB2 1 QP, UK. Introduction. Our research with experienced doctors suggests that communication skills training may not be enough for effective professional-patient partnership. Unable to deal with difficult feelings, professionals stop listening to patients, in part because they feel overwhelmed with responsibility. Governments exhort doctors to be more flexible in an ever-changing health service with patients’ growing expectations while they struggle under the emotional burden of practice. Methods. ‘‘Preparing for Patients’’ is a 3 year research programme to develop ways to help undergraduate medical science students prepare for the realities of modern medicine. It aims to enable students to hear patients and share responsibility. This year’s modular course begins with audiotaped reflective interviews about each student’s vocation, personal concerns about professional development and experience of patienthood; a ‘personal pursuit’ programme, tailor-made with each student, and brief, intensive group work and patient contact. More in-depth individual and group work follows; they meet and learn from patients in their homes, specialist units and clinics. At the local hospice patients as teachers help the students understand the process of loss of health and life and about patients’ strengths as well as needs. Recordings of reflective individual and group interviews with students, patients and teachers are being collected and analysed, as well as the results of student-devised questionnaires and case studies.
S36
Individual presentations / Patient Education and Counseling 34 (1998) S5 –S41
Results. Our course builds students’ confidence and competence in communicating with patients and colleagues by reflecting individually and in groups on early patient contact and how to develop skills from that base. Their enthusiasm, and that of participating professionals and patients, has led to the commitment to make the course available to all Cambridge students (250 per year), extending its principles to later medical training. Conclusions. Professional-patient partnership entails effective preparation following the ‘maxim ‘Physician, heal thyself’. Communication techniques to use when discussing sexuality C. Gamel (a), M. Hengeveld, M. Grypdonck, B. Davis. (a) Utrecht University, Postbus 80036, 3508 TA Utrecht, The Netherlands. Introduction. This study of communication techniques was part of a larger research project designed to investigate how to provide the patient and partner with information and support which enables them to accommodate the effects of illness and disability upon sexuality within their daily living patterns. This research project focused on the effects of gynaecological cancer. This presentation is limited to the findings concerning the subquestion: how can concrete form be given to recommendations in the literature concerning the communication strategies that nurses can use when providing sexual teaching (ST)? Methods. A protocol for providing ST was developed based upon recommendations from sexology and nursing practice literature. To evaluate and refine the protocol, it was used in nursing practice and afterwards, interviews were conducted with the nurses and their patients. Underlying meaning of their perceptions was also analyzed. Two strategies were used to enhance the validity of the interpretations. The interpretations and conclusions were reviewed by a sexologist-researcher. And a different group of patients received ST according to the revised protocol. The interview data obtained from this group were evaluated to determine the accuracy of the previously made interpretations and revisions. Results. Seven recommendations specified communication strategies which decrease discomfort associated with a discussion about sexuality. Few modifications were needed for some recommen- dations, however specific implications for teaching nurses how to use the associated techniques were identified. Three recommen- dations needed modification; after that, they were maintained however the data demonstrated the complexity of the associated issues: - encouraging the patient to talk about her own sexuality, - beginning with the least (sexually) sensitive topic and - avoiding questions about sexuality before illness. To work effectively with these last three recommendations, more extensive training will be required. Conclusions. In this study, a protocol was developed in which recommendations for communication can be spe-
cific rather than vague as often is the case in nursing protocols and nursing literature. The stepwise development of the communication guidelines and the systematic examination against the perception of the communication by nurses and patients provides a better basis for practice and future research. From this study of the isolated components and their underlying assumptions, a firmer basis was developed and this is important to future testing of the protocol in a controlled study.
17
INTERNATIONAL COMPARISON
Doctor-patient communication in Eeuropean countries Atie van den Brink-Muinen, Peter F.M. Verhaak. NIVEL ( Netherlands Institute of Primary Health Care), Postbus 1568, 3500 BN Utrecht, the Netherlands. Introduction. A comparison of doctor-patient com- munication in different European countries is the main objective of the ‘Eurocommunication study’ (1996-2000). The aim is to investigate how the characteristics of various health care systems affect doctor-patient communication and patient expectations, apart from background variables. The following health care characteristics are considered relevant for doctor-patient communication: mode of access of secondary care; registration of patients with a GP; employment status of GPs; health insurance system. The selection of countries for participation in the study (Belgium, Germany, Spain, the United Kingdom, Switzerland and The Netherlands) is based on differences in these structural features. Doctor-patient communication embraces verbal and nonverbal behaviour as well as the content of the conversation. Methods. Doctor-patient communication will be assessed by observing real doctor-patient encounters. In each country 27 to 40 GPs participate in the videotaping of consultations with 15 patients per GP. The consultations are coded by three observers by means of Roter’s Interaction Analysis System to measure verbal affective and instrumental behaviour and nonverbal behaviour both of the doctor and the patient. Multilevel analyses are used to compare the countries. Moreover, the patients are asked to complete a questionnaire (before and after the consultation), among others to examine the patients’ expectations of and satisfaction about the consultation. The GPs complete both a questionnaire and registrate some consultation characteristics, amog others about the content. Results. Differences are found between countries in the conversation style (affective versus instrumental), and in biomedical versus lifestyle and psychosocial exchange. The inclusion of psychosocial factors when establishing a diagnosis also varies between the countries studied. The content of the communication differs in the symptoms discussed, medicines prescribed, referrals, instrumental treatment and diagnostics. The differences are reflected in the patients’ expectations and their satisfaction about the consultation.