Review
Improving patients’ communication with doctors: a systematic review of intervention studies

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Abstract

A systematic review of the literature examined intervention studies designed to increase patients’ participation in medical consultations. Twenty-five papers describing twenty studies met the inclusion criteria. About half of the intervention studies were randomised placebo controlled experimental designs. The studies were predominantly conducted in outpatient or primary care settings, with 50% of the interventions presented in a written form. Overall, half of the interventions resulted in increased patient participation, with slightly more significant results found for bids for clarification than question-asking. However, of the 10 written interventions only two reported a significant increase in question-asking. Patient satisfaction was the most commonly measured outcome, but few significant improvements were found. However, there were significant improvements in other outcomes, including perceptions of control over health, preferences for an active role in health care, recall of information, adherence to recommendations, attendance, and clinical outcomes. Few studies examined the links between patient characteristics and the success of the interventions. Future research needs to establish which forms of intervention are most effective and practical, for which groups of patients.

Introduction

The importance of doctor–patient communication in the process of health care has been established, with studies demonstrating clear links between the quality of communication and patient satisfaction, adherence and clinical outcomes [1], [2], [3]. Recognition of the importance of doctor–patient communication has led to the formal teaching of communication skills being considered as an essential aspect of medical education, and this is now an integral component of most medical curricula [4].

Whilst concerted efforts at behavioural change have been directed at health care professionals, considering only the doctor’s input into the consultation has the consequence of neglecting half of the relationship. The patient’s contribution to the consultation has also been found to be related to outcomes. Patients who are more active during consultations (in terms of asking questions, proffering information, and expressing opinions) are more likely to understand the treatment rationale and recommendations and there is a growing body of evidence to suggest that more verbally active patients may experience improved medical outcomes [5], [6], [7]. Patients who are educated, have higher incomes, and are older, have been found to receive more information [8], which may indicate that different styles of communication are more effective in eliciting information from doctors. Alternatively, these patients may elicit more information because of doctors’ responses to certain subgroups of patients (e.g. positive stereotyping or subjective judgements about the patient’s informational needs or requirements).

However, despite the evidence suggesting that active participation is beneficial, in practice patients often contribute little to the consultation apart from answering direct questions. For example, patient question-asking has been found to be the least frequent category of verbal behaviour in medical visits [9].

A number of researchers have set out to redress the balance, by intervening to improve the patients’ contribution to their consultations. Six separate interventions to train patients to communicate more effectively with their doctors were reviewed by Anderson and Sharpe [10]. The evidence suggested that interventions were beneficial, although there were too few studies to make reliable comparisons among different forms of interventions.

This systematic review specifically examines intervention studies directed at patients. It incorporates the six studies that were subject of the earlier review and considers how the evidence on this topic has accumulated to date.

This review examines intervention studies designed to improve patients’ communication with their doctors. The studies are considered in terms of: (a) the populations investigated; (b) design; (c) the types of interventions used; (d) the impact of the interventions on patients’ participation during the consultation and on outcomes; and (e) the links between patient characteristics and the success of the interventions.

Section snippets

Identification of studies

Literature searches were conducted to identify published reports of studies using Medline (1966–2001), PsycLIT (1966–2001), and BIDS Social Science Citation Index (1981–2001). The key search terms were patient-participation, communication intervention, communication-skills-training, patient involvement, patient empowerment and patient education. The search terms ‘patient-participation’ and ‘patient education’ were combined with the term ‘communication’ to focus the search. Papers were

Populations studied

The settings were primarily outpatient and primary care clinics (Table 1), with one study conducted in the community [34], and one study considering inpatients [22]. No studies considered mental health services, despite evidence that patients attending these services often have unspoken requests [36]. One study used healthy volunteers as simulated patients [13], which is a procedure of questionable validity.

The sample sizes varied considerably, with a range from 20 to 1077 (Table 1). The

Conclusions

The studies considered in this review generally demonstrated that interventions directed at patients can be successful in increasing patient participation, and that, in some circumstances, this can be achieved without an increase in consultation length. Where the findings about patient participation were statistically non-significant, there were trends in the expected direction. The overall increase in patient participation was most frequently assessed by examining patient question-asking or

Acknowledgements

This work was undertaken by Jane Harrington, Lorraine Noble and Stanton Newman, who received funding from the NHS London Regional Office, Research and Development Programme. The views expressed in the publication are those of the authors and not necessarily those of the NHS or the Department of Health.

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