Doctor–patient communication in different European health care systems:: Relevance and performance from the patients’ perspective

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Abstract

Our aim is to investigate differences between European health care systems in the importance attached by patients to different aspects of doctor–patient communication and the GPs’ performance of these aspects, both being from the patients’ perspective. 3658 patients of 190 GPs in six European countries (Netherlands, Spain, United Kingdom, Belgium, Germany, Switzerland) completed pre- and post-visit questionnaires about relevance and performance of doctor–patient communication. Data were analyzed by variance analysis and by multilevel analysis. In the non-gatekeeping countries, patients considered both biomedical and psychosocial communication aspects to be more important than the patients in the gatekeeping countries. Similarly, in the patients’ perception, the non-gatekeeping GPs dealt with these aspects more often. Patient characteristics (gender, age, education, psychosocial problems, bad health, depressive feelings, GPs’ assessment of psychosocial background) showed many relationships. Of the GP characteristics, only the GPs’ psychosocial diagnosis was associated with patient-reported psychosocial relevance and performance. Talking about biomedical issues was more important for the patients than talking about psychosocial issues, unless the patients presented psychosocial problems to the GP. Discrepancies between relevance and performance were apparent, especially with respect to biomedical aspects. The implications for health policy and for general practitioners are discussed.

Introduction

Doctor–patient communication is of great importance to primary health care. Communication is the tool of information exchange, necessary to solve health problems, and to create the therapeutic relationship, required to manage health problems and gain confidence. Communication can meet the patients’ need to ‘know and understand’ as well as to ‘be known and understood’ [1], [2], [3]. Studies on doctor–patient communication have shown that the communication styles of general practitioners (GPs) have an impact on outcome measures like patient satisfaction and compliance [4], [5], [6]. The achievement of effective communication may also be influenced by the GP’s awareness of patients’ expectations about doctor–patient communication. Such awareness can allow the GP to understand the patients’ perspective, provide the desired level of information and inform patients if their desires for particular treatments or tests are inappropriate or unnecessary [7]. So far, studies focusing on the patients’ expectations of doctor–patient communication and how far these expectations are met were restricted to the national level [8], [9], [10]. Despite differences in health care system characteristics, no attention has been paid to cross-national differences in the patients’ views on the relevance of communication and the performance of the doctor. These characteristics of the macro health care systems may influence content and style of doctor–patient communication. If patients do not have direct access to medical care and patients are registered with one GP (in the Netherlands, United Kingdom and Spain) GPs are likely to know their patients better than in the countries where the GPs do not act as gatekeepers (in Belgium, Germany, Switzerland). In the latter countries specialist care is accessible without a referral by a GP and the patients are not registered with a specific GP. A better knowledge of the patients, their health problems and social contexts might lead to a better understanding and effective communication. Since in the GP context, less time must be spent on routine questions, which leaves more time for psychological investigations. Acquaintance with the patient may also facilitate picking up hidden clues and signs of mental distress. The employment status of GPs might influence the communication pattern and the time spent with the patients (the Spanish GPs are predominantly not self-employed, whereas the GPs in the other countries generally are). Studies have shown that in countries with self-employed doctors and a referral system, GPs have a significantly stronger position as the doctor of first contact and their self-perceived involvement in psychosocial care is much higher [11], [12]. Furthermore, a study on physician employment status and practice patterns showed that salaried GPs spent a greater proportion of their patients’ visit time in history-taking and eliciting family information, and a lesser proportion on physical examination than self-employed physicians [13]. Self-employed GPs, especially where working on a fee-for-service basis as in the non-gatekeeping systems and in the Netherlands (having a mixed remuneration system), may aim at increasing their income by spending more time to (paid) interventions and less time to communication. They may choose to optimize their workload whereas salaried GPs may feel less time pressure and therefore have longer consultations.

The impact of health care system characteristics on communication is unknown, nor do we know how cultural differences influence doctor–patient communication. What the patients consider worth talking about with their doctors and the doctors’ performance is likely to depend on society’s prevailing norms and values [14], [15], [16], [17].

Studies of factors that might influence doctor–patient communication at the microlevel have demonstrated that patient and GP characteristics are possibly confounding factors for which there should be controls in measuring the impact of health care system characteristics. Female patients regard talking about psychosocial issues more important and they communicate more with GPs (especially female) about psychosocial issues, while male patients attach more importance to biomedical issues and more often discuss them [18]. Younger patients find it easier to talk with the doctor and they communicate more than older patients about issues they consider to be important. Similarly, patients with a higher educational level consider it more important than other patients to talk to the doctor and are able to talk more easily because they are more or less on the same intellectual level and understand the professional terms [19]. Higher expectations with regard to the discussion of specific problems is probably also related both to the type of patient problems, i.e. biomedical or psychosocial, and to the extent to which patients and GPs are acquainted with each other. Research into the impact of GPs’ characteristics on doctor–patient communication revealed that more attention was paid to psychosocial aspects of patients’ problems in consultations with female, younger and part-time GPs [20], [21], [22].

The research questions which will be addressed in this study are:

  • 1.

    Are European health care systems related to the importance attached by patients to different aspects of doctor–patient communication, taking into account patient and GP characteristics?

  • 2.

    Are these differences reflected in the patients’ assessment of doctor–patient communication?

Section snippets

Data collection

Data was derived from the Eurocommunication study [23]. It was collected in 1996–1999. The study design was cross-sectional. Six European countries (the Netherlands, United Kingdom, Spain, Belgium, Germany and Switzerland) were selected, based on a variety of health care system characteristics (see Introduction) and the availability of participants. The coordination, analyses and reporting were carried out by the NIVEL Institute. National coordinators from universities and research institutes

Explanation of differences between countries

Table 5 shows the results of the multilevel regression analysis used to investigate which characteristics attributed to explaining differences in the patient-reported relevance and performance, both biomedical and psychosocial, between six European countries. On the country level, the GPs’ gatekeeping role explained some variance. The patient characteristics explained some variance as well, no variance was explained by the GP characteristics.

The gatekeeping system (with fixed patient lists and

Conclusions and discussion

The first aim of the present study was to learn more about the influence of health care system characteristics on the relevance patients attached to aspects of doctor–patient communication and their performance by the GPs, from the patients’ perspective. Secondly, differences in communication aspects between different European countries were investigated.

The principal conclusion in our findings suggests the GPs’ gatekeeping role is an important factor in doctor–patient communication. Probably,

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