Patient participation in the medical specialist encounter: Does physicians’ patient-centred communication matter?

Abstract

Objective

Physicians’ patient-centred communication is assumed to stimulate patients’ active participation, thus leading to more effective and humane exchange in the medical consultation. We investigated the relationship between physicians’ patient-centred communication and patient participation in a medical specialist setting.

Methods

Participants were 30 residents and specialists in internal medicine, and 323 of their patients. Participants completed a questionnaire prior to a (videotaped) follow-up consultation. Physicians’ patient-centred communication was assessed by coding behaviours that facilitate or rather inhibit patients to express their perspective. Patient participation was determined by assessing (a) their relative contribution to the conversation, and (b) their active participation behaviour. Analyses accounted for relevant background characteristics.

Results

Physicians’ facilitating behaviour was found to be positively associated with patients’ relative contribution to the conversation as well as patients’ active participation behaviour. Physicians’ inhibiting behaviour was not related to patients’ relative contribution, and was, unexpectedly, positively associated with patients’ active participation behaviour. Physicians’ behaviour was particularly associated with patients’ expression of concerns and cues.

Conclusions

Physicians in internal specialist medicine appear to be able to facilitate patients’ active participation in the visit. The findings indicate that inhibiting behaviour may not have the expected blocking effect on patient participation: patients voiced their perspectives just the same and expressed even more concerns. Showing inhibiting behaviour may, alternatively, be a physician's response to the patient's increased participation in the encounter.

Practice implications

The results may give directions for future medical education and specialist training.

Introduction

A patient-centred approach is universally advocated in modern medical education. Despite different definitions [1], authors agree that patient-centred care acknowledges the patient as a person with a unique personal history and individual needs. Patient-centred interactions can be seen as “those in which the patients’ point of view is actively sought by the physician” [2].

Although several elements of patient-centred care have been described [1], [3], [4], the physician's exploratory communication or active listening skills are generally considered central. Patient-centred communication may accordingly be operationalised as the presence of facilitating behaviour, enabling patients to express their perspective on illness, treatment and health-related behaviour [5], [6], and the absence of inhibiting behaviour, discouraging patients to express their view [7]. Through such patient-centred communication the patient could feel encouraged and legitimized to tell more about symptoms, concerns, ideas and expectations, and to actively participate in the consultation [6], [8]. Indeed, health care providers’ facilitating communicative style was found to be related to patients’ active participation (e.g. [8], [9], [10], [11]) and certain physician behaviours appeared to promote or inhibit the disclosure of patients’ concerns and cues [12], [13].

Active patient participation during the medical encounter is expected to benefit the patient. It may reinforce patients’ confidence in their ability to manage their disease, leading to closer adherence to treatment regimens and in turn to improved health status [14]. Patients who actively participated in consultations were indeed able to change the focus of the consultation and control the amount of information provided [15], and had higher compliance levels [16]. In patients with chronic diseases active participation in the visit predicted better health status [10], [14], [17].

To date, research mainly focused on the effects of physicians’ facilitating behaviour, while the relationship between physicians’ inhibiting behaviour and patient participation was explored occasionally only. Furthermore, most research relating physicians’ facilitating behaviour to patient participation was conducted in primary care, other than some studies in paediatric care, pre-operative anaesthetics and oncology. Whether their results can be translated to other healthcare settings, e.g. medical specialist care, remains uncertain. As compared to general practitioners, medical specialists possess a more in-depth, expert understanding of a limited number of diseases within their respective domains [18]. In internal medicine specialties the average patient population tends to be older, more severely impaired and is more likely to have chronic diseases.

The aim of the present paper is to establish whether the degree of physicians’ patient-centred behaviour in internal specialist medicine is related to patients’ participation in the medical encounter (Fig. 1a). Evidently, besides physicians’ communicative behaviour, patient participation is related to patients’ socio-demographic, illness-related [10], [19], [20], [21], [22] and psychological characteristics [20], [23], visit-related characteristics [21], [24], [25] and physician characteristics [26] (Fig. 1b). Therefore we accounted for these. We hypothesize that when physicians display more facilitating behaviour and less inhibiting behaviour, patients will (a) have a greater relative contribution to the conversation and (b) display more active participation behaviour during the encounter.