Determinants of physicians’ patient-centred behaviour in the medical specialist encounter

https://doi.org/10.1016/j.socscimed.2006.01.024Get rights and content

Abstract

It has been suggested that patient-centred communication does not necessarily translate into a ‘one-size fits all’ approach, but rather that physicians should use a flexible style and adapt to the particular needs of their patients. This paper examines variability in physicians’ patient-centred behaviour in medical specialist encounters, and determines whether patient, visit, and physician characteristics influence this variability.

Participants were 30 residents and specialists in internal medicine at an academic teaching hospital in The Netherlands, and 323 patients having a (videotaped) outpatient follow-up appointment. Physicians and patients completed a questionnaire prior to the encounter. Consultations were coded using the Patient-centred Behaviour Coding Instrument (PBCI); physicians’ patient-centred behaviour was determined by behaviours that facilitated rather than inhibited the patient's expression of his/her perspective.

The results show that physicians differ in their communicative behaviour (i.e. inter-individual variability): some internists had a more ‘patient-centred’ communication style and others less so. At the same time, physicians show intra-individual variation; apparently they adjust their style according to the situation. Physicians displayed more facilitating behaviour when patients were older, reported more physical symptoms, when they rated patients’ health condition as more severe and when the physician was a woman. Physicians also displayed more inhibiting behaviour when patients reported more physical symptoms and when the physician rated patients’ health condition as more severe. Apparently, sicker patients were targets of both greater facilitation and greater inhibition. Variability in physicians’ facilitating and inhibiting behaviour was explained by patient characteristics, i.e. patients’ age and health condition, and—with the exception of physician gender—not by physician or visit characteristics. This indicates that physician patient-centred behaviour is related to the type of patient visiting, especially in relation to the seriousness of symptoms.

Introduction

Patient-centredness is a concept that has been used in medical practice since the early 1970s and attracted renewed attention recently (Bensing, 2000). Though different definitions go round (Mead & Bower, 2000b), authors agree that patient-centred care acknowledges the patient as a person with a unique life-history and needs. Patient-centred interactions can be seen as “those in which the patients’ point of view is actively sought by the physician”(Stewart, 1984). A patient-centred approach is increasingly advocated and incorporated in medical education, where some regard patient-centred communication as the desirable approach, while others see it as a means to varied ends (Lewin, Skea, Entwistle, Zwarenstein, & Dick, 2001). According to Epstein et al. (2005), the term patient-centredness (a moral philosophy with certain core values), should be distinguished from patient-centred communication (communication among clinicians, patients and family members that promotes patient-centredness).

It has been suggested that patient-centred communication or behaviour does not necessarily translate into a ‘one-size fits all’ approach, but rather that physicians would use a flexible style and adapt to particular needs of their patients (Epstein et al., 2005; Krupat et al., 2000; Winefield, Murrell, Clifford, & Farmer, 1996). Paradoxically, in some situations it may then be patient-centred to display less patient-centred behaviour. Indeed, although most patients watching two versions of a videotaped consultation were found to favour a patient-centred style, including elements like developing an understanding of the patient as a person, conveying empathy and finding common ground regarding treatment and goals of care, 31% preferred more traditional, directive communication (Swenson et al., 2004). Likewise, in an oncology setting a substantial minority of breast cancer patients, family and friends preferred a doctor-centred consultation style, including more task-focused and high-controlling behaviour and less empathy (Dowsett et al., 2000). Patients may be uncomfortable with their doctor behaving in a patient-centred way if such behaviour is unfamiliar, and a patient-centred style may not be appropriate to all conditions or circumstances (Bradley et al., 2000). If so, physicians should rather be flexible in their patient-centred behaviour.

Do physicians vary in their patient-centred behaviour, i.e. do physicians differ and are they constant or flexible in their behaviour? Picollo and colleagues (Piccolo, Mazzi, Saltini, & Zimmermann, 2002) noticed a scarcity of studies on the inter- and intra-individual variability in physicians’ specific communication behaviours. Regarding physicians’ patient-centred behaviour we found two studies only, both of which were conducted in primary care. Wensing and colleagues (Wensing, Elwyn, Edwards, Vingerhoets, & Grol, 2002) found higher consistency among 60 general practitioners in patient-centred behaviour, including exploring the patient's reason for the encounter, eliciting information, exploring emotions and expressing empathy, as compared to their behaviour when practising shared decision making. Stewart et al. (Stewart, Brown, & Weston, 1989) report that six family physicians showed different levels of patient-centredness, defined as doctor responses which enabled patients to express all of their reasons for coming. Interestingly, those displaying more patient-centredness were more flexible in style and less patient-centred physicians were so consistently (Stewart et al., 1989).

This paper investigates the inter- and intra-variability of physicians’ patient-centred behaviour in a specialist setting, i.e. the outpatient internal specialist encounter, and factors that influence such variability. From the several different elements of patient-centred care that have been described (Bensing, 2000; Epstein et al., 2005; Mead & Bower, 2000b; Stewart et al., 1995), we chose to focus on observable implications of patient-centredness, i.e. physicians’ explorative communication skills, as these can be directly experienced by the patient, and may give future directions for skills training in medical education. Physicians’ patient-centred behaviour was accordingly defined as behaviour that enables patients to express their perspective on illness, treatment and health-related behaviour: symptoms, concerns, ideas and expectations (Levenstein, McCracken, McWhinney, Stewart, & Brown, 1986; Smith & Hoppe, 1991). This implies, on the one hand, that the physician uses facilitating behaviours, i.e. behaviours that aim to elucidate the patient's perspective on illness and treatment such as reflections and open questions. On the other hand, it implies that the physician avoids inhibiting or blocking behaviours, i.e. behaviours that restrain the patient from expressing his or her view such as change of subject and premature reassurance (Zandbelt, Smets, Oort, & De Haes, 2005).

Our study begins with the premise that physicians will adjust their patient-centred behaviour in accordance with certain characteristics of the patient or certain dimensions of the clinical setting. In their overview, Mead and Bower (2000b) indicate that patient-, physician- and consultation-level factors may influence physicians’ tendency to display patient-centred behaviour. Some studies reported greater levels of patient-centredness with patients who are female (Butow, Dunn, Tattersall, & Jones, 1995; Stewart, 1984), older (Winefield et al., 1996), more anxious or emotionally distressed (Butow et al., 1995; Mead & Bower, 2000a) and better known to the doctor (Butow et al., 1995; Mead & Bower, 2000a), and with psychosocial or complex consultations (Winefield et al., 1996). Butow et al. (1995) found no association between patient-centredness and patient age or preference for involvement in decision making. Female (Henbest & Stewart, 1989; Mead & Bower, 2000a; Roter, Hall, & Aoki, 2002) and better trained physicians (Henbest & Stewart, 1989) have been found to display more ‘patient-centred’ behaviour and a female/female dyad consultation was found to be more patient-centred (Law & Britten, 1995).

Yet, earlier studies have been done in primary care settings mainly, and leave unanswered the question of whether physicians in a specialist setting vary their behaviour similarly. Besides, studies have defined patient-centred behaviour in many different ways. Following Mead and Bower (2000b), all measures of patient-centredness used in the individual studies mentioned above included their dimension Sharing power and responsibility, but different combinations of variables were used. Some measures also included the dimensions Biopsychosocial perspective (Butow et al., 1995; Mead & Bower, 2000a), Patient as a person (Henbest & Stewart, 1989; Law & Britten, 1995; Mead & Bower, 2000a; Winefield et al., 1996) or Therapeutic alliance (Mead & Bower, 2000a; Winefield et al., 1996). Generally, these measures of patient-centredness incorporate our definition of facilitating behaviour, but the focus of most was broader. To our knowledge, no studies have examined whether physicians adjust inhibiting behaviour according to certain characteristics.

The research questions addressed are therefore:

  • 1.

    To what extent do physicians in an internal specialist setting vary their patient-centred behaviour? (a) Do physicians differ in their facilitating and inhibiting behaviour, i.e. do they show inter-individual variability? (b) Do individual physicians adjust their behaviour to a specific visit, i.e. do they show intra-individual variability?

  • 2.

    Are patient, visit and/or physician characteristics predictive of internal specialists’ facilitating and inhibiting behaviour? We assume that, ideally, physicians adjust their communication to the person in front of them. If so, patient-centred behaviour would mainly be associated with patient characteristics, and to a lesser extent with physician or visit variables.

Section snippets

Procedures and sample

All physicians working in the outpatient departments of general internal medicine, rheumatology and gastro-enterology of the Academic Medical Centre in Amsterdam were invited to participate in this study between August 2001 and August 2002. Their consecutive patients having a follow-up appointment were mailed the informed consent letter 1 week prior to their scheduled appointment. Patients were eligible if they were able to speak, read and write Dutch. The study was approved by the hospital

Participant characteristics

Thirty physicians (response: 81%) consented to participate in the study (see Table 1). While 15 (50%) of the participating physicians were staff members and 15 (50%) were residents, all non-participating physicians were staff members (p=0.03). No other differences between participating and non-participating physicians were found.

Of the 30 participating physicians, 455 eligible patients were invited to participate, of whom 330 (73%) gave consent (averaging 11 patients per physician, range 3–18).

Discussion

Our results show that physicians do indeed differ from one another in their communicative behaviour: some internists had a more patient-centred style, and others less so. Inter-individual differences among internists explained a substantial portion of variance in their behaviour (18–20%). At the same time, physicians also show intra-individual variability: they apparently do not use a ‘one-size fits all approach’, but adjust their style according to the situation. These results confirm that

Acknowledgements

We thank the patients and physicians who participated in the study. Furthermore, we thank Robert Hulsman and Heleen Dekker, who participated in the coding of the videotaped encounters, and Per Vaglum, Peter Graugaard and Arnstein Finset from the department of Behavioural Sciences in Medicine, University of Oslo, for their useful comments. Finally we thank the Board of Directors of the Academic Medical Center/University of Amsterdam, The Netherlands, who funded this study.

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