Quality of the communication in the consultation
Analysis of participant interviews and of the consultation recordings highlighted a number of features that contributed to a sense of high quality communication and of patient satisfaction. Patient interview responses were almost universally positive, with all but one of the patients expressing satisfaction overall with the communication in the consultations. Comments on communication ranged from “good” (AN-SP34R-01 PT interview), to “he’s very good with his communication skills” (AN-SP29–01 PT interview), through to “amazing…. I think the best doctor I’ve seen.” (AN-SP36R-01 PT interview).
The following more specific positive features of the communication emerged from the mixed methods analysis. Tables
3 and
4 contain illustrative quotes from the interview data and excerpts from transcripts of the actual consultations that are referred to below.
Table 3
Interview quotations that illustrate the themes from the interactional analysis
1 Informative, thorough and clear communication |
Quote 1.1: “you could see what was going on in their head a little bit” AN-SP25R-01 (PA) (PT interview) Quote 1.2: “For a person that I haven’t met before, [they were] really good with explaining information…it’s hard to find doctors who can actually sit you down and take you through everything.”6 AN-SP29–01 (PT Interview) Quote 1.3: “Yeah, I mean [they were] very thorough” AN-SP26–02 (PT Interview) Quote 1.4: “[they] definitely addressed everything that we needed to think about.” AN-SP30R01 (PT Interview) |
2 Explanations delivered in clearly signalled components |
Quote 2.1: “The way they structure it... instead of jumping from one information to the other, [they] must have structured the whole entire appointment, yeah, which was really good.” AN-SP29–01 (PT Interview) Quote 2.2: “talked point by point... rather than looking at the big, scary picture. Sort of broke it down, which made it a lot easier to be able to discuss you know, the little details, and then building up into the... the big conversations” AN-SP36R-01 (PT Interview) |
3. Feeling listened to and their experience acknowledged (especially anxiety) |
Quote 3.1: “they didn’t just cut me off and dismiss my... concerns” AN-SP34R-02 (PT Interview) Quote 3.2: “it felt like it’s okay to be worried kind of you know, like it’s okay how you’re feeling” AN-SP25R-01 (PT Interview) |
4. Feeling able to ask questions and get them answered |
Quote 4.1: “Lots of opportunity to ask questions” AN-SP30R-01 (PT Interview) Quote 4.2: “I did ask a lot of questions…. but they were all answered, so yeah.” AN-SP31–02 (PT Interview) |
5. Consideration of patient wishes and provision of options |
Quote 5.1: “[they] gave us options” AN-SP27–02 (PT Interview) Quote 5.2: “Just like, ask me my opinion, what I want to do” AN-SP31–01 (PT Interview) |
6. Realistic and honest communication |
Quote 6.1: “[they are] quite realistic, so that’s something I like to know. I don’t want to bat around the bridges.” AN-SP29–01 (PT Interview) Quote 6.2: “it felt it felt very open … and kind of factual and that they weren’t hiding anything i suppose” AN-SP25R-01 (PT Interview) |
7. Good rapport |
Quote 7.1: “[they] made me feel very at ease pretty quickly … [they] seemed very relaxed, and … I guess it made me more relaxed too” AN-SP36R-01 (PT interview) Quote 7.2: “[they] made me feel very comfortable” AN-SP28R-02 (PT interview) |
8. Patient displays of knowledge |
Quote 8.1: “I think she came in with a good idea about these risks.” AN-SP29–01 (SP Interview) Quote 8.2: “They were a lovely couple that had already done a lot of reading... which makes it a lot easier. I think it’s difficult when people come in and they have either done no reading, or have no idea about which way they want to go. And then it becomes a lot more difficult, because of the clinic... we do kind of pressure them into trying to make a decision one way or the other. But then that is difficult to make such a big decision in a sort of 15 to 30-min consult. So they were sort of already well up-to-date with what they needed to know. So that was helpful.” AN-SP30R-01 (SP Interview; VBAC clinic) Quote 8.3: “I think they’d come well prepared” AN-SP29–03 (SP Interview) |
Table 4
Data extracts from the consultation transcripts that illustrate the interactional analysis
1.
Informative, thorough and clear communication
Nearly every patient (and/or accompanying adult) who was interviewed (15/16) mentioned this in their evaluations of the communication, as shown in the selection of quotes in Table
3. One patient appreciated the way in which the thought processes of the doctor were made visible (Quote 1.1), while another specifically acknowledged the difficulty of good communication with someone you have not met before (Quote 1.2). Patients also explicitly mentioned thoroughness or described a thorough approach, as in Quotes 1.3 and 1.4. Within the consultations, this was evidenced by the coverage of multiple topics and the detailed discussions observed (the length of which make it impractical to reproduce an example here). An example of clear and informative communication is given in Consultation Excerpt 1.1 in which the registrar goes to some length to explain the reason for the extra concern with a baby that is small for dates, using an extended metaphor to make the point.
2.
Explanations delivered in clearly signalled components
Informativeness and clarity was enhanced by clearly structured communication that patients reported experiencing in their consultations, as evidenced in Quotes 2.1 and 2.2.
Clear signalling of topics and agendas was directly observed in many of the consultations; this made the structure more obvious, as seen in Consultation Excerpts 2.1 and 2.2 in which the doctor first explicitly indicates they are about to deliver an ‘informing’, then numbers off the topics to be discussed in the consultation as a way of signposting the stages of the explanation.
3.
Feeling listened to and feelings/experience acknowledged (especially anxiety)
While the question was not always specifically asked in the semi-structured interview (depending on how the conversation went), when 12 patients were explicitly asked if they felt they were listened to, all responded positively for example, in Quote 3.1. One patient in particular mentioned feeling that their anxiety had been legitimised (Quote 3.2).
Within the consultation, several doctors explicitly acknowledged the worry or anxiety patients may feel, as shown in Consultation Excerpt 3.1, and also in excerpt 6.2 (lines 13–20). In excerpt 6.2 (lines 15–16), the clinician explicitly claims to understand that the patient is and will be ‘anxious’ and ‘stressed out’, using informal language (such as ‘gonna’ and ‘aren’t ya’) that serve to minimise the social distance between clinician and patient, and quiet talk to index the sensitivity of this. The clinician also phrases their statement so that patient agreement is the ‘preferred response’ [
53] by using a tag question (‘aren’t ya’). The patient does indeed agree (line 17).
A good example of a patient’s previous experience being acknowledged with empathy is shown in Consultation Excerpt 3.2, where in addition to the minimal responses (such as “yeah”), the doctor provides brief but effective acknowledgement of the impact of the experience on the patient at line 6 with a simple “wow”, and with an explicitly empathic statement at line 15–16.
4.
Feeling able to ask questions and get them answered
Many patients (9/16) specifically mentioned in interviews that they felt comfortable to seek further information or explanation, as seen in Quotes 4.1 and 4.2. One illustration is seen in Consultation Excerpt 4.1 where the partner of the patient spontaneously asked the doctor to provide more information, which was responded to at length.
In Consultation Excerpt 4.2, the consultant has been giving information at some length, and it is noteworthy that the patient, at line 6, begins an assertive bid to participate (“so”, just before the consultant has finished speaking. The patient here successfully gains the floor at line 8 and asks their question. This illustrates that even in more challenging interactional contexts such as this, where a specialist is engaged in an extended informing sequence (which patients typically do not interrupt), the patient here indeed had a level of comfort with active participation. The doctor, while completing their turn in the face of the patient’s bid for a turn, then gives the floor to the patient, maintaining mutual gaze and nodding as a ‘go-ahead’.
5.
Consideration of patient wishes and provision of options
Five of the patients specifically mentioned the fact that they were given options and that they felt their wishes were sought and respected, as seen in Quotes 5.1 and 5.2. Again there was evidence of this occurring in the consultations. Consultation Excerpt 5.1 illustrates an obstetrician explicitly telling patients that they aim to inform them of their options. Consultation Excerpt 5.2 is from a Vaginal Birth After Caesarean (VBAC) clinic consultation with a non-native speaker of English. The clinician makes it clear that patients’ preferences for VBAC or caesarean will be considered, quickly checking on whether the patient has received information on the options. At line 5, the clinician asks a completely open question that is not tilted towards either of the available options. The patient expresses her preference for a caesarean section and the clinician explicitly affirms the importance of the patient’s preferences in lines 16–19, after noting the need for clinical assessments (lines 11–14).
In another consultation (for which no patient interview was conducted), there was a little more negotiation as to whose wishes might prevail (see Consultation Excerpt 5.3). When the obstetrician expressed an opinion that was at odds with the patient’s preferences (lines 4–5), there was push-back from the patient in line 6. The obstetrician went on to explain the risks if a herpes lesion was present in labour and that the patient may not be aware of a lesion, adding:
“as long as you're aware of that situation then you'd be better informed to make that decision, that's number one”
While emphasising the importance of medication and extra scans regarding small gestational size, the obstetrician also acknowledged that the patient had a “fair point” on several occasions during the consultation, which explicitly validated the patient’s perspective. By presenting information and options and acknowledging the patient’s perspective, even when being challenged, the obstetrician succeeded in keeping the interaction on positive terms and negotiations friendly and respectful.
6.
Realistic and honest communication
Two patients particularly appreciated straightforward and realistic communication from the doctors (Quotes 6.1 and 6.2). Other patients reported positively on consultations in which open and realistic talk was observed, such as Consultation Excerpt 6.1 in which a registrar comments on the inherent uncertainty in this setting. Consultation Excerpt 6.2 is another example of plain talking that appeared to be appreciated. In line 5, the doctor uses very direct, colloquial language to talk about the possibility of the uterus ‘pulling apart’, albeit softening the words by lowering the volume of talk.
Several patients mentioned the way in which doctors made them feel relaxed and comfortable, as in Quotes 7.1 and 7.2.
Simple things like handshakes and small talk that may elicit laughter contributed to building rapport and making patients and those accompanying them feel welcome and comfortable. A simple example is shown in Consultation Excerpt 7.1 where the patient’s partner, who arrived late, was explicitly made welcome with introductions and small talk that elicited laughter.
8.
Patient displays of knowledge
In addition to the opportunities patients had to ask questions and participate, patients and those accompanying them were also able to display their knowledge, with many of them having experienced childbirth before. Such patients spontaneously used clinically appropriate technical terms such as “placenta praevia” (AN-SP31–02) or “breech” (AN-SP36R-01). The patient in Consultation Excerpt 4.2 (discussed above) displayed her confidence in her knowledge with an interruption (line 6) that treats the doctor’s partial utterance (‘if it’s not going well’) as sufficient (indicating that she doesn’t need to hear the rest of the explanation). Her following turn (lines 8–9) further displays her understanding by her use of the term ‘induction’ in a way that links back to the doctor’s discussion of triggering labour by breaking waters (i.e. displaying her understanding that this is a form of induction).
In interviews, the obstetricians explicitly valued patients being well-informed, especially in view of the limited consultation time available (see Quotes 8.1–8.3), and were observed in consultations giving patients opportunities to display their knowledge, thus also ascertaining their current understanding. Even those without previous childbirth experience were given opportunities to display recently acquired knowledge, as shown in Consultation Excerpt 8.1 in which the patient is a young first time mother. Here the doctor initially talked in non-technical terms (line 1) and asked a question at line 3 which opened up the floor to the patient to answer with a narrative that led up to her attempting to provide the technical term herself. The patient also later displayed her familiarity with the type of twins in line 11.