Describing the factors that influence the process of making a shared-agenda in Japanese family physician consultations: a qualitative study

Prior to recruiting patients, we obtained informed, verbal and written consent from all staff members of the Department of Family Medicine in the hospital chosen for the investigation to observe their patient consultations. Patients were then recruited while waiting to be examined by the consenting physicians (n = 8). We screened patients and asked those who were first-time visitors, to participate in our research after explaining the research purpose, both verbally and in writing. From among 50 new patients screened, 15 finally consented to participate in this research.

For the analysis, a modified grounded theory approach was used [18] wherein two researchers categorized the data, and constructed a final theory together with another researcher (Fig. 1). In cases of uncertainty, the decision of the researcher who conducted the interview was given priority.

We found that the past medical experiences of patients had an effect on their attitude towards their present doctor, which affected agenda-sharing.

In Japan’s “free access” medical system, patients are free to move between doctor and hospitals. As a result, many patients came from other clinics in hopes of better care. There were many specific reasons, such as, dissatisfaction with a previous consultation, little or no improvement in symptoms, as well as many others. In addition, several had been referred by previous doctor, who judged that they would receive superior care at a larger institution.

Accordingly, many of the patients in this study came to the hospital chosen for this investigation, due to negative experiences with previous doctors; for example.

“The doctor said, “There’s nothing abnormal. Perhaps it’s just your imagination.” And I said, “I need medicine,” and he prescribed only Isodine and Troche. I thought it was a joke.” (M11: male patient)

Moreover, in many cases, patients’ past medical experiences had a large impact on their attitude during medical consultations; for example:

“I’m going to keep asking questions to my doctor as I did today.” (M7: male patient)

In addition, while there were some patients who questioned their doctors extensively, there were others who did not want to annoy their doctors and refrained from asking any questions outside the doctors’ specialty; for example:

“I don’t want to ask about anything outside a doctor’s specialty because I am afraid that they become annoyed with me. Asking things without considering the consequences are rude and I don’t feel comfortable doing it.”

(F4: female patient)

There were substantial amounts of relevant information not mentioned to the doctor.

Some of anxieties expressed by patients following the consultation were not limited to worries about the severity of their illness or the pain involved in their treatment. Patients also worried about secondary effects the disease could have on their lives, the lives of those around them, and their professional lives; for example one patient expressed concern that their employment status could be affected by their condition:

“I can’t say that. I say that and that’s it, my job’s over, you know?” (F13: female patient)

In addition, patients’ anxieties were also closely connected to their family background, job status and social background.

“We did not have a father, and my mother raised me and my brother. I don’t want to make her worried.” (M8: female patient)

This patient wanted to undergo the same treatment as his mother, who also suffered from diabetes mellitus. In his mother’s case, she remained in the hospital until her treatment was complete. Because of this, the patient seemed likely to refuse outpatient medication and seemed set on inpatient hospital care. None of these things, however, were mentioned to the doctor.

While patients demonstrated a wide range of attitudes in facing their illnesses, those patients who refrained from discussing their outlook with their doctor tended to have similar views. Several procrastinated over coming to the hospital, or ignored their disease on days where their symptoms were less noticeable. These patients talked about how they valued their time and enjoyment rather than worrying about their disease, for example, they don’t exercise even if they had been overweight, and in fact often did not give credence to medical test results that indicated more severe problems, even if symptoms were present during the medical examination.

Over the course of any consultation, the patients and doctors build a relationship. During our analysis, we found there to be two general categories of relationship: viable relationships and compromised relationships. These categorizations were based on the observed level of agenda-sharing achieved as well as the patient’s own evaluation of the consultation experience.

Examples of viable relationships are characterized by the following statements:

“He listened to me a lot, and I did not feel uncomfortable talking to him. I felt I could talk about anything with him.” (M7: male patient)

“He listened to me fully, and he listened to all my concerns. The doctor that I saw today was very easy to talk to.” (F5: female patient)

“I am very satisfied. I am glad I came. He is a great doctor.” (F5: female patient)

On the other hand, regarding compromised relationships, many patients did not directly answer in the negative, but instead gave vague responses indicating that the communication had in fact been insufficient.

Well, today was my first time with this doctor. I mean, I guess I talked to him. (F4: 48 year old female patient)

Other patients clearly stated that they were not able to fully communicate with the doctor.

“Yeah, there was something I couldn’t talk about.” (F13: female patient)

Each patient had their own explanatory model for describing their disease. Patients often arrived with an original explanatory model for their particular disease and situation. For example, one patient with symptoms of general fatigue worried that it could have been caused by cancer or a brain tumor, both of which had occurred in family members. Another patient who suffered from three months of diarrhea suspected an unknown type of bacteria to be the cause. A third patient, who had numbness in her hands thought that it was due to child-birth 10 years prior.

“I feel blood is not circulating to the ends of my body. I wonder if I have this kind of abnormality because I had a baby at an older age.” (F4: female patient)

After the first meeting with a new doctor, and hearing the doctor’s diagnosis, some patients accepted this diagnosis, while others did not. The patients who accepted the doctor’s diagnosis and integrated this information into their previous explanatory model are said to have adaptive explanatory models.

For example, one patient whose chief complaint was various pains throughout her body initially suspected it was due to decompression sickness, a condition she was aware of through her hobby of scuba diving. After the doctor’s diagnosis of the pain as stemming from job-related stress, the patient’s explanatory model changed to consider this cause as well.

“Since such a thorough examination couldn’t find anything abnormal, I’m beginning to feel there is nothing wrong with my body.” (F6: female patient)

Another example of an adaptive explanatory model is the previously mentioned, patient, who complained of general fatigue. This patient, (in her early 20s), worried that the cause of her complaint could be a brain tumor or cancer. After the doctor conducted a neurological examination, the patient felt that a CT scan, which she had initially hoped for, was no longer necessary. In this case the doctor’s diagnosis was that the fatigue was likely caused by dehydration.

“I think I need to take better care of myself.” (F12: female patient)

In contrast to patients who accepted the new doctor’s diagnosis, those who rejected the diagnosis are said to have a non-adaptive explanatory model. In some cases, the explanatory model previously held by the patient was re-enforced and strengthened by the conflict with the doctor’s diagnosis. In other cases, the patient seemed to lose confidence in their explanatory model while still rejecting the received diagnosis.

“The doctor said “Don’t worry about it too much”, but that’s not going to cure my disease.” (F12: female patient)

The doctor’s statements were grouped into five categories to clarify the factors affecting the agenda sharing process, on their part:

Family physicians experienced patients with widely varying levels of preparedness and understanding of their own conditions. While some patients continually postponed visits and check-ups, due to not wanting to hear bad news about their own health, other patients were steadfast when faced with even the most difficult prognosis. Patients also varied in their ability not just to accept, but to understand and deal with health problems.

“This patient does not know how to modify his lifestyle and it may take some time before he is motivated to make any changes.” (D4: female doctor)

Family physicians that have experience with many patients were more likely to think about their diseases, fears and uncertainties, and hopes regarding the results of the examination. These physicians take the patient’s explanatory model into consideration when announcing the results of their differential diagnosis.

“The patient’s explanatory model is a physical disorder, and the patient requests testing. The patient has stress, but he does not think it is the cause of his illness.”

(D5: male doctor)

The physicians included in this research were aware of the patient’s expectations, and attempted to meet these expectations in order to strengthen the doctor-patient relationship.

The physicians interviewed understood that patients had various expectations from the consultation. Some patients wished for the family physicians to understand their suffering or reassure them. Other patients hoped for, or even requested, a diagnosis that contrasted with the diagnosis received from their previous doctor, or even just a chance to complain about their previous medical experience.

“What this patient wants from me is probably not about reducing stress.” (D5: male doctor)

The physician’s understanding of these expectations determined the approach used during the consultation. For example, in cases where the patient felt their previous doctor had been dismissive of their fears, the physicians interviewed often felt the need to conduct a comprehensive examination in order to both gain the patient’s trust, and reestablish confidence in the medical system in general, often by conducting thorough examinations. In other cases, the physician expressed the need to calm the patient and give them assurances that they would be fine. In cases where patients had already seen several family physicians and had yet to find effective treatment, doctors assured patients that they would continue to work with the patient until an acceptable treatment was found.

Patients may react badly to a physician suggesting that their problems may be psychosomatic in nature. Doctors who sensed the potential for this often began with a physical examination to help preserve the doctor-patient relationship, before suggesting other options.

“If I had said “Your illness is due to stress,” I think the patient would reject my diagnosis, so I purposely chose a physically-centered approach.”

(D6: male doctor)

The physicians interviewed expressed the needed to encourage patients to understand the diagnostic process, and to show patients what they are checking for.

Family physicians assessed the appropriate strategy for the consultation given the patient’s situation, to ensure that the patient’s complaint had been fully addressed, and the patient was able to understand and talk about the diagnosis. In the case of an obese patient, the doctor planned the flow of the consultation to make sure the patient realized the problem he needed to address on his own. In another case, to dispel any concerns about neurological problems, the family physician was careful to emphasize those aspects of the examination that excluded neurological problems.

“I tried to allocate time to talk about different things according to the patient’s symptoms.” (D2: male doctor)

The physicians we interviewed reported using strategies to facilitate the acquisition of new explanatory models. For example, in a case where a family physician indicated to a patient that a disease was psychosomatic in nature, the patient responded with a request for a CT scan in order to check brain function. In this case, the family physician said that he made sure to do extensive nerve testing so that the patient would be convinced it was not a physical problem. This was sufficient to convince the patient that her brain function was normal without the need for a CT scan. Thus, the family physician helped to prompt the patient to come to their own conclusions and develop a new explanatory model for their disease.

“I’m pretty sure the patient is satisfied that I performed a thorough neurological examination.” (D5: male doctor)

Family physicians did not unilaterally announce their diagnosis, but addressed patient questions and confirmed patient’s understanding while explaining their findings.

The family physician did not simply speak, but conversed with the patient to confirm how and to what extent the patient had understood the diagnosis. In a case where a patient suffering from diarrhea asked if it might be due to some unknown fungus, the family physician did not merely reply “No, it’s not.” Instead, the family physician offered an explanation, such as the fact that a fungus alone would not cause the patient’s symptoms, and offered suggestions on how the patient might change his diet. In another case, when a patient complained about noise in their ears, the family physician named the disease and also explained how to clean the ears.

“I told the patient not to overdo ear cleaning and not to use a hard ear pick; to loosen the tip of a commercial cotton swab because it is hard; and to clean only the shallow part instead of going too far in.” (D1: female doctor)

In another case, after the end of the consultation, the doctor-patient connection was not over, but the family physician continued to offer help to the patient regarding her ear discomfort, and offered explanation on ear care. The family physician used an appropriate conversation for the patient’s psychosocial background and fully addressed the needs of the patient.

“There are many cases where patients haven’t accepted a diagnosis on the first visit, so I often tell them, “Please take your time to consider this information.”

I thought the patient had almost prepared to accept the cure.”

(D1: female doctor)

The family physician was conscious of his/her actions during the consultation.

Family physicians reflected on their consultation, and wondered how to improve, considering difficult points, areas where communication had worked well and where it hadn’t, and the timing of giving information to patients. While ordering further tests, the family physician reviewed the consultation he had just given, wondered if he had maintained the proper pace of speaking, if he had been too fast or repetitive, if he had been sufficiently specific in describing causes of the disease, if he had addressed all the worries of the patient, or if he had in fact been overly reassuring to the patient in spite of the seriousness of the disease. Through all these steps the family physician reflected on the diagnosis and consultation procedure.

“In this case, I had information from the patient’s previous doctor, so I started asking about psychiatric problems more quickly than usual.” (D5: male doctor)

“I told her there is no abnormality, but that doesn’t mean she now feels relieved.”

(D4: female doctor)

The number of patient interviews was 15, which is wholly sufficient for qualitative research. However, these results may not be generalizable to other primary care settings, because data collection was carried out only in the one hospital chosen for this investigation. Further research is required to address this limitation.