Physician–patient communication and patient satisfaction in Japanese cancer consultations
Introduction
Over the past few decades, the medical environment has experienced dramatic changes, including rapid advances in medical technology, an increase in chronic illnesses, and the rise of consumerism. The physician–patient relationship is also changing; different forms have been explored in various studies (Balint & Shelton, 1996; Emanuel & Emanuel, 1992). Communication between physician and patient has received special attention as a major component of medical encounters and a key to patient satisfaction and compliance (Kaplan, 1997; Ong, De Haes, Hoos, & Lammes, 1995).
Recently, changes in physician–patient relationships have been noted in Japan (Hattori et al., 1991). Various concepts and models developed in western countries have been introduced, including informed consent, decision-making, patient autonomy and patient-centered care. On the other hand, many aspects of social and cultural life relevant to physician–patient relationships differ between western and Asian countries (Nilchaikovit, Hill, & Holland, 1993). In particular, ways of communicating and relating to others are deeply rooted in language and social structure (Barnlund, 1975). Thus, features of physician–patient interaction in Japan might differ from those reported in previous studies. Yet, there have been few systematic studies of physician–patient interaction in Japan, and no specific instrument to measure this. Applying the instrument developed in western countries to the analysis of physician–patient communication in Japan would allow us to make direct comparisons with previous studies and explore cross-cultural similarities and differences.
Given the growing attention being accorded to physician–patient interaction in western countries, researchers have become interested in the objective assessment of physician–patient communication in conjunction with outcome measures of care, such as patient satisfaction, recall and compliance. Various instruments have been developed for this purpose, including scales, checklists and Interaction Analysis Systems (IAS). (For reviews, see Boon & Stewart, 1998; Wasserman & Inui, 1983.) The Roter Interaction Analysis System (RIAS) is one of the most widely used systems in western countries, and has some notable features. It has been specifically developed for the assessment of physician–patient interaction, and it captures both types of important behaviors in the interaction, namely instrumental and affective behaviors. Coding is carried out directly from audiotapes rather than transcripts, which allows for evaluation of verbal as well as aspects of nonverbal communication (such as vocal quality). Moreover, the validity and reliability of the RIAS have been assessed in western countries (Ford, Fallowfield, & Lewis, 1996; Hall, Irish, Roter, Ehrlich, & Miller (1994b), Hall, Irish, Roter, Ehrlich, & Miller (1994a); Ong et al., 1998; Roter et al., 1997), and have rated favorably in a comparison study (Inui, Carter, Kukull, & Haigh, 1982).
Although most of the studies on physician–patient interaction have been conducted in primary care settings, recently some researchers have started to specifically examine the interactions in cancer consultations. In the case of life-threatening illness, such as cancer, the physician–patient relationship may be even more critical in the treatment process as continuing care, complicated decision making, and patients’ uncertainty and anxiety place greater demands on the relationship (Ben-Sira, 1980; Molleman et al., 1984). Under these circumstances, the content of physician–patient interaction might have a stronger impact on patient outcomes.
Patient satisfaction is considered to be an attitudinal response to value judgments that patients make about their clinical encounter (Kane, Maciejewski, & Finch, 1997). It has been widely used in physician–patient communication studies as an outcome measure that directly reflects patients’ voice. The interpersonal aspects of care, including physician attitudes and communication, are regarded as the principal component of patient satisfaction (Sitzia & Wood, 1997). Although several concerns have been raised about the limitations of patient satisfaction as a measure of quality of care (Avis, Bond, & Arthur, 1997; Williams, 1994), it can still be a useful measure when aimed at measuring specific aspects of the service in a specific context (Williams, Coyle, & Healy, 1998).
Previous studies have revealed that certain behaviors or styles of communication are related to patient satisfaction. Particularly, since 1980, patient-centered interviewing style has received frequent attention (Lambert et al., 1997). Although patient centeredness has been defined in various ways (Christine & Frank, 1996; Henbest & Stewart, 1989; Smith & Hoppe, 1991; Stewart et al., 1995), generally it involves the physician being open and responsive to the concerns and needs of patients (Mead & Bower, 2000). Several studies have demonstrated positive consequences of patient-centered consultation on various outcomes including patient satisfaction, their psychosocial adjustment, compliance to treatment, and state of health (Butow, Dunn, Tattersall, & Jones, 1995; Henbest & Stewart, 1990; Stewart, 1984).
In patient-centered care, the key physician behaviors are those that are supportive and empathic, and those that facilitate patient self-expression (Stewart, 1984). Specifically, effective communication skills for physicians include open-ended questions, asking for patient opinion, paraphrase, supportive and empathic responses, and legitimization (Carter, Inui, Kukull, & Haigh, 1982; Kaplan, Greenfield, & Ware, 1989; Roter, Hall, & Katz, 1987; Roter & Hall, 1993; Smith & Hoppe (1991), Street (1992); Stewart et al., 1995).
On the other hand, patients are expected to express their feelings and to participate actively in the discussion in the patient-centered consultation (Stewart, 1984). Although relatively few studies focus on patient communication behaviors, question-asking is a frequently measured one. However, its relation to patient satisfaction remains controversial (Greenfield, Kaplan, & Ware 1985; Roter, 1977; Roter, 1984; Street, 1992; Tabak, 1988). Further, it has been reported that patient talk about biomedical topics is negatively related to satisfaction, while psychosocial talk has a positive association with it (Bertakis, Roter, & Putnam, 1991).
In summary, the purpose of this study is (1) to explore the characteristics of physician–patient communication in a Japanese cancer consultation according to the RIAS and to compare the interactions with those of western countries, and (2) to investigate the relation between physician–patient communication during consultation and patient satisfaction with the consultation.
Section snippets
Sample
The original data were collected for a study on the relation between physician communication style and patient anxiety level in cancer consultations (Takayama, Yamazaki, & Katsumata, 2001). The participants in this study were 200 outpatients who visited the National Cancer Center Hospital from September to November in 1997. Patients were eligible for the study if they had been diagnosed with cancer, had seen their physician before, and their cancer was not too debilitating for them to
The applicability of the RIAS
Most of the utterances by physicians and patients in our data were categorized according to the RIAS categories without major difficulty. Table 3 shows the mean frequency and percentage of each communication for physician and patient.
A major part of the interaction concerned information-giving on the part of both physician and patient; this consisted of 35% and 34% of their communication, respectively. On the other hand, some categories showed striking differences between physician and patient.
Physician–patient communication in Japan
This study applied the RIAS to Japanese cancer consultations to explore the characteristics of Japanese physician–patient communication. Overall, the RIAS seemed to be a reliable and valid instrument in Japan. Inter-coder reliability in terms of the congruence in identifying and categorizing utterances was acceptably high. Also, the major components of the interaction were classified reasonably well according to the original method used in the RIAS.
We also found some RIAS categories and methods
Acknowledgements
This research was supported by Grant-in-Aid for Scientific Research (B) 11410042 on “Practitioner–Patient Relationship and Patient’s Autonomy” from the Japanese Ministry of Education, Science, Sports and Culture. We are grateful to Dr. Hideki Hashimoto for his helpful suggestions and comments, and to Dr. Debra Roter for her instruction concerning the RIAS and her valuable advice. Special thanks are due to Mr. Yutaka Aoki for his advice on statistical analysis, and to Dr. L.M.L. Ong and Dr.
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