Patient Perception, Preference and Participation
The doctor and the patient—How is a clinical encounter perceived?

https://doi.org/10.1016/j.pec.2011.04.002Get rights and content

Abstract

Objective

To examine the population distribution of different types of relationships between people with chronic conditions and their doctors that influence decisions being made from a shared-decision making perspective.

Methods

A survey questionnaire based on recurring themes about the doctor/patient relationship identified from qualitative in-depth interviews with people with chronic conditions and doctors was administered to a national population sample (n = 999) of people with chronic conditions.

Results

Three factors explained the doctor/patient relationship. Factor 1 identified a positive partnership characteristic of involvement and shared decision-making; Factor 2 doctor-controlled relationship; Factor 3 relationship with negative dimensions. Cluster analysis identified four population groups. Cluster 1 doctor is in control (9.7% of the population); Cluster 2 ambivalent (27.6%); Cluster 3 positive long-term relationship (58.6%); Cluster 4 unhappy relationship (4.4%). The proportion of 18–34 year olds is significantly higher than expected in Cluster 4. The proportion of 65+ year olds is significantly higher than expected in Cluster 1, and significantly lower than expected in Cluster 4.

Conclusion

This study adds to shared decision-making literature in that it shows in a representative sample of people with chronic illnesses how their perceptions of their experiences of the doctor–patient relationship are distributed across the population.

Practice implications

Consideration needs to be given as to whether it is better to help doctors to alter their styles of interactions to suit the preferences of different patients or if it is feasible to match patients with doctors by style of decision-making and patient preference.

Introduction

The doctor/patient relationship within any clinical encounter, like for example a consultation, has been described for a long time as the keystone of care that leads to optimum health outcomes [1]. Decision-making in the medical encounter has been described as paternalistic [2], and the term doctor/patient may contribute to this, however, our focus is on the increasing interest in shared decision-making models [3]. It has been asserted that improvements for patients and the health services can only come about as a consequence of a fundamental shift in the balance of power in the clinical encounter and development of more concordant relationships, which describes “negotiated agreement” between doctor and patient [4]. For people with chronic conditions, there is evidence that engaging with a doctor over time in ongoing clinical encounters does not necessarily result in a partnership approach with people as active and critical consumers [5]. Indeed, there are arguments suggesting that patients do not necessarily want shared decision-making [6]. The focus of our mixed methods study was on exploring how a clinical encounter referred to as a consultation between the health consumer and the health professional can ensure that complex chronic health needs are met, the individuality of all persons respected and shared decision-making encouraged.

Qualitative and quantitative methods were employed to examine how people with diagnosed chronic disease perceive their doctor–patient relationship, the characteristics of these perceptions, and how they were distributed across the Australian population. In this paper, we understand shared decision-making to refer to the ‘involvement of both the patient and the doctor… to build a consensus about the preferred treatment, and reaching an agreement about which treatment to implement’ [7]. Our focus is on the interactional nature of the clinical encounter and how decisions are made [2], [3]. Our overarching conceptual framework that integrated our qualitative and quantitative methods situated the clinical encounter as social space [8], [9]. In this social space how patients and health professionals think and feel about their relationships and interactions is important to explore [10].

Section snippets

Clinical encounter as social space

A clinical encounter is a constructed social space – ‘a structure of objective relations which determines the possible forms of interactions and of the representations the interactors can have of them’ [11]. A clinical encounter is structured by the location of an office, and by government policy and payment schedules, professional standards/qualifications and business arrangements within whatever location (e.g. time for appointments, resources available). As social space, the clinical

Methods

Data for this study were obtained in two discrete stages – Stage 1 qualitative and Stage 2 quantitative methods.

Results

This representative sample attended their physician on an average of 1.5 times per year for a chronic disease problem. The main chronic conditions reported were for blood pressure (11.1%), diabetes (8.2%), arthritis (4.2%), heart problems (3.7%) and asthma (8.3%). Table 2 shows the demographic details of the sample. Regarding self-reported general assessment of health, fair or poor health was reported by 16% (32/200) of those aged 18–34 years, 21.8% (63/289) of 35–64 year olds, and 26.4%

Discussion

Three factors emerge from the data that suggest how different aspects of the doctor–patient relationship and interactions in the clinical encounter as social space tend to group together. Factor 1 (“positive partnership”) identifies a group of variables describing a cooperative, values-concordant partnership. The variables captured under this factor do suggest elements of “positive partnership” within which both patient and doctor have much to contribute to the management of chronic disease,

Acknowledgements

This study was funded by a Discovery Grant from the Australian Research Council who had no influence on the collection, analysis and interpretation of the data or in writing the manuscript. The authors acknowledge Prof. Julianne Cheek for her contribution to conceiving and initiation of the study.

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