Background
Methods
Videotaped consultations
Participants
Background characteristics | Patient observers with hypertension (N = 108) |
---|---|
Gender | |
Female | 73 (68 %) |
Male | 35 (32 %) |
Age | |
< 40 | 2 (2 %) |
40 – 49 | 12 (11 %) |
50 – 59 | 46 (43 %) |
60 – 69 | 39 (36 %) |
70 – 79 | 9 (8 %) |
Education level | |
Primary education | 2 (2 %) |
Secondary education | 59 (54.5 %) |
Third-level education | 47 (43.5 %) |
Employment | |
Retired | 35 (32 %) |
Employed | 31 (29 %) |
Self-employed | 5 (5 %) |
Other (student, housewife, job seeker) | 37 (34 %) |
Native background | |
Dutch | 96 (89 %) |
First generation migrant | 6 (5.5 %) |
Second generation migrant | 6 (5.5 %) |
Health | |
Using medication for hypertension | 81 (75 %) |
Comorbidity other chronic disease | 50 (46 %) |
Health care use | |
Contact with GP in last two months | 76 (70 %) |
Contact with medical specialist in past year | 72 (67 %) |
Part I: Quantitative study
Quality assessments by participants
Communicative behaviour of the GP coded with RIAS
Statistical analyses
Part II: Qualitative study
Comments given by participants
Qualitative analyses
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Step 1: construction of the code list. Based on the comments of participants, a thematic analysis of quality aspects was conducted by two researchers (LB and HB), in order to construct a conceptual code list [43]. In a first round of open coding, the positive as well as the negative comments on ten consultations from both periods were coded by the two researchers independently. The three dimensions of quality of doctor-patient communication (biomedical, psychosocial and interpersonal) were used as a conceptual framework for the coding of the comments. However, the researchers were also free to identify any new dimensions of quality of doctor-patient communication while coding. For example, while the three dimensions of quality of communication were identified and further specified in different components, patients also mentioned general communication characteristics that were added as basic conditions for the three quality dimensions. Discussion of this first round of coding resulted in an initial list of codes, which was used and modified by the two researchers in a second round of coding. For example, one of the discussion points was whether or not to create a separate code ‘being involved’ in addition to the existing codes ‘offering continuity’, ‘treating respectfully’ and ‘reassuring’. In the final version we decided to add this code because involvement was indeed a different category as it appeared in the comments. The final code list is displayed in Table 2.
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Step 2: examining frequencies of codes. The constructed code list was used to code the total dataset of comments. LB performed the coding of the dataset, while HB randomly cross-checked assigned coding categories. We calculated the frequencies of comments assigned per code.
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Step 3: comparing frequencies of codes. We identified the top 3 frequencies of each group of comments (positive versus negative comments and first versus second period) and we examined whether there were shifts in these top frequencies between the two periods.
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Step 4: identifying themes in comments. We studied the content of the comments for each period separately, to identify overall themes. Themes were first identified by the two authors LB and HB, and then discussed with all authors.
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Step 5: comparing themes in comments. Finally, we explored whether any changes had occurred in the focus and terminology of the identified themes in step 4 between the two periods.
General communication characteristics
| ||
---|---|---|
Code | Definition | Examples |
Preparing patient | Preparing and directing patients by announcing examination or provide structure in the consultation |
+ GP: “I am going to take your blood pressure”
|
- Does not announce what he is going to examine
| ||
Asking questions | Questions by the GP that refer to the medical complaint or psychosocial aspects related to the complaint |
+ The doctor asked about her leg cramps
|
- Did not ask relevant questions
| ||
Explaining | Giving explanations about the medical complaint, examination, or psychosocial aspects of the complaint |
+ Explains the function of the medicine
|
- Did not mention the blood pressure after examination
| ||
Working efficiently | Working efficiently and being organized |
+ Immediately comes to the point talking about the ECG
|
- Was very busy with paper work before he could give attention to the patient
| ||
Taking time for patient | Being patient and calm |
+ Takes a lot of time for the patient
|
- Is fast, hurried, and uninterested
| ||
Talking intelligibly | Any comments on talking intelligibly; patient unable to understand what GP is saying |
+ Clearly pronouncing the sentences because of patient’s deafness
|
- Talking too softly and not finishing his sentences
| ||
Communicating appropriately | General comments on communication and the words used by the GP |
+ Very relaxed communication between doctor and patient
|
- GP is too nonchalant
| ||
Biomedical quality
| ||
Code
|
Definition
|
Examples
|
Decision making | Deciding on a treatment, giving advice, prescribing medicine |
+ Gives multiple options, lets the patient make a choice
|
- Does not give an advice
| ||
Performing correctly | Technically good performance, proceeding correctly |
+ Takes the initiative to measure blood pressure
|
- Does not examine the shoulder
| ||
Psychosocial quality
| ||
Code
|
Definition
|
Examples
|
Being alert to psychosocial signals | Noticing psychosocial signals, paying attention to patient’s mental state |
+ He identifies the concerns of the patient
|
- GP does not react when Mrs says that she does not sleep well because of tension
| ||
Giving advice | Giving advice on psychosocial aspects of the complaint |
+ Patient gets a referral to psychologist
|
- Only gives brief information about whether or not the patient can go back to work
| ||
Interpersonal quality
| ||
Code
|
Definition
|
Examples
|
Offering continuity | Being familiar with the patient and knowing patient’s personal background |
+ Recaps what was discussed in the past
|
- Not well informed about the patient’s medical history
| ||
Being involved | Showing sincere involvement and adopting a personal approach |
+ Asks how patient experienced her recent hospitalization
|
- Very business-like
| ||
Treating respectfully | Being polite; being friendly; taking time to greet patient |
+ Speaks very respectfully to older lady
|
- Does not greet the patient at the start of the consultation
| ||
Listening attentively | Paying full attention to patient; listening; showing interest; not permitting distraction by telephone interruptions |
+ Shows interest in the patient
|
- There is not much eye contact
| ||
Reassuring | Verbally and non-verbally showing reassurance and support |
+ Reassures patient by saying ‘You don’t have to worry’
|
- Tense atmosphere; which does not reassure the patient
| ||
Treating patient as equal | Taking patient seriously; not being arrogant or patronizing |
+ Takes the patient seriously
|
- The GP talked about the patient and did not put much effort in establishing contact with the patient
| ||
Following the patient’s story | Being patient-centered; reacting to the patient’s input; taking patient’s view into account |
+ Reacts to patient’s comments
|
- Rejects all suggestions by the patient (e.g. taking vitamin supplements)
| ||
Showing appraisal | Giving compliments; show appraisal |
+ Gives a compliment about quitting smoking
|
- Did not react to the fact that patient lost weight
| ||
Respecting privacy | Dealing correctly with confidentiality |
+ GP says: I’d rather give it [prescription] to the person who is going to use it
|
- It is not professional to talk about other patients during the consultation
|
Results
Part I: Quantitative study
Communicative determinants of quantitative assessments
Period 1982–1984 (N observations = 485) | Period 2000–2001 (N observations = 542) | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Biomedical quality | Psychosocial quality | Interpersonal quality | Biomedical quality | Psychosocial quality | Interpersonal quality | |||||||
GP Communication
|
| Z|
|
| Z|
|
| Z|
|
| Z|
|
| Z|
|
| Z|
| ||||||
Constant | 6.07 | 5.36 | 5.93 | 6.80 | 5.77 | 6.46 | ||||||
Task-oriented communication
| ||||||||||||
(questions, information, counselling)
| ||||||||||||
- Biomedical |
0.013
|
2.14 *
| 0.008 | 0.95 | 0.007 | 0.88 | 0.004 | 0.98 | −0.005 | 1.03 | −0.003 | 0.64 |
- Psychosocial | 0.018 | 1.79 |
0.031
|
2.30 *
|
0.024
|
1.92
| 0.004 | 0.36 |
0.051
|
3.71 ***
|
0.026
|
2.05 *
|
- Lifestyle | −0.019 | 1.46 | 0.006 | 0.31 | −0.012 | 0.73 | 0.023 | 1.41 | 0.022 | 1.19 | 0.028 | 1.62 |
Affect-oriented communication
| ||||||||||||
- Personal remarks | 0.014 | 1.37 | 0.024 | 1.73 |
0.031
|
2.43 *
| −0.015 | 1.64 | 0.015 | 1.38 |
0.020
|
2.09 *
|
- Sharing concern | 0.021 | 0.98 | 0.022 | 0.79 | 0.037 | 1.41 | −0.025 | 0.53 | 0.005 | 0.09 | −0.049 | 0.97 |
- Rapport building | 0.002 | 0.82 |
0.013
|
3.31 **
|
0.008
|
2.18 *
| 0.003 | 0.72 |
0.011
|
1.96
| 0.008 | 1.55 |
- Disagreements | −0.047 | 0.90 | −0.111 | 1.59 | −0.112 | 1.73 | 0.082 | 0.49 | −0.080 | 0.42 | −0.065 | 0.37 |
Process-oriented communication
| ||||||||||||
- Giving directions | 0.012 | 0.90 | 0.004 | 0.26 | 0.007 | 0.44 | 0.025 | 1.74 | 0.027 | 1.64 | 0.030 | 1.95 |
- Partnership building | −0.032 | 1.23 | −0.040 | 1.14 | −0.020 | 0.61 | 0.032 | 0.54 | 0.014 | 0.20 | 0.049 | 0.80 |
Part II: Qualitative study
Examining and comparing frequencies of codes (step 2 and 3)
Period 1982-1984 | Period 2000-2001 | |||
---|---|---|---|---|
+ Positive comments | - Negative comments | + Positive comments | - Negative comments | |
General communication aspects
| ||||
- Preparing patient | 11 (2 %) | 4 (1 %) | 7 (1 %) | 6 (1 %) |
- Asking questions |
102 (16 %) ▴
| 25 (6 %) |
132 (17 %) ▴
| 27 (6 %) |
- Explaining clearly |
90 (14 %) ▴
|
57 (13 %) ▼
|
141 (18 %) ▴
|
48 (11 %) ▼
|
- Acting efficiently | 6 (1 %) | 23 (5 %) | 17 (2 %) | 26 (6 %) |
- Taking time for patient | 31 (5 %) | 8 (2 %) | 33 (4 %) | 5 (1 %) |
- Talking intelligibly | 3 (1 %) | 5 (1 %) | 3 (0.5 %) | 4 (1 %) |
- Communicating appropriately | 14 (2 %) | 31 (7 %) | 29 (4 %) | 18 (4 %) |
Biomedical quality
| ||||
- Making decisions | 19 (3 %) | 27 (6 %) | 41 (5 %) | 23 (5 %) |
- Performing correctly |
67 (11 %) ▴
|
39 (9 %) ▼
| 52 (7 %) |
48 (11 %) ▼
|
Psychosocial quality
| ||||
- Being alert to psychosocial signals | 22 (4 %) | 13 (3 %) | 20 (3 %) | 16 (4 %) |
- Giving advice | 16 (3 %) | 7 (2 %) | 6 (1 %) | 1 (0.5 %) |
Interpersonal quality
| ||||
- Offering continuity | 27 (4 %) | 21 (5 %) | 25 (3 %) | 16 (4 %) |
- Being involved | 36 (6 %) | 6 (1 %) | 39 (5 %) | 18 (4 %) |
- Treating respectfully | 27 (4 %) | 30 (7 %) | 15 (2 %) | 18 (4 %) |
- Listening attentively | 47 (7 %) |
48 (11 %) ▼
| 47 (6 %) |
54 (12 %) ▼
|
- Reassuring | 38 (6 %) | 23 (5 %) |
66 (9 %) ▴
| 41 (9 %) |
- Treating patient as equal | 26 (4 %) | 33 (8 %) | 17 (2 %) | 22 (5 %) |
- Following the patient’s story | 37 (6 %) | 25 (6 %) | 64 (8 %) | 46 (10 %) |
- Showing appraisal | 8 (1 %) | 1 (1 %) | 14 (2 %) | 1 (0.5 %) |
- Respecting privacy | 0 (0 %) | 6 (1 %) | 1 (0.5 %) | 5 (1 %) |
Total
|
627
|
433
|
772
|
443
|