Background
Overactive bladder (OAB) is a common chronic bladder dysfunction worldwide. Population-based studies in Europe and Canada have estimated that the overall prevalence of OAB in people aged 40 years or older at 16.6 % [
1] and 13.9 % [
2] respectively. In Hong Kong, a study estimated that approximately 15 % of the population experienced OAB symptoms [
3]. Urinary urgency accompanied by frequency, with or without urgency urinary incontinence, and with the absence of urinary tract infection (UTI) or other obvious pathology [
4] are defined as OAB. Approaches to treating and managing OAB include lifestyle modifications, behavioural therapy, pharmacotherapy, neuromodulation, botulinum toxin therapy, and surgical intervention [
5].
As the first contact point in the health care system, primary health care providers are often consulted by patients who require specialist secondary care [
6], and the evaluation and treatment of OAB often starts in primary care doctors’ offices [
7]. The American Urological Association recommends in a new guideline on OAB care that primary care doctors be placed in the position of gatekeeper for OAB, in which stable patients are advised to remain under the care of primary care providers [
7]. The relatively short history of the existence of OAB in medicine and low public awareness of OAB in Hong Kong, however, often serves as a challenge to primary health care providers in treating patients with OAB.
This study was inspired by earlier research on patients with OAB, covering their illness experiences [
8] and doctor-shopping behaviour [
9]. Doctor shopping involves patients visiting different doctors every time they are sick rather than consulting the same doctor. These earlier studies showed that sampled OAB patients’ doctor-shopping behaviour was closely related to their unpleasant illness experiences [
9], which often started when they first experienced OAB symptoms and sought an initial consultation for them. Their unpleasant experiences had numerous causes. The sampled patients reported difficulties in the treatment-seeking process in addition to physical bladder symptoms. The flippant attitudes of doctors often made these patients feel embarrassed during the treatment process, and the long but inefficacious treatment also made the patients frustrated with the treatment outcome. Furthermore, the patients commonly perceived doctors as lacking the necessary empathy to understand their conditions and difficulties, making their illness experiences unpleasant. Past studies have shown that patients who seek medical treatment for OAB often encounter negative experiences such as experiencing miscommunication with health care providers [
10,
11] and receiving treatment from doctors who lack knowledge about the diagnostic tests for OAB [
11].
The experiences of patients and health care providers are often influenced by the interaction between these two groups, hence both health care providers and patients are key determinants of the entire treatment experience, and the perspectives of health care providers should not be overlooked. Treatment experience not only influence patient treatment satisfaction, compliance, and thus treatment outcome [
12]; it can also affect the satisfaction and morale of health care providers [
13] and in turn influences treatment outcome [
13]. However, patient experiences have been the main focus of past research. Studies on the treatment provision experiences and perspectives of health care providers, though crucial, are lacking. The literature has a paucity of research on the treatment provision experiences of health care providers in Chinese communities, and even less is known about their treatment provision experiences involving patients with OAB. Therefore, investigating the treatment provision experiences of health care providers treating patients with OAB is crucial for improving the experiences of both parties. Primary health care providers are the first contact of patients, including those with OAB; hence, the experiences of primary health care providers are critical because these experiences can influence patient motivation to seek and follow advice and treatment. In view of the aforementioned literature gap, this study adopted a qualitative approach to investigate the treatment provision experiences of primary health care doctors treating patients with OAB in Hong Kong.
Discussion
As primary care doctors, those sampled serve as the first contact for most patients, including patients with OAB. However, the sampled doctors experienced challenges when treating patients with OAB. Lacking confidence in treating patients with OAB, experiencing mismatch in both treatment expectations and communication style with OAB patients, and feeling embarrassed when communicating with OAB patients were the experiences encountered by the sampled doctors. The lack of knowledge and support in treating patients with OAB, the embedded tension between private practice doctors and patients in Hong Kong, the expectations of doctor professionalism and behaviour in Chinese cultures, and the cultural perceptions of urinary diseases all made treatment provision challenging for the sampled doctors.
Past studies have shown that primary care doctors often provide little appropriate and accessible information about OAB to patients with the condition [
6]. The insufficient knowledge about OAB and lack of diagnostic instruments in primary care settings often limited the confidence of the sampled doctors in diagnosing and treating patients with OAB. However, the common patient expectations of receiving a confirmed diagnosis often presented the sampled doctors with a dilemma. The doctors were aware of their limitations regarding knowledge and the tests available for potential OAB patients; but were reluctant to reveal these limitations to patients because doing so may have subverted patient expectations. Addressing their limitations in diagnosing procedures and treatment provision to patients was perceived as taboo by the sampled doctors, who said that doing so would damage the patients’ trust in the capability of doctors. Doctors represent the authority of medical knowledge; in Chinese culture, patients in particular have high regard for their doctors’ recommendations [
21], and doctors’ treatment decisions are respected and trusted [
22]. Therefore, receiving respect and deference from public is expected by doctors in Chinese culture [
22,
23]. At the same time, patients also expect doctors to be highly capable in confirming diagnoses and providing effective treatment in Chinese culture. These popular attitudes and expectations regarding doctors contributed to the reluctance of the sampled doctors, who did not wish to ‘lose face’, to articulate their limitations to their patients.
The high social status and respect accorded in the Chinese cultures can also result in arrogance among doctors [
24], making the medical virtue of humility difficult to understand and practice [
25], which could ultimately affect the sampled doctors’ treatment provision experiences. The practice of humility as a medical virtue encompassing unpretentious openness, honest self-disclosure, the avoidance of arrogance, and the modulation of self-interest, though valued, can also indicate doctor weakness and indecisiveness [
25], implying incapability and thus putting the doctor at risk of losing face. Some sampled doctors reported being perceived and blamed as incapable by their patients because of their limitations in making definite diagnoses of OAB and providing treatment in primary care settings. The intention of the sampled doctors to protect their professional image and avoid breaking the taboo of admitting their limitations, thus, may have exacerbated the tension between the doctors and patients, making the treatment provision experiences unpleasant for the sampled doctors. Thus, both the sampled doctors and their patients were disadvantaged in the treatment process.
Coordinating care for patients by making referrals to secondary health care specialists for further treatment is a major role of primary care doctors [
26]. However, coordination between primary and secondary health care providers is not always straightforward [
6], especially in places like Hong Kong where patients do not have high trust or confidence in private practice doctors, and where private practice doctors are often perceived as profit-oriented [
27]. As this study demonstrated, making referrals could be perceived by some patients as a deceptive money-making technique because of embedded negative stereotypes about and lack of trust in private practice doctors in Hong Kong. Therefore, any additional procedures and referrals made by private practice doctors have a high chance of being interpreted by patients as attempts to extract more money from them. As a result of such cultural stereotypes of private practice doctors, the sampled doctors reported being accused of intentionally delaying treatment and seeking more money by making referrals to secondary specialists. As a result, the sampled doctors were reluctant to make such referrals, even though they recognised their limitations in treating patients with OAB. Their treatment provision experiences were thus affected.
The differing definition of ‘treatment’ between the sampled doctors and their OAB patients often led to tension in the doctor–patient relationship. To the sampled doctors, the consultation and physical and pathological examination procedures were considered ‘treatment’ even though no medication was prescribed. However, their patients, who considered themselves to be sick, viewed medication as an integral component of the entire treatment process, according to the doctors. Unlike patients in Western countries, among whom expecting prescriptions is less common [
28], patients in Hong Kong typically expect doctors to prescribe medication after a consultation [
29]. Only after being prescribed medication do most patients consider consultation and treatment as complete. According to the sampled doctors, when the expectation of being prescribed medication was not met, patients became dissatisfied. Thus, the doctors felt forced to prescribe medication to satisfy the patients, which many of them did. Such difference in the definition of ‘treatment’ between the sampled doctors and their patients resulted in tension between them. The sampled doctors also said that the feeling of being pressured to prescribe medication created an unpleasant experience in the treatment provision process.
Although patient expectations played a substantial role in contributing to the cultural definition of ‘treatment,’ the sampled doctors also played a crucial role in reinforcing the view that prescribing medication was a necessary part of treatment. Bladder problems were widely perceived as being caused by bacterial infections among the sampled doctors’ patients, who thus viewed antibiotics as the ideal treatment. To meet the patients’ expectations, some sampled doctors prescribed antibiotics even though they knew that doing so would yield no improvement. Indeed, doctor perceptions of patient expectations for antibiotics are strong factors in antibiotics prescription [
30]. Antibiotic efficacy reaches near-mythical levels among patients [
31], and doctors frequently prescribe antibiotics to err on the side of caution or satisfy the patient expectations [
32‐
34], leading antibiotics to become overprescribed worldwide [
31]. Antibiotics, thus, were an effective medium through which the sampled doctors were able to satisfy their patients, which for them was crucial considering existing doctor–patient tension and the culture of mistrust in private practice doctors in Hong Kong. The prescription of antibiotics also demonstrated the sampled doctors’ lack of confidence in handling OAB patients because of their limited knowledge and diagnostic testing ability; thus the doctors were motivated to prescribe antibiotics, which they expected their patients to desire. Prescribing antibiotics was viewed by the sampled doctors as their only choice because doing so could fulfil patient demands and maintain their professional dignity and perceived capability. However, not only did prescribing antibiotics delay OAB patients receiving appropriate treatment, more importantly it resulted in the misuse and abuse of antibiotics, leading to antibiotic resistance that can endanger public health [
31].
Differing expectations of bladder condition treatment and outcome between the sampled doctors and their patients also created tension in the doctor–patient relationship, thus making the treatment provision experiences unpleasant. OAB is a chronic condition, therefore full recovery was considered impossible by the sampled doctors. However, the patients often expected quick efficacy or even a cure. With such differences in treatment outcome expectation, in addition to the embedded distrust and negative stereotypes of private practice doctors in Hong Kong, the sampled doctors reported being blamed and perceived as having intentionally prolonged treatment to extract more money from their patients. The tension between doctors and patients increased further if there was a lack of communication about the gap between the actual situation and patient expectations regarding treatment outcomes, thus making the treatment provision experiences even more unpleasant for sampled doctors. Patients with OAB should be informed about the limitations of their current treatment and advised to think realistically regarding the treatment outcome; this would not only help the patients cope with the condition more positively, but also improve the treatment provision experience and morale of health care providers.
Mismatch in communication style between the sampled doctors and their patients also created tension between them, leading to unpleasant treatment provision experiences. Patients in Chinese cultures tend to have a high respect for doctors [
21]. Stereotypes of doctors’ authority and professionalism also prevail, reinforcing the hierarchical differential [
35]. In the current study, such stereotypes, in addition to the perceived higher hierarchical status of doctors, influenced not only how patients communicated with the sampled doctors, but also the patient expectations of doctor communication style. The doctors were expected to communicate in a serious and professional manner, and show empathy for the suffering of their patients. The casual and relaxed communication style adopted by the doctors violated the expectations of the patients, who interpreted the style as indicating that the doctors were insincere and lacked empathy. Miscommunication resulted from the mismatch in communication style between the sampled doctors and their patients, thus the doctor–patient tension increased further, worsening the treatment provision experiences of the doctors as a result.
Diseases are often attached with stigma [
36]. The literature shows that not only do the patients with stigmatised diseases endure painful experiences [
37], but the health care providers also encounter difficult experiences when treating them [
38]. Disease stigmas can influence the communication between treatment providers and patients because both of them have internalised the stigmas [
39], making the communication between them appear judgemental to the other. The urinary symptoms of OAB are similar to those of sexually transmitted diseases and ketamine use, both of which are severely stigmatised in Hong Kong. Therefore, patients with OAB are highly vulnerable to having their conditions misinterpreted. Because of the entrenched stigma of sexually transmitted diseases and the new stereotyping of bladder symptoms as being a consequence of ketamine use, the internalisation of these stigmas further intensified the communication tension and mismatch between the sampled doctors and their patients. Although the sampled doctors did not intend to stigmatise the OAB patients as potential sexually transmitted disease carriers or ketamine users, and though it is a clinical norm for doctors to investigate their patients’ personal habits and health histories, history taking involving sensitive topics such as sexual practices and ketamine use could easily have made the patients feel like they were being stereotyped by the doctors. This could damage the mutual trust between the sampled doctors and their patients, worsening the doctor–patient relationship. This could also affect the treatment satisfaction of the patients (and subsequently the treatment compliance and outcomes) as well as contribute to unpleasant treatment provision experiences of the sampled doctors. However, none of the sampled doctors exhibited awareness of the importance of clarifying with patients the reasons for asking the sensitive questions. Thus, the mutual misunderstanding between the sampled doctors and their OAB patients remained unresolved, unfavourably affecting their long-term treatment relationship.
Because of the characteristics and stigmas of OAB, patients often felt embarrassed when they communicated about their bladder symptoms with the sampled doctors. The gender difference between the sampled doctors and their patients often compounded the overall embarrassment. The patients’ embarrassment frequently spread to the doctors, even though such a sense of embarrassment violated the expectation of doctors to maintain a high level of professionalism. As noted by some of the sampled doctors, a sense of embarrassment affected their consultation and history-taking practices by leading them to avoid asking sensitive questions, which could have hindered them from diagnosing appropriately and thus affected the treatment outcome.
Looking ahead: The possibility of primary care doctors to serve as gatekeepers in OAB care in Hong Kong
Differences in the explanatory models between doctors and patients about a disease can negatively influence doctor-patient relationship [
40], and thus the treatment provision experiences of doctors. This study also shows substantial differences between the sampled doctors and their patients regarding treatment expectations and communication style (see Table
1), making the provision of long-term care to patients with OAB difficult at the primary care level. Lacking knowledge about OAB care and feeling embarrassed with patients also affected the confidence of the sampled doctors and their experiences in treating their patients. To overcome these problems, it is suggested that, through narrative and role modelling techniques [
25], greater emphasis be placed on teaching medical students about the importance of humility [
24]. Doing so may improve both the treatment and treatment provision experiences of patients and doctors. However, developing an awareness of humility and willingness to admit limitations in treating OAB may be challenging for doctors in Chinese cultures, in which doctors have become accustomed to high social status and deference, and thus a sense of arrogance among doctors may be inevitable. This also requires changing the stereotypes and expectations of doctors among the general public, which may prove difficult. Therefore, to enable primary care doctors to serve as gatekeepers in OAB care as suggested by the American Urological Association, it is crucial to enhance their knowledge about OAB through continuing medical education so that they are empowered in long-term care provision for patients with OAB and can preserve their professional dignity without breaking the taboo of admitting their limitations. Introducing empathetic communication skills and addressing the specific psychological needs of patients with OAB in undergraduate, postgraduate, and continuing medical education may yield improved experiences for both patients and doctors. These skills are particularly critical for primary care doctors because they are the first contact point for patients, and should aim to provide continual and comprehensive care to patients.
Table 1
Conflicting explanatory models between the sampled doctors and their patients with OAB
Perception on the patients’ bladder complaints | 1. Chronic condition | 1. Infection due to rare bacteria |
Expectations of treatment | 1. Consultation and physical examination alone are considered as treatment 2. Prescribing medication is not necessary | 1. Being prescribed with medication is a norm; merely consultation and physical examination are not enough to accomplish a treatment 2. Expect antibiotics in some cases |
Expected outcome | 1. Limitations to confirm OAB in primary care setting 2. Full recovery as impossible since OAB is a chronic condition | 1. Expect definite diagnosis from doctors 2. Expect quick recovery 3. Not aware of the treatment limitations |
When failing to experience improvement | 1. Patience is required to see the improvement because of the limitations of current treatment 2. Suggest referral | 1. Blamed doctors as incapable, deceptive money-making, prolonging treatment with bad intention to extract more money 2. Refuse referral |
Communication style | 1. Adopted casual communication style to ease patients’ embarrassment | 1. Doctors were expected to show sincerity and empathy; casual communication style was perceived as unacceptable |
History taking | 1. Norm to ask for every possibility | 1. Felt offensive when asked about their sexual life and substance abuse habit |
Limitations
This article summarises the experiences of the sampled doctors in treating patients with OAB in Hong Kong, thus the findings are specific to Hong Kong. Although performing a cross-comparison with primary care providers who have treated patients with OAB in other cultures is difficult because of the paucity of foreign literature on this topic, the current findings still provide an initial understanding that may be generalised to other cultures. The findings of this article were based on a sample of 30 primary care doctors working in the private sector in Hong Kong. Primary care doctors working in the public sector were excluded. Further research using larger samples with more therapeutic settings may provide a more holistic understanding of primary care doctor experiences in treating patients with OAB. Furthermore, this study was conducted by a single researcher. All the research procedures, including study conception and design, data collection, data analysis, and the writing of this article, were conducted by the researcher. Although data collection conducted by a single researcher ensured interview quality and consistency, it rendered the crosschecking of the entire study with other researchers impossible. To overcome the limitations raised by the participation of a single researcher, recoding of the transcripts was performed 1 month after the initial coding, which enabled the crosschecking of the analysed data, and to ensure that the codings and categories were free of ambiguity and overlap.
Competing interests
The author has no competing interests to declare.