Formato de entrevistas de estudiantes y docentes

An early example of this type of study was undertaken to determine if patient-centred interviews were related to positive outcomes (Stewart, 1984). Stewart defines patient-centred interactions as:-

"those in which the patient's point o f view is actively sought by the physician. This implies that the physician behaves in a manner that facilitates the patient's expressing himself and that, for his part, the patient speaks openly and asks questions"(Stewart 1984).

The two hypotheses tested in this study draw on categories of behaviour from Bales' Interaction Process Analysis System and are set out below.

1) The following categories of emotional tone will be related to patient compliance and satisfaction: a patient's giving suggestions, giving opinions, giving information, disagreeing, showing tension and antagonism and a physician showing solidarity, expressing tension, agreement, asking for opinions, asking for suggestions and asking for help.

This hypothesis is based on the notion that in patient-centred care, the important physician behaviours are those that are supportive and which encourage the patient to express him/herself. Important patient behaviours are expressions of feelings, including those that are negative and active participation through offering suggestions and providing information.

2) When physician and patient behaviours are considered together, high patient compliance and satisfaction will be related to interactions in which both the doctor and patient show the desired behaviour. Moderately high compliance and satisfaction are predicted when the physician demonstrates a high frequency of supportive and encouraging behaviours in the presence or absence of desired patient behaviours.

This contention is based on the belief that although patient characteristics influence the quality of interactions, the physician's facilitating behaviour is essential and will determine whether the patient expresses him/herself or not. To test this hypothesis each interaction studied was designated one of the following categories:-

(A) high frequency of the desired patient behaviour and the corresponding physician behaviour, (B) high frequency of physician behaviour, but low frequency of patient behaviour,

(C) low frequency of physician behaviour and high frequency of the patient behaviour, (D) low frequency for both patient and physician.

The study was conducted in 24 family physician offices where 140 consultations were audiotaped. Physicians were not told of the hypotheses regarding patient-centred interactions. Patients suffering from either new or continuing illnesses were eligible for the study but those visiting for psychotherapy were not, as these interviews tended to be long and complex. Some patients received new prescriptions on the day they were audiotaped and others were on long-term medication, which had been prescribed on a previous visit. Ten days after their audiotaped consultation, patients were interviewed by a research assistant to assess the two outcome measures of satisfaction and compliance. Satisfaction was measured on a 17 item scale developed by Zyzanski and Hulka, 1974. Fourteen items measured patient satisfaction with professional competence and 3 the personal qualities of the physician. Compliance with medication was measured in two ways:- (i) the patient's subjective report of missed doses and (ii) an objective pill count. The audiotapes were analysed using Bales Interaction Process Analysis (Bales, 1951).

To test the first hypothesis, interviews containing high levels of patient-centred statements were compared with those having low levels. Interviews in which physicians obtained high scores on patient-centred behaviour in general reflected higher patient satisfaction, but this was not statistically significant. Specific physician behaviours that were significantly related to high patient satisfaction were 'asking for opinions' and 'asking for help'. High patient satisfaction was also associated with two specific patient behaviours, namely 'giving opinions' (statistically significant) and 'showing tension' (approaching significance). Physicians' patient-centred behaviours combined were significantly associated with patient's reported compliance and approaching significance in relation to the pill count measure. The only specific physician behaviour related to compliance was 'agreement'. Patient behaviour in general was not significantly related to compliance.

The second hypothesis focused on the congruence of patient and physician behaviours. It was found during interviews in which both physician and patient had demonstrated the desired behaviours (group A), there were significantly higher numbers of compliant patients. Least compliance was found in patients who had interviews in which neither physicians nor patients

demonstrated expression of opinions and suggestions. These findings support the second hypothesis. However, there were no significant associations between group A interviews and satisfaction.

From this study, Stewart concluded that physician behaviour is crucial to the interaction and in general, a positive outcome depends on behaviour which is facilitating rather than dominating. The main draw-back of this study is the use of Bales' system of interaction process. As described in the previous chapter. Bales' system has two main weaknesses. First, because affective and information transfer categories are separate, it is difficult to code a statement which involves information transfer and has affective importance. The coder has to choose between the two. Secondly, the categorisation of information transfer into 3 main categories i.e. 'suggestion', 'opinion' and 'orientation' is not detailed enough for describing information exchange in clinician-patient encounters.

In a later prospective follow-up (or cohort) study, Henblest and Stewart (1990) investigated both patient and doctor outcomes in relation to patient centredness. Patient-centred care was defined as:-

"care in which the doctor responded to the patient in such a way as to allow the patient to express all o f his or her reasons for coming to the doctor, including symptoms, expectations, thoughts and feelings"(Henblest & Stewart, 1990).

The study was conducted in the consulting rooms of 6 family doctors practising in small towns in south-western Ontario. Seventy three patients (all presenting with a new symptom) had their consultation audiotaped and later scored by an independent rater using the patient centredness method (Henblest and Stewart, 1989). After each consultation patients were asked to complete the self-report Medical Interview Satisfaction Scale (MISS), (Wolf et al, 1978). This was then followed by a structured interview and 2 weeks later a second assessment of patients' satisfaction was obtained by follow-up telephone interview. The authors postulated that patient-centredness would be positively associated with six main outcomes:-

i) attainment by the doctor of the patient's reasons for attending; ii) doctor-patient agreement regarding the patient's problem; iii) the patient feeling understood by the doctor;

iv) patient satisfaction with the consultation; v) resolution of the patient's symptoms; vi) resolution of the patient's concerns.

Each of these hypotheses was measured and correlated with patient-centred scores obtained from the patient-centredness rating sheet. Patient-centred scores ranged from 0.58 to 1.92 (out of a possible 3.0) with a median of 1.00.

For the first hypothesis, 82% of patients discussed their reasons for attending, but only 25% reported that their reasons were Very well understood' and only 7% stated that all of their reasons had been fully explored. It was found that patients who had experienced a patient-centred consultation were significantly more likely to report that their reasons for coming had been discussed completely; the importance of each had been understood by the doctor and that if asked after the consultation, the doctor would know the reasons why the patient had come.

Approximately 75% of patients agreed 'completely' with the doctor's assessment of their main symptom. No association was found between doctor-patient agreement regarding the patient's problem and patient-centredness.

Patients' feeling of being understood was measured by asking them to respond to the statement; 'I really felt understood by this doctor', on a five point scale as part of the MISS. It was found that 61% of patients who had experienced patient-centred consultations agreed strongly that they felt understood by the doctor compared with 36% who had not had patient centred visits. However, this result was no longer significant after controlling for confounding variables.

The median score of the Medical Interview Satisfaction Scale was 4.20 out of a possible total of 5.00. Ninety percent of telephone follow-up patients were at least 'quite satisfied' with their consultation and only 50% 'very satisfied'. No significant relationship was found between patient- centred scores and the post consultation satisfaction measure or the follow-up assessment. However, although not statistically significant, consultations in the highest patient-centred quartile had the largest percentage of patients who were highly satisfied (46% versus 15% in the lowest quartile).

The last two hypotheses focused on the association between patient-centredness and physical recovery. The amount of discomfort caused by the main symptom was assessed at the time of the consultation and two weeks later. The number of patients' concerns were measured before and after the consultation. These concerns included the seriousness of the symptoms, expectations of what might need to be done, specific thoughts or fears of what the problem might be, and any problems of living. In addition, patient concern regarding the seriousness of the main complaint was re-assessed during the two week follow-up interview.

Nearly half of patients complained of a great deal of discomfort and 50% had their main symptom resolved completely by two weeks. No significant association was found between patient- centredness and symptom resolution at 2 weeks. Over half of patients were initially at least a 'fair amount' concerned about their symptom. Over one third still had some concern two weeks after the consultation. There was no association between severity of the symptom and patient level of concern at the time of the consultation. A significant relationship was found between the level of discomfort and patient concern at two weeks, i.e. the greater the level of discomfort present, the greater degree of concern. It was also found that patients who had received the highest level of patient-centred care were significantly more likely to have decreased concern about that symptom immediately after the consultation than patients who had less patient-centred care.

The main findings of this study were that patient-centredness was associated with the doctor having ascertained the patient's reasons for coming and with the resolution of patients' concerns. The authors therefore, contend that a patient-centred approach 'really does make a difference'. They also note that only when a high level of patient-centredness was achieved was patient-centred care related to outcomes. However, they could not draw any conclusions concerning patient-centredness and satisfaction as larger numbers of patients are needed for this. The limitations of this study stem from the flawed method of rating patient-centredness (described in the previous chapter). The scoring sheet is drawn up so as to record doctor responses to patient utterances (or offers) rather than vice versa, i.e. the patient's response in the light of the doctor's preceding behaviour. By definition this method is biased towards the patient as only one side of the consultation being studied in detail (the patient's). Some consultations may have long periods where a patient expresses his or her thoughts in response to, for example, two facultative utterances from the doctor and this would be scored as patient-centred. However, if the patient expressed his or her thoughts in response to closed ended responses by the doctor, the scoring method would classify the consultation as having a low level of patient centredness, even though the patient expressed his or her thoughts in an expanded form.

Another limitation of the study is that the patients selected were those whose presentation included a new symptom. Therefore, if the sample was not restricted to patients only presenting with new symptoms this may have reduced the strength of association between satisfaction and patient centredness as defined by the authors. It is possible that patients with established problems may have already expressed their expectations, thoughts and feelings about their condition during a previous visit.

A larger study concerning the relationship of medical interviewing and patient satisfaction was conducted by Bertakis et al (1991). Interviews from 550 return visits to 127 different physicians were audio-recorded and analyzed using the Roter Interaction Analysis System (BIAS). A post visit satisfaction questionnaire was completed by each patient. The questionnaire included 43 items

related to different aspects of patient satisfaction and one global satisfaction item. Each item was measured on a five-point Likert scale where a low score indicated more satisfaction. The questionnaire was subjected to a principal components analysis from which 5 distinct factors emerged. These were: (1) task-directed skill, (2) interpersonal skill, (3) attentiveness, (4) emotional supportiveness and (5) partnership. It was found that task-directed satisfaction was the most important factor affecting patients' overall satisfaction - explaining 31% of the variance in global satisfaction.

This study specifically focused on patients in established on-going relationships with primary care physicians. The majority of physicians (75%) were audiotaped in hospital clinic settings, with the remainder in solo or small group practices. The relationship between actual communication during the interview and different dimensions of patient satisfaction were explored.

It was found that communication regarding psychosocial topics was consistently related to satisfaction. There was an inverse relationship between physician question asking (open and closed- ended) about biomedical topics, compared with psychosocial topics. The former variable was negatively correlated to almost all aspects of satisfaction, whilst the latter was positively related. Patient talk concerning biomedical topics was negatively related and psychosocial talk was positively related. The ratio of physician to patient talk was also related to satisfaction, i.e. the more the physician talked relative to the patient during the interview, the less satisfied patients were on all satisfaction dimensions. This was regardless of the length of the visit.

Global affective ratings of interviews were also made. Physician dominance had a negative relationship to patient satisfaction, whilst friendliness and interest had a positive relationship. Several demographic variables were also related to satisfaction. In general, older white patients experienced the greatest satisfaction. Women were more satisfied than men only in terms of emotional supportiveness. Affluent patients were more satisfied than less affluent patients on interpersonal skills but less so with supportiveness.

The authors concluded from their study that patients are most satisfied by interviews that enable them to talk about psychosocial issues conducted by a non-dominant, friendly and interested physician. However, a limitation of the research is that no baseline measures of psychological morbidity were collected. It is possible that the discussion of psychosocial information with patients suffering from an underlying mood disturbance may have influenced high satisfaction rates.

The majority of process-outcome studies have tended to focus on general practice or primary care situations. The following work by Butow and colleagues (1995) is a notable exception. Having developed a cancer-specific interaction analysis system (CN-LOGIT), this research group went on

to use it to investigate the relationship between doctor-patient behaviour and patient outcomes in the cancer consultations of one oncologist. The authors hypothesised that patient satisfaction, psychological adjustment and information recall would be higher in patients whose consultations were patient centred, i.e. where:-

i) the doctor is rated as affiliative, friendly and relaxed;

ii) the doctor talks more about social and non-medical matters; iii) patients have more input into the consultation;

iv) the patient's questions are answered.

Participants were 142 newly referred patients with cancer attending for an interview with a medical oncologist. Prior to the consultation patients completed the 20-item Spielberger State Anxiety Scale (Spielberger, 1983) and two items designed to assess preferences for information and involvement in decision-making. The latter instrument was derived from the Information Styles Questionnaire (Cassileth et al, 1980). Each consultation was audiotaped and analysed using CN- LOGIT. Patients were contacted by telephone 1 - 3 weeks after the consultation to assess recall. A patient satisfaction and a psychological adjustment to cancer (PAG) questionnaire were sent separately by mail (Dunn et al, 1993).

The interaction analysis system used in this study (described in the previous chapter) enabled an in-depth description of the oncology consultation in terms of the frequency and duration of content areas and forms of language. However, no effects were found for psychological adjustment, satisfaction or recall. None of these outcomes were affected by consultation style, doctor affect, duration of conversation about non-medical matters or the ratio of doctor to patient talk. Of note was the finding that patients whose questions were answered reported feeling that cancer had less of an impact on their daily lives and thus showed better psychological adjustment. The lack of positive outcome findings is most likely due to the consultation style of the single oncologist not being significantly variable along these dimensions. A larger study with more than one participating oncologist would need to be conducted in order to achieve more meaningful results.

The above studies investigated the value of patient centred interviewing techniques in relation to various outcomes. The authors of each study had different interpretations of the meaning of patient centredness. It is apparent from the literature that there is no agreed 'gold standard' (Mead & Bower, 2000a). This lack of an agreed definition of patient centredness has led to some ambiguity over the meaning of this concept and has hindered the development of valid, reliable methods for measuring it and its outcomes. It is therefore, important for researchers to exercise caution in their choice of measurement method because of differences in how the concept of patient centredness is

operationalised. Studies employing different methods of quantifying patient-centredness may not actually be measuring the same domain of care (Mead & Bower, 2000b).