Is the communicative behavior of GPs during the consultation related to the diagnosis?: A cross-sectional study in six European countries

https://doi.org/10.1016/j.pec.2004.02.004Get rights and content

Abstract

This study explores the relation between the diagnosis made by the general practitioner (GP) and his or her communicative behavior within a consultation, by means of the analysis of 2095 videotaped consultations of 168 GPs from six countries participating in the Eurocommunication study. The doctors’ diagnoses were coded into ICPC chapters and merged into seven clinically relevant diagnostic clusters. The communicative behavior was gauged by means of the Roter interaction analysis system (RIAS). We found the most important differences for consultations about psychosocial problems as compared to all other diagnostic categories. In these consultations, doctors show more affective behavior, are more concerned about having a good relationship with their patients, ask more questions and give less information than in other consultations. The percentages of utterances in the other diagnostic categories were pretty similar. The communicative behavior of doctors reflects a global pattern in every consultation. This pattern is the most stable for affective behavior (social talk, agreement, rapport building and facilitation). Within instrumental behavior (the other categories), the directions and the information the doctor gives are adapted to the problems presented.

Introduction

Some decades ago the shift from doctor centered medicine towards patient centered care was made. Nowadays, the doctor is no longer seen as the expert whose advice has to be followed without questioning. The emphasis of treating diseases has shifted towards caring for the whole person. Patients’ expectations, their need for reassurance and support became more and more important. Meeting the affective needs (care aspects like support, reassurance, partnership building) as well as the instrumental needs (cure aspects like medical questioning, examination, giving information, counseling, giving advice) has become inevitable [1].

Several studies emphasized the importance of doctors’ communication skills in relation to patients’ compliance, satisfaction and to clinical outcomes [2], [3]. Prevention of somatisation [4], recognition of mental disorders [5], [6] and referral and prescription rates [7] are also strongly related to the doctor–patient communication.

In general, studies on communication focus on two topics: describing task-related (“cure”) aspects of communication (e.g. information giving and information seeking behavior of doctors and patients) and describing the “care” related behavior of doctors, e.g. focussing on the context of the patient, empathizing and reassuring [8], [9], [10], [11].

The evidence about communication found in literature deals with the generic aspects of communication skills [12], [13]. A lot of questions remain unanswered: are the communicative principles the same for every person, for every complaint, in every stage of the life?

Most of the studies focus on the communicative behavior of doctors and patients without taking into account the diagnosis or the reason for encounter. Some studies have assessed the concordance about reason for encounter between doctor and patient [14]. Other studies focus on the communicative behavior in consultations about a specific medical diagnosis like high blood pressure, weight control or rheumatoid arthritis and medically unexplained complaints [15] or mental illness [5], [6]. In 1997, Roter et al. determined communication patterns of general practitioners (GPs) [16]. They defined five different styles, but also showed that these styles predominantly were determined by the characteristics of the doctor. This study did not explore the relationship with diagnoses.

Patients have access to medical information and ask for the best available cure for their problem. Randomized controlled trials produce evidence for treatment and this stimulates the development of protocols to handle a disease. The number of guidelines suggests that, at least in medical technical respect, every health problem requires its own treatment. The question can be asked if a disease requires not only its own medical technical treatment but also its own communication?

Although one can easily make hypotheses about the relation between communicative style and complaint none of the studies we found compared the communicative behavior of the doctor in relation to the diagnosis or provided a theoretical framework.

In this observational, explorative study we focus on the relation between communication and diagnoses. The first step in answering this question is looking at the reality within practice. Do GPs adapt their communicative behavior in relation to the diagnosis?

Therefore we focus on the following questions:

  • Is the communicative behavior of GPs different for different diagnoses?

  • If so, which are the characteristics of these differences?

Section snippets

Method

To answer those questions we used the data form the Eurocommunication study [17]. Doctor patient communication was compared in six European countries: The Netherlands, United Kingdom, Spain, Belgium, Germany and Switzerland. The Netherlands Institute for Health Services Research (NIVEL) institute carried out the co-ordination, analyses and reporting. National coordinators from universities and research institutes were responsible for implementing the study and collecting the data in their

Description of the population studied

The representativity of the GPs in the Eurocom study was documented in previous publications [17], [26], [27], [28] showing that the workload was lower and the percentage of female doctors and city practices were both higher as compared to the mean of the participating countries.

The inter-rater reliability of the video observers in the Eurocom study was measured by calculating Pearson’s correlation coefficients between the ratings of pairs of observers, for 20 consultations (per country) of

Discussion and conclusion

Looking at the communicative behavior across the seven diagnostic categories, based on ICPC chapters, we found the most important differences between consultations about psychosocial problems and the other diagnoses. In these consultations doctors showed more affective behavior, were more concerned about good relationships with their patients, asked more questions and gave less information than in other consultations.

Across the other diagnostic categories the percentages of utterances were

Acknowledgements

This study has been funded by the BIOMED-II research program of the European Union (contract no. BMH4-CT96-1515) and by the FWO-Belgium (F9885). The authors thank the national coordinators for the BIOMED program: L. Gask, N. Mead (UK), O. Bahr (Germany), A. Perez (Spain), V. Messerli, M. Peltenburg, L. Oppizzi (Switzerland). The authors thank the general practitioners that participated in this study. We thank the colleagues–researchers for their useful comments of and suggestions for the

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