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Agreement between health professional and patient

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Agreement between health professional and patient
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DOCTOR–PATIENT COMMUNICATION
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recommended patient centredness as the preferred style of doctor–patient communication as a means to improve patient outcomes (Neighbour 1987; Pendleton et al. 1984;
McWhinney 1995). Further, empirical research has explored both the extent to which
consultations can be deemed to be patient centred. For example, in one classic study
Tuckett et al. (1985) analysed recorded consultations and described the interaction
between doctor and patient and a ‘meeting between experts’. Research has also
addressed whether patient centredness is predictive of outcomes such as patient satisfaction, compliance and patient health status (Henbest and Stewart 1990; Savage and
Armstrong 1990). Such research has raised questions concerning both the definition of
patient centredness and its assessment which has resulted in a range of methodological
approaches. For example, some studies have used coding frames such as the Stiles verbal
response mode system (Stiles 1978) or the Roter index (Roter et al. 1997) as a means to
code whether a particular doctor is behaving in a patient centred fashion. In contrast,
other studies have used interviews with patients and doctors (Henbest and Stewart
1990) whilst some have used behavioural checklists (Byrne and Long 1976). Complicating the matter further, research studies exploring the doctor patient interaction and the
literature proposing a particular form of interaction have used a wide range of different
but related terms such as shared decision making (Elwyn et al. 1999), patient participation (Guadagnoli and Ward 1998) and patient partnership (Coulter 1999). However,
although varying in their operationalization of patient centredness, in general the construct is considered to consist of three central components; namely (i) a receptiveness by
the doctor to the patient’s opinions and expectations and an effort to see the illness
through the patient’s eyes; (ii) patient involvement in the decision making and planning
of treatment; and (iii) an attention to the affective content of the consultation in terms of
the emotions of both the patient and the doctor. This framework comparable to the six
interactive components described by Levenstein and colleagues (Levenstein et al. 1986)
and is apparent in the five key dimensions described by Mead and Bower (2000) in their
comprehensive review of the patient centred literature. Finally, it is explicitly described by
Winefield and colleagues in their work comparing the effectiveness of different measures
(Winefield et al. 1996). Patient centredness is now the way in which consultations are
supposed to be managed. It emphasizes negotiation between doctor and patient and
places the interaction between the two as central. In line with this approach, research
has explored the relationship between health professional and patient with an emphasis
not on either the health professional or the patient but on the interaction between the
two in the following ways: the level of agreement between health professional and
patient and the impact of this agreement on patient outcome.
Agreement between health professional and patient
If health professional–patient communication is seen as an interaction between two
individuals then it is important to understand the extent to which these two individuals
speak the same language, share the same beliefs and agree as to the desired content and
outcome of any consultation. This is of particular relevance to general practice consultations where patient and health professional perspectives are most likely to coincide.
For example, Pendleton et al. (1984) argued that the central tasks of a general practice
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94 HEALTH PSYCHOLOGY
consultation involved agreement with the patient about the nature of the problem, the
action to be taken and subsequent management. Tuckett et al. (1985) likewise argued
that the consultation should be conceptualized as a ‘meeting between experts’ and
emphasized the importance of the patient’s and doctor’s potentially different views of the
problem.
Recent research has examined levels of agreement between GPs’ and patients’ beliefs
about different health problems. Ogden et al. (1999) explored GPs’ and patients’ models
of depression in terms of symptoms (mood and somatic), causes (psychological, medical,
external), and treatments (medical and non-medical). The results showed that GPs and
patients agreed about the importance of mood-related symptoms, psychological causes
and non-medical treatments. However, the GPs reported greater support for somatic
symptoms, medical causes and medical treatments. Therefore, the results indicated that
GPs hold a more medical model of depression than patients. From similar perspective,
Ogden et al. (2001a) explored GPs’ and patients’ beliefs about obesity. The results showed
that the GPs and patients reported similar beliefs for most psychological, behavioural and
social causes of obesity. However, they differed consistently in their beliefs about medical
causes. In particular, the patients rated a gland/hormone problem, slow metabolism and
overall medical causes more highly than did the GPs. For the treatment of obesity, a
similar pattern emerged with the two groups reporting similar beliefs for a range of
methods, but showing different beliefs about who was most helpful. Whereas, the
patients rated the GP as more helpful, the GPs rated the obese patients themselves more
highly. Therefore, although GPs seem to have a more medical model or depression they
have a less medical model of obesity. Research has also shown that doctors and patients
differ in their beliefs about the role of the doctor (Ogden et al. 1997), about the value of
patient centred consultations (Ogden et al. 2002), about the very nature of health
(Ogden et al. 2001b), about chronic disease and the role of stress (Heijmans et al. 2001)
and in terms of what is important to know about medicines (Berry et al. 1997). If the
health professional–patient communication is seen as an interaction, then these studies
suggest that it may well be an interaction between two individuals with very different
perspectives. Do these different perspectives influence patient outcomes?
The role of agreement in patient outcomes
If doctors and patients have different beliefs about illness, different beliefs about the role
of the doctor and about medicines, does this lack of agreement relate to patient outcomes? It is possible that such disagreement may result in poor compliance to medication
(‘why should I take antidepressants if I am not depressed?’), poor compliance to
any recommended changes in behaviour (‘why should I eat less if obesity is caused by
hormones?’) or low satisfaction with the consultation (‘I wanted emotional support and
the GP gave me a prescription’). To date little research has explored these possibilities.
One study did, however, examine the extent to which a patient’s expectations of a
GP consultation were met by the GP and whether this predicted patient satisfaction.
Williams et al. (1995) asked 504 general practice patients to complete a measure of their
expectations of the consultation with their GP prior to it taking place and a measure of
whether their expectations were actually met afterwards. The results showed that having
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