Doctor-patient interactions with respect to type of practice

INTRODUCTION

The doctor-patient relationship is the core foundation for healing, care, establishment of trust and an essential part of modern-day medical ethics. In health care setting, trust and communication are labelled a tool for better patient care and patient satisfaction.¹ The doctor patient relationship consists of the six C’s: choice, competence, communication, compassion, continuity and no conflict of interest. All of the six C’s are required for maintenance of this relationship.² Since a long time, the doctor patient relationship has been of one to one communication. The last few decades have seen an exponential growth in the scientific component of the medical field which has led to a strain on this relationship.³ In this fast-paced resource limited environment, doctor-patient relationship is lost.

There is a need to analyse the growing distance in the physician patient relationship in terms of the management of chronic conditions. Here a substantial dependence on the patient and encouragement from the practitioner is needed to ensure compliance to their treatment regime and lifestyle modification. Considering the growing trend of patients wanting more information from their doctor in order to have a more active role in their health-care, active communication from the physician’s end is needed.^1,3

There has been a shift in how a patient is diagnosed. A greater reliance is seen on a battery of tests like X-rays, blood tests, scans, and other investigations carried out in specialized laboratories or clinics in part to ensure established evidence to combat the wave of growing litigations faced by a practitioner. The discovery of a system of cut practice amongst the medical fraternity has also led to a sense of distrust between patients towards their treating physician.⁴

For any mistakes made by a doctor they are judged not merely as being unskilled and being poor businesspeople, but also considered morally blameworthy, as having not lived up to patients’ expectations, and having violated the trust that is an essential and moral feature of the doctor–patient relationship.⁵

It is necessary to establish a healthy relationship not only for the patient but also for the doctor. The status of doctor-patient relationship determines the ease of information disclosure from both sides. A better relationship results in more complete medical history, improved clinical judgment with regard to laboratory tests and procedures, more accurate diagnoses, more cost-effective prescribing, a more satisfied patient who is more informed and adherent to the treatment plan, and overall better treatment outcomes.^6-11

Though there are a few studies which examined the doctor patient relationship from patient’s point of view, the doctors view in this regard is seldom studied. Present study aims to find out what doctors over various fields expect out of this relationship.

Objectives of this study was to analyse the doctor-patient interactions while communicating with the patient. The study was to evaluate the association of problems in communicating with the patient with respect to experience of doctor and also to compare duration of consultation with respect to qualification of doctor.

METHODS

A cross sectional prospective study was conducted among a total of 49 urban and rural doctors of various specialties in a semi urban area of Maharashtra using a pre-structured questionnaire. The study was conducted at MIMER Medical college, Talegaon dab hade, Pune. The study was anonymous and consent was taken prior to participation in the study. Graduation from the respective medical course was the selectin criteria for the participants. Non-consenting participants as well as undergraduates (interns) were excluded from the study. The study was completed in a duration of three months between January 2016 to March 2016.

Data was collected in a pre-structured questionnaire consisting of both open and close ended questions. All data to the questions was entered into a spreadsheet and reviewed for accuracy before analysis. Time spent by the doctor was analysed with respect to their specialty and experience of the physician. Several aspects such as communication and behaviour of the physician was analysed with regards to the practice and experience of doctors. Each aspect of the study was studied separately. The statistical tools used to analyse the data was by using Microsoft excel software.

RESULTS

Doctors of different pathies were included in the study with 7 belonging to MBBS, 22 being specialists and 20 practicing BAMS and BHMS combined respectively. Out of the 49 participants, 35 (71%) were males and 14 (29%) were females and the average age was 40±11.88 years. The mean experience of these doctors was found to be 15.74±11.52 years.

Total time given by a doctor to a patient can broadly be divided into four areas namely History taking, clinical examination, explanation of drug and answering patient queries. This was studied with respect to type of pathies (Figure 1).

It was observed that time spent during consultation was reported to be maximum for history taking irrespective of the type of practitioner. It was also noted that time spent with patients was less by the specialists as compared with other doctors for all aspects of consultation. BAMS or BHMS doctors reported to spend less time for clinical examination as compared to other aspects of consultation. However, these differences were not statistically significant.

Time spent by doctors was also studied with respect to the experience of the doctors (Table 1).

On evaluating experience with the duration of consultation, we noted that doctors having more than 30 years of experience gave lesser time for all aspects of consultation as compared to those with lesser experience. Doctors with experience between 11-20 years spent maximum duration of time 11.88±8.21 mins in history taking while the least amount of time 6.6±2.35 was spent by doctors with more than 30 years of experience. We observed that doctors with more than 30 years of experience had no variation in the time given with respect to the component of the consultation. Another interesting finding was that a wide range of time allotted when the experience was less than 20 years (1-30 min), while doctors with more than 30 years of experience showed a meagre variation (5-10 min). Behaviour of doctors with patients was studied with respect to their specialty (Table 2).

Across MBBS and alternative medicine practitioners, 86% and 95% respectively emphasized on adequately greeting the patient and ensuring that their social problems were addressed during the visitation while this was followed by only 68-72% of specialists. MD doctors gave significant priority to ensuring patients had a prior appointment (73%) as opposed to other practitioners (MBBS: 43%, BAMS, BHMS: 70%). A close range, between 45%-57% of all physicians, admitted to answering phone calls during consultations. Maximum apprehension was felt by BAMS, BHMS doctors (20%) while treating patients of the opposite gender followed by MD (14%) and MBBS (0%) practitioners. However, the difference between the behaviour was not statistically significant. Behaviour of doctors with patients was studied with respect to their experience (Table 3).

All the doctors who had more than 30 years of experience reported that they greeted the patients and that the patients were free to discuss their social and emotional problems with them. More than 75% younger doctors gave appointments to the patients and the percentage was more as compared to those who had more experience. Percentage of doctors who greeted the patients increased with experience. Answering phone calls during consultation was least in those with the least experience. Less than 20% of the doctors reported that patient found it difficult to confide in opposite sex.

DISCUSSION

The doctor patient interaction has been the centre of study since decades. However, very few studies have been conducted to understand the doctor’s perspective. We have evaluated the duration of consultation against the specialty and experience of the physician.

Robbins et al, studied patient satisfaction in an academic family medicine practice and found that the time a physician spent in health education and the effects of treatment had an important bearing on patient satisfaction.¹² Our study indicates that time invested for answering queries and explaining drug schedule by specialists was the least.

Phone calls during consultation subject the physician to a risk of committing more medical errors, compromising patient safety and have an adverse effect on the doctor patient interactions.¹³ More than half (51%) of our study population answered phone calls during consultation.

In our study, a majority of physicians believed that patients had no issues confiding in them irrespective of the gender. This is in contradiction to another study which suggests that higher patient satisfaction was observed when patients chose physicians of opposite sex than those opting physicians of the same sex.¹⁴

It is reported that physicians under 50 years of age had a greater rate of dissatisfaction (33%) with the amount of time they spent with patients than those older than 50 (23%).¹⁵ Thus, how much time a doctor spends with his patients during consultation is important from both doctors as well as patient satisfaction. There was a lower range of time devoted for every aspect of the consultation for doctors having more than 30 years of experience. This may be because they might be requiring less time to diagnose because of their experience. However, a literature review analysing 62 published studies that assessed physician knowledge and quality of care against time since graduation and experience found that a majority 63% noted a decreasing performance with increasing years of practice for almost all outcomes measured.¹⁶

Other studies of patient satisfaction and visit length have come from Great Britain. Morrell et al and Ridsdale et al both found a greater likelihood of patients feeling they had inadequate time with their physician in visits scheduled to last 5 minutes compared with visits scheduled to last 10 and 15 minutes, respectively.^17,18 Moreover 33% patients of physicians with a greater rate of malpractice suits claim that they had spent ten minutes or less with the physician as compared to only 12% patients of practitioners with no history of malpractice claims. In our study while 70% of the specialists spent less than 20 min with their patients, 50% of MBBS and other doctors spend more than 20 min.

Many research papers have stated that dissatisfied patients can lead to workplace violence. Study by Ciluz T et al, (Israel) observed that the most common causes of violence were long waiting time (46.2%), dissatisfaction with treatment (15.4%) and disagreement with the physician (10.3%).^19,20

The doctor patient relationship is greatly influenced by the doctor’s behaviour towards the patient and the objective time spent during a visitation. The growing trend overall is that doctors across all fields had to compromise some component of their consultation to meet the time crunch faced probably due to increased patient load. Thus, it is for the good of the doctors individually and for the society to give sufficient time to the patients.

CONCLUSION

It is imperative to study doctor-patient interactions since a better relationship results in a more satisfied patient with better treatment outcome. On assessing the duration of consultation with experience of the physician, more experienced consultants gave lesser time to patients. On comparing duration of consultation with the respective qualification of the doctor, it was noted that specialists spent less time with patients in all aspects of consultation. Interaction of doctors with patient was of better quality for experienced physicians compared to the lesser experienced doctors. However, it was worse for specialist as compared to general practitioners. In order to establish a healthy doctor-patient relationship it is critical to have effective communication and better patient satisfaction.

Hence it is necessary to sensitise doctors in the early years of practice towards good interaction with patients. Similarly, it is important to emphasise during post-graduation the importance of better communication with patients. In order to achieve complete or a holistic health care approach.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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