Joe and Brenda are now in their 60s they have a number of chronic healthcare problems some of which will put them at risk of life limiting pathology (hypertension) and others detract from their quality of life (low back pain). Everyone involved in providing healthcare to this couple wants the best for them. Best case scenario Joe and Brenda are satisfied every time they consult their doctor and improve from whatever ails them. It is also better if their use of the healthcare resources is minimised. But what predicts that outcome?
In 2001 the BMJ considered the issues. Paul Little and his colleagues approached three local practices that served 24 100 patients. They invited consecutive patients attending the surgery to participate. All patients able to complete the questionnaire were eligible. 661 participants completed a questionnaire before their consultation in which they were asked to agree or disagree with statements about what they wanted the doctor to do. A questionnaire after the consultation asked patients about their perception of the doctor’s approach. Both questionnaires were based on the five main domains of the patient centred model: exploring the disease and illness experience, understanding the whole person, finding common ground, health promotion, and enhancing the doctor-patient relationship
The post-consultation questionnaire included items about the reason for consultation and a positive and definite approach of the doctor to diagnosis and prognosis as well as sociodemographic details, the short state anxiety questionnaire, number of medical problems, and current treatment. The team also included questions relating to important patient related outcomes from the consultation: enablement (six questions about being enabled to cope with the problem and with life), satisfaction (medical interview satisfaction scale), and symptom burden (measure yourself medical outcome profile, which measures the severity of symptoms, feeling unwell, and daily restriction of activity). Patients were followed up after one month with the measure yourself medical outcome profile, and the team reviewed the medical records after two months for reattendance, investigation, and referral.The outcome measures of interest were patients’ enablement, satisfaction, and burden of symptoms. Factor analysis identified five components:
- Communication and partnership (a sympathetic doctor interested in patients’ worries and expectations and who discusses and agrees the problem and treatment);
- Personal relationship (a doctor who knows the patient and their emotional needs);
- Health promotion;
- Positive approach (being definite about the problem and when it would settle); and
- Interest in effect on patient’s life.
- Satisfaction was related to communication and partnership and a positive approach.atisfaction was reduced if expectations were not met for communication and partnership, a positive approach, and an examination but were not affected by expectations of a prescription.
- Enablement was greater with interest in the effect on life, health promotion, and a positive approach. Enablement was also less if expectations were not met for an examination, health promotion, and a positive approach.
- A positive approach was also associated with reduced symptom burden at one month. Symptom burden at one month was worse if expectations of a positive approach were not met.
- Referrals were fewer if patients felt they had a personal relationship with their doctor.If expectations of a personal relationship were not met, referrals were more likely.
- To have their perspective considered by someone who clearly cares
- To be examined
- To have the impact of the illness on their lives taken into consideration
- To be advised when they are likely to feel better and
- To receive advice on how to avoid problems in the future
In return they will use healthcare resources less and their symptom burden will reduce. All this might be achieved without major policy reform and can be implemented locally to improve the patient experience and by corollary reduce the strain on healthcare resources.
Picture by Jenny Mealing