jurnal metode perawatan gigi anak3

8/12/2019 Jurnal Metode Perawatan Gigi Anak3

1/19


2/19

I D oc to r Pa tien t In te ra c tion and Pa tien t Sa tis fa c tionB arb a ra M K ors c h M D E th e l K G o z zi P H N M S n

V id a F ra n c is P H N M SD e p a r t m e n t o f P ed ia tric s, C h ild rens Hosp i ta l of L os A nge les , U n iv ers ity o f

Sou thern C a lifo rn ia , Scho o l o f M ed icine , L os A nge les

R e ceived Jan uary 12 ; rev isio n ac cep ted M ay 29 , 1 968 .)S uppor te d b C h ild ren s B ureau G ran t H -b .C o m puting ass istance w as ob ta ined from the H ea lth S ciences C o m puting F ac ility , U n iversity o f

C a lifo rn ia , L os A ng eles , sp onsore d by N a tio nal Institutes o f H ea lth G ran t F R -3 .B .M .K . is recip ie n t o f C areer D eve lopm ent A w ard 5 -K 3-H D -2 8 , 297-0 3 , N ationa l Institu tes o f

Health .ADDRESS: (B .M .K .) C hild re ns H osp ita l o f L o s A ng ele s, 4 61 4 S u nse t B ou lev ard , L o s A ngeles, C a li-

fo rn ia 900 27 .P E D I A T R I C S , V o l. 4 2 , N o . 5 , N ovem ber 1 968

GAPS IN DOCTOR PATIENT COMMUNICATION

85 5

T H E a rt of m edic ine has been thetop ic o f m uch d iscussio n b u t has n ev er

b een su b jected to scien tif ic sc ru tiny .W h ereas o th er asp ects o f m ed ica l p rac ticeare inc lu ded in the phy sic ian s train ing , theap proach to th e pa tien t is exp ec ted to be onthe basis o f intui t ion an d it is trad itio na llylea rned on ly b y precep t an d by exp e rience .

U n til recen tly , long -stand ing , on e-to -onere lationsh ips b etw een pa tien t an d phys ic ianw ere the ru le ra the r than the excep tion . Inth at settin g w arm th an d m u tua l und e r-stand ing cou ld d ev elo p an d flou rish . A s p at-te rns o f m ed ical ca re h av e changed , the in -d iv id ua l doc to r-pa tien t re la tio n is be ing re -p laced by short-te rm encoun ters w ith nu-m erous d ispara te sp ecia lists and o therhea lth w orkers . In add ition , the re is thed aily tes tim o ny to the d iscon ten t o f thecom m un ity w ith the m ed ica l ca re o ffe red .M ost espec ia lly , the re is c ritic ism aim ed a tthe lack o f w arm th and h um anity in theav a ilab le m ed ica l ca re . F ina lly the re is gen-eral aw aren ess , as w ell as m uch prin ted ev i-dence , o f th e fa ilu re of p a tien ts to ac ce p tm edica l adv ice . T h is cons titu tes fu rthe rd ocum en ta tion o f the b reak dow n of doc -to r-pa tien t co m m unica tio n . T he presen tstud y represen ts one effo rt to in troducem ore ob jective sc ien tific p rinc ip les in to th isim portan t face t o f m ed ical p rac tice . C areo f the d oc to r-p atien t rela tion has fo r toolo ng b een lef t to chance; because of its im -por tance to genera l p rac tice it m u st n ow beexam in ed , de fined , an d taug h t, fo r on lyth en can it be prac ticed effic ien tly .

It is gene ra lly he ld tha t pa tien ts healthbehav io r an d the ir re spo nses to m ed ica lcare a re in fluenced by th eir soc ia l, eco -nom ic, and cu ltu ra l h er itage , a s w ell as b ype rsona lity ch aracte r is tic s , p rev io us exp en i-ence , and k now ledge . I t is a lso as sum ed ,ho w eve r , tha t the w ay in w h ich th e p hys i-c ian app ro aches th e p atien t-ho w he re -spon ds to h im th at is , h is bedsid e m an-n er )-af fect the pa tien ts fee lings and be -h av io r. T he b asic hypo th es is o f the p resen ts tudy has been tha t the re is a r el at io ns hi pbe tw een th e n atu re o f the ve rb a l co m m u ni-ca tion be tw een do cto r and pa tien t, and theou tcom e in te rm s o f satis faction an d re-sponse to m ed ica l adv ice .

F o r tech n ical rea sons the stu dy w as lim -ited to docum enta tion of v erba l com m uni-ca tio n on ly . T h is lim ita tion also seem ed jus-tified s in ce the teach ing o f s tuden ts, to theex ten t th a t th is sub jec t is inc luded a t a ll,has been a im ed a t th e v erba l a spec t o f there la tionsh ip . It is to th is v e rba l in te rac tio ntha t th e p resen t stud y is d irected , a ltho ugh ,of co urse, the non -v erba l in te rac tion a lso isre flec ted in the pa tien ts respon ses and per-cep t ions .

MATERIALS AND METHODSR e s e a rc h D e s ig n

T he resea rch d es ign rem ain ed co nsis ten tth rou gho u t the su bstan tiv e da ta co llectio n .P atien t v isits w ere s tu d ied by m ean s oftape record ing the m ed ica l in te rv iew , bychart rev iew , and by fo llow -up in te rv iew .

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3/19

Pat ient Visi t

T ape R ecor ding

P ost -vi si t I nt er vi ew

D a t a

Char t

S em i-stru c tu red In te r-v i e w

C hart R e v ie w

Fol low -up i nter view

Semi-s tructu ied P l u sFoc use d In terv ie w

85 6 D O C T O R -PA T IE N T IN T E R A C T IO NT A B L E I

DAT A COL LECT I ON PR OC E D U R ES FO R G R OU P I

D ata co l-lectionme t h o d

A ttrib u tes o f d o c to r-p atie n t c oin m unic a-t ion .ind epe nd ent v ariable

Patients per ceptions ofm e dic al v is it.Independent va i iable

D em ograph ic charac -te rist ics o f patien t .D octors rec om nie nd a-tion s, d iagn os is.In de pen den t v at iahle

Furthe r de m ographicand o the r b ac k grou nddata.In de petiden t v ariab le

S tatem en ts regardingc om plianc e, reassur-ance, sa t i s fact ion .1 )ep end ent v ariab le

Figu re 1 illustrates th e research design andde f ines th e ind ep en den t and depend en tvariables.S tu d y G ro up s

T here w ere three group s in th e sam ple .A ll data co llec tion procedures w ere carriedo u t on G ro up I cases as sh ow n in T able I.In th e tho ugh t that th e post-v isit in te rv iewitse lf m ig h t in f luen ce patien t { 1 76} satis f ac tionand co m pliance , th is p ro cedu re w as om it-ted f rom G rou p II . B ecause o f the g en eralb elie f th at the presence o f a tape reco rderin th e ex am in in g roo m m ig h t alte r the ph y -sic ians beh av ior and th e patien ts re -sp o n ses, tap e reco rd in g w as o m itted f ro mG ro u p III . U po n arriv al in the c lin ic , pa-tien ts w ere assig ned to th e three group s inrotatation.Th e C lin ic a l S e ttin g

A f ter caref u l inv es tig ation o f v ariousc lin ical se ttin g s , th e E m erg en cy C lin ic atC hildren s H o sp ital o f L os A nge les w asfo und to b e m o st su itab le f or the stu dy .B as ically , th is u n it se rv e s as a w alk -in c lin icw h ere m an y co m m o n p ed iatric p ro b lem s

In p ediatrics, th is m ore of ten re f ers to th e pa-t ien ts p aren t, m o s t co m m o n ly th e m o th er. H en ce,th e p atien t an d p aren t w ill b e re f e rred to in te r-ch ang eab ly and th e parent w ill b e re f e rred to asshe.

in clu d in g acu te in f ec tio n s, m in o r in ju rie s ,and illnesses o f all ty p es ) are cared f o r.C atastro p h ic em erg en cy s itu atio n s aretreated there also , bu t th ose are f ew innu m ber. T he ad v an tages o f th is area f orstu d y w ere 1 ) v is its w ere u su ally sh o rt,m ak in g tap in g an d an aly z in g reco rd s p rac -tical; 2 ) the v isit w as m o re lik e ly th an no tto resu lt in sp ec if ic adv ice to the paren t,th u s m ak in g f o llo w -u p on co m pliance f easi-b le ; 3 ) th e re w as n o lo n g -stan d in g re la-tio n sh ip b e tw een p atien t an d p h y s ician toin f lu en ce th e n atu re o f th e v isit; an d (4 )th e ch ild m o st lik ely had no prev ious ad-v ice f o r th e ailm en t to co n f o u n d th e p resen tc lin ical s itu atio n . T h ere f o re , th e u n it fo rs tu d y w as de f ined as an in itial encou n terb e t w e e n a p atien t an d a d o cto r in th e p ed i-atric w alk -in c lin ic at th e C h ild ren s H o sp i-tal o f L o s A ng e le s.

In teg ratin g th e re search g ro u p in to th e

T A B L E IIA G E O F S T U D Y S A MPL E

Ag e Number ofPar ienis - cU n d e r 6 too 16 1 206 18 m o 190 2 418 m o-S y r 25 0 315 1 0 y r 1 9 9 2 5

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4/19

I N T E R A C T I O N MO . P E R C E P T I O N SO F V IS IT

Ethnicity Number ofPatients

Caucas ianN e g r oS pan ish su rn am eO the r, n ot rep orted

31 125 419 8

37

39324

S PE C IA L A R T IC L E S 85 7

4POST V I S I T - 9 F O L L O W - U PM O T h E R IN T E R V IE W IN T E R V IE W

C O M P L I A N C EOUTCOME REASSURANCE

S A T I S F A C T I O N

I NDEPENDENT VAR IABLE D EPENDEN T VAR IABLEF IG . 1. R esearch des ign .

c lin ical se ttin g , an d in f o rm in g , w o o in g , an dw in n in g th e su p p o rt o f th e m ed ical, n u rs-ing , an d adm in istrativ e s taf f o f th e em er-g en cy c lin ic w as o n e o f th e g reates t ch al-len g es to th e re search team . A lth o u g h th es tu d y p ro ced u res d id n o t d elay m ed icalcare , they w ere an en cum b rance as w e ll asa th reat. H ence , the m ed ical staf f had to bepersu ad ed o f th e in trin sic w orth o f the en -d eav o r-th is d esp ite h av in g th e h y p o th ese san d co n ten t o f the stud y w ith he ld f romthem les t the f in d ing s b e con tam inated .T h e S a m p le

D etails o f sam p lin g th e ch ild ren s h o sp i-tal p atien t po pu lation w ere p lan ned in con-su ltation w ith a m ed ical soc io lo g ist and stat-is tic ian s . It w as d ecid ed th at a larg e sam -p le, i.e ., 8 0 0 p atien t v is its , w as n eed ed inv iew o f the m any v ariab les af f ectin g d oc-tor-patien t com m unication . T ab les II andIII and Fig ure 2 lis t so m e o f th e d em o -g rap h ic ch arac te ris tic s o f th e s tu d y sam p le .

T h is sam p le d if f e rs f ro m a larg er o n e re -cen tly stu d ied in th e p ed iatric em erg en cyc lin ic at L os A nge les C o unty G en eral H os -p ital in th at th e re w as le ss u n em p lo y m en tan d soc ial d isorg an iz atio n an d th ere w erere lativ e ly f ew er N eg ro an d m o re C au casianf am ilies in th e C hildrens H osp ital sam ple .H o w ev er, ev en in the C h ildren s H osp italsam p le there w ere propo rtion ately m o reS p an ish su rn am e an d N eg ro f am ilie s th anin the L o s A ng eles pop u lation at large .4

Tab le IV sh o w s th e d istrib u tio n o f p a-tien ts ch ie f co m p lain ts in v ario u s d iag n o s -t ic c at eg ori es .

T h e 6 4 p ed iatric ians w h ose v isits w ithp atien ts m ad e u p th e su b stan tiv e sam p lew ere m o stly th e f u ll-tim e res id en ts, o r f e l-lo w s w ith 1 to 5 y ears ex p erien ce in pediat-

rics w h o co n s titu te th e reg u larly assigneds taf f o f th e em erg en cy clin ic. A n o ccasion alp atien t w as seen b y a p ed iatric specialist o ran o th er f u ll-tim e staf f m em b er w ith lo n g erex perien ce . T h e stud y describ es , there f ore,a sam p le o f p ed iatric p rac tice as carried ou tl)y y o u n g , w e ll train ed , f u ll-tim e h o sp italp ed iatrician s . L est it b e assu m ed th at th e irm o re ex perienced co lleag ues, it can b e saidth at d u rin g th e p ilo t stu d y an d o n an o cca-s io n al v en tu re in to a priv ate ped iatricianso f f ic e, th e p rac tice s th e re d id n o t ap p eard ras tically u n lik e tho se d ocum en ted in thes tu d y . T h is h as n o t b een ad eq uately stud-ied o n a larg e scale , h o w ev er.

D a t a C o l l e c t i o n P r o c e d u r e sT A P E R E C O R D IN G IN T HE E M E R G E N C Y

C L iN Ic -T ran scrip ts o f do cto r-patien t in te r-ac tio n s w ere o b tain ed b y u s in g a U h ert tap ereco rd er in co n ju n c tio n w ith a L im p an d ertm e th o d s are b asically d ifferent from the iram plif ier to m ak e f or be tter q uality o f re-co rd in g o f f req u en c ies in th e ran g e o fsp eech . T he eq u ipm en t w as incorpo rated inan attrac tiv e m o bile cab ine t w ith a v isib lemicrophone attach ed . Perm iss io n w as o b -tain ed f rom all patien ts and all d oc tors to

f M a gn et ic R e cor d er s C om p a n y 7 1 2 0 M elro seA v e n u e , L os A ng e le s, C alif o rn ia 9 0 0 4 6 .

T A B L E IIIE T II S IC B A C K G R O U N D O F S T U D Y S A M PL E



5/19


6/19

T A B L E VD I ST al BU T I O N O F SA T I SF A C T I O N

T ABLE VIST U D Y (imu A ND SA TI SF AC TI O N

S t u d y Group

1 1I I I

Vumber of a t i e n t s

293294213

{182}atisfied

7 2 676.176 3

SPECI A L A RT IC L ES 859cessing. I ntercoder rel i abi l i ty w as of centralconcern. T he rate of agreement f or the f inalcoding w as 95.2% . B ackground inf ormation,demographic data, and factual data con-cerning al l aspects of the patient v i si t w erecoded.

T he interacti on has been analy zed forcontent by a m ethod uti l i zi ng the categoriesestabl i shed for coding the fol l ow -up inter-v iew responses. T his makes possible thecompari son by com puter of the interacti oncontent w i th the mother s perceptions, andassessm ent of the degree to w hich her ex -pectati ons and percepti ons of the chi l d s i l l -ness are responded to by the phy sician.O ther m ethods including notably B ales i n-teracti on process analy si s w i l l be descr ibedin subsequent reports. A l l data have beenpunched on IB M cards and then transposedonto m agnetic com puter tape for pr ocessingat the U niv ersi ty of Cal i fornia, L os A ngeles,H eal th Sciences Computing Faci l i ty .

RESULTSSom e of the descr ipti v e qual i tati v e re-

sul ts em erging f rom the inv esti gati on w i l lbe reported here since they are new and ofintr insic i nterest. In addi ti on, the resul ts ofcorrelati ng certain basic attri butes of thepatients, f eatures of the doctor-pati ent in-teracti on, and the fol l ow -up interv iew re-sponses w i th patient sati sfacti on w i l l bepresented. Resul ts of i nterv iew s w i th thephy sicians, f i ndings f rom prel im inary con-tent analy si s, and som e data f rom indiv id-ual cases w i l l be included w hen they arerelevant.G en eral ind ing s on P atient S atisfactio n

Seventy -si x percent of the patient v i si tsstudied resul ted in high or moderate sati s-f acti on as expressed by the m other on inter-v iew . T he various sati sf acti on rati ngs dis-tr i buted themselv es ov er the sample asshow n in T able V .

T he f inal sati sfacti on rati ngs w ereev olved careful l y f rom responses to thosequestions in the interv iew that addressthem selves di rectl y to the patient s sati sf ac-tion (e.g., how did your v i si t go?), com-

a t i s f a c t i o n .Vumber (If a t i e n t s

hi ghl y sati sf ied 316 40M oderatel y sati sf ied 292 36M o der at el y di ssat isf ied 47 I iI - hi g hl y d i ssat i sf i ed 105 13

Total 8(N ) lO ()

bined w ith responses to other questionsthat indi rectl y address themselves to pa-t ien t sat isf act ion ( e.g., w hat w ere som e ofthe things that y ou did not l i ke about y ourv i si t w i th the doctor?) . T his aggregate ofi tem s y iel ded a m ore internal ly consi stentand rel i able rati ng of sati sf acti on than anyother combination that w as dev ised ortested. T o gi ve a m ore representati ve pro-f i l e of patient responses, the global rati ngsby ex peri enced interv i ew ers in the f iel dw ere al so tak en into account. Reassurancew as f ound to correlate so consistentl y w i thsati sf acti on that these tw o dependent van-ables w ere com bined f or al l aspects of theanalysis.

W hen al l patients had been rated f or sat-i sf acti on, certain basic questions could beasked. Fi rst, i t w as necessary to seew hether any aspect of the investigati v eprocedure inf l uenced patient sati sfacti on.T able V I show s that patient sati sf acti onw as in no w ay di f f erent i n the three groupsof p ati ent s.

T he next basic question related to thegeneral concept that patient sati sf acti onmay be m ore closely related to attr i butes of



7/19

860 D O CT O R-PA T IEN T I N T ER A CT IO NT A B L E V I I

SOCI AL CLASS AND S A T I S F A C T I O N

S oc ia l C lass2N u m b er o f

Pa t ien ts SatisfiedIIII I II VV

1483 7 32 3 0

2 4

79.274.37 5 77 6 66 2 5

the patient himsel f , hi s back ground, hi s ed-ucation, and so forth than to the experiencew i th the physician. I n the present sampleno significant differ ences in satisfactionw ere found w hen di f f erent social classes T able V I I ) or di f ferent educational l ev els T able V I I I ) wer e com par ed. A lso, i t w asnot possible to demonstrate a signi f i cant re-lati onship betw een any other attr i butes ofthe populati on measured and the degree ofsati sfacti on w i th patient v i si ts.

T he nex t obv ious query relates to thespeci f i c physician s personal i ty or approachto patient care and patient sati sf acti on.T here w ere 17 physicians w ho had seenmore than 15 patients in the study . Each ofthese had some patients in each of the sati s-facti on groups.L en gth of V isit

I n di scussions of optimal patient care, i ti s of ten stated by pediatri cians that i f only

Si gni f i cance w as determ ined by m eans of chisquare tests using 2 X 2 tables w i th conti ngencycorrection. I n rel ationships repor ted as signi f i cant,P = 0 .01 .

T A BL E V I I IE D U C A T I ON A N D SA T I SF A C T IO N

Grades omple tedNu m b e r

ofP at ien ts

cSatisfied

1-3 yr hi gh school yr high school1 3 yr c o l l e g eOther

1592211 5 0270

74.872.878.772.2

there w ere enough tim e patient carew ould automati cal l y be better and doctor-patient communication w ould become moreef f ecti v e. For the recorded patient v i si ts,the tim e of interv iew ranged f rom 2 to 45m inutes. N o signi f i cant relati onship w asfound betw een the time of interacti on andthe percent of patients w ho w ere sati sf i ed( T able IX ).

I t w as also suggested that the i l l nessf rom w hich the v isi t to the cl i ni c w as madem ight i nf luence the length of the v i si t andthat certain k inds of patient complaintscould be handled quick l y w hi le sti l l sati s-fying the patient. For instance, a simplelocal i nfecti on of the sk in m ight be diag-nosed promptl y ; the physician and m otherw ould be in good comm unication aboutthe i l l ness imm ediatel y , and therapy couldbe insti tuted at once T able X show s, how -ever, that in the patient v i si ts studiedthere w as no correlati on betw een diagnosisand interacti on tim e, or betw een diagnosis,time of interacti on, and sati sf acti on.P a tie n t x p ec ta tio n s

One of the hy potheses general l y ac-cepted and basic to the present investiga-ti on i s that the ex tent to w hich the patientsex pectati ons f rom the cl i ni c or the phy si -cian are m et w i l l i nf l uence the outcome ofthe v isi t i n terms of sati sf acti on and/orcom pl iance. W hen look ing at the total sam -ple of patient v i si ts, thi s theory i s val i datedconsistently.

Interv iew responses indicate that a highproporti on of pediatri c cl i ni c patients haveexpectati ons of thei r physician w hich tran-scend his technical com petence. T his groupexpects their physician to be f r i endly , con-cem ed, and sympatheti c and to take timeand trouble f or questions and explanations.M ost of the phy sicians interv iew ed w hoparti cipated in the study thought of them-sel ves as f ri endly , and m ost of the pati entsstated that in general they think doctorsshould be f ri endly . Sti l l , there w ere 193 pa-ti ents w ho reported that thei r doctor hadbeen m ore business-l i ke. A s can be seen onT able X I , the patients w ho thought of thei r



8/19

T A B L E IXL F : N G T I I O F IN TERA CT IO N A ND SA TI SFA CT IO N

T A B L E XD I S T R I B U T I O N OF SA T ISFIED PA TIEN T S I N CERT A IN

D I A G N O ST I C C A T E G O R I ES BY I N T E R A C T I O N T I M E

SPECI A L A R T I CL ES 861physician as being f ri endly had a signi f i -cantl y greater proportion of satisf actionaf ter the v isi t, as did those w ho fel t thei rdoctor understood thei r concern.

Present day-pediatri c patients apparentl yal so expect thei r doctors to comm unicatew el l w i th them . O f the pati ents studied, 244spontaneousl y si ngled out the doctor s com-m unication sk i l l s as being w orthy of note.T hose w ho comm ented f av orably ( e.g., hel i stened to m e, he answ ered al l m y ques-ti ons, he explained so w el l ) wer e m or ef requentl y sati sf i ed than others in the sam -pie, and w ere dram ati cal l y m ore satisf i edthan those w ho disparaged the communica-ti on sk i l l s of thei r pediatri cians as show n inT able X I I .

O ne of ti l e str i k ing f indings consistentl ydem onstrated in al l phases of the study i sthe patients i ntense concern w i th and needfor inform ation and explanation of thei rchi ld s di sease and w hat caused i t. I n anal yz-ing patient gr oups w i th certain expecta-ti ons in com mon, there i s def ini te ev idencethat f or those parents expecting to learn thecausation and nature of thei r chi l d s i l l nessthe fai l ure to have thi s expectati on ful f i l l edleads to dissati sf acti on in a signi f i cantl ylarger number of v i si ts than in the remain-der of the sam ple. T able X I I I show s thepercentages of sati sf acti on in these patients.C o n te n t n a ly s is

C ontent analy si s of the interacti onthrows addi ti onal l i ght on the im portanceof m eeting patient expectati ons and deal ingw i th thei r concerns. W hereas the interv iewm ateri al presented so f ar show s onl y thatthose pati ents w ho percei ved that thei rhopes and expectati ons had not been fu l -f i l l ed w ere more dissati sf i ed, the contentanal ysi s m akes i t possible to determ inew hether an ex pectati on w as actual l y han-dled by the physician in w ord and/or indeed. T he content data conf i rmed in largem easure the f i ndings presented so f ar. T hef ai l ure to have ex pectati ons handled doesincrease the probabi l i ty of di ssati sf acti on int he p at ient .

C losel y rel ated to the idea that patients

MinutesAumber

ratzents

CSatisfied

L ess than 33 56-1()i l - ISMo r e than 15

21 6 3199110

8 4

717 575697 5

expectations need attention i s the conceptthat the parent s percepti ons of the i l l nessand anx ieti es about thei r chi l d need to betaken i nto account. T he interv iew usedgave par ents in the study an opportuni ty totel l thei r m ain w orri es about thei r chi ld si l l ness. T w o questions that y ielded highlyrel evant i nf orm ati on concerning alm ost al lpati ents w ere: W hat w orri ed you the m ostabout Siby l s i l l ness? W hy did that w orryyou? T he most unex pected, unreal i sti c,dramatic fear s w er e readi l y expressed in re-sponse to these questions. M others answ ered I thought she m ight choke to death, Ihave heard that chi l dren get hopelessl y re-tarded w hen they have a convulsion, I w asaf raid her stom ach w ould burst, w hen(1ueri ed about chi ldren w i th apparentl ym inor i l l nesses. T he highest incidence ofdi ssati sf acti on on f ol low -up occurs i n thosev i si ts w here nei ther expectati ons nor m ainworry receiv ed attention.

D;agnos.

M nu1es Satisfied

NiI7flber< 5 14 l5-4 #{149}5 of %

Patient.,

I . (l i sorder 0 as .s7 69Ear infeetioti 4 47 iS 5 69 86Coid. U RI ISk in di sease 4W el l chuI I 4Pneunm oi i i aBehavior pr oblem 0

3151710

1

84741

11I00

4342916

9

5371778037



9/19

862 D OC T OR -PA T I EN T I N T ER A C T I ONT A B L E X I

M OT H ERS PERCEPT ION S OF DocToRsA ND SA TI SF AC T IO N

ot he r s Pe r ce p t i o n o f oc t or Numberof Sa t isf iedP at ien ts

Fr iendlyBusiness-likeDi d u n d e r s t a n d c o n c er nD id not understand concern

3231936 2 5

8

8 3608 33

Interaction coding for content also al -l ow ed f or noting w hether m ain w orries orexpectations w er e m entioned to the doctordur ing the interacti on. I t w as not too star-tl i ng to f i nd that ex pectati ons w ere of tennot verbal i zed to the phy sician 65% of ex-pectati ons not mentioned ) but i t w asimpressiv e to f i nd that only 24% of mainw orries w ere speci f i cal l y m entioned to thedoctor by the patient dur ing the medicalv i si t. Pediatr i cians tended to handle a sig-nif icant ly l arger proporti on of concerns andexpectations in m ore highly educated pa-ti ents. T he converse is al so true-amongthose w hose concerns w ere not mentionedor responded to, there w ere signi f i cantl ymore w ho had not f i ni shed high school .O ther ind ing s on xp ectatio n

W hen al l other patient groups w hose ex-pectati ons had not been m et w ere com-pared to the rest of the sample in respect tosati sfacti on, the fol l ow ing resul ts w ere ob-tained. A mong 128 mothers w ho stated thatthey had ex pected shots, tests, or x -rays,

T A B L E X I ID O C T O R S C O M M U N I C A T I O N SK I L L S A N D

M OT H ERS SA TI SFA CT IO N

M e n t wn e d C ommunica t ionSki l ls

Nu m b e rof

Patien ts ; Sa t isf ied

L ik edDisliked

T otal Sam ple

2 4 453

800

8 62 576

and w ho fai l ed to receive these, there w ereonly 62% w ho lef t the cl i ni c sati sf i ed. T herew ere 73 m others w ho ex pected to receivemedicine but did not get any ; only 51% ofthese w ere sati sf i ed w i th thei r v i si t. O f 67cl i ni c v i si ts w hich the mothers vainl y hopedw ould resul t i n cure f or thei r chi l d s i l l -ness only 44% resul ted in sati sfacti on. Six ty -one v isi ts w ere made by m others w ho ex-pected to have thei r chi l d hospi tal i zed butw ere told to care f or the chi ld at hom e; 62%of these w ere sati sf i ed. A l l these sati sf acti onf i gures represent a signi f i cant reductionw hen compared to the rem aining sample asshow n in T able X I V .

A sm al l number of m others w ho statedthat they had hoped for phy sical exam ina-ti on of thei r chi l d or reassurance f or them -selves also w ere signi f i cantl y less l i k ely tobe sati sf i ed. T he only unmet ex pectati onsw hich did not mak e f or signi f i cant dim inu-ti on of fol l ow -up sati sf acti on w as ex pecta-ti on f or treatment. T his may have beendue to the rather broad def ini ti on of treat-ment used in coding.

Ref erred patients w ere signi f i cantl y moreprone to dissati sfacti on f ol l ow ing thei r v i s-i ts than those w ho sought out Chi ldrensH ospi tal on thei r ow n w hich may also bedue to unmet expectations, since a referredpatient w ould tend to expect m ore thanw hat i s usual l y of f ered in the em ergencyclinic.M iscellan eo us in din gs

M ED I C A L JA R G O N -A n outstanding bar-nier to comm unication encountered in morethan hal f the recorded cases is the pedia-tr i ci an s use of di f f i cul t techni cal l anguage.One m other said on interv iew that thedoctor tal ked medical , another motherdur ing an interacti on requested that thepediatr ician r epeat w hat he had said in Engl i sh. T he technical term s used apply toanatom ic porti ons of the chi l d (e.g., nares,l abia, sphincter), to physiologic processese.g., i njecti on, edema, peri stal si s, and soforth ) of ten to laboratory procedures (e.g.,l um bar puncture, C oom b s ti tre, T ine test) ,and to the many other subjects deal t w i th



10/19

T A B L E X I I IEX PECT A TI ON S REGA RD IN G CA USE NI )

I )I AG N O SI S A N D SA T I SF A C T IO N

Cause and D iagnosis

E xpected -not to ldWanted explanation--not given

T otal Sam ple

Numberof /0SatisfiedPatients7 5

149 42800 76

SPEC IA L A RT I CL ES 863in medical consul tati on. L ulnbar punc-tures w ere thought to drain the lungs, meningi ti s w as understood to be locatedin the throat, and the incubation periodw as interpreted to be the prescribed tim ef or the patient to stay in bed. A l though theuse of medical j argon tends to block ef f ec-ti v e com munication of ideas, i t does notalways l ead to dissati sf acti on. T here aresome m others w ho, al though they appar-entl y could not understand the explanati onsof f ered, w ere im pressed w i th the quanti tyand the fancy nature thereof , and possibl yf el t f lat ter ed.

I n addi ti on to the foregoing technicaland compl i cated examples of jargon, thereare a great many instances in the recordedI ati ent v i si ts i n w hi ch routi ne stereotypelanguage, a k i nd of hospi tal shorthand, isused. W ords l i ke w orkup, f ol l ow , and hi story , are as obscure to the patient asfancy techni cal term s, and they are usedceaselessl y by the m edi cal staf f , of ten incrucial contex t ( e.g., one m other told thei nterv i ew er the doctor said that they w ould adm i t her for a w ork up-w hatev er thatmeans ) . I t w as not clear to her that thi sm eant hospi tal i zati on of the chi l d.

I L L U ST R A T I O N S O F D I F F E R E N C E S I N V A L U ESY ST E M S-T hat patient and physician op-crate al l too of ten in w idely di sparate v aluesystems w as one of several observationsw hich prom pted the present study . M anyinci dental f i ndi ngs as w el l as m ore f orm alresul ts bear out thi s im pression. T he m oth-ers i ntense concern w i th ti l e causation ofthei r chi ld s i l l ness m ay be related to thealm ost uni versal tendency f or parents toblame themselv es f or thei r chi l d s i l l nessand other shortcom ings. O n fol l ow -up in-terv iew 326 m others openly verbal i zed thatthey blam ed them sel ves f or thei r chi l d si l l ness. O thers m ade strong def ensi ve state-m ents suggesting equal l y def ini ti ve f eel i ngsof gui l t. T here w ere onl y a f ew i solated in-stances w here th e phy si ci ans explored orattempted to rel i eve these f eel i ngs, andthere w ere even a f ew cases in w hich the pe-diatri ci an speci f i cal l y bl am ed the m otheral though she had not incr im inated hersel f .

I nspection of indi v idual cases revealedthat mothers preoccupied w i th sel f -blameand gui l t seem to be more av id for explana-t ion of cause, as i f to v indicate them selves.I t may be relevant in thi s contex t thatm others and physicians i deas concerni ngthe cause of chi l dren s i l l nesses w ere incon-gruent i n a num ber of respects. Som ethingeaten w as causing the chi l d s i l l ness accor-ding to the m others of 49 patients in thestudy , and in onl y 6 of these patients didthe physici an of f er the sam e ex planation. In111 i nst an ces m others blamed thei r chi l d strouble on exposure to env i ronm ental haz-ards such as getting chi l l ed, and thi s w asconf i rm ed by the exam ining physi ci an inonly 11 of the cases. I t w ould seem thatm others are prone to incr im inate f actors inthei r i mm ediate k now n env i ronm ent, w hichm ight be thought i n thei r ow n pow er tocontrol , and w hich are f am i l i ar to them,w hi l e physici ans invoke more objecti ve out-side etiologic f actors.

A l l but 65 of the m others interv iew edspeci f i ed w hat they had assum ed to be thediagnosis before they saw the doctor. I n agreat many instances thi s w as the sam e asthe doctor s diagnosis or highly sim i lar. Onestrik ing di f f erence, how ever, w as that in122 cases the m other thought the i l l nessw as gastrointesti nal i n nature, w hereas only47 doctors m ade a diagnosi s in thi s cate-gory. T his can be readi l y understood since,in the pediatr i c patient populati on, al lty pes of acute i l l nesses m ani fest them selv esby gastrointestinal sy mptoms.

M others also seem to feel greater need toprotect thei r chi ldren and to al l ow them to



11/19


12/19

SPECI A L A RT ICL ES 865m other w i th other chi l dren at hom e or atschool , pressures on the doctor, outsidenoises, and underly ing medical problemsw ere among the many intrusions that w eredi f f i cul t to ignore. On occasion, the tape re-corder w as on and running in the exam in-ing room during the long periods w hi le thepatient w ai ted f or the doctor. A l thoughthese records had not been obtained de-l i beratel y , they did serve to reveal howsome patients behav ior w as completel y di f -f erent in the presence of the doctor. Acheerf ul tal kati ve N egro f am i l y w ould besinging and jok ing unti l the doctor enteredand reduced them to m onosy l l abi c, sul l en,depressed-appearing respondents. O ne N e-gro couple speculated during thei r l ongwait w hether the delay in thei r receiv ingserv i ce could be due to racial di scnim ina-ti on. T hese f indings i l l ustrate dramati cal l ysom e of the cul tural barri ers betw een doc-tons and certain patients w hich are unre-lated to the atti tudes and behav ior w hichare show n by the exam ining physician inattendance.

B R IE F R E V IE W O F R E LA TE D L ITE R A T U R EA w eal th of publ i shed inf ormation on

subjects relevant to doctor-patient relati on-ship i s av ai l able to those w ho have thecourage to venture into the non-m edical l i t-erature as w el l as into medical j ournals.Some of the w ork deals w i th basic sociolog-i c concepts of the respecti ve roles of doc-tor and patient; Parsons proposes the use-f ul di v i sion of the physicians acts into in-strumental ones ( deal ing w i th the techni -cal aspects of medical care ) and expres-si ve ones ( concerned w i th the psy chologicand social aspects of the doctor-patient re-lationship ) . H e also elaborates the conceptof the si ck -role played by the patientw hich i s not as di rectl y appl i cable to thepediatr i c si tuati on. Szasz and H ol lender8 { 176}described the physicians role as rangingf rom doing to the patient to participationby the pati ent, depending on the nature ofhis i l l ness and the phase of the relati onship.B loombo emphasizes the ef fects of the re-specti ve subcul tures on the doctors and pa-t ient s f unct ioni ng.

T he P rocessT he process of doctor-patient interacti on

has been studied by a number of inv estiga-tors5 3 but unf ortunatel y , usual l y not asi t appl i es to a regular medical consul tati on.\I ore recentl y D av is13 and A dler et al.14have appl ied the techniques of interactionP rocess Analysis of B ales { 176}o the documen-tati on and analysi s of medical v isi ts m osteffectively.T he C on ten t

T he content of the verbal communicationbetween doctor and patient has been scruti -ni zed ex tensiv el y in many di f ferent cl i ni calsetti ngs. Everyone em phasizes the need f orthe physician to l i sten to the patient and torespond to the emotional overtones in thesi tuation. T he disadvantages of using termstoo technical or too ambiguous or in beingtoo hurr ied or perf unctory w ere docu-m ented in sev eral studies.155 T hese studiesal so show di rect relati onship betw een com -m uni cation and outcom e. O ther studies em-phasize w hi ch m edical topi c should be dis-cussed during the doctor-patient v i si t.Moh le r , et ai 1 relate patient cooperation toem phasis on treatm ent. B al i nt2o stresses thatpati ents need a nam e f or thei r i l l ness andpoints out that a statem ent of di agnosi sshould precede therapy . Y udk in21 hasstressed that the same patient m ay havetw o diagnoses-one overt and another one,of ten more important, w hich needs greaterdiagnosti c sk i l l to el i ci t and w hich alsoneeds to be responded to during the v isi t.D av i s22 and Parsons23 em phasi ze that di s-cussing prognosi s reduces the pati ents un-certainty and anx iety . T he ef f ect of rai singa n x iety o r th rea ten in g p a tie n ts to makethem cooperate better has been studied242Ow ith som ew hat conf usi ng resul ts. L even-thal m ore recentl y i s f indi ng that rai sing am oderate amount of anx iety in the patientmay be helpf ul i n dieti ng cooperation, i fadequate reassuri ng adv i ce i s given.A ttribu tes o f th e P a tien t

Patient s attri butes such as socioeconom icbackground, cul tural back ground, psycho-

Perso nal com muni cati on.



13/19

866 D OC T O R-PA T IEN T IN T ERA CT IO Nsocial factors, education, and know ledgehave been emphasized by B lum 27 as in-fluencing com munication w i th the doctor.Fai l ure to f ol l ow up on m edical adv ice hasbeen explained by cul tural factors and pa-tients bel ief s in a num ber of studies.2831M any phy sicians blame comm unicationf ai l ure on patient attr i butes such as socio-econom ic, education, and racial back -ground. Publ i shed studies deal i ng w i ththese vaniablesl2I 4 do not y ield a v ery con-sistent pictur e. H ow ever , they suggest thatthe ef fect of these factors has probably beenover estim ated . Social and inter-personal i n-f luences have been show n to inf l uence theoutcom e of m edical consultations33 34 andm ay af f ect doctor-pati ent com m uni cati on.

T he patient s understanding of hi s i l l nessand his general medical know ledge havebeen show n by Sel igmann, et Samora,et al.,#{176}nd others, to af f ect com mu-nication w i th the physician and responsesto medical adv ice to a signi f i cant ex tent.T h e P a t ie n ts E x p e c t a t io n s

Patient s ex pectati ons f rom the v isi t andthe strong inf l uence of mutual expectati onson doctor -patient r elationships have beeninvestigated at l ength. Patients expecta-ti ons may r elate to the doctors ex pressiv erole, i .e., they m ay look f or k indness, under-standing, em ot ional suppor t.3941 Som e pa-ti ents emphasize that they expect ex plana-ti ons about the disease and i ts ser ious-ness.3943 O ther patients simply state thatthey ex pect competence in thei ror sym ptom r elief for them selves.

D I S C U S S I O NP at ie n t S a tis f a c t io n

I t seems appropr iate to point out f i rstthat, al though m any com munication break -downs w er e docum ented in the study , sati s-f actory and effective com m unication wasthe rule and not the exception. A f ter al l ,76% of the patients w ere sati sf i ed w i th thei rv i si ts. T he w isdom of using patient sati sfac-ti on as a yardsti ck to m easure the ef fecti ve-ness of doctor-patient communication maybe questioned, especial l y since insuf f i cient

data are av ai l able at thi s time to demon-strate how and w hen patient sati sfacti oncorrelates w i th fol l ow -through on medicaladv ice. H ere are a few of the reasons w hypatient sati sf acti on w as chosen as an im por-tant outcom e variable: w hen the study w asini ti ated, during the many long ex plorati onsand discussions of objecti ves of an indiv id-ual consul tati on betw een doctor and pa-ti ent, there seem ed to be alm ost universalagreem ent that one aim on the pant of thephy sician w as to meet the patient s needsand to sati sf y the patient. T he w idespreaddisenchantment w i th the medical cane thatis being of f ered to the communi ty at pres-ent also highl i ghts that di ssati sfacti on w i thmedical care needs to be a central concernof physicians. In addi ti on, sati sfacti on in thi sinvesti gation correl ates com pletely w i th ne-assurance w hich is another general l y ac.cepted goal of com munication betw eenpediatri ci ans and patients parents. T here isalso some quanti tati ve ev idence { 176} and astrong conv icti on on the part of many thatlong-term heal th behav ior and the readi -ness to consul t physicians and cl i ni cs for ep-i sodes of i l l ness do ref lect sati sf acti on w i thpast m edical care received. T his w ould ap-pear to consti tute another justi f i cati on forconcentrati ng on patient sati sf acti on. T heconcept of pat ient sat isfaction is a l i ttl e sus-pect among many legi tim ate and honorablem em bers of the prof ession because quack s,f ai th healers, and so forth are notor ious f orproducing high sati sf acti on in thei r cl i en-tele, even though the serv i ce that i s of f eredis of low qual i ty or di shonest at times. T hisseem ed to the research team a reason f or,rather than against, study ing patient sati s-f acti on in relati on to ethi cal and medicaltop-level practi ces. T here seems no v al i dreason w hy ethi cal physicians should shungood com m unication since i t i s the stock- in-trade of thei r less ethi cal competi ti on.

A t present the f indings concerning pa-ti ent sati sfacti on are being correlated w i ththose on compl iance. Even now i t can bestated that there i s no simple, di rect corre-lati on betw een sati sfacti on and compl iancew i th m edical adv ice, and the dependent



14/19

SPECI A L A RT I CL ES 867variables w i l l have to be look ed at sep-aratel y as w el l as together.P atie nt E xp ec ta tio ns

From a practi cal point of v iew , one ofthe m ost relevant resul ts f rom this investi -gation i s the docum ented need for attentionto the patient s ow n ideas about the i l l nessand the f am i l y s expectati ons f rom the med-i cal v i si t. I t has been show n that importantand highly relevant information concerningpatient f ears and expectati ons i s readi l y ob-tamable w i th the simplest i nterv iew ques-t io i is wh ich could easi l y be incorporatedinto regular m edical v i si ts. I t has also beendemonstrated that currentl y these concernsare given insuf f i cient attention during doc-ton-pati ent consul tations. Som e of the re-corded patient v i si ts suggest that, ratherthan adding to the physician s burden, at-tention and recogni ti on giv en to these top-i cs makes for shorter patient v i si ts. O ncethe mother s urgent needs are met sheseem s m ore attentiv e and m ore am enable tothe phy si ci an s i deas and plans. B al i nt2 hasstressed the pati ents need to have a nam ef or thei r i l l ness bef ore they can proceed.T he present f i ndings bear thi s out in that afai l ure to receiv e a clear diagnosti c state-ment w as def ini tel y associated w i th patientdi ssati sf acti on. Y udk inU suggested thatof ten there i s a second diagnosis i n addi -ti on to the ostensiv e chief com plaint w hichneeds attention. Some of the m ain w orr iesmentioned in thi s report w ould seem to rep-resent such ini ti al l y nonexpressed urgentneeds of the patient w hich i t behooves thephysi cian to el i ci t. T hese m ight f i t i ntoY udk in s21 category of the second diag-nosis.D ia g n o s is an d C a u s e

Prev ious ex plorations on pati ent ex pec-tati on had suggested that, w hereas adul tpati ents m ore of ten seek sym ptom rel i ef f orthem selves, pediatr i c patients parents hav ea need to l earn the cause, w hat brought i ton? and so f orth in order to f eel sati sf i edand reassured. I t can be speculated that

#{182}npul -) l j shed (lata.

th is relates not onl y to the w ish to preventsim i l ar problem s in the f uture but also to aneed to be rel i eved f rom f eel i ngs of sel f -blam e. W hatever the basi s, the investiga-ti on reported here i l l ustrates amply that theparents of pediatri c patients are concernedw i th causation and of ten need a clear state-m ent f rom thei r physician in order to besati sf i ed and reassured. A questi on m ight berai sed as to the harm of al l ow ing persi stentuncertainty concerning cause and unabatedf eel i ngs of sel f -blame on the pant of themother. T here i s cl i ni cal ev idence that, i naddi ti on to the anx iety and distress of theparents, these f eel ings lead to overprotec-ti on and inappropr iate behav ior on the partof the parents i n handl ing the chi l d s i l l nessw hi ch m ay be harm f ul and should beav oided i f possibl e. T he present i nvesti ga-ti on suggests that clear di scussion of causa-ti on of i l l ness and rel i ef of feel i ngs of sel f -blame on the part of the parents may aid inprev enting undue parental anx iety and ov -erprotective behavior.

E x p re s s iv e V e rs u s In s tru m e n ta l F u n c tio n so f th e P h y s ic ia n

Som e of the f i ndi ngs presented can be re-garded prof i tabl y in the l i ght of Parsons,6separation of instrumental and expressiv efunctions of the phy sician. O nly 54 of the800 respondents in the study group seni -ousl y questi oned the techni cal com petence i .e., the instrum ental f uncti ons ) of the pe-diatri cian w hom they had seen, and only sixm others f el t that the pediatr i cian s handl i ngof the chi l d lef t something to be desi red.H ow ever, there w ere a considerable pro-porti on of mothers w ho w ished f or morewarmth, greater show of concern, and moref r i endl iness f or them sel ves f rom the physi -cian. A di f ferent sam ple of pediatr ic pa-t i ents w ho have a longstanding rel ationshipw ith a parti cular doctor m ight experience ahigher degree of f r i endl i ness, w arm th, andsympathy. Sti l l , to judge by the publ i c pro-test over the inhum ani ty and im personal i tyof present-day medicine, the problem doesex ist w hen one looks at m edical and pediat-nc care on a broader scale. A recent study



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868 D O CT OR-PA T I EN T I N T ER A CT I ONby Charney , et a1. {176}i l l ustrates that long-standing r elation w i th a pediatri cian come-lates w i th fol l ow -through on medical ad-v i ce. L ong-term com pl iance cannot be esti -mated on the basis of the present study . Pa-ti ent sati sfacti on, on the other hand, i s m e-lated to the expressi ve role of the doctorwithout a question of a doubt.P a t ie n t t t r ib u t e s

T he only speci f i c attri bute of patientsw i th higher education demonstrated in thi sstudy is that they are more prone to expressthei r f ears and hopes to the doctor and thatthey have a better chance of hav ing themr esponded to or deal t w i th. H ow ever, thestudy does not support the v iew that pa-ti ents heal th behav ior in the threat of anacute i l l ness can most f requentl y be ex -plained on the basis of thei r socioeconom ic,ethnic, r eligious, or educational back-gr ound. T hese findings, l i k e the recent re-sui ts of D av is,13 are encouraging to contem-plate at a time w hen heal th cane is beingoffer ed incr easingly to gr oups in the low ereducational and econom ic strata. T hesef indings should also be heeded by al l thosephysicians w ho w i l l readi l y adm i t that theyspend more time and giv e m ore explana-tions to patients w ho seem more intel l i gentand more educated. A s pointed out by Sa-mona, et a l. {17 6}and Sel igm ann, et physi-cians tend to underestimate the patientsunderstanding and m edical i nform ation andthi s leads them in turn to give less infonm a-t ion to these patients, w hich clearl y leads toa k ind of v i cious ci rcle in w hich most inneed of education fr om thei r phy sician areapt to receiv e the least. T ak ing al l thi s intoconsiderati on, i t seem s important f or physi -cians and other heal th w orkers to giv e thepatient the benef i t of the doubt and to givethei r medical explanations w i th as m uchenthusiasm, albei t in a somew hat di f ferentm anner, even w i th those w ho seem lessresponsiv e and less w el l i nformed.P hy s ic ia n t t r ib u t e s

T he physicians in the study w ere gener-al l y homogeneous in training and hack-

ground; hence, no signi f i cant inf erencesw ere made concerning speci f i c phy sician at-tributes in r elation to patient r esponses andsati sf acti on. A s has been presented, ev eryphysician in the study had both sati sf i edand dissati sf i ed patients, and, incidental l y ,there w as also v ar iati on in compl iance. I t i sclear f rom al l aspects of the study that pa-ti ents i ndi v idual needs v ary greatl y andthat no one pediatr i cian can meet them al l .Som e patient ex pectati ons are so unreal i sti cand thei r problem s are of such a naturethat no pediatr ici an can f ul f i l l them in ashort encounter. I t has of ten been sug-gested that the know n presence of a taper ecor der in an exam ining r oom w ould m ak ethe pediatri cian do better. T his assumesthat unobserv ed pediatri cians are not try ingto do thei r best but do know how to do bet-ten. T his w as not an assumption to w hichthe research team subscribed, and hence i tcame as no supnise that there w as no in-crease in patient sati sf acti on or in com pl i -ance in the group of patients w hose v isi tsw ere tape recorded.U t iliz a t io n o f D o c t o rs T im e

Evidence that a doctor-patient commum-cation can be sati sfactory and ef f ecti v e inas l i tt l e as 5 m inutes is of practi cal interest.I nf erences m ust be draw n f rom this w i threservati ons, how ever. I t i s possibl e that anal ready ef f ecti ve consul tati on betw een doc-ton and patient m ight be even m ore sati s-f actory i f m ore tim e w ere avai labl e eventhough more tim e, as such, i s not enough.O ne thing i s clear, how ev er, that much timei s l ost in inef f ecti ve verbal i zati on, especial l yon the part of the doctor, and that the timethe patient and doctor spend in the samer oom is of lesser im por t than how theyspend thi s period of time. I t w ould seemalso that a f ew minutes spent in getti ng ac-quainted w i th the patient s ideas and ex -pectati ons w ould save the physician timelater on and make f or a more sati sf actorydoctor-patient relati onship.

O ne ob ser vation that i s hard to descr ibew i thout lengthy examples f rom the case rec-ords is that m any physi cians lose tim e by



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SPECIA L A RT ICL ES 869l etti ng them sel ves be trapped into w hat canonl y be descr ibed as argum ents andquarrel s w i th the patients. T hese tak e tim eand are r idi culous. For instance, a m otherw i l l descr ibe w hat she cal l s vom i ti ng byher baby . T he phy sician corrects her andi nf orm s her that regurgi tati on i s theproper term for w hat she has descr ibed.She counters that she thought i t w as vom i t-i ng. H e argues back , and many , m any pre-cious m inutes pass w h i le he lectures andshe attem pts to describe things in her origi -nal l anguage. M ost l i kel y the m other w i l lleave the doctor and tel l the sym patheticl i stener in the w ai ti ng room that the doctornever did understand w hat brought her tothe doctor or that her chi l d w as vom i ti ng.A nother tim e-consum ing and unnecessaryactiv ity during physician s consul tati onw i th pediatri c parents i s repeti ti on. Espe-cial l y w hen they f eel that a m other doesnot comprehend them , phy sicians repeatthei r ow n w ords som etim es three or fourt im es, apparentl y hoping that the m otherw i l l accept and understand them the nex ttime even though she did not do so before.O n the contrary , i t m ay be assumed that, i fcertain f ormulati ons are unacceptable to them other the f i rst and second tim e, anotherapproach m ust be needed. Repeti ti ons f romthe mother are also a sign that com munica-tion is not tak ing place. I f she asks thesam e questi on tw o or three tim es, al thoughthe doctor bel i eves he has al ready answ eredi t, som ething has gone w rong ei ther in hi si nterpretation of the question or i n his ap-proach to the answ er. Perhaps she is oneof the m others w ho has a second diagnosisor a hidden agenda. W hichever of theseal ternati ves appl i es, repeti t i on alone w i l l notm eet the prev iously unmet needs.

S U M M A R YEight hundred pati ent v i si ts to the w al k -

i n cl i ni c of the Chi l drens H ospi tal of L osA ngeles w ere studied by m eans of tape re-cordi ng ti le doctor-pati ent i nteracti on andby f ol l ow -up interv iew . Seventy -si x percentof the patient v i si ts resul ted in sati sf acti onon the part of the patient s mother; i n 24%

there w as di ssati sf action. A num ber of com -m unication barri ers betw een pediatr i cianand pati ent s m other w ere f ound to contri b-ute signi f i cantl y to patient di ssati sfacti on:notabl y lack of w arm th and f ri endl i ness onthe part of the doctor, f ai l ure to tak e intoaccount the patient s concerns and expecta-ti ons f rom the medical v i si t, l ack of clear-cut ex planati on concerning diagnosi s andcausati on of i l l ness, and use of m edi cal j ar-gon.

REFERENCES1. Edi tori al Com ment: Patient dem and. L ancet,

1 :4 83 , 1 96 7 .2 H ol l i ngshead, A . B ., and Redl i ch, F. C. : Social

C lass and M ental I l l ness. N ew Y ork : JohnW i ley and Sons, 1958.

3 W ingert, W . A ., Friedm an, D .B ., and L arson,\V . R . : T he D em ographi cal and ecologi calcharacteri st i cs of a large urban pedi atri coutpatient populati on. A mer. J. Publicheal th, in press.

U . S. B ureau of Cenus: U . S. Census of Popu-l ation, 1960. W ashington, D .C . : D epartm ento f C om m er ce.

5. B ales, R . F. : I nteract ion Process A nal ysi s.Cam bridge: A ddison-W esley Press, I nc.1 9 5 0

6 Parsons, T . : I l l ness and the role of the phy si -cian. J. O rthopsychiat . 21:452, 1951.

7 Parsons, T ., and B ales R. F. : Fam il y Soci al iza-ti on and Interact ion Process. Clencoe, I l l i -nois: T he Free Press, 1955.

8. Szasz, T . S., and H ol lender , M . H . : A contni -bution to the phi losophy of medici ne-T hebasic model s of the doctor -patient rel ation-ship. A rch. I ntern. M ed., 97:585, 1956.

9 H ol lender, M . H . : T he Psychology of M edicalPracti ce. Phi ladelphia : W . B . Saunders Co.,1958 .

10 B loom , S. : T he D octor and H is Pati ent-A So-ciol ogi cal I nterpretat ion. N ew Y ork : Russel lSage Foundation, 1963.

11 . Bugental, J. F. : Expl i ci t anal ysis of topi calconcurrence in diagnosti c interv iew ing. J.Cl in. Psy chol ., 9:3, 1953.

12. L ennard, H . L ., and B ernstei n, A . : T he A nat-om y of Psychotherapy . N ew Y ork : ColumbiaU ni versi ty Press, 1960.

13. D av is, M . S. : D ev iant I nteraction in an Insti tu-tional i zed Relationship: V ar iati on i n Pa-tients Com pl iance w i th D octors Orders.Presented at Internati onal Sociological A sso-ciat ion, E vian, F r ance, September, 1966.

14. A dler, L ., and Enelow , A . J.: A Scale to M ea-sure Psychotherapy I nteracti on. L os A ngeles:



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870 D O CT OR-PA T I EN T I N T ERA CT I ONU niversi ty of Southern Cal i f ornia School ofM edici ne, D epartm ent of Psy chi atry , 1964.

15. Col l i ns, E. : D o we real l y adv i se the pati ent? J.F lor ida Me d A s s 42:111, 1955.

1 6 Skipper, J. K ., M asi ksh, H . 0., and T ogl i -arozzo, D. : Som e barr i ers to com muni cati onbetw een pati ents and hospi tal f uncti onaries.N urs. Forum , 11:14, 1963.

1 7 D av is, F. : Passage T hrough Cr isis. N ew Y ork :B obbs-M erri l l Co., I nc., 1963.

18. D ye, M . C. : Clar i fy ing pat ients com munica-t i ons. A mer. J. N urs., 63:56, A ugust, 1963.

1 9 M ohler, D . N ., W al l i n, D . C., and D rey fus, E.C. : Studies in the hom e-treatment of strep.di sease: Fai l ure of pati ents to take peni ci l l i nby m outh as prescri bed. N ew Eng. J. M ed.,2 5 2 : 1 1 1 6 1 9 5 5

20. B al int, M . : T he D octor and H is Patient andT he I ll ness. N ew Y ork : I nternational U ni -versity Press, 1957.

21. Y udk in, S. : Six chi l dren w i th coughs-The sec-ond diagnosi s. L ancet, 2:561, 1961.

2 2 . D av i s, F. : U ncertainty in m edical prognosis-Cl i ni cal and f uncti onal . A m er. J. Sociology,66:41, J u l y 1 9 6 0

23. Parsons, T . : T he Social Systeln. Clencoe, I l l i -noi s: T he Free Press, pp. 466-469, 1951.

2 4. Janis, I . L ., and Feshback , S. : Ef f ects of f earar ousi ng com m uni cat ions. J. A bnorm . Soc.Psychol ., 48:78, 1953.

25. Janis, I . L ., and M ul l hol l and, L . : Ef f ects ofthreatening and non-threatening com m uni -cation on r ecall. J. Psy cho., 37:75, 1954.

26. L eventhal , H . : Fear com m uni cati ons in the ac-ceptance of preventiv e heal th practi ces.B ul l . A cad. M ed., second seri es, 41:1144,1 9 6 5 .

2 7 . B lum , R. H . : T he M anagem ent of the D octor-Pat i ent Rel ati onshi p. N ew Y ork : \ IcGraw-H i l l , 1 9 6 0

28. A bram son, J. H ., M ay et, F. J. H ., and M ajola,C . C. : W hat is w rong w i th m e? A study ofthe v iew s of A f ri can and I ndian pati ents ina D urban hospi tal . S. A f r . M ed. J., 35:690,1 9 6 1

29. B urn, J. L . : W hy do som e parents object todipthenia im munization? H eal th Educati onJ., 9 :70, 1 9 5 1

30. D easy , L . I . : Socio-econom ic status and parti c-ipat ion in the pol iom yel i ti s vaccine tr ial .A m er. Soc. Rev ., 21:185, 1956.

31. Ri f f enburgh, R . S.: T he doctor-pati ent rel ation-ship i n glaucom a therapy . A rch. Ophthal .,75:204, 1 9 6 6

32. M acD onald, M . E., H a g b e r g K . L ., andGrossman, B. J.: Social f actors i n rel ation toparticipation in fo l low-up car e of r heum aticf ever. J. Pedi at., 62:503, 1963.

33. Johnson, A . L : E p i d e mi o l o gy of P o l i o V a c c i n e

A cceptance. Jacksonville, Flori da: StateB oard of H eal th M onograph, N o. 3, 1962.

34. G lasser , M . A . : A study of the publ i c s accep-tance of the sal k vaccine program . A mer. J.Publ i c H eal th, 48: 141, 1958.

35. Sel igm ann, A . W ., M cG rath, N eva E., andPra t t , L : L evel of m edi cal informat ionam ong cl i ni c patients. J. Chronic D is., 6:497,1 9 5 7 .

36. Sam ora, J., Saunders, L ., and L arson, R.:K now ledge about speci f i c di seases in f oursel ected sam pl es. J. Health H um . B ehav .,3:176, 1962.

3 7 . El l i ng, R ., W hi ttem ore, R . and Green, N I . : Pa-tient par ticipation in a pediatr ic pr ogr am . J.H eal th H um . B ehav ., 1:183, FaI l , 1960.

38. Pridan, D ., and N av id, H . : H eal th educationin a clin ic. J. CoI l . G en. Pr act., 7:222, 1964.

3 9 Israel, J. : H ur Patienten U pplever Sjukhuset-( H ow T he Patient Experiences T he I l ospi -tal ). f rom Sw edish. Stockholm : A lm qv ist andW i ksel l , 1962.

4 0. K oos, E. L . : T he H eal th of Regionv i l l e. N ewY or k: C ol um bi a U niv ersi ty Press, 1954.

41. R eader, C. C., et al: What patients ex pectf rom thei r doctors. N I od. H osp., 89:83, Jul y ,1 9 5 7

42. D eisher , R . W ., Engel , W . L ., Spielholz, R .,and Standf ast , S. J. : M others opi nions on

thei r pediatr i c care. PEunA riucs, 35 : 82, 1965.43. M echani c, D . : Role ex pectati ons and comm u-

ni cati on i n the therapi st-pati ent rel ati onship.J. H eal th H um . B ehav ., 2:190, Fal l , 1961.

44. Cahal , N I . F. : W hat the publ ic thi nks of thef am i ly doctor-f olk l ore and facts. CP, 25:146 , F ebr uar y, 1962.

45 . Charnev , E ., B y num , R., E ldredgc, I )., Frank ,D ., M ac\Vh innev , J. B ., M cN ahb, N ., Schei -ner, A ., Sumpter, E . A ., and I ker , I I . : howv el l do pati ents tak e oral penici l l i n? A col -l aborati ve study in pri vate practi ce. P E D I A T -R I C S , 4 0 : 1 8 8 1 9 6 7

A c k n o w l e d g m e n tT he authors w ish to express thei r grati tude to

Mi l t on D av i s, Ph.D ., f or hi s m ost helpf ul consul ta-tions; to D r. R . M ickey at U ni versi ty of C al i f orni a,L os A ngeles, H eal th Sci ences Com put ing Faci l i tyf or stati sti cal counsel ; to m em bers of the pediatri cand nursi ng staf f of the Chi l drens H ospi tal of L osA ngeles f or thei r patience and cooperati on; to theresearch team , B arbara Freem on, M ar ie M orri s,and Elai ne A ley , f or thei r continued invaluableassi stance; and to A nne H inton, M y rene Sm i th,I rene Dalzell , M uriel Schuerm an, and L eah M arti nf or past help i n the project. A ppreciation i s ex -pr essed to M iss C or alee Y a l e f o r h e r c o mp e t e n c ea n d enthusiasm in the preparati on of com puterprograms.



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SPECIA L A RT I CL ES 871APPENDI X

F O LL O W -U P IN T E R V IE W - SH O R T V E R S IO N1 . H ow i s he now? or H ow are thi ngs w i th now? or w hatever opener indi cated).2. B efore you saw the doctor last w hat did you think s t rouble w as?3. B ef ore you came to the hospi tal w hat did you think brought i t on?4. W hat w orri ed you m ost about his trouble?5 . W hy did that w orry y ou?6. W hen you brought to the hospi tal on w hat had you hoped w ould

be done for him?7. A t that tim e, w hat sorts of things did you w ant a doctor to ex plain to y ou?

A . A nd did you get a sati sfactory ex planation?N ow let s tal k about w hat you v e been doing f or him at hom e . . . since your l ast v i si t here.

(Regimen to be copied f rom chart)M edicalDietOther

8. W hat m edicines have y ou been giv ing?9 . W hat w as the dose?

10. H ow of ten?11. H ow long did you f eel he needed the m edi cine?12. W hat other sorts of thi ngs have you been doing to help him get better?13. W hat about changes i n feeding hi m?N ow l et s tal k about your v i si t w i th the doctor on 14. W hat di d the doctor say w as the m atter w i th ?15. \V hat did the doctor say caused the trouble?16. W hat did the doctor say about w hat to expect?17. Regarding your v i si t to the hospi tal , i n general , how satisf i ed w ere you w i th i t?18. W hat w ere som e of the thi ngs you l ik ed about your v i si t w i th the doctor?19 . \Vhat w ere some of the thi ngs y ou didn t l i ke?2 0 . D id the doctor seem to understand how concerned y ou w ere about ?2 1. H ow did he show i t?2 2 . H ow did the doctor act, f or exam ple, wa s he m ore l )U SineSs-l i ke or m ore f ri endl y , or?23. H ow do you thi nk a doctor should act?24. H ow w el l w as the doctor able to rel i ev e your w orri es about s si ckness?25. Parents of ten blam e them sel ves w hen thei r chi l dren get si ck , how about you?26. H ow sati sfied are you w i t h the way th ings have been going since your v i si t here l ast

2Clo$urc: (A sk i f they have any com m ents they w ish to add about the v i si t, and/or re-f ocus on

some earlie r response w hen necessary .



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1968;42;855PediatricsBarbara M. Korsch, Ethel K. Gozzi and Vida Francis

and Patient SatisfactionGAPS IN DOCTOR-PATIENT COMMUNICATION: I. Doctor-Patient Interaction

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