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It’s not what you say, it’s the way that you say it?

Posted Aug 19 2009 5:04pm
I have a bit of a theme happening – health care interactions. I think it’s because this week I’ve been talking about this with patients, and it seems to be something that either raises the hackles or fills them with gratitude! Anyway, I was glad to find this paper the other day on ‘perceived quality of doctor–patient interaction in rehabilitation’. This is slightly different from the usual focus, which is often on interactions in primary care.

It’s an interesting paper written by a group of researchers in Germany. They describe the use of a newly-developed rating instrument, the ‘P.A.Int-Questionnaire’, which stands for (in German) ‘Patient-Arzt-Interaktion’. I’m guessing that’s German for ‘patient-doctor interaction’ (correct me if I’m wrong!). By using this, they aimed to examine the relationship between perceived quality of interaction and long-term treatment outcomes.

The quality of interactions between patients and clinicians were rated on three dimensions – affective behaviour (ie warmth, empathy, ‘coherence’); instrumental behaviour (ie information exchange, structuring and reinforcement); and participation and involvement of patients.

I’ll just briefly describe the methodology, before cutting to the findings and then going onto how this might influence practice in chronic pain management.

Two different questionnaires were developed – tapping into the same domains, but one for patients and one for clinicians.
Seven rehabilitation clinics were involved in the study, with 61 doctors and their 470 patients reviewing their interactions with each other on admission, discharge and ward round. Patients also rated their health status on admission, discharge and six months later.

The key study questions were

  1. whether there were similarities between the patient rating of the experience, as compared with the clinicians rating;
  2. what the relationship was between the perceived quality of the interactions and long-term patient outcomes;
  3. whether there were any differences between those perceiving good interactions and those who perceived interactions as poor; and
  4. whether depression, anxiety or pain intensity influenced those ratings or outcomes.

The findings?

  • Patients and clinicians both rated affective behaviour in  interactions in a similar way, and quite positively.  So people were happy with the warmth demonstrated in the consultations.
  • Instrumental behaviour (information and structuring) wasn’t viewed as positively by patients as it was by clinicians – it seems that clinicians believe they are better at information exchange and guiding an interaction than what the patients experience is.
  • Patients who were happy with the interactions they had on admission were more likely to respond well to treatment in terms of pain reduction, as well as to anxiety when they were discharged – and this was maintained even to six months after discharge.

The final conclusions from the authors of this study relate to both the questionnaire itself and the findings about quality of interactions and treatment outcomes.

Firstly they indicate that the questionnaire has adequate internal consistency and is  sensitive to different situations and subjects (with recognition that the instrument needs further work in terms of factor structure and validity/reliability).

Secondly, they identify that improvements with respect to pain intensity and pain frequency at discharge and six months after discharge were stronger and more sustainable in the patient group reporting high quality of interaction with their clinician.  Again, the authors point out thatthat there are some limitations with respect to interpreting these findings:

Patients rating their interactions as high quality also reported higher pain intensity at admission. This could mean their pain scores ‘regressed to the mean’ (ie, reduced from an artificially high level to a more ‘usual’ level simply as a measurement artifact), or that these patients obtained better interactions from clinicians because they had higher pain intensity. Another drawback to the study is the 40% of patients who were unavailable for the 6 month followup measure.
A further point the authors make is that although pain, anxiety and mood improved, functional measures did not change (good point!). I note also that information about demographics and type of patient (chronicity of problem, previous health status and so on) wasn’t available, so we can’t determine whether there were differences between clinics.

What can we make of these findings?
It seems that these clinicians were really nice people – they conveyed warmth and empathy, and their patients liked this. They didn’t, however, do so well in terms of information exchange, guiding the discussion, or ‘making it work’ (actions). This might mean that although these clinicians were nice people they maybe hadn’t developed the specific skills involved in structuring a patient interaction.

While the clinicians involved in this study were physicians, I wonder whether occupational therapists, physiotherapists, nurses or even social workers could also be relatively under-skilled in the specifics of instrumental behaviour. I’m hoping that psychologists have some skill in this area – but I’m not entirely sure.

What was interesting for several reasons was the specific finding that people who rated the interactions very positively experienced better outcomes even in the long-term.
Now I don’t want to over-interpret this finding, but it does make me wonder whether this study is tapping into one aspect of the so-called placebo effect, or ‘meaning response’. After all, one of the main differences between ‘alternative’ health care providers and those of us working in, for example, a public health system, is the time available for a consultation. At the very least, the longer time available means more opportunity to demonstrate caring and empathy, and for information exchange.

At the same time, ‘alternative’ therapists positively engage with their patients to involve them in their (sometimes) complex treatment regimes (ever tried homeopathic treatments? you often have to stop using peppermint toothpaste, eating peppermints, stop drinking tea, coffee, chocolate…and I don’t even WANT to think about colonic treatments!). Of course, we’re not given the number of patients who drop out from ‘alternative’ treatments either, so I guess I’m not comparing apples with apples here!

I think I’ll go about reviewing my interactions in terms of these three dimensions for a while – and then see what I need to learn to improve my communication with patients.

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Susanne Dibbelt,, Monika Schaidhammer, Christian Fleischer, Bernhard Greitemann (2009). Patient–doctor interaction in rehabilitation: The relationship between perceived interaction quality and long-term treatment results Patient Education and Counseling: 10.1016/j.pec.2009.07.031

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