Scand J Soc Med, Vol. 20, No.4

Patients comment on video-recorded consultations - the "good" GP and the "bad" Elisabeth Arborelius', Toomas Timpka' and James M. Nyce! From the I Department of Community medicine, Linkiiping University, S-581 85 Linkoping, Sweden, 1 Department of Anthropology, Brown University, Providence, RI02912, USA

Patients comment on video-recorded consultations - the "good" GP and the "bad". Arborelius, E., Timpka, T. and Nycc, J. M. (Department of Social Medicine, Linkoping University and Department of Anthoropology, Brown University. USA). Scand J Soc Med 1992.4 (213-216).

The aim of this study was to describe and understand patients' positive and negative experiences of General Practitioners (GPs). Forty-six consultations were videotaped in four primary health care centres in Sweden. Afterwards the patients commented on the recorded consultations. The comments were categorized and analyzed using an exploratory qualitative approach. An image of the "good" GP emerged that had two major characteristics: that of being a caring human; an individual who listens, understands, and is concerned. At the same time, the good GP acts like an ordinary person and treats the patient as an equal. The personal relationship with the GP also influenced the choice and course of medical interventions. For the patient, the manner in which an intervention is seen is linked to whether the GPs treats the patient with respect or not. A typical experience of a "bad" GP was that the GP appeared unreachable as a person. An example is when the patient feels that the GP was not taking his or her symptoms seriously. Another characteristic of the bad GP is failure to communicate to the patient his or her standpoint on issues raised during consultations. Key words: Doctor-patient relationship, practice studies, video recordings, qualitative methods.

INTRODUCTION How does a consultation by a general practitioner (OP) appear to a patient? If we place a TV-camera in the consultation room, record the consultation, show the patient and ask him to tell us - what will he or she say? What can we learn about the communication between the OP and the patient by studying the patient's comments on video-recorded consultations? The aim of this study was to describe and try to understand patients' experiences of OPs by studying their comments on video-recorded consultations.

A study with a similar method - comments to videotaped consultations - has been reported, where the patients were directed by interviews during the reviews (1). No previous study, however, has proceeded from patients' spontaneous statements. The basic argument for the study is that the perspectives and experiences of persons/patients served by primary health care programmes must be understood before interventions and changes in the programs can take place. This paper is part of a series of studies where the intention is to identify key factors in the OP-patient relationship, identify communication deficiencies in primary health care, and to build, from these studies, models with practical and theoretical usefulness (2, 3). However, there are well-known problems with gathering information on patient problems and perceptions using standard methods, i.e., questionnaires and interviews (4). Patients tend to take socially "acceptable" positions and only infrequently express negative attitudes. However, more accurate information can be obtained by a qualitative "stimulated recall" video method for data collection (5). In this method, after video-taping the consultations, the recording is shown to the patient. The patient is instructed to stop the tape wherever he wants to comment. All comments are audio-taped and the time when the tape is stopped is recorded. This method has been further elaborated and evaluated (6). The influence of the video camera was marginal for the patients as well as for the OPs. The evaluation also showed that the patients, with this method, were able to give detailed information about their experiences. Therefore, for the analyses of the comments a method is needed which is explorative, but also aimed at understanding the respondents' experiences. Grounded theory, and models that proceed from it, support these requirements. They do so first by allowing researchers to reflect upon the interaction Scand J Soc Med 20

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between the method of analysis and data, and second, by being based on an interpretative approach (7). METHODS The present study was carried out in the year 1988comprising in total 46 video-recorded consultations in four Swedish health care centres. Collection of data The patients: The selection of patients, stratified with regard to sex and first or return visit, consisted of 23 males and 23 females. evenly distributed between 20 and 97 years of age. The patients got written and verbal information about the study. Ninety-one percent participated. All patients who participated also completed the study. One patient, however, asked later to have "his" video-tape erased. The CPs: Twelve board certified GPs (six males and six females) participated. The average age was 40 (range 35 50). On average. the GPs had practised for 13 years (range 9 - 27). The symptoms: There was no selection of symptoms. The material covered a broad range (about 60 different diagnoses) from "simple" upper respiratory infections to relapse in anorexia. The procedure: About one week after the consultation. the patients watched and commented on the video-tape. They were asked to teIl us about their impressions by stopping the tape as often as desired and by commenting spontaneously. If the patient did not did not say anything for five minutes, we asked the question: "What do you think now when you watch the TV?" When the patient had gone through the whole tape. we also asked: "When you have now seen the whole tape - is there anything else you would like to tell us?" All comments were audio-taped (the point in time for every comment was recorded) and transcribed. life/hod of analysis An explorative approach was made to the comments based on grounded theory (7). In grounded theory, themes arising from the data are identified and worked through in the form'of qualitative, disciplined abstractions. This process of analysis is intended to be constantly reflexive. In brief, it checks concepts and hypotheses against the data, investigates data that do not fit, and refines the initial hypotheses. Hence, all the patient's comments were read and interpreted in respect to the consultations. After that, a provisional classification scheme was constructed, i.e., we searched for and named categories which appeared to elucidate interesting similarities and differences between the comments. All comments were then initially categorized according. to this first, preliminary classification scheme. The categorized comments were then read again focussing on homogeneity of the categories, and both the construction of the scheme and categorization of comments were iterated.

RESULTS The 46 patients presented altogether 279 comments. The analysis showed that the patients mostly (62%) commented on GPs and consultations, followed by health beliefs (16%), and the patient's own behavior (12%). The influence of the video camera was the topic for 2% of the comments, while the remaining 8% addressed various minor issues. No difference was found in the comments between males and females or between first and return visits. In the following, we describe the main themes, broken into categories, that emerged.

The "good" GP The comments in this category describe the good GP in terms of his relationship to the patient and his way of acting/working with patients.

The relation to tire patient These comments related to one of the following three themes. The first theme is the importance of being treated as a person, and not as a patient; e.g.: "This is a good thing with this doctor, that she is a bit more personal and asks where my husband is from. Then at once the relationship becomes better due to the fact that she is more concerned, not only about my disease." "He really takes his time to talk about my children, I mean, you arc not treated as a thing." . The second essential point for the patients is that the GP is involved and seriously listens to the patient, e.g.: "She is incredible as a listener, she takes her time and she listens in a careful way." "There are few doctors, who are involved the way she is." The experience of perceiving the doctor as his or her equal is the third major point patients commented on in positive terms: "I consider him very gentle, on the same level as I am. It's not 'the doctor and his patient'; we are on the same level." Patients say much the same thing when they talk about how these GP's appear, i.e. as ordinary people: "You can ask him about everything, he doesn't behave in a superior way and he doesn't laugh at a simple question." The experience of the "good" GP was summed up

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Patients comment on video-recorded consultations by an old patient (86 years) who suddenly, when he observed the tape, said: "He is nice to be with."

The GP's way of actinglworking These comments relate to one of the folIowing three themes. The first theme deals with the GP's trustworthiness as professional, for example: "He is careful, he doesn't prescribe penicillin for just any reason." The second important issue is the way GPs talk to patients, e.g.: "He gives good explanations. he explains in simple terms what the reason is and the effects may be." The third theme concerned the GP as provider of care, not just medical services: "I really feltI was well taken care of." "He decided for me what to do -lovely." The "bad" GP The first theme in these comments dealt with when the GP appeared unreachable as a person; II1I;nterested and/or distanced: "I felt as if he was a bit stuck-up, not possible to get ncar him, a bit sulky." "I don't know, but I have the feeling that she belittles my problem." "That they listen - I think they have difficulties with it." The second theme dealt with the patient worrying (feeling anxiety) about not getting what he or she wanted from the GP: "I was anxious that I would not get everything I wanted to have." "Forced by time ... will I get what I need right here and now so that I can go on with other things I have td .do?' Thc" third theme concerned GPs who patients thought took a superior position to them and thus humiliated them. "Why did he have to take the call in the middle of the explanation, He totally lost the thread after that "I have to lie undressed after the examination while he is standing beside and asking questions." DISCUSSION For patients, it is most important in primary health care consulations to have a personal relationship with the GP. In the patients' comments, a picture of

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the "good" GP has two parts. First, this GP is a perfect, caring human: who listens, understands, and is concerned; "a quite wonderful doctor, with whom I can discuss everything:" Second, patients also want a GP appears to be a person, with whom it is possible to be on an equal level. For some patients, both these needs are expressed during the same consultation. Some desires about the GP's behavior may appear to be inconsistent. For example, some patients consider it important that the GP has not read the medical record before a consultation but allows the patient to tell why he is there in his own way; others regard it as carelessness when the GP has not read the records. However, in both cases, what is important is that the GP respects the patient's personal needs. This corresponds to the previous studies which show that the GP's respect for the patient's individual needs is of great importance (8) and also that the physician should show interest, kindness and warmth (9, 10).

The "bad" GP - the unreachable doctor A typical experience of a "bad" GP is when" the patient feels that the GP was not taking his or her symptoms seriously, i.e., that a person-to-person encounter never occurred. This experience, that the GP is not concerned about the patient as a person, ignores symptoms, and docs not give the "right" treatment, occurs; when patients see the GP and his behavior as authoritarian. It is this feeling of having been treated as an inferior that, it seems, leads to (and causes anxiety over) not getting what one wants. The patient then feels uncertain towards the GP and wants/attempts to get these anxieties disconfirmed.

The human encounter model These results can be related to theoretical models of the doctor-patient relationship. Of these models, the interpersonal communication model, where the emphasis is on exchange of information, has been used the most. However, other models more applicable to the results of this study have been described, i.e., the human encounter model (11). This model suggests that what the patient expects from the physician is' human felIowship ... Hence, the GP's attitude to medical practice should reflect his own concerns as a person and be oriented towards other persons, not patients. Here, the GP and the patient are confronted with an essential phenomenon of human Scant! J Soc Met! 20

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existence, i.e. to build a relationship between fellowmen. The present study suggests that patient experiences of GPs can be understood in terms of the human encounter model. Thus, in an ideal encounter, according to this model, the desire for a human relationship is fulfilled and the patient feels neither a lack of confidence nor a lack of approval. That this study found that the GP should also appear as an ordinary human being, who treats you as an equal is consistent with this model. A methodological reflection Is it possible to judge whether comments to videorecordings reflect all the patients' experiences of GPs or are there some phenomena so obvious that patients simply do not comment on them? For example, patients may never challenge a GP's medical knowledge. If so, the result could be that deficiencies, if any, in the GPs' medical behavior, patients would interpret as failures in the patient-doctor relationship. However, other studies (12) show that this seldom is the case, i. e. patients are able to differentiate the GP's courtesy from his competence.

CONCLUDING REMARKS This study, like others. shows how important a personal relationship with the GP is for the patient. However, with this exploratory method we can, it seems. obtain and better understand the meanings this relationship has for the patient. In particular, it suggests patients in respect to the GP have and have to deal with multiple needs. Among these is for the GP to be a good listener, to be the "care-taker", to be concerned and involved; and at the same time for him-or her to be an ordinary person. Finally, for patients medical interventions tend to take on particular meanings, often related to whether GPs treat them with respect or not.

ACKNOWLEDGMENTS Ann-Charlotte Nilsson, BA, provided proficient assistence with the data collection. This study was supported by grants from The Swedish Ministry of Health and Social Affairs. The Commission for Social Research and by the Department of Community Medicine. Faculty of Health Sciences in Linkoping.

REFERENCES 1. Engestrom Y. Developmental studies of work as a testbench of activity theory. In: Lave J, Chaiklin S, eds, Situated learning. Cambridge: Cambridge University Press, 1988. 2. Arborelius E, Tirnpka T. General practitioners' comments on video recorded consultations as an aid to understand the doctor-patient relationship. Fam Pract 1990; 7: 84-90. 3. Arborelius E, Bremberg S, Timpka T. What is going on when the general practitioner doesn't grasp the consultation? Fam Pract 1992, in press. 4. Hulka BS, Zyzanski SJ. Cassel JC, Thompsson SJ. Scale for measurement of attitudes toward physicians and primary care. Med Care 1970; 8: 429-36. 5. Frankel R, Beckman H. Impact: An interaction-based method for preserving and analyzing clinical transactions. In: Pettigrew L, edt Straight talk: Explorations in provider and patient interactions. Nashville, Tennessee: Humana Inc., 1982. 6. Arborelius E, Timpka T. In what way may videotapes be used to get significant information about the patient-physician relationship? Medical Teacher 1990; 12: 197-208. 7. Glaser BG, Strauss AL. The discovery of grounded theory. Chicago: Aldine, 1967. 8. Falvo D, Smith J. Assessing residents behavioural science skills: patients views of physician-patient interaction. J Fam Pract 1983; 17: 479-83. 9. Korsch B, Negrete V. Doctor-patient communication. Sci Am 1972; 227: 66-74. 10. Hein N, Wodak R. Medical interviews in internal medicine. Some results of an empirical investigation. Text 1987; 7: 37~5. 11. Pierloot R. Different models in the approach to the doctor-patient relationship. Psychothcr Psychosom 1983; 39: 213-24. 12. Willson P, McNamara R. How perceptions of a simulated physician-patient interaction influence intended satisfaction and compliance. Soc Sci Med 1982; 16: 1699-1704.

Address for offprints: Toomas Timpha Dept of Community Medicine Linkoping University S-58185 Linkoping Sweden

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Patients comment on video-recorded consultations--the "good" GP and the "bad".

The aim of this study was to describe and understand patients' positive and negative experiences of General Practitioners (GPs). Forty-six consultatio...
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