Medical Teacher, Vol. 14, No. 4, 1992
327
Med Teach Downloaded from informahealthcare.com by Mcgill University on 12/09/14 For personal use only.
Professional attitudes of doctors and medical teaching
CHARLES DE MONCHY, Study Conducted at the Centre for Medical Education, Dundee
SUMMARY The attitude of doctors towards the profession influences to a large extent a number of aspects of clinical competence. Their attitude towards the patient is particularly important as it determines the quality of communication. There is reason to believe that a certain number of practising clinicians have not acquired the appropriate attitude to their patients and the skills in communicating that this entails in spite of specific undergraduate education programmes. This would warrant more and different attention to this subject by medical schools than is actually the case. The recently introduced scale of attitudes between doctor-centred, disease-oriented and patient-centred, problemoriented could provide a basis for studying, teaching and evaluating individual attitudes of students.
The concept of attitude An attitude is a property of an individual person, less enduring than temperament but more enduring than a mood. It cannot be directly observed, but can be deducted from behaviour and verbal statements. Like intelligence and character it is a hypothetical construct. Attitudes do not cause fixed responses to a given subject, but rather consist of predispositions to respond in a certain manner. They are learned and tend to persist over time and are amenable to change, although sometimes not easily. Wagner (1 969) distinguishes three components of attitude: 0
the affective, consisting of our liking of, our evaluation of, our emotional response to the subject; the cognitive, our factual knowledge of the subject or what we believe to be the facts;
328 0
Charles de Monchy the conative or behavioural, meaning the overt behaviour we display.
Med Teach Downloaded from informahealthcare.com by Mcgill University on 12/09/14 For personal use only.
Medical professional attitude The attitude of the physician towards the profession in general, and particularly towards the patient, will determine to a large extent a number of aspects of his or her functioning. Attitude governs such diverse aspects of competence as collaboration with other professionals, priorities in health care and medical decision making. The quality of the communication with the patient can easily be considered as the most important area influenced by attitude. There is a growing concern, within as well as outside the profession, about the way a number of doctors deal with their patients. Some patients complain about a lack of personal interest from their doctor, others have difficulty with an authoritarian approach that leaves no room for personal opinions, others again say that their doctor only acknowledges organic disease as a legitimate reason for consulting him or her, and many say that they are not sufficiently informed about the nature of their complaint or the ratio rate behind the treatment. It seems logical to assume that this way of dealing with patients is at least in part a consequence of the scientific explosion of the last 40 years, which has extended the frontiers of medical science in an unprecedented way, and consequently widened the gap between the initiated and the uninitiated, even within the profession itself. We should be concerned about the dehumanization of medicine this has caused and the decline of interpersonal relationships as part of the clinical competence of the doctor. Let us see what is being done today in some medical schools to counteract these influences.
Attitude formation in the medical curriculum In spite of its admitted importance, the subject of attitude is not being taught as such in medical schools. This does not mean however that no attention is paid to the aspect of attitude formation during undergraduate training, but most of the formation is done in an indirect way. The subject of medical psychology offers a chance of broadly discussing interpersonal relationships with pre-clinical students. Inquiries however have shown that a sizeable proportion of the students see little connection at that stage of their studies between psychology and their mental picture of the medical practitioner. In their clinical training phase, the students are offered courses in interviewing, doctor-patient relationship, psycho-social skills or similarly named subjects. Very few follow-up studies have been published about the specific effect of these courses on attitude, or the quality of the doctor-patient contact, but one study is very disappointing (Helfer, 1970) and others do not warrant great optimism (Rezler, 1974). Other medical curricula offer programmes in comprehensive care or general practice in order to stimulate students’ interest in the psychosocial aspects of medicine. There have been several extensive studies published on the short-term and long-term effects of these courses, reported by Rezler (1974). These do not present evidence of a lasting effect on attitude. In summary it seems that most efforts to induce the appropriate attitude in
Attitudes of doctors
329
undergraduate students are less than successful. This could perhaps explain the criticism of attitudes of doctors mentioned above.
Med Teach Downloaded from informahealthcare.com by Mcgill University on 12/09/14 For personal use only.
Professional attitude and clinical competence We must realize that the quality of the relationship between doctor and patient is part of the clinical competence of the doctor and can play an important role in the outcome of treatment. Patients with feelings of anxiety, doubt or uncertainty have longer convalescence periods and more complications after surgical interventions than those who are confident and relaxed. Several studies have demonstrated the relation between the patient’s impression of the doctor’s empathy, courtesy, respect and personal interest on the one hand, and the patient’s satisfaction and compliance with therapeutic advice on the other (Francis, Korsch & Morris, 1969; Korsch, Gozzi & Francis, 1968; Blackwell, 1973). This quality of the relationship is determined by and depends on the quality of communication. By this we mean a communication that is not restricted to the exchange of easily accessible factual knowledge but which reaches a deeper level where the patient’s hidden feelings are stored and where emotional reactions are involved. The ability of the doctor to bring the communication with the patient to this level determines this aspect of clinical competence. This is where the doctor’s professional attitude plays an important part by determining basic convictions about their own role and the patient’s. Broadly speaking we can identify two opposing attitudes in doctors, One contributes positively to this aspect of clinical competence and the other not only does not contribute, but actually inhibits it. In the literature on attitude, two terms have been used to describe these two opposing attitudes: doctor-centred, for the attitude inhibiting deeper contact with patients, and patient-centred for the attitude stimulating this. In studying these attitudes more in detail it turned out to be necessary to extend the catchwords for each attitude and to call them doctor-centred, disease-oriented and patient-centred, problem-oriented. The doctor-centred, disease-oriented attitude can be described as being focused on medical diagnosis and the technical contribution of the doctor in the medical management plan. The role of the doctor is heavily stressed, and the patient is expected to be docile and passive. The doctor dominates the relationship and has an active, talking approach to the patient. Informing the patient, as far as is deemed necessary, is a oneway process with the doctor deciding what the patient should be told and what not. AS long as there is a clear-cut organic pathology, this doctor feels sure of his or her ground, but he or she feels much less capable of dealing with psychosomatic diseases or non-organic or non-classifiable complaints. This attitude is prevalent in many specialist departments of hospitals and especially in academic hospitals, where most of our undergraduate students receive their first instruction in how to behave as doctors. This fact has serious implications for undergraduate medical education. In contrast the doctor who is patient-centred, problem-oriented concentrates on the problem, as perceived by the patient. The patient’s beliefs, knowledge and feelings about health problems are considered to be important and necessary building blocks to the solution of the problem. Medical knowledge and interventions of course form part of the management plan, but the active cooperation of the patient is considered essential. Informing the patient in detail and checking this information against the
Med Teach Downloaded from informahealthcare.com by Mcgill University on 12/09/14 For personal use only.
330
Charles de Monchy
patient’s previous knowledge, are indispensable in attaining this. The doctor’s approach to the patient is predominantly a listening one. This way of dealing with patients can be applied to purely organic as well as psychosomatic diseases or nonorganic complaints. There is evidence that patients trust these doctors more and are better satisfied with their treatment. These descriptions of the two extreme attitudes will only rarely fit exactly the behaviour of an individual doctor. Most of us will exhibit some elements of both attitudes in the way we deal with our patients. Some of us will be more or less doctorcentred, disease-oriented whereas others show more characteristics of the patientcentred, problem-oriented attitude. Therefore a sliding scale has been conceived with each of the opposing attitudes at one end. This is called the DP-scale (see Fig. 1). With an appropriately adapted version of one of the accepted methods for measuring attitudes, for instance the Likert scale, individual attitudes can be located along this continuum, groups of medical professionals can be compared and changes of attitude documented. (de Monchy et al., in press).
1 2 D Doctor-centred Disease-oriented
The DP-Scale 3 4
5 P Patient-centred Problem-oriented
Sees task as a doctor in medical terms.
Sees task as a doctor in human terms.
Needs a diagnosis of (physical) disease.
Looks for the problem of the patient.
Considers the opinion of the doctor decisive in matters of medical management.
Wants the patient to decide after having been fully informed.
Considers the patient basically unequal to the doctor.
Considers the patient basically equal to the doctor.
Has habitually an active, talking approach to the patient.
Has habitually a listening approach to the patient.
Sees ideal health care delivery as:
Sees ideal health care delivery as:
more high technology
0
0
more efficient
0
0
better cure statistics.
0
more personalized more caring less threatening to patient.
FIG. 1. The DP-scale. The two opposing basic attitudes consist of a number of dimensions, along each of
which an individual doctor can be measured.
The teaching of attitude to undergraduate students The definition of a frame of reference for describing professional attitudes of individuals and groups, coupled with a method for measuring them, will create the possibility of studying attitude in a scientific, experimental way. This places the subject of attitude on a level with other academic subjects in the medical curriculum and should make it possible to teach it in a systematic way and also to have it included in evaluating procedures. Following Wagner’s concept of the three components of attitude (Wagner, 1969) i.e. the affective, the cognitive and the behavioural aspects, the teaching of attitude will have to contain elements of motivation, factual knowledge and the training of skills.
Med Teach Downloaded from informahealthcare.com by Mcgill University on 12/09/14 For personal use only.
Attitudes of doctors
331
Each of these elements will require its specific teaching and evaluation methods in keeping with the level of training and experience of the students. A few reservations however have to be made. Undergraduate students generally show a predilection for the cognitive aspects of their future profession. This is reinforced by the structure of the examinations, where factual knowledge determines the grade. Subjects having little or no influence on the final result of examinations will get little or no attention. If the teaching of attitude is not evaluated and the results incorporated in the final grade, the students will not be motivated to work for it. Moreover the pre-clinical student has difficulty in visualizing the importance of interpersonal relationships in medical practice. This also will be an obstacle to mobilizing interest. Finally there is the student’s identification with clinical teachers. Rezler (1 974) tentatively concludes that one of the main reasons why the programmes of comprehensive care had so little influence on the students’ attitude was the low esteem other clinical teachers had of the programme. In view of the fact that many specialists in academic hospitals have a doctor-centred, disease-oriented attitude this is not surprising (de Monchy et al., in press). It should however make those of us who are concerned about attitudes sit up and take notice. Notwithstanding these reservations and possible negative influences however, the teaching of attitude should be integrated in the medical curriculum. The best way to do this would be to teach it as part of all clinical disciplines as a self-evident part of clinical competence and not as a separate subject. A clear definition of the desired attitude and a reliable way of measuring it can contribute considerably to the realization of this ideal.
Correspondence: Dr C . de Monchy, 5 Prim Hendriklaan, 5583 AH Waalre, Holland. REFERENCES BLACKWELL, B. (1973) Drug therapy, patient compliance, New England Journal of Medicine, 289, p. 249. FRANCIS,V., KORSCH,B.M. & MORRIS, M.J. (1969), Gaps in doctor-patient communication. 11. Patient’s response to medical advice, Nee0 England Journal of Medicine, 280, p. 535. HELFER,R.E. (1970) An objective comparison of the paediatric interviewing skills of freshmen and senior medical students, Pediatrics, 45, p. 623. KORSCH,B.M., G o z z ~ E.K. , & FRANCIS,V. (1968) Gaps in doctor-patient communication, I. Doctor-patient interaction and patient satisfaction, Pediam‘cs, 42, p. 855. DE MONCHY,C., RICHARDSON, R., BROWN,R.A. & HARDEN,R.M. (1992) Measuring attitudes of doctors: the doctor-patient (DP)-rating, Medical Education, in press. REZLER,A.G. (1974) Attitude changes during medical school: a review of the literature, Journal ofMedica1 Education, 49, p. 1023. WAGNER,R.V. (1969) The study of attitude change: an introduction, in: WAGNER,R.V.& SHERWOOD, J.J. (Eds)The study of attitude change (Brooke and Cole, California).
327
Med Teach Downloaded from informahealthcare.com by Mcgill University on 12/09/14 For personal use only.
Professional attitudes of doctors and medical teaching
CHARLES DE MONCHY, Study Conducted at the Centre for Medical Education, Dundee
SUMMARY The attitude of doctors towards the profession influences to a large extent a number of aspects of clinical competence. Their attitude towards the patient is particularly important as it determines the quality of communication. There is reason to believe that a certain number of practising clinicians have not acquired the appropriate attitude to their patients and the skills in communicating that this entails in spite of specific undergraduate education programmes. This would warrant more and different attention to this subject by medical schools than is actually the case. The recently introduced scale of attitudes between doctor-centred, disease-oriented and patient-centred, problemoriented could provide a basis for studying, teaching and evaluating individual attitudes of students.
The concept of attitude An attitude is a property of an individual person, less enduring than temperament but more enduring than a mood. It cannot be directly observed, but can be deducted from behaviour and verbal statements. Like intelligence and character it is a hypothetical construct. Attitudes do not cause fixed responses to a given subject, but rather consist of predispositions to respond in a certain manner. They are learned and tend to persist over time and are amenable to change, although sometimes not easily. Wagner (1 969) distinguishes three components of attitude: 0
the affective, consisting of our liking of, our evaluation of, our emotional response to the subject; the cognitive, our factual knowledge of the subject or what we believe to be the facts;
328 0
Charles de Monchy the conative or behavioural, meaning the overt behaviour we display.
Med Teach Downloaded from informahealthcare.com by Mcgill University on 12/09/14 For personal use only.
Medical professional attitude The attitude of the physician towards the profession in general, and particularly towards the patient, will determine to a large extent a number of aspects of his or her functioning. Attitude governs such diverse aspects of competence as collaboration with other professionals, priorities in health care and medical decision making. The quality of the communication with the patient can easily be considered as the most important area influenced by attitude. There is a growing concern, within as well as outside the profession, about the way a number of doctors deal with their patients. Some patients complain about a lack of personal interest from their doctor, others have difficulty with an authoritarian approach that leaves no room for personal opinions, others again say that their doctor only acknowledges organic disease as a legitimate reason for consulting him or her, and many say that they are not sufficiently informed about the nature of their complaint or the ratio rate behind the treatment. It seems logical to assume that this way of dealing with patients is at least in part a consequence of the scientific explosion of the last 40 years, which has extended the frontiers of medical science in an unprecedented way, and consequently widened the gap between the initiated and the uninitiated, even within the profession itself. We should be concerned about the dehumanization of medicine this has caused and the decline of interpersonal relationships as part of the clinical competence of the doctor. Let us see what is being done today in some medical schools to counteract these influences.
Attitude formation in the medical curriculum In spite of its admitted importance, the subject of attitude is not being taught as such in medical schools. This does not mean however that no attention is paid to the aspect of attitude formation during undergraduate training, but most of the formation is done in an indirect way. The subject of medical psychology offers a chance of broadly discussing interpersonal relationships with pre-clinical students. Inquiries however have shown that a sizeable proportion of the students see little connection at that stage of their studies between psychology and their mental picture of the medical practitioner. In their clinical training phase, the students are offered courses in interviewing, doctor-patient relationship, psycho-social skills or similarly named subjects. Very few follow-up studies have been published about the specific effect of these courses on attitude, or the quality of the doctor-patient contact, but one study is very disappointing (Helfer, 1970) and others do not warrant great optimism (Rezler, 1974). Other medical curricula offer programmes in comprehensive care or general practice in order to stimulate students’ interest in the psychosocial aspects of medicine. There have been several extensive studies published on the short-term and long-term effects of these courses, reported by Rezler (1974). These do not present evidence of a lasting effect on attitude. In summary it seems that most efforts to induce the appropriate attitude in
Attitudes of doctors
329
undergraduate students are less than successful. This could perhaps explain the criticism of attitudes of doctors mentioned above.
Med Teach Downloaded from informahealthcare.com by Mcgill University on 12/09/14 For personal use only.
Professional attitude and clinical competence We must realize that the quality of the relationship between doctor and patient is part of the clinical competence of the doctor and can play an important role in the outcome of treatment. Patients with feelings of anxiety, doubt or uncertainty have longer convalescence periods and more complications after surgical interventions than those who are confident and relaxed. Several studies have demonstrated the relation between the patient’s impression of the doctor’s empathy, courtesy, respect and personal interest on the one hand, and the patient’s satisfaction and compliance with therapeutic advice on the other (Francis, Korsch & Morris, 1969; Korsch, Gozzi & Francis, 1968; Blackwell, 1973). This quality of the relationship is determined by and depends on the quality of communication. By this we mean a communication that is not restricted to the exchange of easily accessible factual knowledge but which reaches a deeper level where the patient’s hidden feelings are stored and where emotional reactions are involved. The ability of the doctor to bring the communication with the patient to this level determines this aspect of clinical competence. This is where the doctor’s professional attitude plays an important part by determining basic convictions about their own role and the patient’s. Broadly speaking we can identify two opposing attitudes in doctors, One contributes positively to this aspect of clinical competence and the other not only does not contribute, but actually inhibits it. In the literature on attitude, two terms have been used to describe these two opposing attitudes: doctor-centred, for the attitude inhibiting deeper contact with patients, and patient-centred for the attitude stimulating this. In studying these attitudes more in detail it turned out to be necessary to extend the catchwords for each attitude and to call them doctor-centred, disease-oriented and patient-centred, problem-oriented. The doctor-centred, disease-oriented attitude can be described as being focused on medical diagnosis and the technical contribution of the doctor in the medical management plan. The role of the doctor is heavily stressed, and the patient is expected to be docile and passive. The doctor dominates the relationship and has an active, talking approach to the patient. Informing the patient, as far as is deemed necessary, is a oneway process with the doctor deciding what the patient should be told and what not. AS long as there is a clear-cut organic pathology, this doctor feels sure of his or her ground, but he or she feels much less capable of dealing with psychosomatic diseases or non-organic or non-classifiable complaints. This attitude is prevalent in many specialist departments of hospitals and especially in academic hospitals, where most of our undergraduate students receive their first instruction in how to behave as doctors. This fact has serious implications for undergraduate medical education. In contrast the doctor who is patient-centred, problem-oriented concentrates on the problem, as perceived by the patient. The patient’s beliefs, knowledge and feelings about health problems are considered to be important and necessary building blocks to the solution of the problem. Medical knowledge and interventions of course form part of the management plan, but the active cooperation of the patient is considered essential. Informing the patient in detail and checking this information against the
Med Teach Downloaded from informahealthcare.com by Mcgill University on 12/09/14 For personal use only.
330
Charles de Monchy
patient’s previous knowledge, are indispensable in attaining this. The doctor’s approach to the patient is predominantly a listening one. This way of dealing with patients can be applied to purely organic as well as psychosomatic diseases or nonorganic complaints. There is evidence that patients trust these doctors more and are better satisfied with their treatment. These descriptions of the two extreme attitudes will only rarely fit exactly the behaviour of an individual doctor. Most of us will exhibit some elements of both attitudes in the way we deal with our patients. Some of us will be more or less doctorcentred, disease-oriented whereas others show more characteristics of the patientcentred, problem-oriented attitude. Therefore a sliding scale has been conceived with each of the opposing attitudes at one end. This is called the DP-scale (see Fig. 1). With an appropriately adapted version of one of the accepted methods for measuring attitudes, for instance the Likert scale, individual attitudes can be located along this continuum, groups of medical professionals can be compared and changes of attitude documented. (de Monchy et al., in press).
1 2 D Doctor-centred Disease-oriented
The DP-Scale 3 4
5 P Patient-centred Problem-oriented
Sees task as a doctor in medical terms.
Sees task as a doctor in human terms.
Needs a diagnosis of (physical) disease.
Looks for the problem of the patient.
Considers the opinion of the doctor decisive in matters of medical management.
Wants the patient to decide after having been fully informed.
Considers the patient basically unequal to the doctor.
Considers the patient basically equal to the doctor.
Has habitually an active, talking approach to the patient.
Has habitually a listening approach to the patient.
Sees ideal health care delivery as:
Sees ideal health care delivery as:
more high technology
0
0
more efficient
0
0
better cure statistics.
0
more personalized more caring less threatening to patient.
FIG. 1. The DP-scale. The two opposing basic attitudes consist of a number of dimensions, along each of
which an individual doctor can be measured.
The teaching of attitude to undergraduate students The definition of a frame of reference for describing professional attitudes of individuals and groups, coupled with a method for measuring them, will create the possibility of studying attitude in a scientific, experimental way. This places the subject of attitude on a level with other academic subjects in the medical curriculum and should make it possible to teach it in a systematic way and also to have it included in evaluating procedures. Following Wagner’s concept of the three components of attitude (Wagner, 1969) i.e. the affective, the cognitive and the behavioural aspects, the teaching of attitude will have to contain elements of motivation, factual knowledge and the training of skills.
Med Teach Downloaded from informahealthcare.com by Mcgill University on 12/09/14 For personal use only.
Attitudes of doctors
331
Each of these elements will require its specific teaching and evaluation methods in keeping with the level of training and experience of the students. A few reservations however have to be made. Undergraduate students generally show a predilection for the cognitive aspects of their future profession. This is reinforced by the structure of the examinations, where factual knowledge determines the grade. Subjects having little or no influence on the final result of examinations will get little or no attention. If the teaching of attitude is not evaluated and the results incorporated in the final grade, the students will not be motivated to work for it. Moreover the pre-clinical student has difficulty in visualizing the importance of interpersonal relationships in medical practice. This also will be an obstacle to mobilizing interest. Finally there is the student’s identification with clinical teachers. Rezler (1 974) tentatively concludes that one of the main reasons why the programmes of comprehensive care had so little influence on the students’ attitude was the low esteem other clinical teachers had of the programme. In view of the fact that many specialists in academic hospitals have a doctor-centred, disease-oriented attitude this is not surprising (de Monchy et al., in press). It should however make those of us who are concerned about attitudes sit up and take notice. Notwithstanding these reservations and possible negative influences however, the teaching of attitude should be integrated in the medical curriculum. The best way to do this would be to teach it as part of all clinical disciplines as a self-evident part of clinical competence and not as a separate subject. A clear definition of the desired attitude and a reliable way of measuring it can contribute considerably to the realization of this ideal.
Correspondence: Dr C . de Monchy, 5 Prim Hendriklaan, 5583 AH Waalre, Holland. REFERENCES BLACKWELL, B. (1973) Drug therapy, patient compliance, New England Journal of Medicine, 289, p. 249. FRANCIS,V., KORSCH,B.M. & MORRIS, M.J. (1969), Gaps in doctor-patient communication. 11. Patient’s response to medical advice, Nee0 England Journal of Medicine, 280, p. 535. HELFER,R.E. (1970) An objective comparison of the paediatric interviewing skills of freshmen and senior medical students, Pediatrics, 45, p. 623. KORSCH,B.M., G o z z ~ E.K. , & FRANCIS,V. (1968) Gaps in doctor-patient communication, I. Doctor-patient interaction and patient satisfaction, Pediam‘cs, 42, p. 855. DE MONCHY,C., RICHARDSON, R., BROWN,R.A. & HARDEN,R.M. (1992) Measuring attitudes of doctors: the doctor-patient (DP)-rating, Medical Education, in press. REZLER,A.G. (1974) Attitude changes during medical school: a review of the literature, Journal ofMedica1 Education, 49, p. 1023. WAGNER,R.V. (1969) The study of attitude change: an introduction, in: WAGNER,R.V.& SHERWOOD, J.J. (Eds)The study of attitude change (Brooke and Cole, California).
