Outlines findings from focus groups on the role of effective communication between physicians and patients in improving the quality of health care and outcomes. Analyzes responses by race/ethnicity and gender. Includes recommendations

Alicia Leonard

Ann D. Bagchi

Raquel af Ursin

English

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T r e n ds  i n  H e a lT H C a r e  Q ua l i T yFEBRUARY 2009NUmBER 5Focus on Quality: Communication in the  Health Care Encounterby Ann Bagchi, Raquel af Ursin, and Alicia LeonardTo explore the question of what constitutes “quality” in a health care encounter from the patient perspec-tive, Mathematica conducted focus groups with African Americans, Latinos, Asian Indians, and whites. Participants were asked to define quality in the context of a visit to a primary care physician, and to describe their ideal visit and the characteristics of an excellent physician. Although participants frequently mentioned factors related to the health care setting (for example, waiting times, appearance of the doctor’s office, and efficiency of staff), their most common issues related  to patient-provider communication.Importance of CommunicationEffective communication between patients and their health care providers has been shown to improve the quality of heath care. It is a strong predictor of overall patient satisfaction and associated with improved health outcomes. Patients who can successfully communicate with their providers are more likely to elicit an empa-thetic response from providers, have a better under-standing of their diagnoses and treatment options, and better participate in shared decisionmaking. Research suggests that members of racial and ethnic minority groups are more likely to report communi-cation barriers with their physicians, especially when the patient and provider have different backgrounds. Understanding the needs and expectations of patients, especially members of racial and ethnic minority groups, can help health care providers enhance their communication skills and, subsequently, improve quality of care they provide.Mathematica held focus groups (see box) that show all patients view good communication as key to a high quality physician’s visit. However, three addi-tional issues emerged:1. Although participants had different perspectives on the degree of personal familiarity a physician should have with his or her patients, the major-ity agreed that showing some familiarity with a patient helped build trust. 2. Participants in the African American, Latino, and Asian Indian focus groups stressed the need for physi-cians to demonstrate cultural competence in the health care encounter, including competence in issues related to age and gender. For example, some participants thought that the older Asian woman depicted in the video could not adequately communicate her health concerns to the physician because women of her generation were expected to show deference to a physician and not directly question his or her judg-ment. These participants thought the physician should be aware of such attitudes and adapt his approach to interviewing the patient to encourage more disclosure. Mathematica held 8 focus groups with a total of 84 participants recruited through cold calls to targeted zip codes, fliers posted in the vicin-ity of where the groups would be held, and an advertisement posted on craigslist (an online site for classified ads, including community events and job listings). The 90-minute ses-sions were split into two segments. During one segment, the participants viewed a video of an encounter between a white male physician and an older Asian female patient. The purpose was to determine whether participants viewing the same encounter had different perceptions of the quality of care depicted. The other segment included a more general discussion of the defi-nition of “quality” in health care encounters. BaCkground on THe  FoCus  groupsISSUE BRIEFT i M e l y  i n F o r M a T i o n  F r o M  M a T H e M a T i C aMathematica® strives to improve public well-being by bringing the highest standards of quality, objectivity, and excellence to bear on the provision of information collection and analysis to its clients.2that might be pertinent to diagnosis and treatment. According to one Asian Indian participant:The last thing you want is for your doctor to feel like a stranger to you because that fosters lack of trust or just fear. And so I think the doctor doesn’t have to shake your hand, but even if he touches your shoulder, walks in and says, ‘Hey, how are you, how’s your mom, how’s your father?’ there’s some effort to reconnect, to re-identify, to say, ‘You’re here to see me, and I know who you are. You’re not a stranger to me. And if this is our first time, then we’re going to spend some time, but if I’ve seen you before, I’m going to acknowledge that I know who you are and that I care enough to remember things about you and to show you that you’re right now, at this minute, my only concern.’ An African American participant echoed this senti-ment, saying that a good visit to the doctor is when  “. . . the doctor remembers you and if you guys are  on a personal level . . . One of the doctors, I really like her, she gets close with the patients; she always knows about their personal lives and just has normal conver-sations [with] them.” Most of these participants also said that the ability to show empathy was one of the most important characteristics of their ideal physician. The other set of participants felt that this personal level of communication could interfere with the pro-vision of high-quality care. As one participant noted, “I think a doctor has to be objective when treating a patient in the sense that he doesn’t get into the emo-tional tangle of things. Because if he does, I think it would cloud his judgment for his diagnosis.” After viewing the video, these participants focused on the technical skills that are a part of medical training, as demonstrated in the following exchange:Respondent 1: I think also doctors go to medical school and learn the textbook things. They know how to fix things on the medical level. They’re not necessarily therapists, or analysts, or customer service caregivers or anything like that. I don’t know, when I go to the doctor, I don’t expect them to sympathize with what’s going on in my life. I expect them to just be able to give me the proper medical care because it’s not necessary to be my best friend.Respondent 2: The doctor is treating symptoms, and that’s what he is trained to do.Moderator: Did he understand the symptoms of the patient?3. Participants noted the importance of communica-tion as a bi-directional exchange, with some stat-ing that a patient bears as much responsibility as a physician in ensuring that all needs and concerns are addressed.Sympathy or Symptoms?Participants expressed two prevailing and competing views of a physician’s role in communicating with patients (both views were represented across each racial/ethnic group). One set of participants felt that it was a physician’s responsibility to show empathy and to know a patient at a personal level in order to encourage trust and willingness to share information snapsHoT  oF  FoCus  group  parT iC ipanTs                                   AfricanAmericans LatinosAsian  Indians Whites TotalParticipants 24 19 20 21 84GenderFemale 18 10 7 12 47Male 6 9 13 9 37Age18 to 25 3 12 12 6 3326 to 45 10 5 5 10 3046 to 64 10 1 3 5 1965 and older 1 1 0 0 2EducationHigh school or less3 2 2 2 9Some college 8 12 9 11 40College  graduate13 5 9 8 35Household incomeLess than $20,0002 1 2 0 5$20,000  to $39,9995 8 0 4 17$40,000  to $59,9993 4 4 3 14$60,000  to $79,9995 2 3 6 16$80,000  to $99,9993 0 3 5 11$100,000  or more6 3 8 3 20Missing 0 1 0 0 1United States residenceBorn in  the U.S.22 9 9 21 61Resident  10 years  or more2 6 6 0 14Resident  less than  10 years0 3 5 0 8Missing 0 1 0 0 13In evaluating the quality of care depicted in the video, groups noted a number of potential lapses in the physician’s understanding of cultural differences. For example, at one point in the video, the physician seats himself next to the patient and crosses one leg over the other, exposing the sole of his shoe to his patient. Asian Indians were more likely than other groups to note that this gesture is considered rude in some cultures and that the patient appeared offended. Across the discussions with members of racial and eth-nic minority groups, participants noted that physicians must take into account perceived power differences, especially in interactions with older patients who are more likely to have been raised to respect physicians’ knowledge and authority. Except for those in the white focus group, participants noted these behaviors in the video and also in their personal experiences. For example, one African American participant noted that she frequently takes her mother to the physician and recalled a recent visit in which her mother quietly assented to everything the doctor told her, only to state to her daughter on leaving, “That doctor doesn’t know what he’s talking about.” Latinos and Asian Indians recounted similar experiences with physician visits with elderly relatives. When asked, white respondents did not think culture played any role in the ability of the physician and patient depicted in the video to com-municate with one another. As one respondent put it,  “I don’t think it had anything to do with culture.”There was some discussion of the meaning of “cul-tural competency,” but a common belief was that the concept is tied more to communication than to a base of knowledge. As one participant put it, I don’t think cultural competency means learning about each culture. That’s impossible; there’s [sic] too many cultures. But being culturally sensitive . . . [is] listening to the person and finding out what’s important to them and what it means to them.Patient ResponsibilityIn keeping with the discussion of the degree of personal familiarity a physician should show during an office visit, participants’ views were mixed on the responsibility of a physician to encourage patient disclosure of health status and concerns. Because some patients may be reluctant to share personal information that could ultimately assist physicians with diagnosis and decisions on treatment options, one set of participants said it was the physician’s responsibility to ask open-ended questions to encourage more personal disclosure. For example, with respect to the encounter depicted in the video, one participant noted that:Respondent 2: I think so. When she said she had a problem breathing, he checked her lungs [and] checked her breathing. You treat symptoms. That’s what [it] is all about. To expect to empathize with every patient may not be good; you have to be detached to be able to treat things. Probably I think he did what was expected of him. Respondent 1: I would say the same. I think sympathizing with a patient might change their medical judgment. Another participant summed up the feelings of this group by stating “. . . if you want sympathy, call your mom.” This reaction was more common among men, and was expressed by some participants in each racial/ethnic group. A unique perspective raised by a number of Asian Indian women participants was that greater familiar-ity can lead to violations of patients’ privacy, particu-larly if the physician is a member of the patient’s ethnic group. As one participant put it, One big thing that I’ve also heard of is, especially with certain doctors, they’ll share information. They might not say who, but they’ll start hinting towards things. It’s your private information. You don’t want that out there. It’s shared with other family, friends, other people that we all know. You don’t want your business being spread throughout the community like that. So I kind of avoid [seeing doctors of the same ethnicity] around where my family is.Familiarity Breeds ContentmentDespite these starkly different perspectives on physi-cians’ roles in communicating with patients, most participants agreed that it is important for the physician at least to make a point of showing some familiarity with the patient’s care. In the words of one participant, “I think remembering is the most important thing. The last time I went to the doctor, the doctor asked me how my exams went. I was like, ‘The last time I came was like six months ago.’ He said, ‘Yeah, but I wrote it down.’ I was like ‘Automatically you have my trust.’” More commonly, patients thought that doctors should review a patient’s chart prior to entering the exam room, so they were aware of the patient’s health history and ready to begin the physical examination. Cultural CompetencyWith the exception of the focus groups with white participants, issues of cultural competency arose in  a variety of contexts during the group discussions.  4[The doctor] didn’t have to ask just specific ques-tions. He should have asked, ‘Well, you had this before, so what makes you think you have the same thing?’ So just not a specific question, because if he has just specific questions, [the patient] is only going to answer those questions. She’s not going to talk about other symptoms.Although participants acknowledged a patient’s responsibility for facilitating open communication, they also felt that the ultimate responsibility lies with the physician as the professional. As one African American participant noted, “I think though, gener-ally speaking, that the doctor obviously has a large weight of responsibility for the communication part. But I think that the patient also needs to have a cer-tain level of responsibility.”The second set of participants placed much greater responsibility on the part of patients. In the words of one participant, “How will the physician know what other problems the patient has if she won’t tell him?” These participants did not see it as the physician’s role (or as part of their training) to counsel patients  to facilitate more open communication.Nurses’ Communication SkillsIn general, minority group participants felt that nurses were often better than physicians at explaining prob-lems and treatments. Some said that they actively seek out care from nurse practitioners. Several participants attributed differences in communication skills to differ-ences in training between physicians and nurses. Some suggested that physicians should receive more training of the kind that nurses receive in interpersonal commu-nication. These attitudes were common across all racial/ethnic groups, as the following quotes demonstrate:African American Respondent 1: I actually try to get the nurse practitioner instead of the physician because my experience is the nurse practitioner  is more patient oriented and spends more time and is a better listener.Respondent 2: Exactly.Respondent 3: They’re trained differently.Asian Indian Respondent: I think a lot of times doctors also leave the personality up to the nurses. So, like I get to know the nurses really well . . . So, if they could, if the doctors could act a little more like the nurses.Latino Respondent: I think that’s why a lot of times patients talk to the nurses and feel more comfort-able with the nurses, because they’re usually the ones that explain things that perhaps the doctor doesn’t really feel comfortable [with] or have the time to explain.Keys to Improving CommunicationEffective patient-provider communication is essential for ensuring quality health care. The following key points for improving the process emerged from focus group sessions: • Show familiarity with the patient at the outset  of the health encounter.• Achieve greater cultural competency by practic-ing good listening and communication skills and understanding what is important to each patient.• Acknowledge patients’ and providers’ roles and responsibilities for encouraging an open dialogue. • Enhance medical training for physicians to focus on more therapeutic communication skills.For further information, contact Ann Bagchi, senior researcher, at (609) 716-4554, abagchi@mathematica-mpr.com. The Robert Wood Johnson Foundation funded this project. Mathematica® is a registered trademark of Mathematica Policy Research, Inc.Respect in the physician-patient interactionPhysician-patient communicationPerceptions of “quality” in a health care visitCharacteristics of an ideal doctor and doctor’s visitRating the quality of care provided by a physicianEvaluating the quality of care depicted in a video of a primary care visitTopiCs  Covered  in  FoCus  groupsvisit our website at www.mathematica-mpr.comPrinceton Office P.O. Box 2393Princeton, NJ 08543-2393Phone: (609) 799-3535Fax: (609) 799-0005Washington Office 600 Maryland Ave., SW, Suite 550Washington, DC 20024-2512Phone: (202) 484-9220Fax: (202) 863-1763Cambridge Office955 Massachusetts Ave., Suite 801Cambridge, MA 02139Phone: (617) 491-7900Fax: (617) 491-8044Ann Arbor Office555 South Forest Ave., Suite 3Ann Arbor, MI 48104-2583Phone: (734) 794-1120Fax: (734) 794-0241Oakland Office505 14th Street, 8th FloorOakland, CA 94607Phone: (510) 830-3700Fax: (510) 830-3701

Focus on Quality: Communication in the Health Care Encounter

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Focus on Quality: Communication in the Health Care Encounter

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