Communication in the health services : two examples

Background: The first objective of this thesis was to pinpoint decisive factors in the physician- patient encounter, i.e. factors in the behaviour of orthopaedic surgeons which can facilitate or impede communication in order to improve their communication with patients. The second objective was to determine whether a patient-centred way of communication influenced exposure to passive smoking in infants, i.e. to evaluate effects of a counselling method. These fields represent two different cultures in the health service; highly specialised care at a hospital and a routine setting in public health. Subjects and Methods: Eighteen physicians and 18 patients participated in the first study, and 37 child health nurses plus corresponding mothers (n= 41) in the second study. Qualitative methods were used in both studies. In the first part of the thesis, consultations were videotaped and the patients and the physicians gave spontaneous comments one week after the videotaped consultation. A modified form of phenomenography was used to analyse the comments. Patients' experiences of satisfaction/dissatisfaction were further used to describe the encounter using a 'Consultation Map'. In the second part - an intervention study - several methods were used, i.a. telephone interviews, interview at home, and biomedical analyses. The intervention was influenced by the notion of 'SelfEfficacy'; a person's capability to effect a certain change of behaviour. The study group consisted of smoking mothers who had recently given birth. They were allocated to either an intervention group (n= 21) or a control group (n= 15). The communication method is based on the principles of discussing the smoking habits themselves instead of providing further information, and starting out from the mothers' standpoint instead of 'putting them right'. Results: The patients reported i.a. difficulties in understanding what the physician asked, said or did. They also reported that the physician arrived unprepared for the consultation. The physicians reported i.a. adapting the way they communicate to the patient's situation, and encountering difficulties in helping certain patients. The follow-up patients were more satisfied than first-time patients. In the second study, there was a discrepancy between self-reported smoking and cotinine (a breakdown product of nicotine) values. Cotinine levels at baseline were somewhat higher in the control group, but this was not statistically significant. After the intervention cotinine levels had increased by 40 % in the control group and had diminished by 10 % in the intervention group (Repeated measures ANCOVA, p= 0.027). Conclusions: The results are consistent with the view that a patient-centred approach is effective and most likely to promote satisfaction. It is more effective when recipients of care understand the caregiver, when the caregiver involves the recipients, and when there is a common goal, i.e. a shared understanding of the encounter