Family Practice Vol. 18, No. 1, 60-63
© Oxford University Press 2001
Doctor-patient relationships |
Effectiveness of a learner-centred training programme for primary care physicians in using a patient-centred consultation style
Unidad Docente de Medicina de Familia y Comunitaria de Córdoba, Spain.
Correspondence to Dr Roger Ruiz Moral, Unidad Docente de Medicina de Familia, C/Dr Blanco Soler, 4, Cordoba, Spain.
Ruiz Moral R, Muñoz Alamo M, Alba Jurado M and Pérula de Torres L. Effectiveness of a learner-centred training programme for primary care physicians in using a patient-centred consultation style. Family Practice 2001; 18: 60–63.
Received 17 February 2000; Revised 6 July 2000; Accepted 5 September 2000.
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Abstract |
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Objective. The aim of the present study was to find out if a training programme adapted to family physicians with several years of clinical experience changes their behaviour when they deal with fibromyalgic patients in the sense of introducing the communication skills that define the ‘patient-centred’ approach.
Methods. A randomized, and simple blind, educative study was carried out. Twenty full-time family physicians were invited to participate. They were allocated randomly to two groups: an intervention and a control group. A total of 110 patients were recruited from people attending physicians’ surgeries for the first time and who complained of generalized pain that finally fulfilled criteria for generalized musculoskeletal chronic pain/fibromyalgia. This was done for an entire year. The intervention group received an 18 hour intensive course. One week after the course, all doctors carried out a video-recorded encounter with a patient who played the part of a typical fibromyalgia clinical case. The interviews were coded by an observer blind to the training status of the participants, using the GATHARES-CP questionnaire. All patients were contacted by telephone during a 1–2-month period by a different interviewer who was ‘blinded’ to the patient’s experimental status. They were asked to respond to three questions that represent the key components of patient-centred style.
Results. The average score on the GATHARES-CP questionnaire was 11.3 ± 0.9 and 9 ± 2.3, for doctors from the intervention and control groups, respectively (P < 0.01). For 11 items, scores were higher in the intervention group. The patients' answers to all three questions showed statistically significant differences in a positive direction for the trained doctors.
Conclusions. The doctors improved the use of strategies and skills for carrying out patient-centred consultations after they had received an interactive course. The doctors' behaviour appeared to have changed as much in a more experimental situation as in the actual consultations. Moreover, the gain was observed inmediately after the intervention was completed, and after having run for a variable period of time up to 1 year.
Keywords. Continuing medical education, doctor patient communication, Primary Care.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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Patient-centredness is a concept of thinking of patient care in terms more of people and their problems than of the diseases. The ‘patient-centred’ communication approach has been defined as the doctor–patient interaction where the psychosocial exchanges, the mutual participation and the information given are high. The most important dimension of communication that shapes this consultation style has been found to influence significantly some important health outcomes.1 There is also evidence that clinical communication skills can be taught effectively.2 However, practical experience in these topics is scarce, particularly in Spain where no ‘educational’ trials are being carried out.
The aim of this study is to determine if a training programme adapted to Spanish family physicians with several years of clinical experience changes their behaviour when they deal with patients with fibromyalgia, in the sense of introducing the communication skills that define the ‘patient-centred’ approach.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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A randomized, and simple blind, educational study was designed. Twenty full-time family physicians were assigned randomly to two groups to undergo or not undergo the training programme. Patients were recruited from people attending physicians' surgeries for the first time and who fulfilled criteria for generalized musculoskeletal chronic pain/fibromyalgia (GMCP/FM). This was done for an entire year (1997). Informed consent was obtained from 110 patients; one patient refused to participate and two were excluded because they were referred. Of these patients, 107 were women; 47 were recruited from the control group and 63 from the intervention group.
Intervention
The intervention group received a course of 18 hours duration. We first tried to reach agreement with the doctors about: the main features and way of presentation of the most common primary care clinical problems; the importance of psychosocial aspects involved in the reasons for patient attendance; and the general objectives and best strategies to cover in a consultation. A general scheme for consultation similar to that proposed by other authors was found.3 These aspects were highlighted by means of watching exemplary videos. We also included information about the scientific evidence of the effectiveness of the diverse communication strategies usually employed. They practised communication skills for: (i) establishing an effective relationship; (ii) obtaining biopsychosocial information; (iii) giving information and negotiating; and (iv) closing the interview. We used role-playing, selected video-recorded interviews as models and as a ‘trigger’, and feedback. Finally, an interview with a ‘simulated’ patient was carried out by all doctors, following individualized feedback by the facilitator.
Measures
Standardized patient..
One week after the course, all doctors carried out a video-recorded encounter with a standardized patient who played the part of a typical fibromyalgia clinical case: a 38-year-old woman with a past history of 9 years suffering from fibromyalgia. The doctors were aware that the patient was role-playing.
Process analysis of the audiotapes. .
The GATHARES-CP questionnaire is a tool which explores the patient-centred style. It comprises 13 items with dichotomous (yes/no) answers (Appendix 1), with an intercoder reliability (
: > 0.42 and <0.82) and internal consistency (
: 0.76) established on a sample of 68 video-recorded interviews scored by two independent coders.4 The interviews were coded by an observer blinded to the training status of the participants. The coder had been trained previously in the use of this instrument and her intercoder reliability index was established on a sample of 30 actual interviews (previously coded by two experts) (: >0.46 and 1). The intraclass correlation coefficient (‘R’) was 0.88. The intracoder reliability was established with the same 30 interviews, separated by a 1-month test–retest (: >0.7 and 1).5
Telephone follow-up.. All patients were contacted by telephone during a 1–2-month period by a different interviewer who was ‘blinded’ to the patient’s experimental status. They were asked to respond to the following three questions: (i) how fully had she been able to discuss her pain and the problems surrounding it with her doctor; (ii) how clearly had her doctor discussed the cause of her pain; and (iii) if her doctor had listened to and considered her opinions and suggestions concerning the management plan.
A descriptive and bivariate statistical analysis was carried out using the Mann–Whitney U and chi-squared tests.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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The comparability of both groups of doctors is shown in Table 1
. Except for the number of tender points (intervention: 9.6/control: 7.3; P = 0.006), we did not find significant differences in other important variables between both groups of patients (gender, age, civil status, job, education, pain onset, family-APGAR, anxiety and depression, weight, pain intensity and number of associated symptoms). The average score for the GATHARES-CP questionnaire for doctors from the intervention group was 11.3 ± 0.9, range: 10–12; and for the control group it was 9 ± 2.3, range: 4–12; P < 0.01. The fulfilment of 11 out of the 13 items was highest in the doctors of the intervention group. Items 7, 4, 3, 1, 12 and 13, in that order, were those with the biggest differences. The results of the patients' answers to the three questions are shown in Table 2.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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Our study shows that the doctors improved the use of strategies and skills for carrying out patient-centred consultations after they had received an interactive course, both in an immediate post-intervention standardized patient assessment and in an assessment by their actual patients. Moreover, the gain was observed immediately after the intervention was completed, and after having run for a variable period of time, up to 1 year.
The design we have used allows us, reasonably, to establish cause–effect relationships between the training programme received by the doctors and the behavioural changes detected. However, a record of the doctors interviewing skills before they started the study would have been of value in the determination of the effectiveness of the intervention. The generalization of these results could also be limited by the fact that participants were volunteers, had teaching responsibilities and they allowed themselves and their patients to be evaluated.
With regard to the teaching methodology, we think that the most interesting aspect of this programme was its ‘learner-centred’ character which was intended to be similar to the method we were trying to convey to the doctors. The methodology we used was mainly interactive: experiential and problem-based methods, which have been reported not only in clinical interviewing2,6–8 but also in other fields of medicine.9
We wanted to know the effectiveness of this kind of programme in Spanish primary care settings. The main challenge was to design it for our busy doctors, i.e. to create a course of acceptable duration. The second target was to test the programme's effectiveness for doctors dealing with patients suffering from a complex condition, a condition which is a good example of somatization in primary care surgeries. Some authors6,7 have designed courses similar to and even shorter than ours, also with positive results. However, it is difficult to compare our programme's results with those studies, due to the different instruments we have used. Although there were small differences in mean scores after the intervention, our questionnaire detected, with a small sample, statistically significant differences in doctors' behaviours; on the other hand, we also have explored some patients' opinions which represent the key components of a patient-centred style.10 Indeed, the answers they gave could be reasonably related to the impact of their physicians' behaviour. This can be considered as one construct and predictive validation of the tool. We believe that the structure of GATHARES-CP allows us to assess the effect of the patient-centred consultation style as a whole.
Finally, a long lasting programme for trainees based on consultation models closer to ours8 correlated positively with better somatization management and with appropiate trends in patient satisfaction and patient well-being. Further study is needed on the impact of this course on some relevant clinical outcomes, such as functional capacity, disability, cost and satisfaction.
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Appendix 1 |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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Acknowledgments |
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We thank Drs Jose A Prados and Rosa Cabrera for their helpful assistance with the study.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1References |
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1 Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M. Evidence on patient–doctor communication. Cancer Prev Control 1999; 3: 25–30.[Medline]
2 Kurtz SM, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. Abingdon (Oxon): Radcliffe Medical Press, 1998.
3 Neighbour R. The Inner Consultation. Dordrecht, The Netherlands: Kluwer Academic Publishers, 1987.
4 Prados Castillejo JA, Ruiz Moral R, Bellón J, Cabrera R, Alba M, Pérula L. An instrument for assessment interviewing of residents of family medicine. Communication in Medicine Conference. Northwestern University, Chicago, IL, 20th–23rd July, 1999.
5 Ruiz Moral R, Prados Castillejo JA, Alba M, Pérula L. Validación de un observador en la utilización del cuestionario GATHARES para la medición del perfil comunicacional de médicos residentes. Educ Med 1999; 2: 156.
6 Levison W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med 1993; 8: 318–324.[Web of Science][Medline]
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Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians' interviewing skills and reducing patients' emotional distress. Arch Intern Med 1995; 155: 1877–1884.
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Smith RC, Lyles JS, Mettler J et al. The effectiveness of intensive training for residents in interviewing. A randomized, controlled study. Ann Intern Med 1998; 128: 118–126.
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Davis D, Thomson O'Brien MA, Freemantale N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education. Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? J Am Med Assoc 1999; 282: 867–874.
10 The Headache Study Group of the University of Western Ontario. Predictors of outcome in headache patients presenting to family physicians—a one year prospective study. Headache 1986; 26: 285–294.[Web of Science][Medline]
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