Family Practice Vol. 20, No. 3, 248-253
© Oxford University Press 2003
Communication |
What’s in a name? An experimental study of patients’ views of the impact and function of a diagnosis
Department of General Practice, Guys Kings and St Thomas’s School of Medicine, Kings College London, London, UK.
Correspondence to Jane Ogden, Department of General Practice, GKT, 5 Lambeth Walk, London SE11 6SP, UK; E-mail: Jane.Ogden{at}kcl.ac.uk
Ogden J, Branson R, Bryett A, Campbell A, Febles A, Ferguson I, Lavender H, Mizan J, Simpson R and Tayler M. What’s in a name? An experimental study of patients’ views of the impact and function of a diagnosis. Family Practice 2003; 20: 248–253.
Received 22 July 2002; Revised 25 November 2002; Accepted 13 January 2003.
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Abstract |
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Objective. The aim of the present study was to examine patients’ views about the relative impact and function of lay and medical diagnoses for stomach and throat problems.
Methods. A questionnaire survey was carried out among 900 consecutive patients attending nine general practices across England. A total of 740 questionnaires were completed (response rate: 82.2%). Each participant rated a series of statements describing the impact upon the patient and the function for the doctor following both a stomach and a throat problem case scenario involving either a lay (stomach upset/sore throat) or medical (gastroenteritis/tonsillitis) label.
Results. The results showed consistent differences between the lay and medical labels for both stomach and throat problems in terms of their impact upon the patient and their function for the doctor. In particular, the medical labels were rated as beneficial for the patient in terms of validating the sick role and improving their confidence in the doctor. In contrast, the lay labels resulted in a greater sense of ownership of the problem which could be associated with unwanted responsibility and blame. In addition, the medical labels were seen to provide the doctor with a greater sense of professionalism, as giving them a clearer role in the consultation and to imply less blame on the part of the patient. ‘Stomach upset’ was also seen as a more pragmatic label than ‘gastroenteritis’.
Conclusion. Although much current prescriptive literature in general practice advocates the use of lay language in the consultation as a means to promote better doctor–patient partnerships, the issue of diagnosis is more complex than this. Patients attribute greater benefits to the use of medical labels for themselves and state that such medical labels are of greater benefit to the doctor.
Keywords. Diagnosis, doctor, patient communication, general practice, language.
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Introduction |
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The shift towards shared decision making, patient centredness and patient participation over recent years1–5 has encouraged GPs to use language that can be understood by their patients. In terms of diagnosis, however, the situation is more complex than this as both lay and medical labels have been hypothesized to have implications for both the patient and doctor. Some of the literature indicates that the type of label offered can influence the way a patient feels about their symptoms, and suggests that at times medical labels can be harmful. For example, labels such as epilepsy and depression are stigmatizing and may result in feelings of inferiority,6,7 whilst others such as obesity and HIV are associated with personal responsibility and blame.8 In contrast, Parsons9 argued that a medical label facilitates the transition from person to patient and that adopting the sick role can bring benefits such as being excused one’s normal role and gaining sympathy from others. Further, for some patients, lay labels may make the patient feel that their symptoms have not been taken seriously by the doctor or that the doctor is not competent. Labels can also serve a function for the doctor. Balint10 argued that general practice involves "organizing unorganized illness", and a medical label offers the mechanism for this process. Furthermore, given the emphasis on doctors reaching targets for the detection of specific problems, the ability to offer a label may also influence how a doctor perceives their own competence and professionalism. A lay label may also serve to minimize a patient’s problem and prevent them from returning to see the doctor at a later time.
Doctors are therefore being encouraged to use lay language as a means to improve communication with their patients. The choice of a lay or medical label, however, may influence patients in different ways and serve a variety of functions for themselves. To date, although the impact and function of labels have been explored within the social science literatures, and theories have been developed, these theories remain untested. The present experimental study aimed to explore the relative impact of either a lay or medical label on patients and to examine patients’ views about the function of such labels for doctors.
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Methods |
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Participants
Questionnaires were given to 900 consecutive patients attending nine general practices in London (n = 5), Sussex (n =1), Essex (n = 1) and Surrey (n = 2). Receptionists gave the questionnaires to patients as they arrived at the different practices and they completed them prior to seeing the doctor or nurse. Completed questionnaires were collected in a labelled box. Patients were excluded by the receptionists if they were aged 16 years or under, did not speak reasonable English or were deemed to have serious mental health problems. Completed questionnaires were received from 740 patients (response rate 82.2%).
Design
An experimental design was used and participants were allocated randomly to receive two matched cases relating to stomach problems and throat problems which differed only in containing either the lay label (stomach upset/sore throat) or the medical label (gastroenteritis/ tonsillitis). Each participant therefore received a throat problem case and a stomach problem case with a random combination of labels (lay/lay; lay/medical; medical/ medical; medical/lay). Throat and stomach problems were selected as they occur commonly in general practice, have both lay and medical labels and would be familiar to the patients. The use of two problems rather than one also enabled the results to be generalized beyond the specific problem.
Measures
For the stomach problem, participants were presented with the statement "Mrs A goes to her doctor with diarrhoea and vomiting. The doctor tells her that she has a STOMACH UPSET/GASTROENTERITIS". For the throat problem, participants were presented with the statement "Mrs A goes to her doctor with a red and painful throat. The doctor tells her that she has a SORE THROAT/TONSILLITIS". Participants rated each case for both the impact of the label on the patient and the role of the label for the doctor in terms of a series of constructs which were derived from the literature.6–10 The constructs were: validate sick role, confidence in doctor, ownership of problem, pragmatic, professionalism, clear role in consultation and blaming patient. Each construct was operationalized using a range of statements which were analysed individually. The statements were then summated and divided by the number of items in each construct to create a total construct score. The reliability of the constructs was assessed using Cronbach’s alpha.
The impact of a lay or medical label on patients
Participants were asked "to what extent do you think that using the term (lay versus medical) would make the patient feel ..." The constructs and statements used to operationalize them were as follows:
Validates the sick role (four statements): "that her problem had been taken seriously", "that she was allowed to take time off work", "that her problem had a definite physical cause" and "that she deserves sympathy from her family and friends" (alpha = 0.75).
Confidence in doctor (four statements): "confident in doctor", "satisfied with her visit to the doctor", "that she understands her problem", "frightened or anxious" (reverse scored for total score) (alpha = 0.64).
Ownership of problem (three statements): "that she can take care of her problem herself", "that the problem has been brought on by herself" and "that the problem will not last very long" (alpha = 0.52).
Function of lay or medical label for doctor
Participants were asked "To what extent do you think that using the term (lay versus medical) would make the doctor feel . . ." The constructs and statements used to operationalize them were as follows:
Pragmatic (three statements): "that they can enter the patient’s details onto the computer", "that they can finish the consultation quicker" and "they won’t need to see the patient again for this problem" (alpha = 0.42).
Professionalism (three statements): "satisfied with the consultation", "that they will be respected by other doctors", "that they know their job" (alpha = 0.72).
Clear role in the consultation (three statements): "that they know what advice to give", "that they know what treatment to give" and "that they should not change their mind" (alpha = 0.72).
Blaming patient (two statements): "that the patient has brought the problem on themselves", "that the patient should not have come" (r = 0.63).
Data analysis
The results were analysed in the following ways: first, the profile characteristics of the patients were described using descriptive statistics. Patients’ views about either a lay label or a medical label were then compared in terms of both the impact upon patients and the function for doctors for the individual statements and the total construct scores. These comparisons used t-tests and Levene’s test for homogeneity of variance.
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Results |
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Profile characteristics
Not all profile questions were completed by all participants. This may have been due to the positioning of these questions at the end of the questionnaire or may reflect concerns about confidentiality.
The majority of patients were women (male = 197, 30.1%; female = 457, 69.9%; missing data n = 86) mostly white (n = 540, 82.8%) with some black (n = 79, 12.1%), Asian (n = 10, 1.5%) and ‘other’ (n = 23, 3.5%) (missing data n = 88). The majority spoke English as their first language (n = 617, 93.3%; missing data n = 79) and stated that they had been to visit their doctor 0–3 times n = 282 (45%); 4–7 times n = 223 (35.6%); 8–10 times n = 8 (10.1%) or >11 times n = 7 (9.3%) (missing data n = 220). Their average age was 41 years (SD 16.8; missing data n = 105). The sample therefore seemed comparable with most general practice populations in the UK. Analysis showed no significant differences between the different groups for sex, ethnic group, whether English was their first language, number of visits to the doctor or age, indicating that randomization had been successful.
The impact of lay and medical labels on patients
Some participants did not complete all of these items and so were deleted from the analysis. Patients’ views for stomach and throat problems are shown in Tables 1 and 2
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The results for individual statements showed consistent differences between the lay and medical labels for both stomach and throat problems. In particular, patients rated the medical label (i.e. gastroenteritis/tonsillitis) as indicating that the problem had been taken more seriously, that the patient would be allowed time off work, that the problem had a definite cause, that the patient would feel more confident in the doctor, be more satisfied with their visit to the doctor, feel more frightened or anxious and show greater understanding of the problem. In contrast, the use of a lay label (i.e. stomach upset/sore throat) was seen to imply that the patient could take care of themselves, that the problem would not last very long and that it had been brought on by the patient.
In terms of the total construct scores, the medical labels (i.e. gastroenteritis/tonsillitis) were deemed to provide a greater validation of the sick role and to result in greater confidence in the doctor. In contrast, the lay labels (i.e. stomach upset/sore throat) were seen to reflect greater ownership of the problem by the patient.
The function of medical and lay labels for the doctor
Some participants did not complete all of these items and so were deleted from the analysis. Patients’ views about the function of labels for stomach problems and throat problems are shown in Tables 3 and 4.
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The results for individual statements showed consistent differences between lay and medical labels for both stomach and throat problems. Specifically, the medical labels (gastroenteritis/tonsillitis) were seen to be easier for the doctor to enter onto the computer, to result in the doctor feeling more satisfied with the consultation, to make the doctor feel that they would be more respected by other doctors, that the doctor would know their job better, know what advice and treatment to give and feel that they should not change their mind. In contrast, the use of lay labels (stomach upset/sore throat) was deemed to indicate that the doctor could end the consultation more quickly, would not need to see the patient again, would feel that the patient had brought the problem on themselves and that the patient should not have come.
In terms of total construct scores, the medical labels (gastroenteritis/tonsillitis) were seen by the patients as providing the doctor with a sense of professionalism and as giving them a clearer role in the consultation. In contrast, the lay labels (stomach upset/sore throat) were seen as more blaming of the patient. The label of ‘stomach upset’ was also seen as more pragmatic than ‘gastroenteritis’. There was no difference between the lay and medical label for throat problems for the total pragmatic score.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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The present study aimed to explore the relative impact of a lay or medical label on patients and showed consistent differences for both stomach and throat problems for all measures. In particular, the medical labels of gastroenteritis and tonsillitis were rated as more beneficial for the patient in terms of validating the sick role, including feeling that they can take time off work and deserve sympathy, and improving their confidence in the doctor. In contrast, the lay labels of stomach upset and sore throat resulted in a greater sense of ownership of the problem, which could be associated with unwanted responsibility. This provides empirical support for previous research which has suggested that the choice of label attached to a set of symptoms can have profound effects upon patients and is consistent with work on the sick role9 and studies of stigma and blame.6,8 Furthermore, although the shift in the prescriptive literature has been towards an emphasis on the use of lay language in the consultation,1–5 the results from this study indicate that patients find medical language of greater benefit.
The present study also explored patients’ views about the function for the doctor of different terms, and showed consistent differences between lay and medical labels. In particular, the medical labels of gastroenteritis and tonsillitis were seen to provide the doctor with a greater sense of professionalism including respect from their peers and a feeling that they know their job, as giving them a clearer role in the consultation and to imply that the patient was less to blame for their condition. ‘Stomach upset’ was also seen as a more pragmatic label than ‘gastroenteritis’ in terms of finishing the consultation more quickly and not needing to see the patient again. This provides empirical support for the suggestion that a label provides the mechanism for organizing symptoms10 and suggests that patients perceive medical labels to have additional benefits for the doctor.
To conclude, the present experimental study provides empirical support for the suggestion that different labels can have different effects upon patients and serve different roles for doctors. Much general practice literature currently advocates the use of lay language as a means to promote doctor–patient partnerships in the consultation. This study indicates that the issue of diagnosis is more complex than this, with patients preferring medical labels and believing that such medical labels serve a more beneficial function for the doctor.
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Acknowledgments |
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This project was completed as part of the research methods module for an MSc in General Practice at Kings College London supervised by JO.
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References |
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1 Pendleton D, Schofield T, Tate P, Havelock P. The Consultation: An Approach to Learning and Teaching. Oxford: Oxford Medical Publications, 1984.
2 McWhinney IR. Why we need a new clinical method. In Stewart M, Brown BB, Weston WW, McWhinney IR, McMillan CL, Freeman, TR (eds). Patient Centred Medicine. Transforming the Clinical Method. London: Sage, 1995: 1–20.
3 Levenstein JH, McCracken EC, McWhinney IR, Stewart MA, Brown JB. The patient centred clinical method. 1. A model for the doctor patient interaction in family medicine. Fam Pract 1996; 3: 24–30.
4 Coulter A. Paternalism or partnership? Patients have grown up and there’s no going back. Br Med J 1999; 319: 719–720.
5 Royal College of General Practitioners. Assessment of Consulting Skills. RCGP web page. 2000.
6 Scambler G, Hopkins A. Being epileptic: coming to terms with stigma. Sociol Health Illness 1986; 8: 26–43.
7 Ogden J, Boden J, Caird R et al. You’re depressed, no I’m not: GPs’ and patients’ different models of depression. Br J Gen Pract 1999; 49: 123–124.[Web of Science][Medline]
8 Ogden J, Bandara I, Cohen H et al. GPs’ and patients’ models of obesity: whose problem is it anyway? Patient Educ Counsell 2001; 40: 227–233.
9 Parsons T. The Social System. New York: Free Press, 1951.
10 Balint M. The Doctor His Patient and the Illness. London: Pitman, 1964.
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