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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Highly Commended at the British Medical Association Book Awards 2016 Clinical Communication in Medicine brings together the theories, models and evidence that underpin effective healthcare communication in one accessible volume. Endorsed and developed by members of the UK Council of Clinical Communication in Undergraduate Medical Education, it traces the subject to its primary disciplinary origins, looking at how it is practised, taught and learned today, as well as considering future directions. Focusing on three key areas - the doctor-patient relationship, core components of clinical communication, and effective teaching and assessment - Clinical Communication in Medicine enhances the understanding of effective communication. It links theory to teaching, so principles and practice are clearly understood. Clinical Communication in Medicine is a new and definitive guide for professionals involved in the education of medical undergraduate students and postgraduate trainees, as well as experienced and junior clinicians, researchers, teachers, students, and policy makers.
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Seitenzahl: 605
Veröffentlichungsjahr: 2015
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Table of Contents
Cover
Title Page
List of Contributors
Foreword
CHAPTER 1: Introduction
PART 1: The doctor-patient relationship
CHAPTER 2: Introduction to the Doctor–Patient Relationship
CHAPTER 3: History of the Doctor–Patient Relationship
From a trade to a profession
Rise of the scientific paradigm and dominance of the biomedical model
Healthcare as a right
Challenges to the biomedical model and rise of the biopsychosocial model
The era of evidence-based medicine: studying the doctor–patient relationship
Patient-centredness and models of the doctor–patient relationship
Training on the doctor–patient relationship
National drivers and policy on training about the doctor–patient relationship
The era of research on training and evidence of its effectiveness
Public inquiries in the 21st century: Trust in the doctor–patient relationship
Whole systems and teamworking
The patient in the patient-doctor relationship: the Internet and democratisation of knowledge
Globalisation, information technology and consumerism
References
CHAPTER 4: Models of the Doctor–Patient Consultation
Historical overview
Current practice
Future directions
References
CHAPTER 5: What Is Effective Doctor–Patient Communication? Review of the Evidence
Models for teaching and assessing communication skills
Patient perspectives on essential communication skills
How communication heals
A seemingly simple premise
Meeting the challenges of contemporary practice
Future directions
References
CHAPTER 6: Patient-Centredness
Evolution of the term ‘patient-centred’
What is the evidence of the effect of patient-centred care on healthcare outcomes?
Is the concept of
patient-centred care
justified?
Teaching and learning of patient-centredness with medical students
Future directions
References
CHAPTER 7: The Impact of Training
Transfer and clinical communication
What factors improve the chance of transfer?
How else can the workplace support the learning?
The learners medical schools create
Future directions
References
CHAPTER 8: The Future of the Doctor–Patient Relationship
Current practice
Future directions
Conclusion
References
PART 2: Components of Communication
PART 2A: Core Tasks in Clinical Communication
CHAPTER 9: Overview of Core Tasks in Clinical Communication
The importance of structure
Core tasks, core skills and specific issues
Content, process and clinical reasoning
References
CHAPTER 10: Relationship Building
Historical context
Current practice – the skills of relationship building
Future directions
References
CHAPTER 11: Information Gathering and Clinical Reasoning
Historical context
Current teaching practice – the skills of Information gathering
Future directions
References
CHAPTER 12: Information Sharing and Shared Decision Making
Historical context
Current teaching practice – the skills of Information sharing and shared decision making
Future directions
References
CHAPTER 13: Communicating about Risk and Uncertainty
Historical context
Current practice
Future directions
References
CHAPTER 14: Responding to Emotions
Historical context
Evidence on doctors’ responses to patients’ emotion
Future directions
References
CHAPTER 15: Breaking Bad News
Historical context
Current practice
Future directions
References
CHAPTER 16: Facilitating Behaviour Change through Motivational Interviewing
Historical context
Current practice
Future directions
References
CHAPTER 17: Responding to Medical Error and Complaints
Historical overview
Error
How does communication cause error?
How can communication help to resolve the consequences of error?
Openness about error
Example: being open about a medication error
Responding to complaints
Supporting colleagues after errors occur
Future directions
References
PART 2B: Diversity Issues in Clinical Communication and Cultural Diversity
CHAPTER 18: Overview of Diversity Issues in Clinical Communication
References
CHAPTER 19: Diversity Issues in Clinical Communication
Historical context
Current practice
Future directions
References
CHAPTER 20: The Family Consultation
Historical context
Current practice
Future directions
References
CHAPTER 21: Consulting with Children and Young People
Historical context
Current practice
Future directions
References
CHAPTER 22: The Older Patient
Historical context
Current practice
Future directions
References
CHAPTER 23: End of Life Issues
Historical overview
Current practice
Why might healthcare professionals find end of life care challenging?
Conclusions and the way forward
References
CHAPTER 24: Mental Health Matters
Historical context
Current practice
Future implications
References
PART 2C: Interprofessional Communication
CHAPTER 25: Interprofessional Communication and Its Challenges
Overview
Challenges associated with interprofessional communication
Concluding remarks
References
PART 3: Learning, Teaching and Assessment
CHAPTER 26: Introduction to Learning, Teaching and Assessment
CHAPTER 27: The History of Clinical Communication Teaching
Conclusion
Acknowledgements
References
PART 3A: Models of Learning
CHAPTER 28: Behaviourism as a Way of Learning
Historical context
Current practice
Future directions
References
CHAPTER 29: Situated and Work-Based Learning
Historical context
Current practice
Future directions
References
CHAPTER 30: Experiential Learning
Historical context
Current practice
Future directions
References
CHAPTER 31: Transformative Learning and High-Fidelity Simulation
Historical context
Simulation-based medical education
Current practice: Feedback and cognitive processes in simulation
Future directions
References
CHAPTER 32: Reflective Practice
Historical context
Current practice
Incorporating critical reflection into clinical communication skills teaching
Future directions
References
CHAPTER 33: Models of Feedback
Historical context
Current practice
Future directions
References
PART 3B: The Assessment of Communication
CHAPTER 34: Introduction to Assessment in Communication
Historical context
Current practice
Future considerations
References
CHAPTER 35: Assessing Performance
Historical context
Current practice
Future directions
References
CHAPTER 36: Workplace-Based Assessment
Historical context
Current practice
Future directions
References
PART 4: Afterword
CHAPTER 37: Afterword
Reference
Index
End User License Agreement
List of Tables
Chapter 21
Table 21.1 Models underpinning effective communication with children and young people.
Table 21.2 Key reasons for the children’s limited involvement, as reported by children and doctors
Chapter 31
Table 31.1 A typology of simulation-based education
Chapter 34
Table 34.1 Example of a behaviourally anchored global rating scale assessing the domain of initiating the consultation.
Chapter 36
Table 36.1 The seven domains of the consultation assessed in the mini-CEX modified for the NHS in the UK.
Table 36.2 The original 11 domains of the DOPS assessment tool.
Table 36.3 Domains of the team assessment of behaviour.
List of Illustrations
Chapter 04
Figure 4.1 The UK Council consensus statement.
Guide
Cover
Table of Contents
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This book is dedicated to all those who experience healthcare.
This title is also available as an e-book.For more details, please see www.wiley.com/buy/9781118728246or scan this QR code:
Clinical Communication in Medicine
EDITED BY
Dr Jo Brown
Reader in Medical Education, Academic Director of the Student Experience, Head of Clinical Communication, National Teaching Fellow, St George’s University of London, London, UK
Dr Lorraine M. Noble
Senior Lecturer in Clinical Communication, University College London Medical School, London, UK
Dr Alexia Papageorgiou
Associate Professor in Clinical Communication, University of Nicosia Medical School, Nicosia, Cyprus
Dr Jane Kidd
Undergraduate Quality Manager, Education Training and Research, University Hospitals Coventry and Warwickshire NHS Trust; External tutor, Institute of Medical and Biomedical Education, St George’s University of London, London, UK
On behalf of the UK Council of Clinical Communication in Undergraduate Medical Education
The UK Council of Clinical Communication in Undergraduate Medical Education is a representative body of the communication teaching leads from all of the medical schools in the UK. The UK Council aims to share good teaching practice, and encourages research and development of effective clinical communication teaching in the UK.www.ukccc.org.uk
This edition first published 2016 © John Wiley & Sons, Ltd
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List of Contributors
Lucy AmbroseGeneral Practitioner, The Tutbury Practice, Tutbury, Staffordshire, UK
Jennifer BallsConsultant in Palliative Medicine, Saint Francis Hospice, Romford, Essex, UK
Victoria BatesLecturer in Modern History, University of Bristol, Bristol, UK
Jo BrownReader in Medical Education, Academic Director of the Student Experience, Head of Clinical Communication, National Teaching Fellow, St George’s University of London, London, UK
Xavier CollHonorary Senior Lecturer at the Norwich Medical School, University of East Anglia; Consultant Child and Adolescent Psychiatrist at the Children, Families, and Young People Service, Norwich, Norfolk, UK
Costas S. ConstantinouAssistant Professor, University of Nicosia Medical School, Nicosia, Cyprus
Annie CushingProfessor of Clinical Communication, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
Jill DalesCommunication Skills Lead & Director (retired), roleplaynorth communication skills, School of Medical Education, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
Nisha DograProfessor of Psychiatry Education and Honorary Consultant in Child and Adolescent Psychiatry, University of Leicester, Leicester, UK
Eva DohertyDirector of Human Factors and Patient Safety, Royal College of Surgeons in Ireland, Dublin, Ireland
Rosie IllingworthSenior Lecturer in Clinical Communication, Manchester Medical School, University of Manchester, Manchester, UK
Katherine JoekesSenior Lecturer in Clinical Communication, St George’s University of London, London, UK
Theano V. KalavanaAssistant Professor in Clinical Communication, University of Nicosia Medical School, Nicosia, Cyprus
Jane KiddUndergraduate Quality Manager, Education Training and Research, University Hospitals Coventry and Warwickshire NHS Trust, Coventry; External tutor, Institute of Medical and Biomedical Education, St George’s University of London, London, UK
Rob LaneHead of Clinical Communication Skills, School of Medicine, University of Leeds, Leeds, UK
Janet LefroySenior Lecturer in Medical Education, School of Medicine, Keele University, Staffordshire, UK
Susanne LindqvistSenior Lecturer in Interprofessional Practice and Director of Centre for Interprofessional Practice, Norwich Medical School, University of East Anglia, Norfolk, UK
Gregory MakoulCEO, PatientWisdom, Chicago, IL; Founding Director, Connecticut Institute for Primary Care Innovation, Hartford, CT; Professor of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
Vinnie NambisanConsultant in Palliative Medicine, Saint Francis Hospice, Romford, Essex; Tutor in Medical Ethics and Law, University College London Medical School, London, UK
Lorraine M. NobleSenior Lecturer in Clinical Communication, UCL Medical School, UCL, London, UK
Alexia PapageorgiouAssociate Professor in Clinical Communication, University of Nicosia Medical School, Nicosia, Cyprus
Lindsey PopeClinical University Teacher, Undergraduate Medical School, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
Sally QuilliganLecturer in Clinical Communication, School of Clinical Medicine, Cambridge, UK
Jonathan ReinarzProfessor in the History of Medicine, University of Birmingham, Birmingham, UK
Wesley Scott-SmithSenior Clinical Teaching Fellow and Course Lead in Simulation, Brighton and Sussex Medical School, East Sussex, UK
Jonathan SilvermanHonorary Visiting Senior Fellow, University of Cambridge School of Clinical Medicine, Cambridge; President, European Association for Communication in Healthcare, Salisbury, UK
John SkeltonProfessor of Clinical Communication, University of Birmingham, Birmingham, UK
John SpencerProfessor of Primary Care and Clinical Education, School of Medical Sciences Education Development, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
Andrew TarbuckConsultant in Old Age Psychiatry, Norfolk and Suffolk NHS Foundation Trust; Honorary Senior Lecturer, University of East Anglia; Dementias & Neurodegenerative Diseases Local Research Network in East Anglia, Norfolk, UK
Margot TurnerSenior Lecturer in Community Medical Education with special responsibility for embedding diversity in the curriculum, St George’s University of London, London, UK
Jan van DalenCo-ordinator of Communication Training and Assessment, School of Health Professions Education, Maastricht University, Maastricht, the Netherlands
Sandra van DulmenProgramme Co-ordinator Communication in Health Care, Netherlands Institute for Health Services Research (NIVEL), Utrecht; Professor in Communication in Healthcare, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands; Professor II, Faculty of Health Sciences, Buskerud and Vestfold University College, Drammen, Norway
Catherine J. WilliamsonDirector of Clinical Learning, Phase 1 Medicine, School of Medicine, Pharmacy and Health, Durham University, Stockton, UK
Jonathan WilsonClinical Senior Lecturer, University of East Anglia, Norfolk, UK; Associate Professor, St George’s University, New York, USA; Consultant Psychiatrist, Consultant Psychotherapist (Early intervention/Youth), Child Family and Young Person Service, Norfolk, UK
Connie WiskinSenior Lecturer, Co-Director ISU, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
Foreword
In these utilitarian times our eyes are sadly deviated from our patients as ‘individuals’ to the hustle and bustle of treating large numbers of people. Yet, the everyday practice of medicine for all healthcare workers is about communicating well with individual people and being able to reach a satisfactory and true account of a problem to enable a correct diagnosis to be made.
The theories on medical education and the ways of its delivery have changed enormously over the last few decades. New curricula have come and been modified, but gone are the days of the ‘see one, do one, and teach one’ concept that many of us were brought up on. Now, medical education is based on robust concepts of competence and knowledge, but above all and central to everything is the role of doctors in their daily communication with patients.
There are many books on the market about clinical communication, so why is this book different from the others? First, it is unique, as it gives a historical background as well as an evidence base for how theories have developed. Second, it has been written by a group representing clinical communication teaching in the UK, and most of them are members of the UK Council of Clinical Communication in Undergraduate Medical Education.
The book is essentially divided into three parts. The first part introduces the reader to the doctor–patient relationship, probing into consultation models dating back to 1850. It discusses the term ‘patient-centredness’, a term that has crept into our everyday practice, and explores what it will mean for us all in the future.
The second part goes into detail about the various components of communication, such as the core skills – for example, sharing bad news, or responding to medical errors and complaints. It also explores topics we all find difficult to communicate to patients, such as explaining risk and talking about the harm/benefit equation when dealing with uncertainty.
Each of these is dissected out and gives helpful comments on how to approach the subject. I was pleased to see that it also looked at diversity issues, such as age, end of life and mental health problems; all difficult issues to deal with in real life.
The third part discusses the various models of learning such as situational, experiential and transformative learning. A lot of educational jargon…but clearly explained! There is also a section on the assessment of communication and the various types of assessment available. Clearly there would be little point in teaching if we cannot assess how well a student has learned, but also exploring what the correct tools are for this assessment.
So, we have come a long way from the ‘seeing, doing and teaching one’ concept, to the ‘knowing, knowing how, showing how, and only at the end when a student is ready, doing’. Hopefully this should result in fewer mistakes and better care for our patients.
This book is written by authors who are all currently active in teaching, and this gives it its authenticity. The editors have brought together a group of 35 authors, mainly from UK universities but also from the USA, Holland and other European countries. It should be read by all medical teachers, researchers and students. In fact, it forms a core thesis for all professions, as the science and art of clinical communication is generic to all.
Parveen J. Kumar CBE, BSc, MD, FRCP, FRCPE, FRCPathProfessor of Medicine and EducationBarts and the London School of Medicine and DentistryQueen Mary University of London
CHAPTER 1Introduction
Jane Kidd
University Hospitals Coventry and Warwickshire NHS Trust, Coventry; Institute of Medical and Biomedical Education, St George’s University of London, London, UK
We believe this book is unique, in that it presents the evidence that underpins effective clinical communication. It covers the theories that inform the patient-centred approach, the topics that are taught, how they are taught and how they are assessed.
We know many books exist about how to teach clinical communication or what to include in a clinical communication curriculum, but no other book on communication in the healthcare setting takes the approach of tracing the subject to its primary disciplinary origins, looking at how it is practised, taught and learned today, as well as considering future directions.
Inspiration for the book drew on our experience in teaching clinical communication, in conversation with our colleagues, both teachers and clinicians, which in turn identified a concern that the wide and disparate evidence base for the subject had not been effectively acknowledged, collated and presented.
The book aims to enhance understanding of effective clinical communication by discussing the theories, models and evidence in each of three areas:
the doctor-patient relationship;
key components of clinical communication; and
effective teaching and assessment of clinical communication.
We hope that this will prove to be an important text for teachers, researchers, academics, learners, practitioners and policymakers alike.
Reading this book, you will find yourself introduced to, or possibly reminded of, theories and models from a wide range of disciplines that support effective communication. We believe that in the absence of this knowledge, learning clinical communication can often be superficial, as students learn simply to copy certain statements or behaviours, without a deep understanding of which approaches are effective and why.
We hope that by linking the evidence to the various facets of clinical communication you will understand both the principles and practice of effective communication and how these have come about in the modern world. For educators it may enhance practice both in the teaching and assessment of the subject, learners may more fully appreciate what they are being asked to learn, and as a consequence patients, carers and colleagues may benefit from the changes resulting from this deeper understanding. We hope mostly, however, that this book will stimulate debate, the foundation of healthy academic development of any discipline.
The book is designed so that you can dip in and out as you wish, or you can simply start at the beginning and read through. The chapters begin by providing historical context before describing current practice, providing you with an appreciation of the depth of the evidence supporting the various components covered. Each chapter concludes with a personal view from the chapter’s author on what the future might hold, given the changing context of the healthcare system, the complexity of the learning environment and the evolving roles of the professional and the patient.
We hope that you enjoy the book, that you learn something that you did not know when you picked it up, and that even if you do not agree with the ideas on what the future might hold for this infinitely complex topic, it challenges you to think about the subject and open it up for discussion.
PART 1The doctor-patient relationship
Section lead editor: Lorraine Noble
CHAPTER 2Introduction to the Doctor–Patient Relationship
Lorraine M. Noble
University College London Medical School, London, UK
The relationship between the doctor and the patient is fundamental to clinical communication. The perceived role of the doctor – as a healer, service provider, professional or evidence-based practitioner – creates an implicit contract that drives expectations, not only about clinical tasks to be accomplished but about the parameters of how doctors approach and respond to patients.
In this section, the historical development of the role of the doctor will be described, including milestones such as the birth of professionalism and the impact of evidence-based medicine. The influence of the context and practice of healthcare on the relationship will be considered, with its consequent implications for doctor–patient communication.
Models of the doctor–patient relationship will be discussed, exploring the changing notions of expertise and power and the focus on the patient as a person. Models of the doctor–patient consultation will be described, highlighting key frameworks that have influenced research, training and healthcare practice. As a backdrop to this discussion, key milestones arising from the research evidence about doctor–patient communication and the synthesis of evidence and practice will be considered, to summarise the current understanding of what constitutes an effective doctor–patient relationship and effective clinical communication.
The current focus on patient-centredness as an approach will be discussed, including the complexities of its definition and use in practice. The impact of current teaching and assessment on the present and next generation of doctors will be considered, including factors affecting the transfer of what is learned to the healthcare environment. The implications for learners of construing communication as a ‘set of skills’ and relationship building as a ‘skill’ will be explored.
The effects of changing healthcare practices and societal expectations about the roles of doctors and patients will be considered, including a discussion about what patients want, the impact of a team- or systems-based approach to care, and the role of technology. The section will conclude by speculating on what the future holds for the doctor–patient relationship in an electronic world.
CHAPTER 3History of the Doctor–Patient Relationship
Annie Cushing
Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
At the very heart of communication in healthcare lies the expectation of the doctor–patient relationship. The doctor is a healer, witness to suffering, interpreter of symptoms, educator, advocate, and a provider of treatment, comfort and access to services. Whilst the Hippocratic Oath of ancient times embodies the virtues and values within the relationship, the ‘medical ideal’ is varyingly shaped by the social, scientific, technological and political contexts of the day (Sigerist 1933).
From a trade to a profession
Historically medicine was more like a trade, and doctors were little more than superior servants of the rich who could afford their services. The latter shopped around and decided what they wanted, whilst the doctor complied with issuing treatments (Porter 1997). This was akin to a consumerist model for those who could afford it, whilst the doctor’s success depended on the ability to attract patrons. Without standards of practice, quality control or accountability, the patient was vulnerable to quackery.
The birth of the profession in the UK came about through restricted practice with a set of standards established by the Royal Colleges in the 16th century (Warren 2000). Surgeons separated from barber-surgeons and became university educated when the London College of Surgeons was founded in 1745 (Science Museum 2014). These developments recognised academic rigour of physicians and surgeons, in contrast to a trade guild, but there was no ‘social contract’ with patients, and in fact doctors were more likely to flee epidemics during the 17th century than see any social obligation to stay and treat patients (Wynia 2008).
The modern use of the term ‘professionalism’ as a basis for the doctor’s role towards individuals and society was first mooted in England by Dr Thomas Percival in 1803, but not until 1847 in the USA was it enshrined as a social contract demanding altruism, civic-mindedness, devotion to scientific ideals and a promise of competence and quality assurance through self-regulation (Wynia 2008). Interestingly it was accompanied by expectations that patients should communicate their problem, but not ‘weary’ the physician with ‘tedious detail’, and would obey the prescriptions of the physician (Baker et al. 1999).
The paradigm of illness underlying the practice of medicine has been dominated since the 17th century by the dualism of mind and body, attributed to the French philosopher René Descartes. Originally his ideas were motivated by religious intentions, in which he argued for the soul’s immortality and maintained that the mind or soul can exist without the body (Skirry 2006). However, Cartesian Mind-Body dualism came to influence the systems-based approach to medicine and underpin the prevailing discourse within the doctor–patient relationship.
Rise of the scientific paradigm and dominance of the biomedical model
The scientific approach to medicine during the 19th century had a major impact on the role of the doctor. Medical care was revolutionised by the discoveries of the circulation of the heart and vascular system, the germ theory of disease and cell theory with its application to the effects of disease on tissues and organs (Hahn & Kleinman 1983). Doctors’ status rose with their scientific knowledge, specialist equipment and professional code. Classifications based on the signs and symptoms of disease became the primary focus. The body was increasingly seen as a machine, and the disease, not the patient’s experience of illness, became the object of study and treatment. The relationship was that of an expert doctor, with loss of humility and increased hubris (Wynia 2008), and the patient as a passive recipient of care.
The patient’s account of his or her illness was subject to the same systematic approach and became known as ‘the medical history’. Its importance in the diagnostic process was recognised by the Canadian physician William Osler, who revolutionised training by insisting that students learned from seeing and talking to patients on the wards. His admonition ‘listen to your patient, he is telling you the diagnosis’ highlighted the central role of the patient’s narrative (Osler 1914). ‘Taking a medical history’ became part of clinical reasoning in establishing the causation of disease.
Biomedicine was the predominant model, based essentially on the belief that abnormalities in the body result in symptoms, and that health is the absence of disease (Hahn & Kleinman 1983). By embracing reductionism, the importance of the psychosocial aspect of illness and the patient’s perspective went unrecognised and unacknowledged. As the patient’s views were unimportant in this biomedical model, informed consent was also a nonexistent phenomenon.
From the late 19th century, psychoanalysis and talking therapies emerged to study the mind and explain conversion of psychological traumas to physical symptoms and expressions of unhappiness (European Graduate School n.d.). Whilst therapeutic alliance in the doctor–patient relationship was crucial to the healing process, the power resided with the doctor.
Healthcare as a right
In the UK in 1945, the creation of a National Health Service (NHS) by Aneurin Bevan brought about healthcare free at the point of need. The benign paternalism of the welfare state provided for the population ‘from the cradle to the grave’ (Beveridge 1942). This was a hugely significant historical moment, enshrining health as a right, and consultation rates increased enormously (Rivett 1998). Doctors now treated people from all socio-economic groups who were grateful, powerless and uncritical. The formers’ success was dependent on approval from hospital superiors and not patients. The medical profession was reluctantly drawn into practising within an NHS, initially fearing control by the state, but they still had enormous freedom with state-sanctioned power and deferential patients.
Challenges to the biomedical model and rise of the biopsychosocial model
In the mid-20th century, sociology and psychology, new fields of discourse, joined the debate about the doctor–patient relationship. The American sociologist Talcott Parsons in 1951 referred to the ‘sick role’, in which patients were regarded as passive victims but were expected to want to get better by following the advice of the expert doctor (Parsons 1951). The patient was absolved of responsibility for their illness and allowed to abstain from their usual roles in society until they were better.
Recognising different contexts, the physicians Thomas Szasz and Marc Hollender described three basic models of doctor–patient relationship: activity-passivity, whereby the physician does something to an inert or unresponsive patient; guidance-cooperation, in which the physician tells the patient what to do and the patient complies; and mutual participation, whereby the physician helps the patient to help him- or herself and the patient participates as a partner (Szasz & Hollender 1956). In all situations however, ‘compliance’, essentially meaning obeying doctors’ orders, was expected (Stimson 1974). In the name of reducing anxiety, the truth was often withheld from patients, and doctors made decisions about treatment (Freidson 1960). This ‘benign paternalism’ was the cornerstone of the relationship. Indeed one might characterise it psychodynamically, or in transactional analysis terms, as a parent–child type of relationship (Berne 1961). It was criticised for maintaining doctors’ power base at the expense of respecting patient autonomy, and Eliot Freidson called for patients, as consumers, to be actively involved to negotiate effectively for services (Freidson 1986). The nature of the doctor–patient relationship was now up for debate.
Whilst the sociologists were concerned with issues of power, others such as George Engel, Michael Balint and Carl Rogers viewed the relationship through the lens of ‘dynamic psychology’. Engel advocated the need for a new medical model that linked science and humanism and used the term ‘bio-psychosocial-cultural’ (Engel 1977). This integrated information concerning what was the matter with the patient and what mattered to the patient. Rogers, a humanistic psychologist, maintained that for a person to “grow”, he or she needed an environment that provided genuineness, acceptance and empathy. Anyone in a therapeutic relationship, such as a doctor or therapist, needed to demonstrate unconditional positive regard, openness, warmth and a willingness to listen and understand the person (Rogers 1961). The goal was to empower the person to fulfil his or her potential. Rogers’ work was hugely important in the 1960s, defining a basis for the doctor–patient relationship, specifying both underlying attitudes and skilled behaviours.
At the same time, the Hungarian psychoanalysts Michael and Enid Balint, working in the UK, recognised the impact on doctors of the limitations of the biomedical model, as they saw doctors struggle with patients where they could find no diagnosis or satisfy the patient. Balint was the first to coin the term ‘Patient-centred medicine’, to describe the belief that each patient ‘has to be understood as a unique human being’ (Balint 1961). Balint training groups enabled doctors to share situations where they did not know what was going on or what to do for a patient, their frustration when the medical model did not help and the impact of their feelings of helplessness on their behaviour. His book, The Doctor, His Patient and the Illness (Balint 1964), was hugely influential on British medicine, and Balint groups spread to the USA and Europe (Salinsky 2003).
The birth of feminism in the 1960s was a significant milestone as a catalyst for social action around the control of women’s reproductive rights. The Boston Women’s Health Collective publication Our Bodies, Ourselves inspired the women’s health movement and challenged the pathology/disease approach to normal life events such as giving birth, menopause, aging and death (Boston Women’s Health Collective 1970). It maintained that informed health consumers can become their own health experts, and that they have a right to know about controversies surrounding medical practices. Deference was being questioned. Ivan Illich further described how over-medicalization was making people lifelong patients, reducing their capacity to deal with life’s problems (Illich 1975a). Doctors, by their classification systems, controlled the definition of illness and tended to see illness and need for treatment rather than normality and health (Foucault 1973). Doctors were neither acknowledging nor explaining risks, and the problem of iatrogenesis (harm caused by medical treatment), both clinical and social, was significant (Illich 1975b).
The two ‘realities’ in the doctor–patient relationship were defined by Elliot Mishler in the terms ‘medicines world’ and patients’ ‘lifeworld’. The world concept and language in each differed (Mishler 1984). The patient is the one who moves in and out of the healthcare setting trying to maintain his or her narrative in the ‘lifeworld’, and problems arise when the patient is ignored or blocked by doctors' use of the voice of medicine (Kleinman 1988).
The broader context was echoed by the lawyer Ian Kennedy in his book The Unmasking of Medicine (Kennedy 1981). He argued that notions of disease, illness and health are not morally neutral and shared decision making was being hindered by protected vested interests and the state-sanctioned power of the medical profession. He advocated a wider debate over values, ethical judgments and the political choices within healthcare, with a moral duty to listen to society at large. He significantly influenced the later introduction of bioethics as a core component of the medical curriculum.
The biopsychosocial concept of health, or ‘Whole Person Health’, was affirmed in the World Health Organisation’s Alma-Ata Declaration in 1978, a major milestone of the 20th century, defining health as ‘a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity’ (World Health Organisation 1978).
The era of evidence-based medicine: studying the doctor–patient relationship
The seminal research of the American paediatrician Barbara Korsch first demonstrated how outcomes of medical care were affected by doctor–patient communication (Korsch et al. 1968). She identified how mothers frequently left the consultation without having expressed their main concerns or questions. Half had not received an explanation of the cause of their child’s symptoms and doctors often used jargon that families did not understand.
The concept of ‘evidence-based medicine’ was beginning to emerge, and in 1972 Archie Cochrane called for evidence as a priority for the NHS (Cochrane 1972). The Cochrane Collaboration was subsequently established to coordinate and publish systematic reviews. Criticism of evidence-based medicine from within and outside the profession was countered by David Sackett, who argued that evidence-based practice was the integration of individual clinical expertise with the best available external clinical research evidence and judicious application to the care of individual patients (Sackett 1996).
Research on the doctor–patient interaction burgeoned from the 1980s with audio- and videotaping now enabling observation of the process. The ground-breaking work of Patrick Byrne and Barrie Long in the UK identified consultations ranging from heavily doctor-dominated, closed questioning to very open, facilitative listening styles (Byrne & Long 1976). High control styles were common, and interruption of patients only 18 seconds into the consultation, as reported by Howard Beckman and Richard Frankel, led to important information being missed (Beckman & Frankel 1984; Platt & McMath 1979). David Tuckett and colleagues revealed how patients’ thoughts and ‘expertise’, particularly of those from lower socioeconomic groups, remained unknown to doctors (Tuckett et al. 1985).
Howard Waitzkin found that doctors only used about 1 minute of a 20-minute consultation to give advice (Waitzkin 1984). Patient dissatisfaction with information provided was compounded by the finding that doctors did not organise their information to align with patients’ thinking, so explanations were less effective, not understood or forgotten (Ley & Spellman 1968). Patients often misinterpreted what doctors were intending to convey, and understanding of terminology, anatomy and disease was poor (Boyle 1970). Aaron Lazare found that despite 99% of patients having treatment preferences, only 37% voiced these spontaneously (Lazare et al. 1975). Moreover Peter Maguire showed how clinicians avoided emotionally challenging situations by using distancing tactics, and in so doing, mental health problems often remained undiagnosed and untreated (Maguire 1985). This highlighted how doctors’ own emotions and psychological needs were central in the doctor–patient relationship, as well as the skills they did or did not possess. Hence such studies on the doctor–patient relationship revealed how communication and partnership might be threatened.
Evidence was amassing of correlation between doctor–patient communication and health outcomes and a significant milestone was the publication in 1988 by Judith Hall and colleagues of a meta-analysis study (Hall et al. 1988). Moira Stewart’s review found that outcomes associated with doctor–patient communication were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e. blood pressure and blood sugar level) and pain control. The key aspects of communication found to enhance patients’ cooperation with the management plan were orientation, facilitation of patient’s ideas and questions, sharing ideas and humour (Stewart et al. 1999). Ineffective communication was associated with medication errors and malpractice claims (Hulka et al. 1976; Levinson et al. 1997).
During the period 1986–1996, over 40 patient–physician communication instruments were published (Boon & Stewart 1998). Amongst the many, Deborah Roter’s Interactional Analysis Scale (Roter 1995) correlated most highly with other instruments and was to become used worldwide with application to more than 45 areas of communication contexts and outcomes.
A significant milestone in 1991 was the evidence-based Toronto consensus statement on doctor–patient communication, with implications for practice and training (Simpson et al. 1991). From their review of research, a strong message emerged; within the relationship, doctors needed to use their power wisely, not to control but to ‘find common ground’, show care, and guide and empower patients in collaborative relationships and shared decision making to improve outcomes (Brown et al. 1989; Stewart et al. 1999).
Patient-centredness and models of the doctor–patient relationship
The concept of patient-centredness, first mooted by Balint, now increasingly appeared in the literature, and in 1999, the Society of General Internal Medicine in the USA endorsed this approach (Association of American Medical Colleges 1999). The Transformed Clinical Method was proposed by Ian McWhinney and colleagues in Canada to operationalise Engel’s biopsychosocial model (McWhinney 1989). The increasingly systematic approach to studying the doctor–patient interaction in practice led to a variety of models of the doctor–patient relationship being developed, which are discussed in Alexia Papageorgiou’s chapter on models of the doctor–patient consultation (chapter 4).
The psychodynamic models were highly relevant to the underlying doctor–patient relationship. Notably, Eric Berne’s channels of communication identified verbal and nonverbal behaviour embodying ‘parent’, ‘adult’ and ‘child’ (superego, ego and id) states (Berne 1961). The ‘parent’ relationship maps particularly to the paternalistic approach, whilst the ‘adult’ relationship embodies respect for patient autonomy and partnership. John Heron described ‘authoritative’ and ‘facilitative’ interventions, both of which were appropriate, depending on context (Heron 1976). Additionally he identified inappropriate and potentially ‘harmful’ interventions that he termed ‘perverted’. These arose from conscious or unconscious attitudes and underlying assumptions. The skills-based models have, however, largely dominated in training, and Keith Taylor argues that the change in underlying assumptions about the relationship in the patient-centred model have been more implicit than explicit (Taylor 2009). The concept of patient-centredness has become a dominant paradigm and is discussed in Rosie Illingworth’s chapter (chapter 6).
At the end of the 20th century, the concept of ‘concordance’ was proposed by the Royal Pharmaceutical Society in the UK. This was a radical shift in the consultation dynamic, which traditionally demanded that both parties act to avoid tension or conflict that could jeopardise the encounter in the immediate and long term. It involved honest sharing of ideas and real negotiation ‘so that both doctor and patient together can proceed on the basis of reality and not of misunderstanding, distrust or concealment’ (Royal Pharmaceutical Society Great Britain 1997). It was however frequently misunderstood and misrepresented in the literature as ‘patient concordance’; in other words a patient behaviour rather than a process in which ‘agreement to differ’ could also be legitimate. Kristian Pollock argued that its true meaning was not recognised in everyday practice and that professional paternalism with pseudo-concordance prevailed, in which ‘informed compliance’ persists (Pollock 2005).
Training on the doctor–patient relationship
Formal training on the doctor–patient relationship and doctor–patient communication emerged in the 1970s. Howard Barrows, a neurologist, introduced standardised patients in 1968 as an educational device to teach history and examination skills (Barrows 1968), whilst Paula Stillman, a paediatrician, trained ‘simulated mothers’ to teach interviewing skills and assess students’ performance (Stillman et al. 1976). By the mid-1970s, communication skills training was widespread in the USA, but a third of British medical schools provided no training (Wakefield 1983). In the UK, a group of general practitioners pioneered vocational training on the consultation, and courses for trainers were developed using videotaping of patient consultations (Pendleton et al. 1984).
In the USA, the American Association of Medical Colleges established a Task Force on the Doctor and Patient in the 1980s and launched a national facilitator training programme to promote knowledge, attitudes and skills relating to the medical interview across all specialities (Lipkin et al. 1995). This prompted the first UK training initiative for senior hospital doctors in 1989, with the founding of the Medical Interview Teaching Association (Bird et al. 1993). Postgraduate training was important to promote best practice by clinicians and to develop trainers for the expanding undergraduate and postgraduate teaching. The development of ‘clinical communication skills’ as a discipline is discussed in Victoria Bates and colleagues’ chapter (chapter 27).
National drivers and policy on training about the doctor–patient relationship
The resurgence of neoliberalism worldwide, associated with the ideas of economic theorists such as Milton Friedman, was embraced by the conservative government of Margaret Thatcher in the 1980s (Scott-Samuel et al. 2014). It supported extensive economic liberalisation, free trade and reduction in government spending to enhance the private sector in the economy. Within the neoliberal paradigm, healthcare was less a social right and more a market commodity (McGregor 2001). Accordingly, marketization would take care of services, whilst individual personal responsibility and aspirations for healthcare would increase consumer choice and power. Professional power would be tempered. Application of private-sector management principles paved the way for subsequent privatisation of elements of the NHS by Conservative and Labour governments.
The UK government’s Patient’s Charter, published in 1991, called for fuller and greater public and patient involvement in healthcare services at a strategic level to assure accountability for public funds, together with empowerment of patients in their own healthcare decisions (Department of Health 1991). Powerful lobbying charities and independent health policy groups influenced the patient partnership agenda, reflecting wider societal cultural changes towards rights, respect, dignity, openness and partnership (Cayton 2004; Coulter & Collins 2011). Evidence-based medicine also grew at this time with the pressure for public accountability of resources and managerial control over medical practice (Scally & Donaldson 1998). Burgeoning healthcare costs, patient safety issues and recognition that many illnesses and acute exacerbations result from lifestyle factors fuelled the call for a new doctor–patient relationship (Department of Health 1996, 2001, 2010; National Patient Safety Agency 2009).
In the USA, where much of the communication research originated, training and assessment were already widespread in the 1990s (Klass et al. 1998). In 1993 the General Medical Council, the registration body in the UK, published Tomorrow’s Doctors, which recommended that ‘communication skills and attitudes that befit a doctor’ be explicitly incorporated into undergraduate medical education (General Medical Council 1993). The doctor–patient relationship could no longer be left to chance or customary practice. The General Medical Council also published Duties of a Doctor, which specified honesty as a duty (General Medical Council 1995). Despite scepticism within the profession, these influential documents led to development of curricula, explicit teaching on the doctor–patient relationship and ethics, and the incorporation of communication competences into qualifying examinations across the UK (Doyal & Gillon 1998; Hargie et al. 1998).
National consensus documents to foster best practice in communication education established quality criteria (Makoul & Schofield 1999; von Fragstein et al. 2008). By 1998 assessment of clinical communication competency was part of licensing examinations for international medical graduates applying for provisional registration to work in the UK (General Medical Council 2013). Compulsory postgraduate advanced communication training for all clinicians working in cancer medicine was introduced as part of the NHS Cancer Plan of 2000 (Department of Health 2000).
The General Medical Council in the UK defined postgraduate communication curriculum outcomes and the Royal Colleges specified the requirement for competency in communication within the new doctor–patient partnership and shared decision-making model, and assessments of clinical communication became part of membership examinations (Federation of the Royal Colleges of Physician 2006; Academy of Medical Royal Colleges 2009; General Medical Council 2010).
The era of research on training and evidence of its effectiveness
Associations for research into medical education date back to the mid-20th century. However it was not until 1999 that the first Best Evidence Medical Education review of communication skills teaching studies was published (Aspegren 1999). Studies were of low quality with only one long-term follow-up, but key points were that learning methods should be experiential, occur in the ‘clinical’ (clerkship) years and primarily focus on problem definition. Robert Hulsman and colleagues’ review of postgraduate training also found that most of the studies used inadequate research designs (Hulsman et al. 1999). Those with the most adequate designs reported the fewest positive training effects, with half or less of the observed behaviours evident. A significant milestone was the publication of the first randomised controlled trial in 2003, showing an enduring effect of communication skills training with transfer to the clinic (Fallowfield et al. 2003). However, other research revealed problems with application to clinical settings (Dwamena et al. 2012). The issue of transfer of learning to the clinical environment is discussed in John Skelton’s chapter (chapter 7).
Public inquiries in the 21st century: Trust in the doctor–patient relationship
At the beginning of this century the doctor–patient relationship came under scrutiny in the UK. A number of high-profile cases of serious failures of care, ranging from Bristol Royal Infirmary Inquiry in 2001 into care of children receiving complex cardiac surgical services (Bristol Royal Infirmary Inquiry 2001), the serial killer Dr Harold Shipman (Home Secretary and the Secretary of State for Health 2007), and the recent Francis Report (Francis 2013) on neglect at the Mid Staffordshire Hospital in 2013, brought trust in the profession into question. The Bristol Inquiry spoke of a ‘club culture’ with lack of standards for evaluation of performance, quality of care, appraisal and revalidation. These professional failures prompted renewed debate around professionalism and reports on safeguarding patients (Department of Health 2007). Sir Donald Irvine, chairman of the Picker Institute Europe (an international charity), pointed out that ‘We know quite a lot about communication and skills and how to teach them but there is not much known about the attitudes that underpin this’ (Royal College of Physicians 2005, p. 33).
In 2005 in the UK, the Royal College of Physicians’ report on professionalism restated the values of integrity, compassion, altruism, continuing improvement, excellence, working in partnership with members of the wider healthcare team, personal responsibility and accountability that underpin the science and practice of medicine (Royal College of Physicians 2005). The Kings Fund (an independent charity in the UK) in 2010 included views of lay people, amongst the various stakeholders, to define the basis for a moral contract between the medical profession and society in achieving the goals of best care for both the population as a whole and for the individual (Levenson et al. 2010).
In the USA, Matthew Wynia warned about the domination of respect for individual autonomy and loss of the societal aspect of the initial understanding of professionalism. He argued that a contemporary social contract requires retention of commitment to science with negotiation between the patient’s expectations, resource distribution, and service to society, artful practice, humility and self-regulation (Wynia 2008).
Whole systems and teamworking
By the turn of the century, healthcare was increasingly complex, with multiprofessional healthcare teams and many traditional duties of a doctor extended to allied professionals. The concept of relationship-centred care had been introduced in the USA in the 1990s and encompassed collaborative relationships within teams, team working and organisational practices impacted on the doctor–patient relationship (Tresolini & the Pew-Fetzer Task Force 1994). The culture and values of an organisation profoundly affected congruence of the workforce. It was recognised that interactions between clinicians and all other staff in the healthcare institution, especially in hierarchical organisations, affected their own well-being in addition to the health of patients. ‘When an organisation diverges from core principles of relationship centredness, the practitioner is forced to engage with patients in a manner sometimes quite different from how he or she is treated’ (Beach et al. 2006). Stress on healthcare workers had implications for care and risked compromising empathy. In the UK the Francis Report revealed resourcing pressures, stress, attitude and culture as sources of problems (Francis 2013). Increased specialisation in the organisation of care resulted in great benefits of expertise but also weakened continuity of relationships for patients (Cornwall et al. 2012). Audits of the patient’s experience within the whole system became common as one indicator of care quality (Coulter 2005a).
The tension between feeding the data-gathering imperative for financial and management purposes, the needs of research and evidence-based medicine, whilst serving the patient narrative and human experience of care, all within a time-limited consultation, presents a challenge (Iles 2014). The clinician’s capacity for self-awareness and integrity, especially the ability to sustain these in complex and challenging circumstances, was recognised as a basis for positive relationships with colleagues and patients.
The patient in the patient-doctor relationship: the Internet and democratisation of knowledge
Arguably the most profound effect on the doctor–patient relationship has come from the explosion of information available to the public in the 21st century. The potential for patients themselves to influence the interaction has been supported not only by information from a myriad of websites but also formal training aimed at improving patients’ ability to be more skilful in handling the consultation to express their ideas, information and involvement needs. Expert patient programmes evolved to harness the expertise and lay understanding of self-management, to support other patients with long-term conditions, as well as to train health professionals in a collaborative approach to consultations (Department of Health 2001; Wallace et al. 2012).
Focus on patients’ ability and desire for involvement in their healthcare recognised the importance of ‘health literacy’, defined as ‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health’ (American Medical Association 1999). Patients with inadequate health literacy experience a complex array of communication difficulties that interact to influence health outcome (Nutbeam 2008). Lack of understanding, feelings of intimidation and associated shame could be reinforced by hospital staff who become frustrated or angry (Parikh et al. 1996). Those less able to seek help when needed lack confidence and effectiveness in managing their health and healthcare (Hibbard & Gilbert 2014).
These patient factors affect the doctor–patient encounter. Some authors warned of potential risks of ‘victim blaming’ in the individual responsibility model, which could damage the doctor–patient relationship (Marantz 1990). Patients’ dependency and need for support differ, requiring a flexible approach by clinicians in promoting patient engagement and self-care. Iona Heath argued that if not balanced with unconditional positive regard, nonjudgement and compassion, expectations of patient responsibility could be detrimental and oppressive (Heath 1995).
Globalisation, information technology and consumerism
Increasing global migration in the 21st century brought together doctors and patients from diverse social and cultural backgrounds. In 2009, 58% of new General Medical Council registrants qualified in the UK, 23% were from the European Economic Area and 19% were international medical graduates from outside the European Economic Area (General Medical Council 2010). In addition to sociolinguistic challenges (General Medical Council 2014), doctors and patients hold a range of expectations of the doctor–patient relationship and views on healthcare rights, public accountability and personal responsibility. This requires even greater skill in the doctor–patient interaction to work within a patient-centred model of care.
Information technology revolutionised the collection and storage of patient data, with standards for records recently published by the Royal College of Physicians (Royal College of Physicians 2015). The implications of the electronic patient record on the consultation are emerging, with warnings that bureaucratisation ‘risks marginalisation of aspects of quality which lie beyond their focus, in particular attention to patient narrative’ and that doctors need ‘to be creative in using templates to avoid privileging “institution-centred” care over patient-centred care’ (Swinglehurst et al. 2012). Evidence-based medicine’s supremacy, it is argued, has limitations in situations of complex healthcare needs where co-morbidity is so prevalent (Greenhalgh et al. 2014).
Are we moving towards a consumerist model in which power relationships are reversed, with the patient taking the active role and the doctor adopting a fairly passive role, acceding to the patient’s requests for particular treatments, a second opinion, referral to hospital, a sick note and so on? Picker Institute surveys show that the British public remains strongly in favour of equity and participation, with high-quality services available to all, accountability of providers and independent regulation at arm’s length from government (Coulter 2005b).
In the current social, scientific and political climate doctors need to use their expertise wisely in the service of patients and navigate the various demands and constraints within a social contract, whilst at the same time retaining the ability to care, to be trustworthy and share information, decisions, uncertainty and even mistakes openly. The final word must go to Henry Sigerist, who reminds us that “the physician's position in society is never determined by the physician himself, but by the society he is serving” (Sigerist 1933).
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Social Insurance and Allied Services
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