Physician/patient communication: who should understand who?
Ricardo Pérez-Cuevas
Centro de Estudios Económicos y Sociales en Salud, Hospital Infantil de México Federico Gómez, México, D.F., México
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Ricardo Pérez-Cuevas
E-mail: ricardo_perezcuevas@prodigy.net.mx
Fecha de recepción: 25-01-10.
Fecha de aceptación: 26-01-10.
Physician-patient communication is the dialogue between the voice of medicine and the voice of the living world.1 The dynamics and effects of the communication process between physicians and patients have been long analyzed from different perspectives, and few publications address this topic from the pediatric care perspective.
The article by Cabrales et al. "Evaluation of information provided to patients' relatives in an ambulatory pediatrics unit of a tertiar- care hospital", published in this issue,2 portrays the actual understanding of mothers about the medical conditions, prognosis and treatment for their sick children. In this study, patients were not interviewed; however, the paper helps to frame an important unmet need, which is to improve the quality of communication between patients' parents and their treating pediatricians.
Effective communication between patients and physicians influences patient health outcome3 and building rapport because the first encounter is essential. Clinical history-taking represents, from the patient and parent's perspective, the need to open his/ her personal and family matters (symptoms, thoughts, fears, sufferings and expectations) to a stranger (a pediatrician) who is supposed to have the knowledge and moral authority to understand and provide care. During this encounter, history-taking is a semiotic act that transforms lay speech into medical terminology. Nevertheless, if pediatricians are not trained to understand the social context of the illness, their perspective of the actual situation will be narrow and reduced purely to biological processes.
The history-taking should allow patients, parents and pediatricians a better understanding of the nature of the problem and to delineate the next steps. This component represents the opportunity for the pediatrician to learn not only the clinical symptoms and signs, but the social conditions of the patient and also the family. The next step for the pediatrician is to explain to the patient and family about the diagnosis. This must be a clear and comprehensive explanation. Thus, patients and parents are able to fully understand what is happening. An open discussion should then follow in regard to the management plan. This decision-making process must be comprehensive and the patient (even a child) and the family should be encouraged to actively participate. Actually, empowering patients and families throughout the entire process should become an objective of care.
]]> An important component of Cabrales' paper is its description of the way in which the data collection instrument was developed. The information about the construction and validation process is succinct and does not provide sound statistical elements such as the factorial analysis to prove the robustness of the instrument; however, the effort to develop a questionnaire aimed at collecting information to answer important questions from a local perspective is worthwhile.The results of the study show that parents had limited information about the diagnosis, prognosis and treatment of their children. This is one side of the problem and possibly ascertaining whether hospital-affiliated pediatricians are capable of comprehensively transmitting this information to parents would provide valuable information to tally up the other side of the problem.
The article points out that most patients belong to a low socioeconomic status and suggests that such condition negatively influences their capability to understand medical information. Physicians are expected to provide high-quality care to their patients. This includes the ability to comprehensively explain information to patients and parents taking into consideration their culture, education and socioeconomic status. A growing body of literature supports that poverty, vulnerability, low educational level and child neglect are widely known risk factors for many diseases.4 These very risk factors are also important for prognosis and health outcomes. The understanding of the health provider about these aspects is crucial to attain the expected health outcomes.
Children and parents need not only to understand about the diagnosis, prognosis or treatment, but to learn and be motivated to be active participants in the management plan. The study of Cabrales et al. contributes to establish solid groundwork for in-depth study regarding the importance and consequences of the interaction between sick children and their families in the hospital environment. Children and parents are not passive receptors of care. They should be encouraged to ask questions and discuss options. The decision-making process should be egalitarian. It is unavoidable that family members will have great expectations of the treatment for the chronically ill child; however, if they are aware of the nature of the illness and expected outcomes, this can increase their adherence to the care plan,5 which includes attendance to follow-up visits, laboratory exams, and taking medications according to the therapeutic scheme. In other words, physicians must have the notion that the patient can make a contribution to their clinical judgment about the disease and its treatment.
The Kalamazoo Consensus Statement Group identified seven essential sets of communication tasks: (1) build the doctor–patient relationship; (2) open the discussion; (3) gather information; (4) understand the patient's perspective; (5) share information; (6) reach agreement on problems and plans; and (7) provide closure.6 These tasks should be part of physician education regarding their communication skills with patients and parents. The paper of Cabrales et al. allows assuming that pediatricians should improve their communication techniques and behavioral changes. Actually, this is a core competence not only for physicians, but for all health care professionals.
It is advisable to continue and support this line of research within the pediatric hospital care context. Carrying out qualitative studies, patient-centered
interventions and updating and training pediatricians to improve their communication skills are necessary to improve the quality of care and can increase the probabilities of obtaining better health outcomes. These activities can narrow the gap between patients and treating physicians.
References
1. Kleinman A. The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books;1998. pp 127-129. [ Links ]
2. Cabrales-Martínez R, Bustos-Córdova E, Naranjo-López Y, Adell-Gras A, Sánchez-Medina J. Evaluation of information provided to patients' relatives in an ambulatory pediatrics unit of a tertiary-care hospital. Bol Med Hosp Infant Méx 2009;67:108-116. [ Links ]
3. Stewart M. Active physician-patient communication and health outcomes: a review. Can Med Assoc J 1995;152:1423-1433. [ Links ]
4. Lanata C. Children's health in developing countries: issues of coping, child neglect and marginalization. In: Leon D, Walt G, eds. Poverty, Inequality and Health. An International Perspective. London, UK: Oxford University Press. pp. 137-158. [ Links ]
5. Winnick S, Lucas D, Hartman A, Toll D. How do you improve compliance? Pediatrics 2005;115:e718-e724. doi: 10.1542/peds.2004-1133. [ Links ]
6. Editorial. Essential Elements of Communication in Medical Encounters: The Kalamazoo Consensus Statement. Acad Med 2001;76:390-393. [ Links ]
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