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A qualitative study of patients' views on quality of primary care consultations in Hong Kong and comparison with the UK CARE Measure

A qualitative study of patients' views on quality of primary care consultations in Hong Kong and... Background: Patients' priorities and views on quality care are well-documented in Western countries but there is a dearth of research in this area in the East. The aim of the present study was to explore Chinese patients' views on quality of primary care consultations in Hong Kong and to compare these with the items in the CARE measure (a process measure of consultation quality widely used in the UK) in order to assess the potential utility of the CARE measure in a Chinese population. Methods: Individual semi-structured interviews were conducted on 21 adult patients from 3 different primary care clinics (a public primary healthcare clinic, a University health centre, and a private family physician's clinic). Topics discussed included expectations, experiences, and views about quality of medical consultations. Interviews were typed verbatim, and a thematic approach was taken to identify key issues. These identified issues were then compared with the ten CARE measure items, using a CARE framework: Connecting (Care Measure items 1–3), Assessing (item 4), Responding (items 5,6), and Empowering (items 7–10). Results: Patients judged doctors in terms of both the process of the consultation and the perceived outcomes. Themes identified that related to the interpersonal process of the consultation fitted well under the CARE framework; Connecting and communicating (18/21 patients), Assessing holistically (10/21 patients), Responding (18/21 patients) and Empowering (19/ 21 patients). Patients from the public clinic, who were generally of lower socio-economic status, were least likely to expect holistic care or empowerment. Two-thirds of patients also judged doctors on whether they performed an adequate physical examination, and three-quarters on the later outcomes of consultation (in terms of relief or cure and/or side-effects of prescribed drugs). Conclusion: These findings suggest that Chinese patients in Hong Kong value engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and the attitudes and values that underpin them, as well as on the perceived outcomes of treatment. The match between themes relating to consultation process and the CARE Measure items suggests utility of this measure in this population, but further quantitative validation is required. Page 1 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 settings were chosen in order to sample patients with a Background The consultation between doctor and patient is the core of range of ages, conditions, and socio-economic status. The clinical medicine and has been particularly emphasized in patients at FMIC mainly attend for chronic disease man- general practice and primary care [1-4]. Quality can be agement such as hypertension or diabetes mellitus. Nine conceptualized as a combination of access to care and patients (5 males and 4 females), with age group ranged effectiveness of care, with effectiveness depending on from 41–45 to 81–85, were recruited. UHC was selected both technical and interpersonal aspects [5]. Research on because it was the health centre of CUHK and any student interpersonal effectiveness suggests that empathic, or staff and their family members can have access to it and patient-centred consultations improve patient satisfaction many patients consult for acute problems. Six patients (1 [6,7] and enablement [8], and may improve health out- males and 5 females), with age group ranged from <20 to comes [9-11]. 56–60, were recruited. The private FM clinic was selected because it was run by a family physician (a Fellow of the Although patient-centred care is becoming widely advo- Hong Kong College of Family Physicians) and patients cated, there is no single, globally accepted definition. with either acute and/or chronic diseases commonly Research on patient-centred care has predominantly been attend the clinic. Six patients (3 males and 3 females), carried out in the West, especially the UK and North with age group ranged from 26–30 to 76–80, were America [12,13]. Recently however, there has been a recruited. Ethics approval was obtained before the start of growing interest in people and patient-centred care in the study from the Survey and Behavioural Research Eth- Eastern countries [14-17]. Additionally there is now a ics Committee of the Chinese University of Hong Kong. renewed focus on primary care globally, including coun- The doctor-in-charge of each clinic consented to the study tries such as China and Japan [18]. In seeking to develop after receiving full details, and specific nursing staff at effective primary care services in such countries, it is each clinic were assigned to facilitate the recruitment of important that patients' views on what constitutes 'good' patients in order to reduce the disturbance to the smooth consultations are collected and fed into policy and health running of the clinic. The nursing staff approached attend- services developments in primary care. Hong Kong is one ing patients to see if they were interested in participating such region which is currently embarked on health care in an interview. After verbal agreedment, the first author reforms with a strong emphasis on strengthening primary approached the patient, explain the study in detail and care services [19]. obtained written consent. Keeping strict confidentiality and anonymity was emphasized to every interviewee. In the present qualitative study we have explored patients' Although we were not able to purposively select the inter- views on what constitutes quality at consultation in differ- viewees, recruiting from the 3 separate clinics helped to ent primary care settings in Hong Kong. We have then ensure that a maximum variation sample was obtained. compared these views with the ten-item CARE measure, Table 1 shows the characteristics of the 21 patients which is a widely used measure of consultation quality in recruited. the UK, developed by one of the authors [20-22]. The UK CARE Measure captures key aspects of the process of the Patients were encouraged to talk freely and openly on clinical encounter, rather than outcome, and was devel- their views on the quality of the primary care consultation oped from the views of patients of differing socio-eco- in Hong Kong. Open-ended prompting questions nomic status, as well as having a theoretical and empirical included asking about their expectations, their experience base. In a study of over 3,000 patients over 95% of of good or bad consultations, and their definitions of patients felt the items were applicable to their consulta- good or bad doctors/consultations. All the 21 interviews tion in primary care [22]. The CARE measure is currently were conducted by the first author (CF), and a research accredited for appraisal of General Practitioners (GPs) assistant also helped to conduct the interviews on the six and is a compulsory component of work place -based patients recruited from the private FM clinic. The inter- assessment in the training of all GPs in the UK. views were conducted between May and August 2007 and averaged around 30 minutes (ranging from 15 minutes to Methods 60 minutes). The study involved in-depth, semi-structured interviews with 21 Chinese patients recruited from 3 different types The interviews were audio-taped and typed verbatim by a of primary care clinics in Hong Kong: (1) a Family Medi- research assistant, and 4 student helpers (year 4 medical cine Integrated Clinic (FMIC), part of the public health- students of the Chinese University of Hong Kong). All care system run by the Hospital Authority, (2) the transcripts were translated into English (all transcribers University health centre (UHC) of the Chinese University were native Cantonese speakers, fluently bilingual in writ- of Hong Kong (CUHK), and (3) a private family medicine ten and spoken English). Accuracy of translation was (FM) clinic run by a Family Physician specialist. The three checked by CF who read all transcripts in both English Page 2 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 Table 1: Characteristics of the participating patients Patient Code Gender Age Group Marital Status Education Level Occupation Monthly Reason/disease Clinic Attended Household for consultation income (HKD) A001 Female 71–75 Married Tertiary Retired 30001–40000 Chronic disease FMIC A002 Female 76–80 Widowed Nil Retired 20001–30000 Chronic disease FMIC A003 Female 71–75 Widowed Nil Retired <5000 Chronic disease FMIC A004 Male 36–40 Single Lower Non-technical 5001–10000 Chronic disease FMIC secondary manual worker A005 Male 71–75 Married Upper Retired 10001–20000 Chronic disease FMIC secondary A006 Male 81–85 Widowed Primary Retired <5000 Chronic + acute FMIC diseases A007 Female 66–70 Married Primary retired <5000 Chronic + acute FMIC diseases A008 Male 76–80 Married Primary Retired CSSA Chronic disease FMIC A009 Male 41–45 Married Lower Driver 10001–20000 Chronic disease FMIC secondary A010 Female 56–60 Married Upper Clerk 10001–20000 Acute disease UHC secondary A011 Female 46–50 Married Tertiary Housewife >60001 Acute disease UHC A012 Female 21–25 Single Tertiary Student 10001–20000 Administrative UHC reason A013 Female 46–50 Married Tertiary Clerk >60001 Acute disease UHC A014 Female <20 Single Upper Student 10001–20000 Acute disease UHC secondary A015 Male 21–25 Single Tertiary Student 30001–40000 Acute disease UHC A016 Male 71–75 Married Nil Retired 10001–20000 Chronic disease Private A017 Female 61–65 Married Primary Housewife 5001–10000 Chronic disease Private A018 Female 76–80 Widowed Nil Housewife 5001–10000 Chronic disease Private A019 Female 76–80 Widowed Primary Retired 5001–10000 Chronic disease Private A020 Male 26–30 Married Tertiary Officer 30001–40000 Acute disease Private A021 Male 31–35 Married Tertiary Professional 10001–20000 Acute disease Private FMIC = Family Medicine Integrated Clinic, Price of WalesHospital UHC = University health centre, the Chinese University of Hong Kong Private = private clinic of the Family Medicine Specialist and Cantonese. Translation into English was necessary to outcomes of the consultations. At this stage some 109 enable SWM to assist in the analysis of the data. codes were generated in total. At the end of this process, the 109 codes were compared with the ten main items A thematic approach was taken to identify key issues [23]. within the UK CARE measure (Figure 1). We then used the involving systematic identification, charting and sorting CARE Measure items as a framework for categorizing the of the data. Analysis was iterative, with broad themes codes identified regarding the consultation process, and identified initially, then further broken down into sub- assessed how many of the codes could or could not be cat- themes [24]. The constant comparative method was used egorized within one or more of the CARE Measure items. throughout [25] by initially comparing data sets between Categories not fitting within the CARE Measure frame- individual transcripts, and later comparing data with work were also identified. Both CF and SWM carried out emergent hypotheses. Regular meetings between the two this comparison with the CARE measure independently, authors over the duration of the project allowed categori- and then compared notes; mainly there was good agree- sation and classification, and the development of typolo- ment, and areas of differences in if and where codes fitted gies and explanatory accounts to be pursued. within the framework were discussed until consensus was reached. Preliminary coding of the raw data was undertaken inde- pendently by CF and SWM and agreement reached on the We found that all of the codes relating to the interpersonal initial main codes. Initially 16 categories were identified, aspects of the consultation (76 out of 109) fitted within which were then rearranged/re-coded under three major one or more of the ten-item CARE Measure framework; themes: patients' definitions of good doctors and consul- Additional themes which did not fit (33 out of 109) tations, bad doctors and consultations, and expectations/ related to physical examination, the context of care (access Page 3 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 1.Please rate the following statements about today’s consultation. Please tick one box for each statement and answer every statement. Ver y Does Poor Fair Good Good Excellent Not How was the doctor at … Apply 1. Making you feel at ease…… (being friendly and warm towards you, treating you with respect; not cold or abrupt) 2. Letting you tell your “ stor y”…… (giving you time to fully describe your illness in your own words; not interrupting or diverting you) 3. Really listening … … (paying close attention to what you were sayings; not looking at the notes or computer as you were talking) 4. Being inter ested in you as a whole per son … (asking/knowing relevant details about your life, your situation; not treating you as “just a number”) 5. Fully under standing your concer ns… … (communicating that he/she had accurately understood your concerns; not overlooking or dismissing anything) 6. Showing car e and compassion… . (seeming genuinely concerned, connecting with you on a human level; not being indifferent or “detached”) 7 . Being Positive…… (having a positive approach and a positive attitude; being honest but not negative about your problems) 8. Explaining things clear ly… … .. (fully answering your questions, explaining clearly, giving you adequate information; not being vague 9. Helping you to take contr ol…… (exploring with you what you can do to improve your health yourself; encouraging rather than “lecturing” you) 10. Making a plan of action with you … (discussing the options, involving you in decisions as much as you want to be involved; not ignoring your views) Th Figure 1 e CARE Measure The CARE Measure. Page 4 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 and time) and outcomes of care. Financial issues were also Several patients equated "no eye contact" with "not listen- an important contextual issue, but will be reported in a ing" and disliked doctors who did not look at them but separate paper. Rather than presenting our findings on kept on writing or looking at the computer screen during interpersonal aspects of consultations under separate the consultation. headings for all ten the CARE measure items, we have con- densed these into 4 CARE Framework headings in order to "It's not good if the customer [patient] keeps telling, but the present the findings in a more succinct manner; doctor just merely ask you what discomforts you have, then listens to the heartbeat and just says 'okay' and write down 1. Connecting and communicating (CARE items 1,2,3) the things.. (A male patient aged 26–30, from the private clinic) [A020] 2. Assessing holistically (CARE Item 4) "...they usually face the computer and click this and click 3. Responding with understanding and compassion that, and then said, 'there's no problem, po-po [a form of (CARE Items 5,6) address to the elderly female in Cantonese]. The blood pres- sure is normal. You can go to take the prescription now.' 4. Empowering (CARE Items 7–10) That's it. So I just left." (A female patient aged 71–75, from the public primary healthcare clinic) [A003] Results Interpersonal care: The CARE Framework 18 out of the 21 patients interviewed had codes which fit- Connecting and Communicating (CARE measure items 1,2,3) ted under this overall theme of 'connecting' (CARE item 1 A comfortable atmosphere within a consultation facili- = 13/21; CARE item 2 = 12/21; CARE item 3 = 8/21). The tated the patients' ability to relax and talk openly with the 3 who did not mention this overall theme were attending doctor. Patients felt that a polite manner, a warm welcom- the private clinic and had above average household ing smile, and words or gestures from the doctor at the incomes. onset of the encounter were means of putting them at ease. Assessing holistically (CARE measure item 4) 'Whole person' care was seldom explicitly mentioned by "As I do not know much about medical knowledge, I can't patients as a key aspect of high quality interpersonal care, tell what good element should be covered in a consultation. but many of their comments were integral to a holistic, But at least sincerity. Sometimes, the doctor posed a not bio-psycho-social approach. A few patients actually stated friendly facial expression, not even me, other patients, will that they wanted doctors to spend more time understand- also think that it is not good..." (A female patient aged 71– ing the possible psychological and/or social reasons 75, from the public primary healthcare clinic) [A001] behind their symptoms. For many patients, rather than 'volunteering' such issues, they felt a 'good' doctor would "I think it is better if the doctor smiles to patient. This shows ask probing questions that would help uncover or 'dig- care to patient, patient will feel better. You can't see some out' the underlying issues. This expectation that a whole- doctor smiling when you enter consultation room. It is not person approach should be 'doctor-led' reflected a widely very good when the patient is feeling discomfort." (A female held general view that a more assertive approach on the patient aged 56–60, from the UHC, CUHK) [A010] part of the patient would be impolite or rude. Patients valued doctors who allowed or encouraged them "Of course it [asking questions] is important. We [the to 'tell their story' and actively listened in the consulta- patient] only know what we should tell him/her [the doc- tion, as it enabled them to describe their symptoms and tor] if he/she asks us more questions. If he/she doesn't ask problems in detail, and the effects these were having on us, we don't know what we should say, right?" (A female their life. Some patients described such encounters as like patient aged 66–70, from the public primary healthcare 'chatting to a friend' and such a relationship enhanced dis- clinic) [A007] closure of issues that were of importance to the patient. "They may explore the reason behind your stomachache, "For me, I prefer those doctors who are more willing to talk say, why you were suffering from stomachache last month to you and more willing to listen to you. Rather than those but then 2 weeks later, you are suffering again? Is it due to who just talk about, 'ok, this is the prescription, just take something in daily life or something we eat, like sushi, this medicine, you go back and take the medicine. If you are milk?" (A female patient aged 46–50, from the UHC, ok, then that's good; otherwise, you have to come back'..." CUHK) [A011] (A female patient aged 46–50, from the UHC, CUHK) [A011] Page 5 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 "I think the most important thing for a good doctor is that almost most patients interviewed raised as a key feature of he is willing to spend time to understand the patients' situ- a good doctor or a good consultation. The importance of ation. It's not good if it is just like a routine in seeing all explanations to patients was not related to whether they patients who go inside the consultation room." (A male attended the public or the private healthcare sectors. patient aged 26–30, from the private clinic) [A020] "When I come for follow-ups, the doctors will tell me in 10 out of the 21 patients had codes which fitted under this details, tell me about my condition, and let me know it. It's theme. None of the patients attending the public clinic good if they do it in this way. Something like giving advice (FMIC) mentioned this theme, and only 1 male did. to me on avoiding certain kinds of food, or what kind of food I should not eat, what kind of food I can eat." (A male Responding with understanding and compassion (CARE measure patient aged 41–45, from the public primary healthcare items 5,6) clinic) [A009] Many patients considered understanding concerns, being caring, kind, compassionate, having love, were basic "...Besides, being a doctor is like being a teacher...they attributes of a good doctor. When such behaviours were should encourage student or patient what they should do, expressed by doctors, patients deeply appreciated them. because they will accept this easier." (A female patient aged Such doctors were regarded as more trustworthy, and 21–25, from the UHC, CUHK) [A012] patients felt more able to talk openly about their concerns and fears in such encounters. Only a few patients men- Giving advice or educating patients about what they could tioned the education and training of the doctors as an do to help themselves was another area that was highly important factor in deciding whether a doctor was good or valued by patients. Domains of advice included how to not. Instead, the perception of caring from the doctor dur- improve one's health, advice on preventive care, self-help ing the consultation was a key criterion that they used to measures, dietary and lifestyle advice. In general patients differentiate whether a doctor was 'good or bad'. gave high importance to the doctor's role in 'education' in addition to making a diagnosis and prescribing drugs. "A good doctor should have love. It's the hardest time for one when one is sick. Poor is not the toughest, but being sick "If so, patients can learn what they can do to self-help them- is the toughest." (A female patient aged 76–80, from the selves. You know, with the help of the doctor, you can help private clinic) [A019] the patient to cope with his/her own symptoms so that he/ she doesn't have to see doctor so often.." (A female patient "Also doctors have to care about the patients. When aged 46–50, from the UHC, CUHK) [A011] patients feel that the doctor cares about you, wants to know more about your condition, patients will talk more sponta- "For example, he (the doctor) can explain and describe your neously." (A female patient aged 21–25, from the UHC, disease in an easily understandable way. He will also teach CUHK) [A012] you what kinds of exercises that you should do, and will show you on how to do those stretching exercises on shoul- "This doctor has a 'real heart' [enthusiasm] to treat der... He explains your disease well and in a detailed man- patients. It's different from other doctors. He will try all his ner. He will also give me some pamphlets to see so that I can best to treat you if you can be treated. It's different from know more about my disease as well." (A male patient aged other doctors who are aiming at making more money, and 31–35, from the private clinic) [A021] they will still 'treat' you no matter you are treatable or not." (A male patient aged 71–75, from the private clinic) Only two out of twenty-one patients voiced a clear desire [A016] for shared decision making between doctor and patient (one was from the University Health Centre and one was 18 out of the 21 patients had codes under this overall from the private clinic). theme (CARE item 5 = 13/21, CARE item 6 = 12/21). The 3 who did not showed no particular pattern. "The point is doctors have given me their professional advice and it's up to me to decide. If I need antibiotics, the Empowering (CARE measure items 7–10) doctors can give me, otherwise, observation is recom- Many patients felt a 'good doctor' was one with a positive mended. It's fine. We can still do something at home rather approach, which helped to give them hope. Being positive than always using some strong western medication as there was also often associated with the doctor giving direct must be some side effects...the doctors may not have time to advice, a clear diagnosis, treatment, and the likely time- explain all those to you." (A female patient aged 46–50, course of outcome from treatment. This theme was closely from the UHC, CUHK) [A011] related to the theme of explaining things clearly, which Page 6 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 "He (the doctor) will not force me. Even if he tells me that about you more. (A female patient aged 56–60, from the there is a (special) situation, he will not say something like UHC, CUHK) [A010] ' you have to do it.'..." (A female patient aged 61–65, from the private clinic) [A017] "The private doctors are more considerate. They will do some examinations for you, but not here, they will just take However, in other cases, it seemed that the patients' views a look and no examination. The private doctors will exam- on decision were not considered by doctors, even though ine you, measure the blood pressure......but not here. They this may have been desirable by the patients. will just say, 'put some ointments and get some medicines back home.' and tell me when I should return for follow- "Sometimes there are some ointments that I think they are up." (A female patient aged 66–70, from the public pri- effective on me, but the doctors usually refuse to prescribe mary healthcare clinic) [A007] them to me." (A male patient aged 36–40, from the public primary healthcare clinic) [A004] "Some doctors are very meticulous. They examine the nose and throat carefully and answer my query, so I feel satisfied Another patient from the public healthcare sector and think that they are good doctors. I remember an occa- explained that she did not expect the doctor to listen to sion in which a doctor listened to my son's chest and exam- the patient's opinion in decision making but she valued ined his ear and throat, and told me about his findings. I the regular follow-up. got a full picture of my son's illness. I found this doctor very good, very meticulous. Some doctors just glance at my son's "You can come here regularly for body check, do some blood face and take less than a minute examining my child. I find tests, so you will know if there's any problem with you. They them very sloppy." (A female patient aged 46–50, from the won't do this to you if you go to see the doctors elsewhere, UHC, CUHK) [A013] they won't do such checking for you to see if you have any problem. No, no such things. But it is here, it's better to Context of care have such checking in the long term....If the doctor asked Access me, 'is it okay to add some more to the drug dosage?' I usu- Approximately one-third of patients (from each type of clinic) complained about having to wait too long before ally say, 'It doesn't matter for me, if you think it's good for me.' When I go to see doctor, I usually listen to what the their consultations. doctor says. There's no reason for the doctor to listen to my sayings, right? If he wants to add some more, then I just say "...it took me two hours waiting until I saw the doctor. 'okay'. (A female patient aged 76–80, from the public pri- That's really bad. I got herpes zoster that time. It was really mary healthcare clinic) [A002] painful..." (A female patient aged 76–80, from the public primary healthcare clinic) [A002] 19 out of 21 patients had codes under this overall theme (CARE item 7 = 11/21, CARE item 8 = 18/21, CARE item "If you see public doctors, it will be impossible that you can 9 = 10/21, CARE item 10 = 5/21). For items 7, 9, 10, see them whenever you want. You won't be able to see [pub- patients attending the public clinic (FMIC) were in the lic doctors] if you miss your turn." (A female patient aged main those who did not mention these themes. 76–80, from the private clinic) [A018] Physical examination Time spent on consultations Apart from those domains within a consultation that Some patients specifically mentioned the issue of consul- patients had mentioned above, it was interesting to note tation length, and resented the fact that some doctors that almost one-third of patients from each type of clinic spent very little time with them, quickly writing a prescrip- pointed out that they valued the act of physical examina- tion with no explanation. Feeling rushed in consultations tion. They perceived physical examination as an attribute and thus an inadequate consultation length, was implicit of a caring and thorough doctor, and an important part of in many of the above accounts relating to interpersonal diagnosis, and hence getting a 'full-picture' of the prob- quality of care. lem. "I think if the consultation time is longer, they (the doctors) "For example I have abdominal pain, he [the doctor] will can have more understanding on the patients' symptoms. I think about my family history, and consider whether I am think there are lots of reasons behind a symptom. Say, you having that disease or not, then do a detail examination for may think you are suffering from stomachache; in fact, it me. Some doctors... abdominal pain, they will only give you may not be that simple, it may be due to the stress in daily some pain killers. You can feel that which doctor cares life. So, I don't know, sometimes when the doctors are busy, they may just prescribe pain killers, 'ok, that's it, byebye.'..." Page 7 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 (A female patient aged 46–50, from the UHC, CUHK) Some even judged the 'relationship' on the 'outcome' of [A011] the consultation rather than on the process of the consul- tation. Continuity Continuity of care was not overtly discussed in the inter- "If he can cure me, then that's a good relationship. If he views, but lack of relational continuity was apparent in cannot cure me, then the relationship will not be able to the accounts of the patients attending the public health- build up and continue." (A male patient aged 26–30, from care system, where it is unusual for patients to be seen by the private clinic) [A020] the same doctors. Similarly, 'doctor-shopping' in the pri- vate sector is a common phenomenon in Hong Kong. Discussion However, when patients felt they had a good 'match' with In the present study we assessed patients' views on the a doctor, they were keen to continue seeing that doctor if quality of the primary care consultation in Hong Kong by at all possible. means of qualitative interviews of 21 patients attending three different types of primary care clinics (public clinic, Outcomes University clinic, and private family medicine clinic) and Two-thirds of the patients linked a good consultation with tested whether these views are similar or different from the doctor making a correct diagnosis leading to a rapid patients views in the UK, by comparing the themes iden- "cure" of his/her disease or illness. Thus judgments about tified from the present study with the themes that com- quality of consultation and doctor were retrospective prise the UK CARE Measure. Patients judged doctors in based on outcomes; if the patient recovered rapidly then terms of both the process of the consultation and the per- they perceived the consultation, the doctor, and the treat- ceived outcomes. Themes identified that related to the ment, as effective and thus of high quality. interpersonal process of the consultation fitted well under the four theme CARE framework that we devised to incor- "The doctor is very kind, and he can often make a correct porate the ten CARE Measure items; connecting and com- diagnosis." (A female patient aged 76–80, from the private municating (CARE items 1–3), assessing holistically clinic) [A019] (CARE item 4), responding with understanding and com- passion (CARE items 5,6) and empowering (CARE items "If such questions help doctors in making the diagnosis, I 7–10). don't mind to answer them. But if the doctors think that they know enough about my condition without the need to As far as we are aware, this is the first qualitative study of ask such questions, then that's ok. To me, the most concern- patients' views on consultation quality among Chinese ing point is that the doctor can solve the problem and treat patients attending a variety of different primary care pro- my disease." (A male patient aged 21–25, from the UHC, viders in Hong Kong. Although international differences CUHK) [A015] in patient and physician perceptions of "high quality" healthcare have been reported [26] and despite the many Many patients expressed dissatisfaction if their diseases or cultural differences between the East and the West, the illness symptoms did not disappear quickly. Many of core aspects of consultation quality in primary care as them viewed the drugs given by the doctors as an impor- expressed by Hong Kong patients in the present study tant factor as to whether they would get better or not. appear to be broadly similar to studies in Caucasian sub- jects in the West [27,28]. "If his medicine was efficient, I would go back to see him (the doctor), otherwise I won't go back." (A female patient However, there did appear to be some differences in the aged 71–75, from the public primary healthcare clinic) way Chinese patients in the present study 'accessed' high [A003] quality consultations compared with studies in the West. Directly asking for information and advice was uncom- "The medicine private doctors gave me ... I can recover mon; rather patients waited for such advice and informa- faster after I have taken the medicine and have the injec- tion to be 'offered' by the doctor. Similarly, with respect to tion." (A male patient aged 36–40, from the public pri- a holistic approach to care, patients wanted doctors to mary healthcare clinic) [A004] 'dig-out' their problems, rather than assert them them- selves. Similarly, patients had a low expectation, and "He (the doctor) will not lengthen your treatment, and you apparent desire for, shared decision making in the consul- are able to get well in a short time...he is really a good doc- tation. These differences, which at face value suggest that tor... he can treat my diseases, then that means good." (A Chinese patients are somewhat passive in medical consul- male patient aged 71–75, from the private clinic) [A016] tations may relate to cultural factors and/or to a signifi- cant hierarchy and power differential between patients Page 8 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 and doctors in Hong Kong. On the other hand, many of Hong Kong Island. Nonetheless, our sampling frame did the patients in the present study were elderly and of lower include a range of patients of differing ages, gender, socio- socio-economic status. In the UK, although shared-deci- economic status, and disease states. The aim of this study sion making is a key policy and educational objective in (and indeed of all qualitative studies) was not to generate medicine, several studies have reported low expectation findings that can be said to be representative of the gen- of/desire for shared-decision making in older patients and eral population, but to identify themes relating to consul- patients of lower socio-economic status [29,30]. Simi- tation quality that can be tested in larger, quantitative larly, another European study reported that elderly studies. In this respect, we feel the present study has been patients define involvement in care more in terms of the successful, and the fact that the key interpersonal aspects caring relationship and information receiving rather than of the consultations identified matched the items con- on active participation in decision making [31]. tained in the CARE Measure paves the way for further work on translation of the CARE measure into Chinese Patients from the public clinic, who were generally of and validation studies. If the Chinese-CARE Measure lower socio-economic status, were least likely to expect proves to be a feasible, acceptable, and robust tool it may holistic care or empowerment in the present study. Fur- have wide-spread utility in the formative and/or summa- ther work is required to explore this, but it may relate to a tive assessment of medical students and primary care doc- more biomedical approach in these clinics, which deal tors in Hong Kong and mainland China, as well as in mainly with chronic diseases. In the UK patients of lower future research on consultation quality. socioeconomic status gain less enablement from consulta- tions [32] especially if the clinical issues are complex [33] Conclusion and in the USA greater dissatisfaction with health care In conclusion, the results of the present qualitative study amongst low-income patients has been reported with on patients' views on consultation quality in primary care such patients feeling not listened to and 'brushed off by suggest that Chinese patients in Hong Kong value physicians [34]. engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and In addition to these interpersonal aspects of care, these the attitudes and values that underpin them, as well as on Hong Kong Chinese patients placed a high regard of the perceived outcomes of treatment. receiving a physical examination. One reason for this may be that in Traditional Chinese Medicine (which is very Competing interests commonly used by the Hong Kong population), physical The authors declare that they have no competing interests. examination such as looking at the tongue, face, and pal- pating the peripheral pulses is an integral part of a consul- Authors' contributions tation and diagnosis. Given that TCM is still commonly SM will act as the guarantor for the study. SM and CF con- used by people in Hong Kong. ceived and designed the study. CF collected data and car- ried out an initial analysis and interpretation of the data. Contextual issues of access to care, continuity, and consul- SM helped in the secondary analysis and interpretation of tation length interacted with opinions of 'good consulta- the data. CF accomplished the first draft. SM revised sev- tions'. Such judgements perhaps need to be seen within eral versions of the manuscript with CF, and also gave crit- the general context of primary care in Hong Kong and the ical intellectual input into this process. All authors read 'doctor-shopping behaviour' that is common place, at and approved the final manuscript. least in the private sector [35]. The fact that patients judged 'good consultations' not just on interpersonal Acknowledgements We would like to thank Judy Siu and SC Wu for their contributions to this aspects but also retrospectively according to outcome study. We would also like to thank Dr. Augustine Lam, Dr. Ben Fong, and (and hence perceived effectiveness of treatment) has also Dr. Nat Yuen for allowing patient interviews to be done in the Family Med- been reported in the UK [29] but may be of greater impor- icine Integrated Clinic of Prince of Wales Hospital, University health centre tance to patients in Hong Kong given that most primary of the Chinese University of Hong Kong, and the private Family Medicine care is private requiring out-of-pocket payment. clinic, respectively. Finally we would like to thank very much all the patients who agreed to be interviewed. SWM carried out this work as Visiting pro- The present study also had limitations. Because of time fessor in Primary Care Research at the School of Public Health, CUHK. constraints we limited the number of interviews to 21 and thus we cannot be sure that data saturation was reached References 1. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, regarding all themes. 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Mercer SW, Watt GCM, Maxwell M, Heaney DH: The develop- Publish with Bio Med Central and every ment and preliminary validation of the consultation and scientist can read your work free of charge Relational Empathy (CARE) Measure: an empathy-based consultation process measure. Fam Pract 2004, 21:699-705. "BioMed Central will be the most significant development for 22. Mercer SW, McConnachie A, Maxwell M, Heaney D, Watt GCM: disseminating the results of biomedical researc h in our lifetime." Relevance and practical use of the Consultation and Rela- Sir Paul Nurse, Cancer Research UK tional Empathy (CARE) Measure in general practice. Fam Pract 2005, 22:328-334. Your research papers will be: 23. Ritchie J, Spencer L: Qualitative data analysis for applied policy available free of charge to the entire biomedical community research. In Analyzing qualitative data Edited by: Bryman A, Burgess RG. London: Routledge; 1994:173-94. peer reviewed and published immediately upon acceptance 24. Miles MB, Huberman AM: Qualitative data analysis. London: cited in PubMed and archived on PubMed Central SAGE; 1994. 25. Glaser BG, Strauss AL: The discovery of grounded theory: strat- yours — you keep the copyright egies for qualitative research. London: Weidenfeld & Nicolson; BioMedcentral 1968. Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 10 of 10 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Family Practice Springer Journals

A qualitative study of patients' views on quality of primary care consultations in Hong Kong and comparison with the UK CARE Measure

BMC Family Practice , Volume 10 (1) – Jan 27, 2009

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Springer Journals
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Copyright © 2009 by Fung and Mercer; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1471-2296
DOI
10.1186/1471-2296-10-10
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19173724
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Abstract

Background: Patients' priorities and views on quality care are well-documented in Western countries but there is a dearth of research in this area in the East. The aim of the present study was to explore Chinese patients' views on quality of primary care consultations in Hong Kong and to compare these with the items in the CARE measure (a process measure of consultation quality widely used in the UK) in order to assess the potential utility of the CARE measure in a Chinese population. Methods: Individual semi-structured interviews were conducted on 21 adult patients from 3 different primary care clinics (a public primary healthcare clinic, a University health centre, and a private family physician's clinic). Topics discussed included expectations, experiences, and views about quality of medical consultations. Interviews were typed verbatim, and a thematic approach was taken to identify key issues. These identified issues were then compared with the ten CARE measure items, using a CARE framework: Connecting (Care Measure items 1–3), Assessing (item 4), Responding (items 5,6), and Empowering (items 7–10). Results: Patients judged doctors in terms of both the process of the consultation and the perceived outcomes. Themes identified that related to the interpersonal process of the consultation fitted well under the CARE framework; Connecting and communicating (18/21 patients), Assessing holistically (10/21 patients), Responding (18/21 patients) and Empowering (19/ 21 patients). Patients from the public clinic, who were generally of lower socio-economic status, were least likely to expect holistic care or empowerment. Two-thirds of patients also judged doctors on whether they performed an adequate physical examination, and three-quarters on the later outcomes of consultation (in terms of relief or cure and/or side-effects of prescribed drugs). Conclusion: These findings suggest that Chinese patients in Hong Kong value engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and the attitudes and values that underpin them, as well as on the perceived outcomes of treatment. The match between themes relating to consultation process and the CARE Measure items suggests utility of this measure in this population, but further quantitative validation is required. Page 1 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 settings were chosen in order to sample patients with a Background The consultation between doctor and patient is the core of range of ages, conditions, and socio-economic status. The clinical medicine and has been particularly emphasized in patients at FMIC mainly attend for chronic disease man- general practice and primary care [1-4]. Quality can be agement such as hypertension or diabetes mellitus. Nine conceptualized as a combination of access to care and patients (5 males and 4 females), with age group ranged effectiveness of care, with effectiveness depending on from 41–45 to 81–85, were recruited. UHC was selected both technical and interpersonal aspects [5]. Research on because it was the health centre of CUHK and any student interpersonal effectiveness suggests that empathic, or staff and their family members can have access to it and patient-centred consultations improve patient satisfaction many patients consult for acute problems. Six patients (1 [6,7] and enablement [8], and may improve health out- males and 5 females), with age group ranged from <20 to comes [9-11]. 56–60, were recruited. The private FM clinic was selected because it was run by a family physician (a Fellow of the Although patient-centred care is becoming widely advo- Hong Kong College of Family Physicians) and patients cated, there is no single, globally accepted definition. with either acute and/or chronic diseases commonly Research on patient-centred care has predominantly been attend the clinic. Six patients (3 males and 3 females), carried out in the West, especially the UK and North with age group ranged from 26–30 to 76–80, were America [12,13]. Recently however, there has been a recruited. Ethics approval was obtained before the start of growing interest in people and patient-centred care in the study from the Survey and Behavioural Research Eth- Eastern countries [14-17]. Additionally there is now a ics Committee of the Chinese University of Hong Kong. renewed focus on primary care globally, including coun- The doctor-in-charge of each clinic consented to the study tries such as China and Japan [18]. In seeking to develop after receiving full details, and specific nursing staff at effective primary care services in such countries, it is each clinic were assigned to facilitate the recruitment of important that patients' views on what constitutes 'good' patients in order to reduce the disturbance to the smooth consultations are collected and fed into policy and health running of the clinic. The nursing staff approached attend- services developments in primary care. Hong Kong is one ing patients to see if they were interested in participating such region which is currently embarked on health care in an interview. After verbal agreedment, the first author reforms with a strong emphasis on strengthening primary approached the patient, explain the study in detail and care services [19]. obtained written consent. Keeping strict confidentiality and anonymity was emphasized to every interviewee. In the present qualitative study we have explored patients' Although we were not able to purposively select the inter- views on what constitutes quality at consultation in differ- viewees, recruiting from the 3 separate clinics helped to ent primary care settings in Hong Kong. We have then ensure that a maximum variation sample was obtained. compared these views with the ten-item CARE measure, Table 1 shows the characteristics of the 21 patients which is a widely used measure of consultation quality in recruited. the UK, developed by one of the authors [20-22]. The UK CARE Measure captures key aspects of the process of the Patients were encouraged to talk freely and openly on clinical encounter, rather than outcome, and was devel- their views on the quality of the primary care consultation oped from the views of patients of differing socio-eco- in Hong Kong. Open-ended prompting questions nomic status, as well as having a theoretical and empirical included asking about their expectations, their experience base. In a study of over 3,000 patients over 95% of of good or bad consultations, and their definitions of patients felt the items were applicable to their consulta- good or bad doctors/consultations. All the 21 interviews tion in primary care [22]. The CARE measure is currently were conducted by the first author (CF), and a research accredited for appraisal of General Practitioners (GPs) assistant also helped to conduct the interviews on the six and is a compulsory component of work place -based patients recruited from the private FM clinic. The inter- assessment in the training of all GPs in the UK. views were conducted between May and August 2007 and averaged around 30 minutes (ranging from 15 minutes to Methods 60 minutes). The study involved in-depth, semi-structured interviews with 21 Chinese patients recruited from 3 different types The interviews were audio-taped and typed verbatim by a of primary care clinics in Hong Kong: (1) a Family Medi- research assistant, and 4 student helpers (year 4 medical cine Integrated Clinic (FMIC), part of the public health- students of the Chinese University of Hong Kong). All care system run by the Hospital Authority, (2) the transcripts were translated into English (all transcribers University health centre (UHC) of the Chinese University were native Cantonese speakers, fluently bilingual in writ- of Hong Kong (CUHK), and (3) a private family medicine ten and spoken English). Accuracy of translation was (FM) clinic run by a Family Physician specialist. The three checked by CF who read all transcripts in both English Page 2 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 Table 1: Characteristics of the participating patients Patient Code Gender Age Group Marital Status Education Level Occupation Monthly Reason/disease Clinic Attended Household for consultation income (HKD) A001 Female 71–75 Married Tertiary Retired 30001–40000 Chronic disease FMIC A002 Female 76–80 Widowed Nil Retired 20001–30000 Chronic disease FMIC A003 Female 71–75 Widowed Nil Retired <5000 Chronic disease FMIC A004 Male 36–40 Single Lower Non-technical 5001–10000 Chronic disease FMIC secondary manual worker A005 Male 71–75 Married Upper Retired 10001–20000 Chronic disease FMIC secondary A006 Male 81–85 Widowed Primary Retired <5000 Chronic + acute FMIC diseases A007 Female 66–70 Married Primary retired <5000 Chronic + acute FMIC diseases A008 Male 76–80 Married Primary Retired CSSA Chronic disease FMIC A009 Male 41–45 Married Lower Driver 10001–20000 Chronic disease FMIC secondary A010 Female 56–60 Married Upper Clerk 10001–20000 Acute disease UHC secondary A011 Female 46–50 Married Tertiary Housewife >60001 Acute disease UHC A012 Female 21–25 Single Tertiary Student 10001–20000 Administrative UHC reason A013 Female 46–50 Married Tertiary Clerk >60001 Acute disease UHC A014 Female <20 Single Upper Student 10001–20000 Acute disease UHC secondary A015 Male 21–25 Single Tertiary Student 30001–40000 Acute disease UHC A016 Male 71–75 Married Nil Retired 10001–20000 Chronic disease Private A017 Female 61–65 Married Primary Housewife 5001–10000 Chronic disease Private A018 Female 76–80 Widowed Nil Housewife 5001–10000 Chronic disease Private A019 Female 76–80 Widowed Primary Retired 5001–10000 Chronic disease Private A020 Male 26–30 Married Tertiary Officer 30001–40000 Acute disease Private A021 Male 31–35 Married Tertiary Professional 10001–20000 Acute disease Private FMIC = Family Medicine Integrated Clinic, Price of WalesHospital UHC = University health centre, the Chinese University of Hong Kong Private = private clinic of the Family Medicine Specialist and Cantonese. Translation into English was necessary to outcomes of the consultations. At this stage some 109 enable SWM to assist in the analysis of the data. codes were generated in total. At the end of this process, the 109 codes were compared with the ten main items A thematic approach was taken to identify key issues [23]. within the UK CARE measure (Figure 1). We then used the involving systematic identification, charting and sorting CARE Measure items as a framework for categorizing the of the data. Analysis was iterative, with broad themes codes identified regarding the consultation process, and identified initially, then further broken down into sub- assessed how many of the codes could or could not be cat- themes [24]. The constant comparative method was used egorized within one or more of the CARE Measure items. throughout [25] by initially comparing data sets between Categories not fitting within the CARE Measure frame- individual transcripts, and later comparing data with work were also identified. Both CF and SWM carried out emergent hypotheses. Regular meetings between the two this comparison with the CARE measure independently, authors over the duration of the project allowed categori- and then compared notes; mainly there was good agree- sation and classification, and the development of typolo- ment, and areas of differences in if and where codes fitted gies and explanatory accounts to be pursued. within the framework were discussed until consensus was reached. Preliminary coding of the raw data was undertaken inde- pendently by CF and SWM and agreement reached on the We found that all of the codes relating to the interpersonal initial main codes. Initially 16 categories were identified, aspects of the consultation (76 out of 109) fitted within which were then rearranged/re-coded under three major one or more of the ten-item CARE Measure framework; themes: patients' definitions of good doctors and consul- Additional themes which did not fit (33 out of 109) tations, bad doctors and consultations, and expectations/ related to physical examination, the context of care (access Page 3 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 1.Please rate the following statements about today’s consultation. Please tick one box for each statement and answer every statement. Ver y Does Poor Fair Good Good Excellent Not How was the doctor at … Apply 1. Making you feel at ease…… (being friendly and warm towards you, treating you with respect; not cold or abrupt) 2. Letting you tell your “ stor y”…… (giving you time to fully describe your illness in your own words; not interrupting or diverting you) 3. Really listening … … (paying close attention to what you were sayings; not looking at the notes or computer as you were talking) 4. Being inter ested in you as a whole per son … (asking/knowing relevant details about your life, your situation; not treating you as “just a number”) 5. Fully under standing your concer ns… … (communicating that he/she had accurately understood your concerns; not overlooking or dismissing anything) 6. Showing car e and compassion… . (seeming genuinely concerned, connecting with you on a human level; not being indifferent or “detached”) 7 . Being Positive…… (having a positive approach and a positive attitude; being honest but not negative about your problems) 8. Explaining things clear ly… … .. (fully answering your questions, explaining clearly, giving you adequate information; not being vague 9. Helping you to take contr ol…… (exploring with you what you can do to improve your health yourself; encouraging rather than “lecturing” you) 10. Making a plan of action with you … (discussing the options, involving you in decisions as much as you want to be involved; not ignoring your views) Th Figure 1 e CARE Measure The CARE Measure. Page 4 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 and time) and outcomes of care. Financial issues were also Several patients equated "no eye contact" with "not listen- an important contextual issue, but will be reported in a ing" and disliked doctors who did not look at them but separate paper. Rather than presenting our findings on kept on writing or looking at the computer screen during interpersonal aspects of consultations under separate the consultation. headings for all ten the CARE measure items, we have con- densed these into 4 CARE Framework headings in order to "It's not good if the customer [patient] keeps telling, but the present the findings in a more succinct manner; doctor just merely ask you what discomforts you have, then listens to the heartbeat and just says 'okay' and write down 1. Connecting and communicating (CARE items 1,2,3) the things.. (A male patient aged 26–30, from the private clinic) [A020] 2. Assessing holistically (CARE Item 4) "...they usually face the computer and click this and click 3. Responding with understanding and compassion that, and then said, 'there's no problem, po-po [a form of (CARE Items 5,6) address to the elderly female in Cantonese]. The blood pres- sure is normal. You can go to take the prescription now.' 4. Empowering (CARE Items 7–10) That's it. So I just left." (A female patient aged 71–75, from the public primary healthcare clinic) [A003] Results Interpersonal care: The CARE Framework 18 out of the 21 patients interviewed had codes which fit- Connecting and Communicating (CARE measure items 1,2,3) ted under this overall theme of 'connecting' (CARE item 1 A comfortable atmosphere within a consultation facili- = 13/21; CARE item 2 = 12/21; CARE item 3 = 8/21). The tated the patients' ability to relax and talk openly with the 3 who did not mention this overall theme were attending doctor. Patients felt that a polite manner, a warm welcom- the private clinic and had above average household ing smile, and words or gestures from the doctor at the incomes. onset of the encounter were means of putting them at ease. Assessing holistically (CARE measure item 4) 'Whole person' care was seldom explicitly mentioned by "As I do not know much about medical knowledge, I can't patients as a key aspect of high quality interpersonal care, tell what good element should be covered in a consultation. but many of their comments were integral to a holistic, But at least sincerity. Sometimes, the doctor posed a not bio-psycho-social approach. A few patients actually stated friendly facial expression, not even me, other patients, will that they wanted doctors to spend more time understand- also think that it is not good..." (A female patient aged 71– ing the possible psychological and/or social reasons 75, from the public primary healthcare clinic) [A001] behind their symptoms. For many patients, rather than 'volunteering' such issues, they felt a 'good' doctor would "I think it is better if the doctor smiles to patient. This shows ask probing questions that would help uncover or 'dig- care to patient, patient will feel better. You can't see some out' the underlying issues. This expectation that a whole- doctor smiling when you enter consultation room. It is not person approach should be 'doctor-led' reflected a widely very good when the patient is feeling discomfort." (A female held general view that a more assertive approach on the patient aged 56–60, from the UHC, CUHK) [A010] part of the patient would be impolite or rude. Patients valued doctors who allowed or encouraged them "Of course it [asking questions] is important. We [the to 'tell their story' and actively listened in the consulta- patient] only know what we should tell him/her [the doc- tion, as it enabled them to describe their symptoms and tor] if he/she asks us more questions. If he/she doesn't ask problems in detail, and the effects these were having on us, we don't know what we should say, right?" (A female their life. Some patients described such encounters as like patient aged 66–70, from the public primary healthcare 'chatting to a friend' and such a relationship enhanced dis- clinic) [A007] closure of issues that were of importance to the patient. "They may explore the reason behind your stomachache, "For me, I prefer those doctors who are more willing to talk say, why you were suffering from stomachache last month to you and more willing to listen to you. Rather than those but then 2 weeks later, you are suffering again? Is it due to who just talk about, 'ok, this is the prescription, just take something in daily life or something we eat, like sushi, this medicine, you go back and take the medicine. If you are milk?" (A female patient aged 46–50, from the UHC, ok, then that's good; otherwise, you have to come back'..." CUHK) [A011] (A female patient aged 46–50, from the UHC, CUHK) [A011] Page 5 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 "I think the most important thing for a good doctor is that almost most patients interviewed raised as a key feature of he is willing to spend time to understand the patients' situ- a good doctor or a good consultation. The importance of ation. It's not good if it is just like a routine in seeing all explanations to patients was not related to whether they patients who go inside the consultation room." (A male attended the public or the private healthcare sectors. patient aged 26–30, from the private clinic) [A020] "When I come for follow-ups, the doctors will tell me in 10 out of the 21 patients had codes which fitted under this details, tell me about my condition, and let me know it. It's theme. None of the patients attending the public clinic good if they do it in this way. Something like giving advice (FMIC) mentioned this theme, and only 1 male did. to me on avoiding certain kinds of food, or what kind of food I should not eat, what kind of food I can eat." (A male Responding with understanding and compassion (CARE measure patient aged 41–45, from the public primary healthcare items 5,6) clinic) [A009] Many patients considered understanding concerns, being caring, kind, compassionate, having love, were basic "...Besides, being a doctor is like being a teacher...they attributes of a good doctor. When such behaviours were should encourage student or patient what they should do, expressed by doctors, patients deeply appreciated them. because they will accept this easier." (A female patient aged Such doctors were regarded as more trustworthy, and 21–25, from the UHC, CUHK) [A012] patients felt more able to talk openly about their concerns and fears in such encounters. Only a few patients men- Giving advice or educating patients about what they could tioned the education and training of the doctors as an do to help themselves was another area that was highly important factor in deciding whether a doctor was good or valued by patients. Domains of advice included how to not. Instead, the perception of caring from the doctor dur- improve one's health, advice on preventive care, self-help ing the consultation was a key criterion that they used to measures, dietary and lifestyle advice. In general patients differentiate whether a doctor was 'good or bad'. gave high importance to the doctor's role in 'education' in addition to making a diagnosis and prescribing drugs. "A good doctor should have love. It's the hardest time for one when one is sick. Poor is not the toughest, but being sick "If so, patients can learn what they can do to self-help them- is the toughest." (A female patient aged 76–80, from the selves. You know, with the help of the doctor, you can help private clinic) [A019] the patient to cope with his/her own symptoms so that he/ she doesn't have to see doctor so often.." (A female patient "Also doctors have to care about the patients. When aged 46–50, from the UHC, CUHK) [A011] patients feel that the doctor cares about you, wants to know more about your condition, patients will talk more sponta- "For example, he (the doctor) can explain and describe your neously." (A female patient aged 21–25, from the UHC, disease in an easily understandable way. He will also teach CUHK) [A012] you what kinds of exercises that you should do, and will show you on how to do those stretching exercises on shoul- "This doctor has a 'real heart' [enthusiasm] to treat der... He explains your disease well and in a detailed man- patients. It's different from other doctors. He will try all his ner. He will also give me some pamphlets to see so that I can best to treat you if you can be treated. It's different from know more about my disease as well." (A male patient aged other doctors who are aiming at making more money, and 31–35, from the private clinic) [A021] they will still 'treat' you no matter you are treatable or not." (A male patient aged 71–75, from the private clinic) Only two out of twenty-one patients voiced a clear desire [A016] for shared decision making between doctor and patient (one was from the University Health Centre and one was 18 out of the 21 patients had codes under this overall from the private clinic). theme (CARE item 5 = 13/21, CARE item 6 = 12/21). The 3 who did not showed no particular pattern. "The point is doctors have given me their professional advice and it's up to me to decide. If I need antibiotics, the Empowering (CARE measure items 7–10) doctors can give me, otherwise, observation is recom- Many patients felt a 'good doctor' was one with a positive mended. It's fine. We can still do something at home rather approach, which helped to give them hope. Being positive than always using some strong western medication as there was also often associated with the doctor giving direct must be some side effects...the doctors may not have time to advice, a clear diagnosis, treatment, and the likely time- explain all those to you." (A female patient aged 46–50, course of outcome from treatment. This theme was closely from the UHC, CUHK) [A011] related to the theme of explaining things clearly, which Page 6 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 "He (the doctor) will not force me. Even if he tells me that about you more. (A female patient aged 56–60, from the there is a (special) situation, he will not say something like UHC, CUHK) [A010] ' you have to do it.'..." (A female patient aged 61–65, from the private clinic) [A017] "The private doctors are more considerate. They will do some examinations for you, but not here, they will just take However, in other cases, it seemed that the patients' views a look and no examination. The private doctors will exam- on decision were not considered by doctors, even though ine you, measure the blood pressure......but not here. They this may have been desirable by the patients. will just say, 'put some ointments and get some medicines back home.' and tell me when I should return for follow- "Sometimes there are some ointments that I think they are up." (A female patient aged 66–70, from the public pri- effective on me, but the doctors usually refuse to prescribe mary healthcare clinic) [A007] them to me." (A male patient aged 36–40, from the public primary healthcare clinic) [A004] "Some doctors are very meticulous. They examine the nose and throat carefully and answer my query, so I feel satisfied Another patient from the public healthcare sector and think that they are good doctors. I remember an occa- explained that she did not expect the doctor to listen to sion in which a doctor listened to my son's chest and exam- the patient's opinion in decision making but she valued ined his ear and throat, and told me about his findings. I the regular follow-up. got a full picture of my son's illness. I found this doctor very good, very meticulous. Some doctors just glance at my son's "You can come here regularly for body check, do some blood face and take less than a minute examining my child. I find tests, so you will know if there's any problem with you. They them very sloppy." (A female patient aged 46–50, from the won't do this to you if you go to see the doctors elsewhere, UHC, CUHK) [A013] they won't do such checking for you to see if you have any problem. No, no such things. But it is here, it's better to Context of care have such checking in the long term....If the doctor asked Access me, 'is it okay to add some more to the drug dosage?' I usu- Approximately one-third of patients (from each type of clinic) complained about having to wait too long before ally say, 'It doesn't matter for me, if you think it's good for me.' When I go to see doctor, I usually listen to what the their consultations. doctor says. There's no reason for the doctor to listen to my sayings, right? If he wants to add some more, then I just say "...it took me two hours waiting until I saw the doctor. 'okay'. (A female patient aged 76–80, from the public pri- That's really bad. I got herpes zoster that time. It was really mary healthcare clinic) [A002] painful..." (A female patient aged 76–80, from the public primary healthcare clinic) [A002] 19 out of 21 patients had codes under this overall theme (CARE item 7 = 11/21, CARE item 8 = 18/21, CARE item "If you see public doctors, it will be impossible that you can 9 = 10/21, CARE item 10 = 5/21). For items 7, 9, 10, see them whenever you want. You won't be able to see [pub- patients attending the public clinic (FMIC) were in the lic doctors] if you miss your turn." (A female patient aged main those who did not mention these themes. 76–80, from the private clinic) [A018] Physical examination Time spent on consultations Apart from those domains within a consultation that Some patients specifically mentioned the issue of consul- patients had mentioned above, it was interesting to note tation length, and resented the fact that some doctors that almost one-third of patients from each type of clinic spent very little time with them, quickly writing a prescrip- pointed out that they valued the act of physical examina- tion with no explanation. Feeling rushed in consultations tion. They perceived physical examination as an attribute and thus an inadequate consultation length, was implicit of a caring and thorough doctor, and an important part of in many of the above accounts relating to interpersonal diagnosis, and hence getting a 'full-picture' of the prob- quality of care. lem. "I think if the consultation time is longer, they (the doctors) "For example I have abdominal pain, he [the doctor] will can have more understanding on the patients' symptoms. I think about my family history, and consider whether I am think there are lots of reasons behind a symptom. Say, you having that disease or not, then do a detail examination for may think you are suffering from stomachache; in fact, it me. Some doctors... abdominal pain, they will only give you may not be that simple, it may be due to the stress in daily some pain killers. You can feel that which doctor cares life. So, I don't know, sometimes when the doctors are busy, they may just prescribe pain killers, 'ok, that's it, byebye.'..." Page 7 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 (A female patient aged 46–50, from the UHC, CUHK) Some even judged the 'relationship' on the 'outcome' of [A011] the consultation rather than on the process of the consul- tation. Continuity Continuity of care was not overtly discussed in the inter- "If he can cure me, then that's a good relationship. If he views, but lack of relational continuity was apparent in cannot cure me, then the relationship will not be able to the accounts of the patients attending the public health- build up and continue." (A male patient aged 26–30, from care system, where it is unusual for patients to be seen by the private clinic) [A020] the same doctors. Similarly, 'doctor-shopping' in the pri- vate sector is a common phenomenon in Hong Kong. Discussion However, when patients felt they had a good 'match' with In the present study we assessed patients' views on the a doctor, they were keen to continue seeing that doctor if quality of the primary care consultation in Hong Kong by at all possible. means of qualitative interviews of 21 patients attending three different types of primary care clinics (public clinic, Outcomes University clinic, and private family medicine clinic) and Two-thirds of the patients linked a good consultation with tested whether these views are similar or different from the doctor making a correct diagnosis leading to a rapid patients views in the UK, by comparing the themes iden- "cure" of his/her disease or illness. Thus judgments about tified from the present study with the themes that com- quality of consultation and doctor were retrospective prise the UK CARE Measure. Patients judged doctors in based on outcomes; if the patient recovered rapidly then terms of both the process of the consultation and the per- they perceived the consultation, the doctor, and the treat- ceived outcomes. Themes identified that related to the ment, as effective and thus of high quality. interpersonal process of the consultation fitted well under the four theme CARE framework that we devised to incor- "The doctor is very kind, and he can often make a correct porate the ten CARE Measure items; connecting and com- diagnosis." (A female patient aged 76–80, from the private municating (CARE items 1–3), assessing holistically clinic) [A019] (CARE item 4), responding with understanding and com- passion (CARE items 5,6) and empowering (CARE items "If such questions help doctors in making the diagnosis, I 7–10). don't mind to answer them. But if the doctors think that they know enough about my condition without the need to As far as we are aware, this is the first qualitative study of ask such questions, then that's ok. To me, the most concern- patients' views on consultation quality among Chinese ing point is that the doctor can solve the problem and treat patients attending a variety of different primary care pro- my disease." (A male patient aged 21–25, from the UHC, viders in Hong Kong. Although international differences CUHK) [A015] in patient and physician perceptions of "high quality" healthcare have been reported [26] and despite the many Many patients expressed dissatisfaction if their diseases or cultural differences between the East and the West, the illness symptoms did not disappear quickly. Many of core aspects of consultation quality in primary care as them viewed the drugs given by the doctors as an impor- expressed by Hong Kong patients in the present study tant factor as to whether they would get better or not. appear to be broadly similar to studies in Caucasian sub- jects in the West [27,28]. "If his medicine was efficient, I would go back to see him (the doctor), otherwise I won't go back." (A female patient However, there did appear to be some differences in the aged 71–75, from the public primary healthcare clinic) way Chinese patients in the present study 'accessed' high [A003] quality consultations compared with studies in the West. Directly asking for information and advice was uncom- "The medicine private doctors gave me ... I can recover mon; rather patients waited for such advice and informa- faster after I have taken the medicine and have the injec- tion to be 'offered' by the doctor. Similarly, with respect to tion." (A male patient aged 36–40, from the public pri- a holistic approach to care, patients wanted doctors to mary healthcare clinic) [A004] 'dig-out' their problems, rather than assert them them- selves. Similarly, patients had a low expectation, and "He (the doctor) will not lengthen your treatment, and you apparent desire for, shared decision making in the consul- are able to get well in a short time...he is really a good doc- tation. These differences, which at face value suggest that tor... he can treat my diseases, then that means good." (A Chinese patients are somewhat passive in medical consul- male patient aged 71–75, from the private clinic) [A016] tations may relate to cultural factors and/or to a signifi- cant hierarchy and power differential between patients Page 8 of 10 (page number not for citation purposes) BMC Family Practice 2009, 10:10 http://www.biomedcentral.com/1471-2296/10/10 and doctors in Hong Kong. On the other hand, many of Hong Kong Island. Nonetheless, our sampling frame did the patients in the present study were elderly and of lower include a range of patients of differing ages, gender, socio- socio-economic status. In the UK, although shared-deci- economic status, and disease states. The aim of this study sion making is a key policy and educational objective in (and indeed of all qualitative studies) was not to generate medicine, several studies have reported low expectation findings that can be said to be representative of the gen- of/desire for shared-decision making in older patients and eral population, but to identify themes relating to consul- patients of lower socio-economic status [29,30]. Simi- tation quality that can be tested in larger, quantitative larly, another European study reported that elderly studies. In this respect, we feel the present study has been patients define involvement in care more in terms of the successful, and the fact that the key interpersonal aspects caring relationship and information receiving rather than of the consultations identified matched the items con- on active participation in decision making [31]. tained in the CARE Measure paves the way for further work on translation of the CARE measure into Chinese Patients from the public clinic, who were generally of and validation studies. If the Chinese-CARE Measure lower socio-economic status, were least likely to expect proves to be a feasible, acceptable, and robust tool it may holistic care or empowerment in the present study. Fur- have wide-spread utility in the formative and/or summa- ther work is required to explore this, but it may relate to a tive assessment of medical students and primary care doc- more biomedical approach in these clinics, which deal tors in Hong Kong and mainland China, as well as in mainly with chronic diseases. In the UK patients of lower future research on consultation quality. socioeconomic status gain less enablement from consulta- tions [32] especially if the clinical issues are complex [33] Conclusion and in the USA greater dissatisfaction with health care In conclusion, the results of the present qualitative study amongst low-income patients has been reported with on patients' views on consultation quality in primary care such patients feeling not listened to and 'brushed off by suggest that Chinese patients in Hong Kong value physicians [34]. engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and In addition to these interpersonal aspects of care, these the attitudes and values that underpin them, as well as on Hong Kong Chinese patients placed a high regard of the perceived outcomes of treatment. receiving a physical examination. One reason for this may be that in Traditional Chinese Medicine (which is very Competing interests commonly used by the Hong Kong population), physical The authors declare that they have no competing interests. examination such as looking at the tongue, face, and pal- pating the peripheral pulses is an integral part of a consul- Authors' contributions tation and diagnosis. Given that TCM is still commonly SM will act as the guarantor for the study. SM and CF con- used by people in Hong Kong. ceived and designed the study. CF collected data and car- ried out an initial analysis and interpretation of the data. Contextual issues of access to care, continuity, and consul- SM helped in the secondary analysis and interpretation of tation length interacted with opinions of 'good consulta- the data. CF accomplished the first draft. SM revised sev- tions'. Such judgements perhaps need to be seen within eral versions of the manuscript with CF, and also gave crit- the general context of primary care in Hong Kong and the ical intellectual input into this process. All authors read 'doctor-shopping behaviour' that is common place, at and approved the final manuscript. least in the private sector [35]. The fact that patients judged 'good consultations' not just on interpersonal Acknowledgements We would like to thank Judy Siu and SC Wu for their contributions to this aspects but also retrospectively according to outcome study. We would also like to thank Dr. Augustine Lam, Dr. Ben Fong, and (and hence perceived effectiveness of treatment) has also Dr. Nat Yuen for allowing patient interviews to be done in the Family Med- been reported in the UK [29] but may be of greater impor- icine Integrated Clinic of Prince of Wales Hospital, University health centre tance to patients in Hong Kong given that most primary of the Chinese University of Hong Kong, and the private Family Medicine care is private requiring out-of-pocket payment. clinic, respectively. Finally we would like to thank very much all the patients who agreed to be interviewed. SWM carried out this work as Visiting pro- The present study also had limitations. Because of time fessor in Primary Care Research at the School of Public Health, CUHK. constraints we limited the number of interviews to 21 and thus we cannot be sure that data saturation was reached References 1. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, regarding all themes. 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Mercer SW, Watt GCM, Maxwell M, Heaney DH: The develop- Publish with Bio Med Central and every ment and preliminary validation of the consultation and scientist can read your work free of charge Relational Empathy (CARE) Measure: an empathy-based consultation process measure. Fam Pract 2004, 21:699-705. "BioMed Central will be the most significant development for 22. Mercer SW, McConnachie A, Maxwell M, Heaney D, Watt GCM: disseminating the results of biomedical researc h in our lifetime." Relevance and practical use of the Consultation and Rela- Sir Paul Nurse, Cancer Research UK tional Empathy (CARE) Measure in general practice. Fam Pract 2005, 22:328-334. Your research papers will be: 23. Ritchie J, Spencer L: Qualitative data analysis for applied policy available free of charge to the entire biomedical community research. In Analyzing qualitative data Edited by: Bryman A, Burgess RG. London: Routledge; 1994:173-94. peer reviewed and published immediately upon acceptance 24. Miles MB, Huberman AM: Qualitative data analysis. London: cited in PubMed and archived on PubMed Central SAGE; 1994. 25. Glaser BG, Strauss AL: The discovery of grounded theory: strat- yours — you keep the copyright egies for qualitative research. London: Weidenfeld & Nicolson; BioMedcentral 1968. Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 10 of 10 (page number not for citation purposes)

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