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Describing the factors that influence the process of making a shared-agenda in Japanese family physician consultations: a qualitative study

Describing the factors that influence the process of making a shared-agenda in Japanese family... Background: Patients cannot always share all necessary relevant information with doctors during medical consultations. Regardless, in order to ensure the best quality consultation and care, it is imperative that a doctor clearly understands each patient’s agenda. The purpose of this study was to analyze the process of developing a shared-agenda during family physician consultations in Japan. Methods: We interviewed 15 first time patients visiting the outpatient clinic of the Department of Family Medicine in the hospital chosen for the investigation, and the 8 family physicians who examined them. In total we observed 16 consultations. We analyzed both patients’ and doctors’ narratives using a modified grounded theory approach. Results: For patients, we found four main factors that influenced the process of making a shared-agenda: past medical experiences, undisclosed but relevant information, relationship with the family physician, and the patient’sown explanatory model. In addition, we found five factors that influenced the shared agenda making process for family physicians: understanding the patient’s explanatory model, constructing the patient-doctor relationship, physical examination centered around the patient’s explanatory model, discussion-styled explanation, and self-reflection on action. Conclusions: The findings suggest that patient satisfaction would be increased if family physicians are proactive in considering these factors with respect to both the patient’s agenda, and their own. Keywords: Agenda-sharing, Communication, Doctor-patient relationship, Patient’s explanatory model, Taking a medical history Background On the other hand, doctors also have an agenda, Anecdotal evidence suggests that when patients visit a which typically revolves around diagnosis and man- doctor, they typically have an agenda to discuss [1–3]. agement. However, taking the scope and dimensions The agenda includes particular problems which pa- of their work into consideration, family physicians, tients want to discuss with their doctor; for example: must include broader considerations [2]. patients’ ideas about the reasons of their sickness, Levenstein noted that it is important to combine the seriousness of a symptom, recuperation of the prob- agendas from both patient and doctor [6]. Moreover, the lems, expectations regarding the course of the illness literature suggests that doctors may frequently fail to or prognosis, medical examinations and prescription, fully understand patients’ true expectations and requests referral to a specialist and explanation for an absence [2, 7]. Or alternatively, patients may not be able to share from school or work [4, 5]. their agenda completely with their doctors [8]. In such case, his unspoken agenda is referred to as the patient’s hidden agenda [9]. * Correspondence: tamgoto@clin.medic.mie-u.ac.jp Marple et al. suggest that a mismatch of agendas be- Department of Education and Research in Family and Community Medicine, tween patients and doctors lowers patients’ satisfaction Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan Full list of author information is available at the end of the article © 2015 Goto et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 2 of 9 Table 1 Questionnaire (Questions used in post-consultation [5]. Other research suggests that agenda mismatching interviews) Questions toward patients makes compliance lower and may affect the outcome Questions toward patients [10–12]. Indeed, one of the reasons that some patients repeatedly go “doctor shopping” may be because of agenda 1 What do you think about your own illness? mismatching [13]. All things considered, it is clear that 2 What did you want to convey to your doctor most? Were you able to the ability for patients to share their agendas well poten- convey it? tially lowers costs and reduces consultation times [14, 15]. 3 What do you think the reason was for your in/ability to express yourself during the consultation? Were you satisfied with yourself? Charles et al. described the process of agenda-sharing with the expression “it takes two to tango” [16]. Accord- 4 Can you describe your ideal doctor? ingly, the factors that prevent or promote agenda-sharing Question toward doctors should be defined in order to make agenda-sharing more 1 How did you listen to the patient? consistent and productive in terms of patient outcomes 2 What do you think the patient wanted to say the most? and consultation costs. However, until recently, there has 3 What did you emphasize most in the consultation? been little research evidence about the factors which affect 4 Do you think the patient was satisfied? the agenda-sharing process. Thus, the purpose of this research is to describe the factors that influence the process of making a shared- between doctors and patients, and after discussing with agenda in Japanese family physician consultations, by other members. analyzing patient and doctor narratives. All researcher-patient and researcher-doctor inter- This study was approved by the Research Ethics views were audio recorded with consent from both the Committee of the Faculty of Medicine at Mie University. patient and doctor. Audio recordings were sent to a third party for transcription, which was later used for analysis. The written notes from the doctor-patient con- Methods sultation were also collected, to allow for comparison Sampling and recruitment between patient and doctor recollections of the consult- Prior to recruiting patients, we obtained informed, ver- ation with the actual events. All samples so obtained bal and written consent from all staff members of the were coded to maintain anonymity. Department of Family Medicine in the hospital chosen for the investigation to observe their patient consulta- Analysis tions. Patients were then recruited while waiting to be For the analysis, a modified grounded theory approach examined by the consenting physicians (n = 8). We was used [18] wherein two researchers categorized the screened patients and asked those who were first-time data, and constructed a final theory together with another visitors, to participate in our research after explaining researcher (Fig. 1). In cases of uncertainty, the decision of the research purpose, both verbally and in writing. From the researcher who conducted the interview was given among 50 new patients screened, 15 finally consented to priority. participate in this research. Results Data collection Overall, interviews lasted 30 to 40 min for patients, and Patients and doctors met in standard consultation rooms, 15 to 20 min for doctors. The interview was terminated and a member of our research team observed the con- once the conversation seemed to have reached theoret- sultation, and took written notes, but did not participate ical saturation—in other words, when similar opinions in any way. After the initial consultation, the researcher had been repeatedly heard and no more new opinions led the patient to a separate interview room to conduct were likely to be heard [19]. The subjects were 15 an interview in private. Researchers then interviewed patients, and 8 doctors; in total, 16 consultations were the doctor, generally later that day, when the clinic had observed. The doctors consisted of 5 male and 3 female finished. and the patients consisted of 11 female and 4 male Semi-structured interviews were conducted to avoid (Table 2). using leading questions, with the aim of eliminating any The patient’s statements were grouped into four cat- potential for researcher bias [17]. Supplementary ques- egories of factors affecting the agenda-sharing process: tions that aimed to clarify respective answers were posed, as needed, during the main questioning in a way 1. Past medical experiences that did not interrupt the flow of the interviews (Table 1). 2. Undisclosed but relevant information The questions were selected following a thorough review 3. Relationship with the family physician of previous studies concerning the communication gap 4. Patient’s own explanatory model Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 3 of 9 Past experiences Undisclosed information Understanding the explanatory model Relationship building Doctor's Patient's Physical examination Agenda Agenda Discussion-styled Self-Reflection on action Explanatory Relationship model with doctor Factors for Patient's Agenda Making Factors for Doctor's Agenda Sharing Process Agenda Sharing Fig. 1 Overview of shared-agenda making process Past medical experiences In addition, several had been referred by previous doc- We found that the past medical experiences of patients tor, who judged that they would receive superior care had an effect on their attitude towards their present at a larger institution. doctor, which affected agenda-sharing. Accordingly, many of the patients in this study In Japan’s “free access” medical system, patients are came to the hospital chosen for this investigation, free to move between doctor and hospitals. As a re- due to negative experiences with previous doctors; for sult, many patients came from other clinics in hopes example. of better care. There were many specific reasons, such as, dissatisfaction with a previous consultation, little or “The doctor said, “There’s nothing abnormal. Perhaps no improvement in symptoms, as well as many others. it’s just your imagination.” And I said, “I need Table 2 Consultation information Doctor information Case information Patient information Doctor ID Sex Years in practice Chief complaint Patient ID Age Sex Occupation D1 Female 4 The diarrhea caused by bacterial infection M1 69 Male Retired D2 Male 2 Throbbing of the chest, Irritation, Depression F1 59 Female Housewives D3 Female 4 Hypertension F2 51 Female Office worker D1 Female 4 Routine screening for breast cancer, Numbness of joints F3 56 Female Independent business D4 Female 4 Swelling of the finger F4 46 Female Teacher D4 Female 4 Phlegm obstructing the throat F5 63 Female Housewives D5 Male 17 Caisson disease F6 25 Female Medical representative D6 Male 3 Stomachache M7 49 Male Policeman D4 Female 4 Increased urinary frequency M8 36 Male Factory worker D7 Male 12 Venous inflammation of the lower leg, Collagen disease F9 53 Female Housewives D6 Male 3 Abnormal swelling of the lower body F10 50 Female Housewives D5 Male 17 Nausea, “strange feeling” in stomach, listlessness M11 26 Male Builder D5 Male 17 Brain disease, exhausting F12 20 Female Nursing student D2/D7 Male/male 2/12 Hypertension; unusual findings on examination F13 53 Female Worker D8 Male 34 Gastric cancer, gastric ulcer F14 68 Female Housewives Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 4 of 9 medicine,” and he prescribed only Isodine and Troche. and seemed set on inpatient hospital care. None of I thought it was a joke.” these things, however, were mentioned to the doctor. (M11: male patient) While patients demonstrated a wide range of attitudes in facing their illnesses, those patients who refrained Moreover, in many cases, patients’ past medical experi- from discussing their outlook with their doctor tended to ences had a large impact on their attitude during medical have similar views. Several procrastinated over coming to consultations; for example: the hospital, or ignored their disease on days where their symptoms were less noticeable. These patients talked “I’m going to keep asking questions to my doctor as about how they valued their time and enjoyment rather I did today.” than worrying about their disease, for example, they don’t (M7: male patient) exercise even if they had been overweight, and in fact often did not give credence to medical test results that In addition, while there were some patients who ques- indicated more severe problems, even if symptoms were tioned their doctors extensively, there were others who present during the medical examination. did not want to annoy their doctors and refrained from asking any questions outside the doctors’ specialty; for example: Relationship with the family physician Over the course of any consultation, the patients and doc- “I don’t want to ask about anything outside a tors build a relationship. During our analysis, we found doctor’s specialty because I am afraid that they there to be two general categories of relationship: viable become annoyed with me. Asking things without relationships and compromised relationships. These cate- considering the consequences are rude and I don’t gorizations were based on the observed level of agenda- feel comfortable doing it.” sharing achieved as well as the patient’s own evaluation of (F4: female patient) the consultation experience. Examples of viable relationships are characterized by Undisclosed but relevant information the following statements: There were substantial amounts of relevant information not mentioned to the doctor. “He listened to me a lot, and I did not feel Some of anxieties expressed by patients following the uncomfortable talking to him. I felt I could talk about consultation were not limited to worries about the sever- anything with him.” ity of their illness or the pain involved in their treatment. (M7: male patient) Patients also worried about secondary effects the disease could have on their lives, the lives of those around them, and their professional lives; for example one patient “He listened to me fully, and he listened to all my concerns. The doctor that I saw today was very easy to expressed concern that their employment status could talk to.” be affected by their condition: (F5: female patient) “I can’t say that. I say that and that’s it, my job’s over, you know?” “I am very satisfied. I am glad I came. He is a great (F13: female patient) doctor.” (F5: female patient) In addition, patients’ anxieties were also closely con- nected to their family background, job status and social On the other hand, regarding compromised relation- background. ships, many patients did not directly answer in the nega- tive, but instead gave vague responses indicating that the “We did not have a father, and my mother raised me communication had in fact been insufficient. and my brother. I don’t want to make her worried.” (M8: female patient) Well, today was my first time with this doctor. I mean, I guess I talked to him. This patient wanted to undergo the same treatment (F4: 48 year old female patient) as his mother, who also suffered from diabetes melli- tus. In his mother’s case, she remained in the hospital Other patients clearly stated that they were not able to until her treatment was complete. Because of this, the fully communicate with the doctor. patient seemed likely to refuse outpatient medication Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 5 of 9 “Yeah, there was something I couldn’t talk about.” have a non-adaptive explanatory model. In some cases, (F13: female patient) the explanatory model previously held by the patient was re-enforced and strengthened by the conflict with Patient’s own explanatory model the doctor’s diagnosis. In other cases, the patient seemed Each patient had their own explanatory model for to lose confidence in their explanatory model while still describing their disease. Patients often arrived with an ori- rejecting the received diagnosis. ginal explanatory model for their particular disease and situation. For example, one patient with symptoms of “The doctor said “Don’t worry about it too much”, general fatigue worried that it could have been caused by but that’s not going to cure my disease.” cancer or a brain tumor, both of which had occurred in (F12: female patient) family members. Another patient who suffered from three months of diarrhea suspected an unknown type of bacteria The doctor’s statements were grouped into five cat- to be the cause. A third patient, who had numbness in her egories to clarify the factors affecting the agenda sharing hands thought that it was due to child-birth 10 years prior. process, on their part: “I feel blood is not circulating to the ends of my body. 5. Understanding the patient’s explanatory model I wonder if I have this kind of abnormality because 6. Constructing the patient-doctor relationship I had a baby at an older age.” 7. Physical examination centered around patient’s (F4: female patient) explanatory model 8. Discussion-styled explanation After the first meeting with a new doctor, and hearing 9. Self-reflection on action the doctor’s diagnosis, some patients accepted this diag- nosis, while others did not. The patients who accepted Understanding the patient’s explanatory model the doctor’s diagnosis and integrated this information Family physicians experienced patients with widely vary- into their previous explanatory model are said to have ing levels of preparedness and understanding of their adaptive explanatory models. own conditions. While some patients continually post- For example, one patient whose chief complaint was poned visits and check-ups, due to not wanting to hear various pains throughout her body initially suspected it bad news about their own health, other patients were was due to decompression sickness, a condition she was steadfast when faced with even the most difficult progno- aware of through her hobby of scuba diving. After the sis. Patients also varied in their ability not just to accept, doctor’s diagnosis of the pain as stemming from job- but to understand and deal with health problems. related stress, the patient’s explanatory model changed to consider this cause as well. “This patient does not know how to modify his lifestyle and it may take some time before he is motivated to “Since such a thorough examination couldn’t find make any changes.” anything abnormal, I’m beginning to feel there is (D4: female doctor) nothing wrong with my body.” (F6: female patient) Family physicians that have experience with many pa- tients were more likely to think about their diseases, Another example of an adaptive explanatory model is fears and uncertainties, and hopes regarding the results the previously mentioned, patient, who complained of of the examination. These physicians take the patient’s general fatigue. This patient, (in her early 20s), worried explanatory model into consideration when announcing that the cause of her complaint could be a brain tumor the results of their differential diagnosis. or cancer. After the doctor conducted a neurological examination, the patient felt that a CT scan, which she “The patient’s explanatory model is a physical disorder, had initially hoped for, was no longer necessary. In this and the patient requests testing. The patient has stress, case the doctor’s diagnosis was that the fatigue was likely but he does not think it is the cause of his illness.” caused by dehydration. (D5: male doctor) “I think I need to take better care of myself.” Constructing the patient- doctor relationship (F12: female patient) The physicians included in this research were aware of the patient’s expectations, and attempted to meet these In contrast to patients who accepted the new doctor’s expectations in order to strengthen the doctor-patient diagnosis, those who rejected the diagnosis are said to relationship. Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 6 of 9 The physicians interviewed understood that patients to emphasize those aspects of the examination that had various expectations from the consultation. Some excluded neurological problems. patients wished for the family physicians to understand their suffering or reassure them. Other patients hoped “I tried to allocate time to talk about different things for, or even requested, a diagnosis that contrasted with according to the patient’s symptoms.” the diagnosis received from their previous doctor, or (D2: male doctor) even just a chance to complain about their previous medical experience. The physicians we interviewed reported using strat- egies to facilitate the acquisition of new explanatory “What this patient wants from me is probably not models. For example, in a case where a family physician about reducing stress.” indicated to a patient that a disease was psychosomatic (D5: male doctor) in nature, the patient responded with a request for a CT scan in order to check brain function. In this case, the The physician’s understanding of these expectations family physician said that he made sure to do extensive determined the approach used during the consultation. nerve testing so that the patient would be convinced it For example, in cases where the patient felt their previ- was not a physical problem. This was sufficient to con- ous doctor had been dismissive of their fears, the phy- vince the patient that her brain function was normal sicians interviewed often felt the need to conduct a without the need for a CT scan. Thus, the family phys- comprehensive examination in order to both gain the ician helped to prompt the patient to come to their own patient’s trust, and reestablish confidence in the medical conclusions and develop a new explanatory model for system in general, often by conducting thorough exami- their disease. nations. In other cases, the physician expressed the need to calm the patient and give them assurances that they “I’m pretty sure the patient is satisfied that I would be fine. In cases where patients had already seen performed a thorough neurological examination.” several family physicians and had yet to find effective (D5: male doctor) treatment, doctors assured patients that they would con- tinue to work with the patient until an acceptable treat- Discussion-styled explanation ment was found. Family physicians did not unilaterally announce their Patients may react badly to a physician suggesting that diagnosis, but addressed patient questions and confirmed their problems may be psychosomatic in nature. Doctors patient’s understanding while explaining their findings. who sensed the potential for this often began with a The family physician did not simply speak, but con- physical examination to help preserve the doctor-patient versed with the patient to confirm how and to what relationship, before suggesting other options. extent the patient had understood the diagnosis. In a case where a patient suffering from diarrhea asked if it “If I had said “Your illness is due to stress,” I think the might be due to some unknown fungus, the family patient would reject my diagnosis, so I purposely chose physician did not merely reply “No, it’s not.” Instead, the a physically-centered approach.” family physician offered an explanation, such as the fact (D6: male doctor) that a fungus alone would not cause the patient’s symp- toms, and offered suggestions on how the patient might change his diet. In another case, when a patient com- Physical examination centered around the patient’s plained about noise in their ears, the family physician explanatory model named the disease and also explained how to clean the The physicians interviewed expressed the needed to en- ears. courage patients to understand the diagnostic process, and to show patients what they are checking for. “I told the patient not to overdo ear cleaning and not Family physicians assessed the appropriate strategy for to use a hard ear pick; to loosen the tip of a the consultation given the patient’s situation, to ensure commercial cotton swab because it is hard; and to that the patient’s complaint had been fully addressed, clean only the shallow part instead of going too far in.” and the patient was able to understand and talk about (D1: female doctor) the diagnosis. In the case of an obese patient, the doctor planned the flow of the consultation to make sure the In another case, after the end of the consultation, the patient realized the problem he needed to address on his doctor-patient connection was not over, but the family own. In another case, to dispel any concerns about physician continued to offer help to the patient regard- neurological problems, the family physician was careful ing her ear discomfort, and offered explanation on ear Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 7 of 9 care. The family physician used an appropriate conversa- 5. Understanding the patient’s explanatory model tion for the patient’s psychosocial background and fully 6. Constructing the patient-doctor relationship addressed the needs of the patient. 7. Physical examination centered around patient’s explanatory model “There are many cases where patients haven’t 8. Discussion-styled explanation accepted a diagnosis on the first visit, so I often tell 9. Self-reflection on action them, “Please take your time to consider this information.” This study revealed many hurdles to overcome for effective agenda-sharing between doctors and patients. Many patients were observed who had problems with I thought the patient had almost prepared to accept their previous doctors, lacked trust in the medical system, the cure.” and were hesitant to openly communicate with their new (D1: female doctor) doctors. A patient’s past medical experience had lasting effects on how they communicated with their current Self-reflection on action doctor. As Dr. Iwata wrote, medical interviews are “the The family physician was conscious of his/her actions work of reclaiming past events and bringing them to the during the consultation. present [20].” For the best agenda sharing, it may be Family physicians reflected on their consultation, and necessary for doctors to indirectly address the patient’s wondered how to improve, considering difficult points, past unhappiness with the medical system, and allow the areas where communication had worked well and where patient to accept the new doctor-patient relationship. it hadn’t, and the timing of giving information to pa- However, patients’ problems were often much more tients. While ordering further tests, the family physician complicated than the doctors expected [21]. Not all reviewed the consultation he had just given, wondered if patients shared information even when it was needed he had maintained the proper pace of speaking, if he in the consultation, because of the past relationship had been too fast or repetitive, if he had been sufficiently between patient and doctor. specific in describing causes of the disease, if he had Therefore, during examinations, family physicians tried addressed all the worries of the patient, or if he had in to draw out information from patients, such as their fact been overly reassuring to the patient in spite of the personality, job, as well as previous medical experiences, seriousness of the disease. Through all these steps the though not necessarily verbally. This information was family physician reflected on the diagnosis and consult- used by the family physician to confirm the patient’s ation procedure. explanatory model, their comprehension of the disease as well as their problem solving ability. After recognizing this “In this case, I had information from the patient’s background, doctors considered the role expected of them previous doctor, so I started asking about psychiatric from the patient. For example, through assuming a posi- problems more quickly than usual.” tive attitude to encourage the patient, or through trying to (D5: male doctor) eliminate any distrust on the part of the patient, family physicians try to build a good doctor-patient relationship. “I told her there is no abnormality, but that doesn’t If a patients’ explanatory model and doctors’ diagno- mean she now feels relieved.” ses were different, the family physicians we interviewed (D4: female doctor) reported using the physical examination itself to affect changes in the patient’s explanatory model. For example, Discussion in cases where patients had objected to their condition be- The respective narratives made it clear that there were ing referred to in psychosomatic terms, the physicians factors affecting the agenda-making process from both tended to respect the patient-held explanatory model, and patients and doctors. Our analysis summarized these as consciously began with a thorough physical approach to follows: the examination. According to the patients’ narratives: In this way, family physicians examining patients who face psychosocial problems were not ignoring their cues, 1. Past medical experiences but rather addressing these cue indirectly. While the 2. Undisclosed but relevant information doctors have picked up on these cues, rather than trying 3. Relationship with the family physician to force their way of thinking onto patients, through 4. Patient’s own explanatory model doing a thorough physical examination and objectively finding no problems, doctors hoped to allow patients to According to the doctors’ narratives: develop updated explanatory models on their own. Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 8 of 9 Previous research has found that many doctors focused one hospital chosen for this investigation. Further re- solely on somatic aspects of disease and disregarded cues search is required to address this limitation. towards psychological, emotional or social problems. Competing interests Cassell stated that doctors focus more on supporting pa- The authors declare that they have no competing interests. tients’ function of internal organs than personal interests about them [22]. However, our research has shown a Authors’ contributions superficially similar yet substantially different type of MG and TT have made substantial contributions to conception and design. MG and SY analyzed and interpreted the data. MG and TT drafted the interaction: while family physicians have recognized the manuscript and all authors (MG; SY; YT; AG; TT) revised it critically for cues to psychosomatic problems, they refrained from important intellectual content. All authors have read and given final pushing their thinking onto patients, instead carefully approval to the manuscript. carrying out the physical examination and supporting Acknowledgment patients in developing a new explanatory model on their We are grateful to Peter Dryja, Dr. Wakabayashi, and Dr. Evans for their kind own. assistance. And we would like to thank all patients for their cooperation, Despite the efforts of family physicians trying to build and the member of the Department of Family Medicine at Mie University Graduate School of Medicine for their support. a strong doctor-patient relationship, there were patients who did not provide doctors with the necessary informa- Author details tion. While family physicians may pick up on some cues, Department of Education and Research in Family and Community Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie there were limits to the information observation could 514-8507, Japan. Community-based Medicine Education Station kitaibaraki, provide. In these cases, doctors are unable to contribute Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki to patient understanding of any new explanatory model, 305-8575, Japan. Department of Family Medicine, Mie University School of Medicine & Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, and ultimately the examination ended without sharing Japan. Center for Medical and Nursing Education, Mie University School of their explanatory model. Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan. Kikugawa municipal We found that a family physician’s ability of reflection- Family Medicine Center, 1055-1 Akatsuti, Kikugawa, Shizuoka 439-1507, Japan. on-action [23] was one of the important factors of agenda sharing throughout the consultation process. Received: 4 December 2014 Accepted: 26 May 2015 Through this kind of action, family physicians endeav- ored to create better relationship with patients. Accord- References ing to Cassata, active interactions make patients actively 1. McKinley RK, Middleton JF. What do patients want from doctor? Content and positively participate in the interview, and more pre- analysis of written patient’s agendas for the consultation. Br J Gen Pract. disposed to take on more responsibility. However, in this 1999;49:796–800. 2. Campion PD, Butler NM, Cox AD. Principle agendas of doctors and patients study, we found two kinds of consultation: consultations in general practice consultations. 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Describing the factors that influence the process of making a shared-agenda in Japanese family physician consultations: a qualitative study

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Springer Journals
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Copyright © 2015 by Goto et al.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/s12930-015-0023-6
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26097414
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Abstract

Background: Patients cannot always share all necessary relevant information with doctors during medical consultations. Regardless, in order to ensure the best quality consultation and care, it is imperative that a doctor clearly understands each patient’s agenda. The purpose of this study was to analyze the process of developing a shared-agenda during family physician consultations in Japan. Methods: We interviewed 15 first time patients visiting the outpatient clinic of the Department of Family Medicine in the hospital chosen for the investigation, and the 8 family physicians who examined them. In total we observed 16 consultations. We analyzed both patients’ and doctors’ narratives using a modified grounded theory approach. Results: For patients, we found four main factors that influenced the process of making a shared-agenda: past medical experiences, undisclosed but relevant information, relationship with the family physician, and the patient’sown explanatory model. In addition, we found five factors that influenced the shared agenda making process for family physicians: understanding the patient’s explanatory model, constructing the patient-doctor relationship, physical examination centered around the patient’s explanatory model, discussion-styled explanation, and self-reflection on action. Conclusions: The findings suggest that patient satisfaction would be increased if family physicians are proactive in considering these factors with respect to both the patient’s agenda, and their own. Keywords: Agenda-sharing, Communication, Doctor-patient relationship, Patient’s explanatory model, Taking a medical history Background On the other hand, doctors also have an agenda, Anecdotal evidence suggests that when patients visit a which typically revolves around diagnosis and man- doctor, they typically have an agenda to discuss [1–3]. agement. However, taking the scope and dimensions The agenda includes particular problems which pa- of their work into consideration, family physicians, tients want to discuss with their doctor; for example: must include broader considerations [2]. patients’ ideas about the reasons of their sickness, Levenstein noted that it is important to combine the seriousness of a symptom, recuperation of the prob- agendas from both patient and doctor [6]. Moreover, the lems, expectations regarding the course of the illness literature suggests that doctors may frequently fail to or prognosis, medical examinations and prescription, fully understand patients’ true expectations and requests referral to a specialist and explanation for an absence [2, 7]. Or alternatively, patients may not be able to share from school or work [4, 5]. their agenda completely with their doctors [8]. In such case, his unspoken agenda is referred to as the patient’s hidden agenda [9]. * Correspondence: tamgoto@clin.medic.mie-u.ac.jp Marple et al. suggest that a mismatch of agendas be- Department of Education and Research in Family and Community Medicine, tween patients and doctors lowers patients’ satisfaction Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan Full list of author information is available at the end of the article © 2015 Goto et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 2 of 9 Table 1 Questionnaire (Questions used in post-consultation [5]. Other research suggests that agenda mismatching interviews) Questions toward patients makes compliance lower and may affect the outcome Questions toward patients [10–12]. Indeed, one of the reasons that some patients repeatedly go “doctor shopping” may be because of agenda 1 What do you think about your own illness? mismatching [13]. All things considered, it is clear that 2 What did you want to convey to your doctor most? Were you able to the ability for patients to share their agendas well poten- convey it? tially lowers costs and reduces consultation times [14, 15]. 3 What do you think the reason was for your in/ability to express yourself during the consultation? Were you satisfied with yourself? Charles et al. described the process of agenda-sharing with the expression “it takes two to tango” [16]. Accord- 4 Can you describe your ideal doctor? ingly, the factors that prevent or promote agenda-sharing Question toward doctors should be defined in order to make agenda-sharing more 1 How did you listen to the patient? consistent and productive in terms of patient outcomes 2 What do you think the patient wanted to say the most? and consultation costs. However, until recently, there has 3 What did you emphasize most in the consultation? been little research evidence about the factors which affect 4 Do you think the patient was satisfied? the agenda-sharing process. Thus, the purpose of this research is to describe the factors that influence the process of making a shared- between doctors and patients, and after discussing with agenda in Japanese family physician consultations, by other members. analyzing patient and doctor narratives. All researcher-patient and researcher-doctor inter- This study was approved by the Research Ethics views were audio recorded with consent from both the Committee of the Faculty of Medicine at Mie University. patient and doctor. Audio recordings were sent to a third party for transcription, which was later used for analysis. The written notes from the doctor-patient con- Methods sultation were also collected, to allow for comparison Sampling and recruitment between patient and doctor recollections of the consult- Prior to recruiting patients, we obtained informed, ver- ation with the actual events. All samples so obtained bal and written consent from all staff members of the were coded to maintain anonymity. Department of Family Medicine in the hospital chosen for the investigation to observe their patient consulta- Analysis tions. Patients were then recruited while waiting to be For the analysis, a modified grounded theory approach examined by the consenting physicians (n = 8). We was used [18] wherein two researchers categorized the screened patients and asked those who were first-time data, and constructed a final theory together with another visitors, to participate in our research after explaining researcher (Fig. 1). In cases of uncertainty, the decision of the research purpose, both verbally and in writing. From the researcher who conducted the interview was given among 50 new patients screened, 15 finally consented to priority. participate in this research. Results Data collection Overall, interviews lasted 30 to 40 min for patients, and Patients and doctors met in standard consultation rooms, 15 to 20 min for doctors. The interview was terminated and a member of our research team observed the con- once the conversation seemed to have reached theoret- sultation, and took written notes, but did not participate ical saturation—in other words, when similar opinions in any way. After the initial consultation, the researcher had been repeatedly heard and no more new opinions led the patient to a separate interview room to conduct were likely to be heard [19]. The subjects were 15 an interview in private. Researchers then interviewed patients, and 8 doctors; in total, 16 consultations were the doctor, generally later that day, when the clinic had observed. The doctors consisted of 5 male and 3 female finished. and the patients consisted of 11 female and 4 male Semi-structured interviews were conducted to avoid (Table 2). using leading questions, with the aim of eliminating any The patient’s statements were grouped into four cat- potential for researcher bias [17]. Supplementary ques- egories of factors affecting the agenda-sharing process: tions that aimed to clarify respective answers were posed, as needed, during the main questioning in a way 1. Past medical experiences that did not interrupt the flow of the interviews (Table 1). 2. Undisclosed but relevant information The questions were selected following a thorough review 3. Relationship with the family physician of previous studies concerning the communication gap 4. Patient’s own explanatory model Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 3 of 9 Past experiences Undisclosed information Understanding the explanatory model Relationship building Doctor's Patient's Physical examination Agenda Agenda Discussion-styled Self-Reflection on action Explanatory Relationship model with doctor Factors for Patient's Agenda Making Factors for Doctor's Agenda Sharing Process Agenda Sharing Fig. 1 Overview of shared-agenda making process Past medical experiences In addition, several had been referred by previous doc- We found that the past medical experiences of patients tor, who judged that they would receive superior care had an effect on their attitude towards their present at a larger institution. doctor, which affected agenda-sharing. Accordingly, many of the patients in this study In Japan’s “free access” medical system, patients are came to the hospital chosen for this investigation, free to move between doctor and hospitals. As a re- due to negative experiences with previous doctors; for sult, many patients came from other clinics in hopes example. of better care. There were many specific reasons, such as, dissatisfaction with a previous consultation, little or “The doctor said, “There’s nothing abnormal. Perhaps no improvement in symptoms, as well as many others. it’s just your imagination.” And I said, “I need Table 2 Consultation information Doctor information Case information Patient information Doctor ID Sex Years in practice Chief complaint Patient ID Age Sex Occupation D1 Female 4 The diarrhea caused by bacterial infection M1 69 Male Retired D2 Male 2 Throbbing of the chest, Irritation, Depression F1 59 Female Housewives D3 Female 4 Hypertension F2 51 Female Office worker D1 Female 4 Routine screening for breast cancer, Numbness of joints F3 56 Female Independent business D4 Female 4 Swelling of the finger F4 46 Female Teacher D4 Female 4 Phlegm obstructing the throat F5 63 Female Housewives D5 Male 17 Caisson disease F6 25 Female Medical representative D6 Male 3 Stomachache M7 49 Male Policeman D4 Female 4 Increased urinary frequency M8 36 Male Factory worker D7 Male 12 Venous inflammation of the lower leg, Collagen disease F9 53 Female Housewives D6 Male 3 Abnormal swelling of the lower body F10 50 Female Housewives D5 Male 17 Nausea, “strange feeling” in stomach, listlessness M11 26 Male Builder D5 Male 17 Brain disease, exhausting F12 20 Female Nursing student D2/D7 Male/male 2/12 Hypertension; unusual findings on examination F13 53 Female Worker D8 Male 34 Gastric cancer, gastric ulcer F14 68 Female Housewives Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 4 of 9 medicine,” and he prescribed only Isodine and Troche. and seemed set on inpatient hospital care. None of I thought it was a joke.” these things, however, were mentioned to the doctor. (M11: male patient) While patients demonstrated a wide range of attitudes in facing their illnesses, those patients who refrained Moreover, in many cases, patients’ past medical experi- from discussing their outlook with their doctor tended to ences had a large impact on their attitude during medical have similar views. Several procrastinated over coming to consultations; for example: the hospital, or ignored their disease on days where their symptoms were less noticeable. These patients talked “I’m going to keep asking questions to my doctor as about how they valued their time and enjoyment rather I did today.” than worrying about their disease, for example, they don’t (M7: male patient) exercise even if they had been overweight, and in fact often did not give credence to medical test results that In addition, while there were some patients who ques- indicated more severe problems, even if symptoms were tioned their doctors extensively, there were others who present during the medical examination. did not want to annoy their doctors and refrained from asking any questions outside the doctors’ specialty; for example: Relationship with the family physician Over the course of any consultation, the patients and doc- “I don’t want to ask about anything outside a tors build a relationship. During our analysis, we found doctor’s specialty because I am afraid that they there to be two general categories of relationship: viable become annoyed with me. Asking things without relationships and compromised relationships. These cate- considering the consequences are rude and I don’t gorizations were based on the observed level of agenda- feel comfortable doing it.” sharing achieved as well as the patient’s own evaluation of (F4: female patient) the consultation experience. Examples of viable relationships are characterized by Undisclosed but relevant information the following statements: There were substantial amounts of relevant information not mentioned to the doctor. “He listened to me a lot, and I did not feel Some of anxieties expressed by patients following the uncomfortable talking to him. I felt I could talk about consultation were not limited to worries about the sever- anything with him.” ity of their illness or the pain involved in their treatment. (M7: male patient) Patients also worried about secondary effects the disease could have on their lives, the lives of those around them, and their professional lives; for example one patient “He listened to me fully, and he listened to all my concerns. The doctor that I saw today was very easy to expressed concern that their employment status could talk to.” be affected by their condition: (F5: female patient) “I can’t say that. I say that and that’s it, my job’s over, you know?” “I am very satisfied. I am glad I came. He is a great (F13: female patient) doctor.” (F5: female patient) In addition, patients’ anxieties were also closely con- nected to their family background, job status and social On the other hand, regarding compromised relation- background. ships, many patients did not directly answer in the nega- tive, but instead gave vague responses indicating that the “We did not have a father, and my mother raised me communication had in fact been insufficient. and my brother. I don’t want to make her worried.” (M8: female patient) Well, today was my first time with this doctor. I mean, I guess I talked to him. This patient wanted to undergo the same treatment (F4: 48 year old female patient) as his mother, who also suffered from diabetes melli- tus. In his mother’s case, she remained in the hospital Other patients clearly stated that they were not able to until her treatment was complete. Because of this, the fully communicate with the doctor. patient seemed likely to refuse outpatient medication Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 5 of 9 “Yeah, there was something I couldn’t talk about.” have a non-adaptive explanatory model. In some cases, (F13: female patient) the explanatory model previously held by the patient was re-enforced and strengthened by the conflict with Patient’s own explanatory model the doctor’s diagnosis. In other cases, the patient seemed Each patient had their own explanatory model for to lose confidence in their explanatory model while still describing their disease. Patients often arrived with an ori- rejecting the received diagnosis. ginal explanatory model for their particular disease and situation. For example, one patient with symptoms of “The doctor said “Don’t worry about it too much”, general fatigue worried that it could have been caused by but that’s not going to cure my disease.” cancer or a brain tumor, both of which had occurred in (F12: female patient) family members. Another patient who suffered from three months of diarrhea suspected an unknown type of bacteria The doctor’s statements were grouped into five cat- to be the cause. A third patient, who had numbness in her egories to clarify the factors affecting the agenda sharing hands thought that it was due to child-birth 10 years prior. process, on their part: “I feel blood is not circulating to the ends of my body. 5. Understanding the patient’s explanatory model I wonder if I have this kind of abnormality because 6. Constructing the patient-doctor relationship I had a baby at an older age.” 7. Physical examination centered around patient’s (F4: female patient) explanatory model 8. Discussion-styled explanation After the first meeting with a new doctor, and hearing 9. Self-reflection on action the doctor’s diagnosis, some patients accepted this diag- nosis, while others did not. The patients who accepted Understanding the patient’s explanatory model the doctor’s diagnosis and integrated this information Family physicians experienced patients with widely vary- into their previous explanatory model are said to have ing levels of preparedness and understanding of their adaptive explanatory models. own conditions. While some patients continually post- For example, one patient whose chief complaint was poned visits and check-ups, due to not wanting to hear various pains throughout her body initially suspected it bad news about their own health, other patients were was due to decompression sickness, a condition she was steadfast when faced with even the most difficult progno- aware of through her hobby of scuba diving. After the sis. Patients also varied in their ability not just to accept, doctor’s diagnosis of the pain as stemming from job- but to understand and deal with health problems. related stress, the patient’s explanatory model changed to consider this cause as well. “This patient does not know how to modify his lifestyle and it may take some time before he is motivated to “Since such a thorough examination couldn’t find make any changes.” anything abnormal, I’m beginning to feel there is (D4: female doctor) nothing wrong with my body.” (F6: female patient) Family physicians that have experience with many pa- tients were more likely to think about their diseases, Another example of an adaptive explanatory model is fears and uncertainties, and hopes regarding the results the previously mentioned, patient, who complained of of the examination. These physicians take the patient’s general fatigue. This patient, (in her early 20s), worried explanatory model into consideration when announcing that the cause of her complaint could be a brain tumor the results of their differential diagnosis. or cancer. After the doctor conducted a neurological examination, the patient felt that a CT scan, which she “The patient’s explanatory model is a physical disorder, had initially hoped for, was no longer necessary. In this and the patient requests testing. The patient has stress, case the doctor’s diagnosis was that the fatigue was likely but he does not think it is the cause of his illness.” caused by dehydration. (D5: male doctor) “I think I need to take better care of myself.” Constructing the patient- doctor relationship (F12: female patient) The physicians included in this research were aware of the patient’s expectations, and attempted to meet these In contrast to patients who accepted the new doctor’s expectations in order to strengthen the doctor-patient diagnosis, those who rejected the diagnosis are said to relationship. Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 6 of 9 The physicians interviewed understood that patients to emphasize those aspects of the examination that had various expectations from the consultation. Some excluded neurological problems. patients wished for the family physicians to understand their suffering or reassure them. Other patients hoped “I tried to allocate time to talk about different things for, or even requested, a diagnosis that contrasted with according to the patient’s symptoms.” the diagnosis received from their previous doctor, or (D2: male doctor) even just a chance to complain about their previous medical experience. The physicians we interviewed reported using strat- egies to facilitate the acquisition of new explanatory “What this patient wants from me is probably not models. For example, in a case where a family physician about reducing stress.” indicated to a patient that a disease was psychosomatic (D5: male doctor) in nature, the patient responded with a request for a CT scan in order to check brain function. In this case, the The physician’s understanding of these expectations family physician said that he made sure to do extensive determined the approach used during the consultation. nerve testing so that the patient would be convinced it For example, in cases where the patient felt their previ- was not a physical problem. This was sufficient to con- ous doctor had been dismissive of their fears, the phy- vince the patient that her brain function was normal sicians interviewed often felt the need to conduct a without the need for a CT scan. Thus, the family phys- comprehensive examination in order to both gain the ician helped to prompt the patient to come to their own patient’s trust, and reestablish confidence in the medical conclusions and develop a new explanatory model for system in general, often by conducting thorough exami- their disease. nations. In other cases, the physician expressed the need to calm the patient and give them assurances that they “I’m pretty sure the patient is satisfied that I would be fine. In cases where patients had already seen performed a thorough neurological examination.” several family physicians and had yet to find effective (D5: male doctor) treatment, doctors assured patients that they would con- tinue to work with the patient until an acceptable treat- Discussion-styled explanation ment was found. Family physicians did not unilaterally announce their Patients may react badly to a physician suggesting that diagnosis, but addressed patient questions and confirmed their problems may be psychosomatic in nature. Doctors patient’s understanding while explaining their findings. who sensed the potential for this often began with a The family physician did not simply speak, but con- physical examination to help preserve the doctor-patient versed with the patient to confirm how and to what relationship, before suggesting other options. extent the patient had understood the diagnosis. In a case where a patient suffering from diarrhea asked if it “If I had said “Your illness is due to stress,” I think the might be due to some unknown fungus, the family patient would reject my diagnosis, so I purposely chose physician did not merely reply “No, it’s not.” Instead, the a physically-centered approach.” family physician offered an explanation, such as the fact (D6: male doctor) that a fungus alone would not cause the patient’s symp- toms, and offered suggestions on how the patient might change his diet. In another case, when a patient com- Physical examination centered around the patient’s plained about noise in their ears, the family physician explanatory model named the disease and also explained how to clean the The physicians interviewed expressed the needed to en- ears. courage patients to understand the diagnostic process, and to show patients what they are checking for. “I told the patient not to overdo ear cleaning and not Family physicians assessed the appropriate strategy for to use a hard ear pick; to loosen the tip of a the consultation given the patient’s situation, to ensure commercial cotton swab because it is hard; and to that the patient’s complaint had been fully addressed, clean only the shallow part instead of going too far in.” and the patient was able to understand and talk about (D1: female doctor) the diagnosis. In the case of an obese patient, the doctor planned the flow of the consultation to make sure the In another case, after the end of the consultation, the patient realized the problem he needed to address on his doctor-patient connection was not over, but the family own. In another case, to dispel any concerns about physician continued to offer help to the patient regard- neurological problems, the family physician was careful ing her ear discomfort, and offered explanation on ear Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 7 of 9 care. The family physician used an appropriate conversa- 5. Understanding the patient’s explanatory model tion for the patient’s psychosocial background and fully 6. Constructing the patient-doctor relationship addressed the needs of the patient. 7. Physical examination centered around patient’s explanatory model “There are many cases where patients haven’t 8. Discussion-styled explanation accepted a diagnosis on the first visit, so I often tell 9. Self-reflection on action them, “Please take your time to consider this information.” This study revealed many hurdles to overcome for effective agenda-sharing between doctors and patients. Many patients were observed who had problems with I thought the patient had almost prepared to accept their previous doctors, lacked trust in the medical system, the cure.” and were hesitant to openly communicate with their new (D1: female doctor) doctors. A patient’s past medical experience had lasting effects on how they communicated with their current Self-reflection on action doctor. As Dr. Iwata wrote, medical interviews are “the The family physician was conscious of his/her actions work of reclaiming past events and bringing them to the during the consultation. present [20].” For the best agenda sharing, it may be Family physicians reflected on their consultation, and necessary for doctors to indirectly address the patient’s wondered how to improve, considering difficult points, past unhappiness with the medical system, and allow the areas where communication had worked well and where patient to accept the new doctor-patient relationship. it hadn’t, and the timing of giving information to pa- However, patients’ problems were often much more tients. While ordering further tests, the family physician complicated than the doctors expected [21]. Not all reviewed the consultation he had just given, wondered if patients shared information even when it was needed he had maintained the proper pace of speaking, if he in the consultation, because of the past relationship had been too fast or repetitive, if he had been sufficiently between patient and doctor. specific in describing causes of the disease, if he had Therefore, during examinations, family physicians tried addressed all the worries of the patient, or if he had in to draw out information from patients, such as their fact been overly reassuring to the patient in spite of the personality, job, as well as previous medical experiences, seriousness of the disease. Through all these steps the though not necessarily verbally. This information was family physician reflected on the diagnosis and consult- used by the family physician to confirm the patient’s ation procedure. explanatory model, their comprehension of the disease as well as their problem solving ability. After recognizing this “In this case, I had information from the patient’s background, doctors considered the role expected of them previous doctor, so I started asking about psychiatric from the patient. For example, through assuming a posi- problems more quickly than usual.” tive attitude to encourage the patient, or through trying to (D5: male doctor) eliminate any distrust on the part of the patient, family physicians try to build a good doctor-patient relationship. “I told her there is no abnormality, but that doesn’t If a patients’ explanatory model and doctors’ diagno- mean she now feels relieved.” ses were different, the family physicians we interviewed (D4: female doctor) reported using the physical examination itself to affect changes in the patient’s explanatory model. For example, Discussion in cases where patients had objected to their condition be- The respective narratives made it clear that there were ing referred to in psychosomatic terms, the physicians factors affecting the agenda-making process from both tended to respect the patient-held explanatory model, and patients and doctors. Our analysis summarized these as consciously began with a thorough physical approach to follows: the examination. According to the patients’ narratives: In this way, family physicians examining patients who face psychosocial problems were not ignoring their cues, 1. Past medical experiences but rather addressing these cue indirectly. While the 2. Undisclosed but relevant information doctors have picked up on these cues, rather than trying 3. Relationship with the family physician to force their way of thinking onto patients, through 4. Patient’s own explanatory model doing a thorough physical examination and objectively finding no problems, doctors hoped to allow patients to According to the doctors’ narratives: develop updated explanatory models on their own. Goto et al. Asia Pacific Family Medicine (2015) 14:6 Page 8 of 9 Previous research has found that many doctors focused one hospital chosen for this investigation. Further re- solely on somatic aspects of disease and disregarded cues search is required to address this limitation. towards psychological, emotional or social problems. Competing interests Cassell stated that doctors focus more on supporting pa- The authors declare that they have no competing interests. tients’ function of internal organs than personal interests about them [22]. However, our research has shown a Authors’ contributions superficially similar yet substantially different type of MG and TT have made substantial contributions to conception and design. MG and SY analyzed and interpreted the data. MG and TT drafted the interaction: while family physicians have recognized the manuscript and all authors (MG; SY; YT; AG; TT) revised it critically for cues to psychosomatic problems, they refrained from important intellectual content. All authors have read and given final pushing their thinking onto patients, instead carefully approval to the manuscript. carrying out the physical examination and supporting Acknowledgment patients in developing a new explanatory model on their We are grateful to Peter Dryja, Dr. Wakabayashi, and Dr. Evans for their kind own. assistance. And we would like to thank all patients for their cooperation, Despite the efforts of family physicians trying to build and the member of the Department of Family Medicine at Mie University Graduate School of Medicine for their support. a strong doctor-patient relationship, there were patients who did not provide doctors with the necessary informa- Author details tion. While family physicians may pick up on some cues, Department of Education and Research in Family and Community Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie there were limits to the information observation could 514-8507, Japan. Community-based Medicine Education Station kitaibaraki, provide. In these cases, doctors are unable to contribute Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki to patient understanding of any new explanatory model, 305-8575, Japan. Department of Family Medicine, Mie University School of Medicine & Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, and ultimately the examination ended without sharing Japan. Center for Medical and Nursing Education, Mie University School of their explanatory model. Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan. Kikugawa municipal We found that a family physician’s ability of reflection- Family Medicine Center, 1055-1 Akatsuti, Kikugawa, Shizuoka 439-1507, Japan. on-action [23] was one of the important factors of agenda sharing throughout the consultation process. Received: 4 December 2014 Accepted: 26 May 2015 Through this kind of action, family physicians endeav- ored to create better relationship with patients. Accord- References ing to Cassata, active interactions make patients actively 1. McKinley RK, Middleton JF. What do patients want from doctor? Content and positively participate in the interview, and more pre- analysis of written patient’s agendas for the consultation. Br J Gen Pract. disposed to take on more responsibility. However, in this 1999;49:796–800. 2. Campion PD, Butler NM, Cox AD. Principle agendas of doctors and patients study, we found two kinds of consultation: consultations in general practice consultations. 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Journal

Asia Pacific Family MedicineSpringer Journals

Published: Jun 5, 2015

References