Patients' expectations of consultations

Although patients' expectations of general practice consultations influence outcomes, they are not as influential as doctors' assessments. This may sound obvious except for the fact that doctors' assessments of patients' preferences have more influence than those preferences themselves. In this issue Little et al are publishing two studies.¹,² Their observational study generalises the finding from an earlier study³ that doctors' perceptions are a stronger predictor of their actions—from prescribing to other consultation activities—than are patients' expectations. The same factors (including doctors' perceptions) affecting prescribing decisions also affect other clinical decisions. This makes it all the more important that doctors' perceptions are accurate. Inappropriate assessments of patients' expectations can result in actions deemed unnecessary by the doctor and unwanted by the patient.

In their interventional study Little et al used leaflets and found that most of the increased investigations resulting from the intervention were not felt by either the doctor or the patient to be strongly needed. Another observational study about prescribing decisions showed that some prescriptions wanted by the patient but thought not to be strictly indicated by the doctor were not taken as prescribed.⁴

These studies and others show that doctors do things they consider unnecessary in a noteworthy minority of cases. What is going on? When asked, some doctors state that they write prescriptions that are not clinically needed, in order to maintain relationships with their patients.⁵ Perhaps the key to the issue is the notion of pressure. In the observational study by Little, as in other studies, doctors were asked if they felt pressurised by patients.¹ The patients were asked, in a pre-consultation questionnaire, whether they wanted a prescription, referral, and so on. If patients indicated on the questionnaire that they wanted a particular outcome, this was described as “direct pressure.” What is not known from any of these studies is whether patients who endorse a questionnaire item—stating that they want an investigation, for example—say so in the consultation. We know from other observational studies of the consultation that patients do not voice all their agenda items and that requests tend to be indirect.⁶,⁷ We also know that doctors make assumptions about patients' preferences that may not be accurate and that doctors can display more certainty about their perceptions of patients' preferences than the patients themselves. In a study of 161 general practice consultations Jenkins et al found that patients were much more uncertain about their preferences for prescriptions than doctors perceived them to be. Patients expressed uncertainty in 60 instances; doctors in only 13.⁸

All this implies that pressure from patients may be stronger in the doctor's mind than in the patient's mind. Doctors may be making inappropriate decisions for the sake of maintaining relationships with patients without checking whether their assumptions about patients' preferences are correct. To do something clinically unnecessary that the patient wants, for the sake of the relationship, is one thing, but if the patient does not want it it is truly unnecessary. One can only suppose that a better relationship would be based on a more accurate understanding, gained by finding out directly what patients are expecting. The objection is often made that this would take up too much time. But Little et al make the point that carrying out unnecessary investigations is itself time consuming.¹ The evidence shows that, although longer consultations on the whole lead to better patient outcomes, some skilled doctors are able to achieve these outcomes without spending more time.⁹

If we really want to know what is going on in the consultation we need to study the interaction. Without this, interpretation is conjecture. Interventions aimed at changing the dynamics of the consultation cannot be evaluated fully if these interactions are not analysed. Although the leaflets in Little et al's interventional study encouraged patients to list the issues they wanted to raise, the consultations themselves were not analysed.² Thus it is not clear if increased satisfaction arose from patients' greater articulation of their expectations, or from feeling reassured that the doctor was willing to listen, or something else altogether. If the purpose of interventions such as leaflets or decision aids is to alter the dynamics of the consultation then any evaluation should investigate those same dynamics. The growing number of studies of the consultation carried out by specialists in sociolinguistics and conversation analysis promise to provide a better understanding of exactly how expectations are or are not articulated and if articulated how they are responded to.¹⁰ This type of investigation could also help us to understand exactly what skilled doctors, who can achieve good communication within normal time constraints, are doing.