THE DOCTOR-PATIENT RELATIONSHIP: AN EXPLORATION OF TRAINEE DOCTORS’ VIEWS by SARAH ELIZABETH BURKE A thesis submitted to The University of Birmingham for the degree of DOCTOR OF PHILOSOPHY School of Education The University of Birmingham March 2008 University of Birmingham Research Archive e-theses repository This unpublished thesis/dissertation is copyright of the author and/or third parties. The intellectual property rights of the author or third parties in respect of this work are as defined by The Copyright Designs and Patents Act 1988 or as modified by any successor legislation. Any use made of information contained in this thesis/dissertation must be in accordance with that legislation and must be properly acknowledged. Further distribution or reproduction in any format is prohibited without the permission of the copyright holder. ABSTRACT Greater understanding of the ways in which medical trainees perceive the doctor-patient relationship could inform future developments in educational provision. A qualitative study was conducted, using a case study approach to explore the perceptions of postgraduate trainees in two medical specialties, general practice (GP) and otolaryngology (ear, nose and throat surgery, ENT), in the West Midlands region of the United Kingdom. Following a scoping exercise in 2002, interviews with 20 trainees (10 GP and 10 ENT) in 2004 and questionnaires from 16 ENT and 89 GP trainees in 2007 explored trainees’ views of the doctor-patient relationship, including perceptions of the nature of that relationship and how they had learnt to develop relationships with patients. Five conceptual frameworks that participants drew upon when talking about the doctor- patient relationship were identified: paternalism; guided decision-making; partnership; clinical and consumerism. Trainees described a fluid doctor-patient relationship which adapts to differing contexts, taking different forms in different situations and influenced by factors outside the doctor’s control, including time and the patient’s personality. Personal experience and observing senior colleagues were considered to have had the greatest impact on learning. Higher Specialist Training which acknowledges the complexity of the doctor-patient relationship and encourages reflective practice is recommended. Dedication In memory of Rosemary Wakefield. Acknowledgements Firstly I would like to thank all those who participated in this study by taking part in interviews and completing questionnaires for their time and candour. My thanks also go to the staff at the West Midlands Deanery and the West Midlands Higher Surgical Training Committee for Otolaryngology for their advice and support in contacting trainees. My particular thanks to Mr David Proops for his early advice and encouragement. The School of Education at the University of Birmingham has generously supported this thesis. Colleagues in the Centre for Research in Medical and Dental Education are particularly thanked for all their help. I would like to thank my supervisors, Dr Alison Bullock and Professor John Skelton, for their invaluable input and encouragement throughout the study. Finally, thank you to my family and friends for their support, particularly to Vickie, Melissa and Rob, and to Dave for his unrelenting patience. TABLE OF CONTENTS Chapter 1 Introduction 1 1.1 Background and educational context 2 1.1.1 Medical training in the UK 2 1.1.2 The importance of communication skills training 8 1.2 Research aims and scope 12 1.3 The structure of the thesis 15 Chapter 2 The doctor-patient relationship: policy and socio-cultural context 17 2.1 Policy context 17 2.1.1 Public and patient involvement 17 2.1.2 Increased accountability 28 2.2 Socio-cultural context 35 2.2.1 The doctor-patient relationship: a historical perspective 36 2.2.2 Access to health information 39 2.2.3 Mistrust of doctors 42 2.2.4 Consumerism 45 2.3 Discussion 48 Chapter 3 Medical education and the doctor-patient relationship: key influences 50 3.1 The influence of Balint 51 3.2 Models of the consultation 55 3.3 Promoting more equal power relations 59 3.4 Patient-centred medicine 64 3.5 Analysis of textbooks 74 3.5.1 Patients, doctors and the doctor-patient relationship 76 3.5.2 Insights from training texts 86 3.6 The need for further research 89 Chapter 4 Methodology 91 4.1 Underlying philosophical position: epistemology and ontology 91 4.1.1 Ontology 91 4.1.2 Epistemology 92 4.1.3 Philosophical position of this study 95 4.2 Research design 99 4.2.1 Iterative research design 99 4.2.2 Case study 102 4.3 Methods 106 4.3.1 Selection of methods 106 4.3.2 Ethical issues 110 4.3.3 Data collection 111 4.3.4 Data analysis 117 4.4 Summary 120 Chapter 5 Trainee doctors’ conceptualisations of the doctor-patient relationship 122 5.1 Findings from the scoping exercise 122 5.2 Trainees views: background information 123 5.2.1 Interviewees 123 5.2.2 Questionnaire respondents 124 5.3 Conceptual frameworks of the doctor-patient relationship 125 5.3.1 Paternalism 127 5.3.2 Guided decision-making 129 5.3.3 Partnership 131 5.3.4 Consumerism 135 5.3.5 Clinical 140 5.3.6 The doctor-patient relationship: questionnaire responses 142 5.4 Summary 150 Chapter 6 Adapting the doctor-patient relationship 153 6.1 Findings from the scoping exercise 153 6.2 Adapting the doctor-patient relationship 154 6.3 Factors affecting the doctor-patient relationship 154 6.3.1 The patient’s personality and preferences 155 6.3.2 Other patient characteristics 157 6.3.3 Condition 160 6.3.4 Specialty 164 6.3.5 Time 167 6.3.6 Doctor characteristics 169 6.3.7 Adapting the doctor-patient relationship: questionnaire responses 171 6.4 Summary 177 Chapter 7 Learning to develop relationships with patients 179 7.1 Learning to develop relationships with patients 179 7.1.1 Communication skills training 179 7.1.2 Informal training: experience and observation 183 7.1.3 An innate skill 184 7.1.4 Learning to develop relationships: questionnaire responses 185 7.2 Views of patient-centredness 193 7.2.1 The personal meaning of illness 194 7.2.2 A therapeutic alliance 198 7.2.3 Acknowledging the doctor’s limitations 201 7.2.4 Healthcare services 201 7.2.5 Patient-centredness in contrast to doctor-centredness 202 7.2.6 Views of patient-centredness: questionnaire responses 202 7.3 Summary 206 Chapter 8 Discussion and Conclusions 210 8.1 Summary of key findings 210 8.2 Study strengths and limitations 213 8.3 Barriers to partnership 219 8.4 The threat of consumerism 225 8.5 Implications for medical education 230 8.6 Conclusions and ways forward 239 8.6.1 What does this mean for postgraduate medical educators and trainees? 239 8.6.2 What does this mean for educational policy makers? 240 8.6.3 What does this mean for researchers? 242 References 246 Appendices 270 Appendix 1 Scoping exercise: interview schedule Appendix 2 Letter inviting interview participants Appendix 3 Interview consent form Appendix 4 Interview schedule Appendix 5 Pilot letter and feedback form Appendix 6 Questionnaire to ENT Specialist Registrars Appendix 7 Questionnaire to GP Registrars Appendix 8 Questionnaire respondents’ views: responses to paired statements List of Figures and Tables FIGURES FIGURE 1.1 Training pathway for doctors in this study 4 FIGURE 1.2 MMC career framework 5 FIGURE 3.1 The logical form of the consultation 56 FIGURE 3.2 Pendleton’s 7 tasks of the consultation 58 FIGURE 3.3 The patient-centred clinical method 70 FIGURE 3.4 Models of the consultation: a comparison 71 FIGURE 3.5 Competencies for physicians for informed shared decision making 72 FIGURE 3.6 Different types of patient 78 FIGURE 5.1 Responses to paired statements: deciding between treatment options 145 FIGURE 5.2 Responses to paired statements: paternalism 146 FIGURE 5.3 Responses to paired statements: involving patients 146 FIGURE 5.4 Responses to paired statements: patients becoming demanding 147 FIGURE 5.5 Responses to paired statements: responsibility for health 147 FIGURE 6.1 Responses to paired statements: impact of specialty 172 FIGURE 6.2 Responses to paired statements: impact of time 173 FIGURE 6.3 Responses to paired statements: different patients 173 FIGURE 7.1 Responses to paired statements: innate or teachable? 192 FIGURE 7.2 Responses to paired statements: levels of training 193 FIGURE 8.1 Further research: possible research questions 243 TABLES TABLE 3.1 Profile of textbooks 75 TABLE 5.1 Profile of trainee population and interview sample 124 TABLE 5.2 When respondents started specialist training 125 TABLE 5.3 Number of paragraphs coded by each framework 126 TABLE 5.4 Trainee views: the doctor-patient relationship 144 TABLE 5.5 Decision-making in a recent consultation 149 TABLE 6.1 Factors affecting the doctor-patient relationship 155 TABLE 6.2 Trainee views: adapting the doctor-patient relationship 171 TABLE 7.1 Learning to develop relationships with patients 186 TABLE 7.2 Differences in learning between specialties 189 TABLE 7.3 Trainee views: learning to develop relationships with patients 191 TABLE 7.4 Questionnaire respondents’ understanding of patient- centredness 204 CHAPTER 1 INTRODUCTION This thesis is an investigation into trainee doctors’ perceptions of the doctor-patient relationship. It adopted a case study approach to explore the perceptions of postgraduate trainees in two medical specialties, general practice and otolaryngology (commonly called ear, nose and throat surgery, or ENT), in the West Midlands region of the United Kingdom (UK). Interviews and questionnaires explored trainees’ views of the doctor-patient relationship, including their perceptions of the nature of that relationship and how they had learnt to develop relationships with patients.