Academic Medicine Comment on Patient

Academic Medicine Comment on Patient's and Physicians Views of Health in a Rural Area by Verby November 1989 665-6

In Patients' and Physicians' Assessments of Patients' Health in Rural Mississippi (page 669), Lampley and Randolph raise important issues and provide a starting place for future research. The study has easily recognized limitations, but its implications are worth noting for everyone concerned with issues of rural health and communication between doctors and patients.

The study brings to our attention two valuable points: (1) the gap between patients' and health workers' views of illness, wellness, and the patients' reasons for seeking - and not seeking - medical help, and (2) the need for both to narrow that gap by learning from one another. In short, the study highlights that patients can view their health quite differently than do their physicians, which means that physicians need to learn about what patients think and feel about their health.

Narrowing the gap will be difficult, partly because many physicians do not have the special interviewing skills they need. To interview a patient perceptively, achieve a mutual understanding of the patient's illness, and motivate the patient to seek appropriate help if necessary all require interpersonal and persuasion skills. (They also require time - sometimes a great deal of time - but that additional difficulty I will postpone for a few paragraphs.)

Interpersonal and interviewing skills are particularly important in working with patients whose problems appear to have no biological basis and who refuse to disclose to themselves or the physician important personal, psychological, economic, social, and sexual aspects of their lives that influence their health and their perceptions of it. Patients with less than a high-school education and elderly patients are often the ones who need the physician's most sensitive and extensive efforts to educate them to those hidden areas of their lives that may have both fleeting and long-term health effects. The patient's education includes learning to interpret what the physician is saying. And the physician needs to interpret what the physician is saying, by being astute in analyzing verbal and nonverbal behavior in each person who comes for help, and being able to communicate to the patient the health assessment that the physician and perhaps other health professionals have made.

These problems are compounded in poor rural areas where patients have little access to health care, where the background of patients and doctors may be wisely different, and where people may postpone medical treatment because of poverty. But some of the problems stem from the physicians' training.

Over the past 18 years, the staff and I in the Rural Physician Associate Program (RPAP) at the University of Minnesota School of Medicine have been involved with over 500 third-year medical students. We have found that a large majority of them have not been observed completely, during their entire medical school experience prior to RPAP, doing a thorough history or a complete physical examination. Of those who said they had been completely observed doing both prior to RPAP, a significant number were doing portions of the physical examination and/or history inappropriately. How many of our medical schools are neglecting to train their students in these skills? How many are aware of the crucial importance of such skills?

The answers to these questions may not be reassuring. As of this writing, there is, so far as I know, no required standard course in most U.S. medical schools to help physicians improve their interpersonal skills with patients, especially the skills involved in understanding and persuasion. The reason seems to be lack of faculty trained to teach the importance of developing relationship of trust and rapport with patients tend the ways to do so. Further, they are not taught the importance of this rapport as part of therapy and healing. (In our efforts in Minnesota, which have spanned the last 15 years, we call treatment using interpersonal skills and understanding the Adoctor-drug.@)

Abrahamson and Lee^{1 emphasized the Afocused interview@
for second-year medical students, which is similar to the kind of interview
taught in the RPAP to the third-year students. In such interviewing, the RPAP
students are actively involved in emphasizing the quality of the interview
rather than simply whether it meets certain requirements of length and content;
the students are trying to identify the Aproblem behind the problem.@ The RPAP
students interview actual patients in real consulting room settings in
physicians' offices rather than simulated Astandardized@
patients in the classroom. The students work with five of these patients over a
nine- to 12- month period. Intensive follow-up needs to be done during the
senior year and during physicians' residency training so
that they will not lose the interpersonal skills after the third year. I feel
this sort of training should be much more widespread.}

The Mississippi study by Lampley and Randolph presents a sobering picture of the difficulties physicians and patients face in achieving effective communication even when the physicians are well trained. Reviewing the information about the conditions under which the clinic operated, it's not hard to find some of the reasons for there being differences between the patients' and physicians' assessments of the patients' health. In Benton County, the three physicians employed at the clinic at the time of the study were responsible, in theory, for over 8,000 people, plus many more near the other side of the county. Approximately 87% of the country's population had less than 12 years of formal education, and 19% were over 60 years old.

Because Medicaid and Medicare have for some time been the primary modes of payment for services in the county, a large amount of professional time is spent interpreting regulations and fulfilling requirements of documentation. In addition, there are often long periods of delay in payments for services rendered, which add to the workload. Numerous other administrative demands on the physician by non-medical clerical staff decrease the time available for seeing patients. Likewise, the lack of time and energy available for interacting with the patient decreases the chances that good communication - and a narrowing of the health assessment gap - can take place.

As interesting and interactive as the Mississippi study is, there are flaws that should be noted. The authors report that almost half of the health status ratings of the black men and the physicians did not agree. I think that the racial background of the physicians should have been mentioned in the study, since this may be significant; tradition and culture and the attitudes they foster may have had effects on the relationship and understanding between the physicians and their black male patients.

The small sample may have given misleading results. In addition, the analysis in the study may be affected by defining Apoor,@ Afair,@ Agood,@ and Aexcellent@ for the physician but not for the patients, especially for the black men. In addition, combining Apoor@ and Afair@ into@poor,@ and combining Agood@ and Aexcellent@ into Agood@ may again have affected the numbers and distorted the results. Also, the authors indicate that the county is economically and medically depressed, which may be directly related to the black men's attitudes, behaviors, and self-esteem. Some of these men - perhaps many - were unemployed, and unemployed people are more likely to be depressed and to underestimate their health status.

Nevertheless, the basic approach of this kind of study needs to be repeated by other health researchers in similar county environments. For although Benton County, Mississippi, is not typical of the United States as a whole, numerous counties throughout the country have similar problems. This study clearly shows that the possibilities for physician-patients misunderstanding are great and must be studied so they can be addressed.

John E. Verby, M.D.

Dr. Verby is Professor of Family Practice and Community Health and has been Director, since its inception in 1971, of the Rural Physician Associate Program, University of Minnesota Medical School, Minneapolis, Minnesota. Before coming to the medical school, he was in private practice in Minnesota for 20 years.

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Reference

1. Abrahamson, S., and Lee, P.V., Teaching the AFocused Interview@: ^{A Workshop for Second-Year Students, Acad. Med. 64(1989):24}