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Using qualitative methods to understand the patient/GP conversation:
This project was funded by a Cancer Research UK Early Diagnosis Advisory Group grant. The aim of this proposal was to use qualitative methods to explore real-life patient-GP communication and to provide recommendations to improve communication within consultations in order to improve patient experience and timely diagnosis of cancer.
The objectives were:
1. To use qualitative observations and interviews to observe real-life patient-GP conversation about symptoms including how patients declare new symptoms and how doctors elicit information about new symptoms
2. Identify patterns of successful and unsuccessful elicitation of symptoms
3. To provide recommendations about communication within consultations in order to improve patient experience, patient safety (e.g. safety netting) and timely diagnosis of cancer and other serious conditions
Results/conclusions
1. We collected 80 video observations of GP-patient consultations, and 27 interviews with GPs and patients with new or persistent symptoms. We analysed this data qualitatively to produce patterns of communication around new and persistent symptoms, and discovered that the conversation revolves around presenting problem (PP) significance. PP significance is determined by the risk or relevance of elicited symptoms to disease but also the emotional impact as experienced by the patient. Doctor and patient views of significance could differ mainly because they defined and, crucially, expressed significance differently – the doctor expressing it in terms of medical guidelines (medical significance), and the patient expressing it in terms of what the presenting problem means to him or her personally (personal significance). Our analysis was not limited to symptom elicitation as planned in the research proposal, but also to the discussion of symptoms once elicited. This is because we found that negotiations of significance continue throughout the consultation, in a dynamic way that we have termed ‘alignment’. GP and patient could be aligned or misaligned at any point, and most misalignments were resolved by the end of the consultation. Misalignments vary in degree; some were more obvious and were openly discussed, whilst others were more subtle, and not recognised by the doctor and/or the patient. We also identified different types of alignment (e.g. cognitive vs emotional). Resolution was easier when the misalignment was a simple difference in knowledge without (obvious) emotional factors.
2. Twenty-five (31%) consultations involved a misalignment, suggesting that this is a common problem. We subjectively judged four of these to have been unresolved at the end of the consultation, and three only partly resolved. We deemed a GP-patient conversation to be ‘unsuccessful’ if there was a persistent misalignment during the consultation. We identified patient behaviours with potentially harmful consequences for timely diagnosis that resulted from both cognitive and emotional misalignments. Examples include non-attendance at follow-up appointments, declaring lack of trust in the primary care doctor to help resolve problems and deciding to seek help elsewhere.
3. We convened our advisory group to generate recommendations based on our nascent findings. One potential explanation for why emotional misalignment is harder to recognise and resolve in our study than cognitive misalignment could be that eliciting ‘ideas’ (i.e. patients’ hypotheses about what is wrong) is more straightforward than eliciting patients’ underlying concerns and expectations. Evidence suggests that doctors’ awareness of patients’ health beliefs differ significantly from patients’ actual beliefs and falsely believe that patients’ beliefs are aligned with their own. Our advisory group produced the following recommendations with implications for policy/practice: · Strategies for increasing awareness could include pre-consultation assessment of patients’ beliefs. ·
Key recommendations:
• Positive examples of GP practice in relation to resolving misalignment should be foregrounded in our research.
• Emotional complexity should be explored in more depth – we are currently preparing a paper on this topic.
• It was noted that there are currently no interventions that involve engaging patients in the cancer diagnostic interval (clarified by a recent systematic review) and this should be a key focus of future research.
• Our findings should be embedded in existing cancer education tools (e.g. Gateway C) https://www.gatewayc.org.uk/
Principal Investigators: Dr Georgia Black and Dr Katriina Whitaker (University of Surrey)
Project Staff/Co-investigators:
Dr Yin Zhou, University of Cambridge
Researchers:
Dr Dorothee Amelung
Patient collaborators:
Margaret Ogden
Debby Lennard
Clinical/organisational collaborators:
Dr Hardeep Singh, Baylor College of Medicine
Dr Fiona Walter, University of Cambridge - Clinical School
Collaborators:
Dr Georgios Lyratzopoulos, University College London
Dr Jessica Sheringham, University College London
Professor Kathy Pritchard-Jones, UCLH Cancer Collaborative
Professor Charles Vincent, University of Oxford
Funder: Cancer Research UK Early Diagnosis Advisory Group
Start Date: 2017
Duration: 18 months
Contact: Dr Georgia Black g.black@ucl.ac.uk