GULiVer. Travelling into the heart of good doctor-patient communication from a patient perspective. An international multicentre study

Background: A growing body of evidence is demonstrating the importance of a patient centered approach (PCC) in improving health outcomes, including adherence to treatment. Accordingly, concerted efforts have been made by researchers to define the crucial skills that are required to implement PCC in clinical practice. Despite these efforts to bestow the patients a central position in their own health care, the patient's perspective is rarely taken into account underlying the need of more direct approaches to voice patients’ opinions on the quality of doctor-patient communication. Aim: GULiVER is an international, multicentre project developed to explore how lay people in the Netherlands (Utrecht), the United Kingdom (Liverpool) and Italy (Verona) evaluate physicians’ communicative performance. Method: In each centre two set of 4 videotaped OSCE consultations presenting two clinical scenarios was shown to 8 lay panels of 6 to 9 participants each. Among each set, the four medical students differed in their communication skills as assessed by the OSCE examiners and the standardized patient (High-High; High-Low; Low-High; Low-Low). The selection of lay participants was based on two stratification criteria: gender (separate male and female panels) and age (each panel including at least 2 persons across the age bands 18-30; 31-50; >50). Background characteristics included socio-demographics, participants’ own health (COOP-WONCA) and mental health (GHQ), communication preferences (QUOTE-com), and trust in doctors (TMP). Participants were asked to give their assessment, individually or in groups, on different aspects of student-doctor communicative performance through both quantitative (questionnaires) and qualitative (focus groups) assessments in a mixed-methods design. Inductive content analysis was applied to qualitative data (focus groups) to generate a coding system and produce several categories. Descriptive statistic was then applied for the frequency count distribution. Results: The overall sample comprised 211 participants, equally distributed among the centres (64 from NL, 72 IT, 75 UK) and balanced in terms of age, gender and scenario, confirming the quality of collected data. The distribution curves of participants 1-10 evaluations of the 4 videos were less skewed than expected, based on the Expert and SP ratings, particularly for the student-doctors HH (good performance) and LL (low performance) (Skewness index –0.3 for HH and -0.06 for LL). Among the variables under study, only the level of education resulted significantly negatively related with participants’ 1-10 evaluation (secondary and higher school versus none/primary school respectively: =-0.53, p=-0.03; =-0.64, p=0.01). Categories count of frequencies showed that participants placed high importance on a doctor who was: competent, self-confident, able to get a complete picture of the patients’ problems, reassuring, nice, interested in the patients’ problems, and flexible in adapting the structure of the interview to the patients’ needs. Moreover 20% of participants disliked a doctor who shared plans and ideas with the patients Discussion and conclusion: To date, the protocol and some preliminary results have been presented, which have led to the following observations: Overall, the lay participants’ ratings of the student-doctors’ performance were not always consistent with the OSCE-based classification of the 4 videos suggesting that lay people have different criteria when they evaluate the communicative quality of a medical consultation. The interpersonal and nonverbal attitudes of a doctor play a fundamental role in patients’ evaluations. Training courses should therefore avoid underestimating the role of these basic relational aspects, which are at risk to be taken for granted. Notably, a high proportion of people rated attitudes that focused on involving them in decisions as negative and seem to prefer a paternalistic approach, based on the construct “the doctor knows the best.” Further analyses will deeply explore users’ socio-demographic and clinical variables according to focus group to dissect these differences in greater detail. Finally, the participants’ assessments varied widely and, therefore, the ability to adopt a flexible interview style that responds to individual needs is fundamental in implementing a truly patient-centered approach.