A regular topic at Croakey is how social and economic factors contribute to health inequalities and inequitable access to health services.
But what about how these things affect communications and relationships between doctors and patients?
A recent systematic review, published in the International Journal for Equity in Health, identified 20 research papers and meta-analyses published between 1965 and 2011 on the social gradient in doctor-patient communication.
The researchers, from Belgium, found evidence that patients from lower social classes (measured by income, education or occupation) are treated differently by doctors, and also interact differently with doctors compared with better off patients.
Thanks to Mae Hurley, editorial services manager at RaggAhmed, for providing this report on the study, and its implications for Australian patients and health professionals.
(And beneath her article are links to some recent national and global news on health inequalities).
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The social gradient and doctor/patient communication
Mae Hurley writes:
We’re all equal in front of our doctors, but some people are more equal than others. People from wealthier backgrounds tend to have better health.
But how much of this is linked to the way doctors communicate with their patients?
A recent literature review showed that patients from lower socioeconomic backgrounds tended to receive less information and less communication time during a consultation, but more physical examination.
In contrast, people from higher socioeconomic backgrounds tended to receive more information overall, with doctors listening, explaining and also participating in more ‘relationship-building’ with them.
The results come as no surprise to Dr Ronald McCoy, Senior Medical Educator at the Royal Australian College of General Practitioners.
Patients from higher socioeconomic backgrounds are likely to be more health literate, he says, and people from poorer backgrounds can sometimes feel disempowered when interacting with a health professional.
It’s a message that Carol Bennett, CEO of Consumers Health Forum of Australia, echoes. She says that people from lower socioeconomic backgrounds, older people, those with a disability or mental illness, or from marginalised communities, are least likely to be health literate. “And they don’t ask the kind of questions that health professionals respond to.”
Doctors are among the most highly educated people in society, and their expert status and knowledge give them a ‘natural’ authority in discussing health care. This makes it easier for them to direct patients in a consultation through specific questions and in discussing treatment options and providing solutions.
But the best consultations include a conversation that is two-way, with the doctor as an active listener, creating an environment comfortable enough for the patient to share their concerns so they can ask the questions at the back of their minds, without feeling conscious or stupid. “A good practitioner will know how to cross that divide,” says Bennett.
Where once patients were fortunate to have an approachable doctor with natural empathetic qualities, communication training has been actively part of a doctor’s toolkit in the last ten to twenty years.
The curriculum for Australian general practice outlines five domains of general practice, and ‘communication skills and the patient-doctor relationship’ features prominently.
“There’s no mistake as to why it’s first on the list,” McCoy says, “It’s the foundation of everything we do. It can make or break a consultation.”
Good communication can be taught and medical students today often role-play in consultations as part of their studies.
At the University of Sydney, actors are hired to represent different kinds of patients the students may encounter in the future. “And the ‘patient’ gives them direct feedback on their communication,” explains Professor of Medical Education Merrilyn Walton.
“Many doctors see communication as a ‘soft’ skill because it’s not technical,” she says. “But usually the technical works really well. It’s the soft skills that are really hard.”
Helpful communication strategies
What are some of the communication strategies doctors can use to create a good environment and build trust with their patients?
Asking open-ended questions is essential, as it allows patients to speak about problems in their own way. Explaining things in non-medical jargon is also more likely to resonate, even with patients who come from higher socioeconomic backgrounds, and speaking in a slower and deliberate manner gives patients more time to take in new information and sends the message of not being rushed.
Towards the end of a consultation, doctors can also check understanding by asking patients how they might recount their visit to the doctor to a family member or friend. Again, by listening to how the patient characterises their experience, including any possible or agreed treatment of their problems, doctors can be aware of what the patient will take away once they leave the room.
Understanding the wider social context their patients live in is essential, according to Bennett. “They have to treat the person in the holistic sense,” she says. In getting a history from a patient, doctors need to understand “how that person lives, and how they’ll be taking the treatment. All health and medical issues are played out in a context.”
If all these considerations are a big ask for doctors as time ticks along quickly in a consultation, the results of Australia’s most recent survey of patient experience wasn’t too bad. It shows that most people were satisfied with the way they were treated by health professionals.
Around 80% of people reported that they always, or often, felt that their health professionals listened carefully, showed respect or spent enough time with them. Although rates of satisfaction were high for patients in general, those from areas that were most disadvantaged reported slightly lower rates of satisfaction than those from areas of least disadvantage, particularly in relation to hospital doctors and specialists.
Walton emphasises that the patient’s preferences are paramount in any consultation. Without it, she says, “it’s half-hearted medicine”.
But there are things patients can do to make sure they’re getting the best out of the consultation, such as writing down questions in advance so they’re more prepared when they see their doctor. And if it gets to the point where it’s required, changing doctors if possible.
Self reflection is important
Beyond communication skills, McCoy believes that reflecting on their own preferences and practices will help doctors. Sometimes, he explains, there can be a fear in engaging with patients, especially those who are different from them. “We need to be conscious of our own biases and prejudices,” he says, “rather than suppressing them.”
He cites an example of a patient with mental illness who smokes, with poor consequences on their health. However, this is not addressed by the clinician due to the clinician’s own attitude, which may be that smoking is the one comfort the patient has. “But if you talk to people, they can change their lifestyles,” he says. “But you’ve got to give people that option.”
It’s about communicating the same values and treatment for each patient that walks through the door, McCoy adds. This is the kind of approach that leads to more equity in health care.
From her time as a Health Care Complaints Commissioner, Walton has seen many errors in poor communication. “And it wouldn’t have got to that situation if there was better communication and more openness.”
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Related reading
Health inequalities remain an ongoing concern, says COAG
Health inequalities are an ongoing reality in Australia and do not appear to be getting any better, according to the third annual report on the National Healthcare Agreement, released recently by the COAG Reform Council.
Clause 5 of the National Healthcare Agreement says that ‘…the healthcare system will strive to eliminate differences in health status of those groups currently experiencing poor health outcomes relative to the wider community’. This includes Indigenous Australians, people living in remote areas, and people living in socio-economically disadvantaged areas.
A supplement to the report, Healthcare 2010-11: comparing outcomes by socio-economic status, gives dozens of examples of health inequalities, including:
- Incidence rates of lung cancer show a clear relationship to socio-economic status—as the level of disadvantage declines, so too do lung cancer rates
- End-stage kidney disease rises significantly and in step with the level of disadvantage
- The rate of potentially preventable hospitalisations increases in step with disadvantage
- People in the most disadvantaged areas also reported financial barriers to seeing a range of medical professions at rates that were higher than those living in the least disadvantaged areas
- Rates of services for various types of healthcare also showed variation according to socio-economic disadvantage, with people in the most disadvantaged areas having lower rates of: dental services overall, though particularly private dental services; optometry services; ambulatory mental health services
- While emergency department waiting times shows little variation according to the socio-economic disadvantage of the patient, elective surgery waiting times do vary. Waiting times are consistently longer for people living in more socio-economically disadvantaged areas. The degree of difference between waiting times for patients from the most and least disadvantaged areas is more acute than is seen for remoteness
- Cancer survival rates reflect not only on the quality and appropriateness of hospital care, but also on primary care and preventive health. Five-year survival rates increase as disadvantage decreases
- Key indicators for aged care services suggest people from socio-economically disadvantaged areas have poorer access to at least some aged care services
- The rate of hospitalisations for injury and poisoning is about 50% higher in the most disadvantaged areas compared to the least disadvantaged
- The rate of births to teenage mothers—which is more than eight times higher in the most disadvantaged areas and increases in clear step with each decile of disadvantage.
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Spend more on education to reduce health costs?
Investments in education would do far more to drive down health care costs than simply reforming the health care system, according to Dr Steven Woolf, of the Center for Human Needs at Virginia Commonwealth University.
“If there was one thing that modern medicine could do to improve health outcomes, it would be to solve the high school dropout problem,” he said.
Woolf said surveys show most people believe that hospitals or access to doctors determines how healthy people are. But Woolf and his colleagues have found that social determinants ranging from education and poverty levels to jobs, neighbourhoods and family support systems have a far bigger impact on a person’s health.
Interestingly, the report on his comments came from an online health policy news site covering Colarado and the Rockly Mountain West, called Solutions. It is a project of the Buechner Institute for Governance at the School of Public Affairs at the University of Colorado Denver, and features in-depth reporting and analysis, expert commentary, links to supporting research and discussions. The website is funded through foundation grants and staffed by professional journalists.
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Engage the public in understanding health inequalities says new study
Public health advocates need to do a better job of informing the public about health inequalities, conclude the authors of a study in Ontario exploring public awareness of the matter.
“Given that political will is shaped by public awareness and opinion, these results suggest that greater awareness may be required to move the health equity agenda forward in Ontario,” report the researchers in the International Journal for Equity in Health.
“There is a need for health equity advocates, physicians and researchers to increase the effectiveness of knowledge translation activities for studies that identify and explore health inequalities.”
Meanwhile, the Canadian Medical Association (CMA) has called on the Canadian Government to conduct a health impact assessment as part of its policy development process to ensure that the health of Canadians is a key factor in every policy decision it makes.
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Sharing successes online
The Prevention Institute in California in its Communities Taking Action project uses an interactive map to profile successful community initiatives aimed at improving health equity across the US.
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Need more than equitable access to healthcare to solve health inequalities
A recent modelling study investigating SES differences in cardiovascular mortality reductions in England between 2000 and 2007 suggests that equitable access to healthcare is not enough to ensure reductions in mortality are shared equitably.
Here is the editor’s summary:
The researchers found that between 2000 and 2007, death rates from coronary heart disease fell from 229 to 147 deaths per 100,000—a decrease of 36%. Both death rates and the number of deaths were lowest in the most affluent quintile and the pace of fall was also faster, decreasing by 6.7% per year compared to just 4.9% in the most deprived quintile.
Furthermore, the researchers found that overall, about half of the decrease in death rates was attributable to improvements in uptake of medical and surgical treatments. The contribution of medical treatments to the deaths averted was very similar across all quintiles, ranging from 50% in the most affluent quintile to 53% in the most deprived.
Risk factor changes accounted for approximately a third fewer deaths in 2007 than occurred in 2000, but were responsible for a smaller proportion of deaths prevented in the most affluent quintile compared with the most deprived (approximately 29% versus 44%, respectively). However, the benefits of improvements in blood pressure, cholesterol, smoking, and physical activity were partly negated by rises in body mass index and diabetes, particularly in more deprived quintiles.
These findings suggest that approximately half the recent substantial fall in deaths from coronary heart disease in England was attributable to improved treatment uptake across all social groups; this is consistent with equitable service delivery across the UK’s National Health Service. However, opposing trends in major risk factors, which varied substantially by socioeconomic group, meant that their net contribution accounted for just a third of deaths averted. Other countries have implemented effective, evidence-based interventions to tackle lifestyle risk factors; the most powerful measures involve legislation, regulation, taxation, or subsidies, all of which tend to be equitable. Such measures should be urgently implemented in England to effectively tackle persistent inequalities in deaths due to coronary heart disease.
I’ve got 2 doctors in the family. Generally the lower socio-economic classes just want ‘The Doc’ to ‘fix ’em’. They don’t want to know, don’t care, and won’t listen to much advice or communication from their doctor. I hear story after story of my Aunt patiently explaining to patients (she volunteers for clinics in poor areas) why certain things are dangerous, have potential side effects, etc but they come back 2 weeks later with the same problem. She runs through the spiel again and eventually gives up, and just writes the script that will solve the short term issue. There’s only so much talking to a brick wall you can do before you realise it’s pointless. Generally these people arrive because they have some sort of crisis they need resolved.
Those who are more ‘well off’ generally have a worldview of Prevention: eg, avoiding falling off the cliff in the first place. They are future-minded people who think of consequences and plan. The lower socio-economic bloc tend to have a worldview that falling off the cliff happens to someone else – then when it does, they want an Ambulance at the bottom with a magical resurrection device that fixes everything (the Doctor).
Fundamentally, it’s a difference in patient world views. Therefore, it is no surprise Doctors find common ground and communicate much better with those who share the same world view.
Volumes have been written on ‘health communication’, including recent suggestions which highlight effective ways of communicating with men. However, after some years studying health literacy and modifiable risk factors for disease, I have to say that…JSW is absolutely right: there are the worried well, and then there are those who ‘don’t want to know, don’t care, won’t listen,’ and the latter may out-number the former by a fair margin. The reasons are many and varied, and include not only lack of knowledge and sense that ‘it won’t happen to me’, but also: skepticism about causes and effects for disease; confusion about seemingly contradictory information and advice; not wanting to bow to moralistic ‘healthism’ or the ‘agendas’ being run by governments and health groups; and a belief that ‘prevention’ means giving up just about everything that makes life enjoyable. There is some evidence to support the claim that your ‘world view’ (or at least your ‘life view’) affects how you run your health-life: research has shown that ‘masculinity beliefs’ are far more important than socio-economic class, education, occupation, etc. when it comes to men adopting and providing a context for preventive behaviours. This should not be taken as an endorsement of the ‘individual responsibility’ view of health, however: we need to look for ‘the causes of the causes’ to consider what encourages people to have the attitudes that they do and whether these are amenable to change or whether it will be more productive to focus on making the healthy choices easier and requiring less conscious and deliberate individual action.