Methods and Variables Stage

The videotapes to be used in the analyses were chosen by a senior lecturer in communication skills who has vast experience of facilitating communication skills courses for doctors and nurses with differing abilities. The selection was made from a pool of 100 doctors each of whom had 4 MIPSED consultations. Twenty doctors were chosen: 10 whom the senior lecturer considered to be effective communicators and 10 she considered to be less skilled. Fourteen of those selected were consultants and the remainder specialist registrars working in oncology. For each doctor, the corresponding 4 videotaped consultations were reviewed by the senior lecturer in order to compile written feedback and make a global judgement, based on her experience, as to whether the doctor was skilled or less skilled. The reports compiled for each doctor can be found in appendix 13, The identification codes for the two groups of 10 doctors were given to the author so that comparative tests could be conducted on key MIPS variables. Stage II

This stage involved deciding which MIPS indices to compare between the 'skilled group' and the 'less skilled group'. Rather than test for differences between every MIPS variable it was decided to test the key skills most likely to discriminate between the two groups.

Millar and Goldberg (1991) have argued that the ability to identify emotional disturbance and the ability to manage emotional illness are characteristics of a superior interview style and reflect the possession of good communication skills. These authors demonstrated that there are wide variations between family doctors in the way in which they interview their patients and in their ability to make accurate assessments of emotional distress (Goldberg & Huxley, 1980). As mentioned in chapter 2, Goldberg and colleagues found that doctors who were better able to identify emotional distress made more eye contact with patients throughout the interview.

interrupted the patient less, made more facilitating noises, responded to verbal cues suggestive of emotional distress, asked more questions about patients' feelings, enquired about home life, made supportive comments and maintained eye contact (Marks et al, 1979).

Fundamental skills for good communication, regardless of the clinical context, include listening, empathy, response to cues and appropriate use of reassurance (Razavi and Delvaux, 1997).

Direct scrutiny of interactions between health professionals and patients with cancer has found that there is a lack of training in key interviewing skills and fears about the adverse effects of enquiring about patients' reactions to their predicament (Maguire, 1985). Furthermore, health professionals in cancer care have difficulty in eliciting patients' concerns about their illness and treatment (Heaven & Maguire, 1996). From a series of 12 residential workshops on communicating with cancer patients, Maguire et al (1996a) established which skills most promoted patient disclosure and which inhibited it. Skills that promoted disclosure included: acknowledging and exploring verbal cues, open directive questions, establishing and maintaining eye contact, being empathie, summarising and making educated guesses. Empathy is one of the key skills in building the doctor-patient relationship (Spiro, 1992). It involves the understanding and sensitive appreciation of another's predicament or feelings and the communication of the understanding back to the patient in a supportive way (Silverman et al, 1998). Skills that inhibit disclosure included: premature reassurance, closed and leading questions and narrow physical focus.

Maguire (2000) also advocates a patient-centred interviewing style for promoting patient disclosure, described by Stewart (1995):-

An interviewing style which both focuses on eliciting symptoms and signs o f illness and shows genuine interest in patients as individuals, their reasons fo r seeking help, their perceptions o f what might be wrong, their feelings about this and the impact o f any problems on their daily lives, mood and personal relationships is more effective, leading to greater patient compliance with advice and treatment, as well as to greater patient satisfaction.

The skills and approaches cited above informed the choice of MIPS variables for the comparative analysis. These are presented in table 8.1. As there were only 4 coded interviews per doctor it was decided to combine some variables and calculate others using ratios in an attempt to avoid empty cells. It was expected that skilled doctors would exhibit significantly more disclosure- promoting behaviours and significantly fewer inhibitory behaviours than the less skilled group.

Variables Used in the Analyses

There were 3 main sets of variables used in the analyses. These were (1) ratio variables, (2) combination and single variables and (3) global and non-verbal ratings. 1) MIPS ratio variabies

In order to include variables with low frequencies and to control for differences in consultation length, 5 ratios were calculated:

(i) Patient focused : disease focused. This ratio concerns the amount of input patients have in the consultation (being able to ask questions, disclose concerns and give psychological information), and how much empathy and support they were given in comparison to how many physical questions they were asked by the doctor and how much physical information they received. Ideally a doctor should adopt an interviewing style that seeks to elicit symptoms of physical illness, and also demonstrate an interest in the patient as a person. It was predicted that skilled doctors would have a higher ratio than less skilled doctors.

(ii) Psychosocial focus : physical focus. This is the ratio of patients' concerns, psychosocial disclosure, Drs' non-physical counselling and psychosocial questions versus patients' physical information, Drs' physical counselling and physical questions. It is important for doctors to focus equally on physical and non-physical issues, so that patients realise that non-physical aspects are just as important as physical issues. Physical in this context refers to all the MIPS medical categories (set out in table 5.6, chapter 5). These are: Med, Omed, Tests, Tmt, S.Effs and Drugs. It was predicted that less skilled doctors would focus more on physical than psychosocial aspects.

iii) Dr disclosure-promoting : Dr Inhibitory behaviours. The variables used in this ratio are Dr non-physical focused open questions, reflective questions, empathy/reassurance, checking and summarising versus Dr directing/advising physical aspects, false/premature reassurance and physical leading questions. Non-physical in this context refers to all the MIPS psychosocial variables (set out in table 5.6, chapter 5). These are Psych, Lstyle, SocDem and SocCon. It was predicted that skilled doctors would have a higher ratio than the less skilled group.

iv) Dr listening : Dr Information-giving. Attentive listening is a basic interviewing skill. Using the MIPS, this is signaled by the doctor registering information or using 'verbal head-nods', such as ahuh; okay etc. A patient centred interview is one in which the clinician listens as much as he or she talks.

v) Number of missed cues : total number of patient cues (%). By immediately picking up on patients cues a doctor can signal an interest in what the patient is going through. This tends to be an advanced communication skill. It was predicted that less skilled doctors would have a higher percentage of missed cues than their more skilled counterparts.

2) Combination and single variables