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Background

Methods

Conclusion

Patient-physician communication is an overlooked aspect of care in low-income countries, despite its proven significance in improving patient outcomes.

Miscommunication leads to burdens on healthcare, including misdiagnoses and poor treatment adherence, and on the economy and healthcare resources, resulting in wasted expenses on repeated visits due to poor communication and complications arising from misdiagnoses.

The findings demonstrate inconsistency in the application of communication standards during physician-patient interactions in low-income settings. Logistical barriers such as time constraints and high patient volume further hinder effective communication. Offering training, constructive feedback, and better work environments could help overcome these issues.

Learn More

We conducted a qualitative descriptive study of two phases at the gastroenterology (GI) outpatient clinic in Latakia University Hospital in Syria.

OBSERVATION PHASE

44 outpatient visits to 9 resident physicians (convenience sampling) was done as part of the first cycle of an ongoing clinical audit to identify gaps in adhering to the NICE recommendations on adult patient experience.

INTERVIEWS PHASE

Semi-structured interviews with 11 GI residents investigated the reasons behind those gaps and proposed solutions to guide the implementation of change in the ongoing clinical audit.

We used thematic analysis and applied a hybrid coding approach, combining deductive codes based on existing communication frameworks with inductive codes emerging from participants’ narratives.

Thematic analysis of the interviews identified

4 key themes:

Suzana Sultan^1#, Maya Sabboh^1#, Jameel Suliman^1#, Hasan Ashkar¹,

Daad Daghman², Abdul Fattah Mohandes³.

1 Faculty of Medicine, Latakia University, Latakia, Syrian Arab Republic.

2 Department of Gastroenterology, Latakia University Hospital, Latakia Syrian Arab Republic.

3 Faculty of Medicine, University of Aleppo, Aleppo, Syria.

# Contributed equally.

Patient-Physician Communication in a University Hospital in Syria:

A Qualitative Study of Two Phases on Challenges and Proposed Solutions

Introduction

Low-income countries lack structured training and application of effective communication. The relevance of high-income countries' approaches is questionable when applied to the low-income countries' resources and societal contexts.

We aim to assess the current application of patient-physician communication standards by resident physicians, identify deficiencies, and propose suggestions for communication skills applications at a major university hospital in a low-income country.

Observation revealed

limited adherence to four main communication aspects:

1. establishing acquaintance between residents and patients,

2. personalization of communication,

3. indirect communication,

4. and empathy.

Results

Barriers to effective communication

Related to patients,
Related to residents,
Other factors

Recommendations to improve communication quality

Need for

consistent training,
better clinic time and resource management,
structured feedback systems

Status quo of communication skills

Limitations in the four mentioned communication aspects),

Residents’ perceptions

Mismatch between knowledge and skills,
Subjective approaches,
Resource variability,
Reliance on self-experimentation

Barriers to communication		Proposed recommendations
Residents barriers	Inconsistent perceptions of the qualities of effective communication	Need for consistent training by specialists in basic communication concepts
	Lack of objective training
	Lack of feedback on communication	Need for developing a guide and a positive feedback system
	Work-related stress
Other Barriers	Logistical factors	Need for better time and resources management in outpatient clinics
	Time limitations
	Patient privacy compromise	Focused communication training on dealing with different patient backgrounds and demographics
	Cultural, societal and economic contexts
	Difficulty discussing certain topics
Patient barriers	Presuppositions, unmet expectations	-
	Perceptions of residents credibility	-

Table 2 : Identified barriers to effective communication and proposed solutions

Assessment Point	Perfect Adherence	Moderate Adherence	No Adherence	Reasons for the Lack of Adherence	Interview-based theme
Did the doctor ask for the patient’s name at the beginning of the interview?	80%	12%	7%	NI	NI
Did the doctor call the patient by their name most of the time?	0%	22%	78%	Lack of time - Excessive workload- Lack of perceived importance	Most physicians agreed on its importance in building a better bond with patients, and that it's commonly more used with older patients (Uncle- Auntie) when things are calmer and less chaotic at the clinic.
Did the doctor(s) introduce themselves (say their name) at the beginning of the visit or before they first addressed the patient if they weren’t involved from the beginning of the visit?	0%	0%	100%	Lack of perceived importance - Fear for one's safety	Most physicians indicated that they don't usually ask such a question. Their opinions varied on its importance. One common theme is that they don't like saying in which year they are of their specialty training because patients misunderstand that and think they are medical students and refuse to seek care from them.
Did the doctor(s) state their role at the beginning of the interview? (Specialty, Year of residency)	0%	0%	100%	Lack of perceived importance - Fear of decreased patient trust
Did the doctor ask open-ended questions enough?	51%	46%	2%	NI	NI
Did the doctor ask “What does the patient know about their condition”?	0%	49%	51%	Lack of time - Excessive workload - Lack of perceived importance - Lack of time and patience - Dependence of patients to confess their fears on their own	Most physicians didn't think this kind of question would be important. All but one don't usually ask or care for it. They generally also made an exception for cancer and chronic illness patients.
Did the doctor ask “What does the patient fear about their condition”?	2%	12%	85%
Did the doctor ask the patient "How does their condition/complaint affect them and their life"?	0%	22%	78%	Lack of time - Excessive workload - Lack of perceived importance	Most physicians agreed on the importance of this question. However, they insinuated its medical importance and not in terms of communication. Most doctors indicated asking this question despite its low adherence rate.
Did the doctor ask the patient "How do their circumstances/experiences/habits/job affect their condition"?	0%	29%	71%
Did the doctor pay attention and show interest, i.e. maintain eye contact with the patient, and face the patient directly/ from the same level most often when addressing or listening to them?	68%	32%	0%	Lack of time - Excessive workload - Mismatch of theory and application	Most physicians recognized the importance of body language and indicated that their skills in it improved unconsciously over time. There appears to be some mismatch between the doctors' perceptions and their practice which may be due to the excessive workload.
Did the doctor allow adequate time so that discussions do not feel rushed?	66%	32%	2%	NI	NI
Did the doctor listen to the patient’s concerns in a nonjudgmental way?	80%	17%	2%	NI	NI
Did the doctor discuss the patient in their presence without involving them in the discussion?	46%	46%	7%	Lack of perceived importance - Hierarchical structure of medical residency	Most physicians indicated that such discussions are expected in a crowded public hospital with a hierarchical teaching structure. They presumed that patients don't care for such practices and shouldn't mind them since they're meant to offer better healthcare for the patient.
Did the doctor use lots of medical jargon?	83%	15%	2%	Desire to educate patients	Most physicians recognized the importance of simplifying medical terminology using colloquial language alongside stating the medical term to increase health literacy among the public.
Did the doctor ask “If the patient has understood”? or if they have any questions?	14%	36%	48%	Lack of time - Lack of perceived importance	Most physicians indicated that adequate history-taking is enough for patients to express their concerns. They indicated that time constraints prohibit them from prompting patients to ask further questions
Did the doctor explain how to use medications/ how some equipment works/why lab tests?	49%	29%	22%	NI	NI
Did the doctor address the patient’s guest(s) when needed?*	30%	52%	17%	Lack of time - Lack of perceived importance - Clinic's overcrowding and chaos	Most physicians indicated that it's important to communicate with the guest only for medical reasons and to get clearance about the patient's condition and symptoms depending on the patient's age and condition. They also indicated that better communication with them is achieved when the clinic is calmer and less chaotic.
Empathic Communication Coding System**	46%	51%	2%	Lack of perceived importance - Concern over misunderstandings	Opinions on this topic varied. Some doctors acknowledged its importance, while others expressed concerns that empathy could be perceived as pity. Some struggled to strike a balance between demonstrating empathy and maintaining realism and transparency. A few noted that expressing empathy can be challenging because both doctors and patients have become accustomed to difficult and distressing experiences.

Table 1 Summary of gastroenterology residents' adherence to the NICE guideline on physician-patient communication in the out-patient clinic

Table Key: NI: Not Included in the Interview - *: Only 23 came with a guest. - **: Grading was based on Bylund et al.

What residents consider important in communication does not always translate to their practice, likely due to limited training, lack of support, and challenging work conditions.

When it comes to the shortcomings in physician-patient communication, a core problem is physicians resorting to what they're used to without critically appraising its validity.

The main reason for that is the lack of specialized training on communication, making personal experience and imitation of others the only resource for learning these skills.

PRESENTER

Suzana Sultan

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Patient experience in adult NHS services: improving the experience of care for people using adult NHS services Clinical guideline [CG138] Published: 24 February 2012 Last updated: 17 June 2021 RECOMMENDATIONS https://www.nice.org.uk/guidance/cg138/chapter/Recommendations
No.	Guidance
1.1.1	Develop an understanding of the patient as an individual, including how the condition (or conditions) affects the person, and how the person's circumstances and experiences affect their condition (or conditions) and treatment.
1.2.1	All staff involved in providing NHS services (including chaplains, domestic staff, porters, receptionists and volunteers) should: • treat patients with respect, kindness, dignity, compassion, understanding, courtesy and honesty • respect the patient's right to confidentiality • not discuss the patient in their presence without involving them in the discussion.
1.2.4	Listen to and discuss any fears or concerns the patient has in a non- judgemental and sensitive manner.
1.3.4	Hold discussions in a way that encourages the patient to express their personal needs and preferences for care, treatment, management and self- management. Allow adequate time so that discussions do not feel rushed.
1.3.5	Review with the patient at intervals agreed with them: • their knowledge, understanding and concerns about their condition (or conditions) and treatments • their view of their need for treatment.
1.4.4	All healthcare professionals directly involved in a patient's care should introduce themselves to the patient.
1.4.5	Inform the patient about: • who is responsible for their clinical care and treatment • the roles and responsibilities of the different members of the healthcare team • the communication about their care that takes place between members of the healthcare team.
1.5.2	Maximise patient participation in communication by, for example: • maintaining eye contact with the patient (if culturally appropriate) • positioning yourself at the same level as the patient.
1.5.3	Ask the patient how they wish to be addressed and ensure that their choice is respected and used.
1.5.6	Avoid using jargon. Use words the patient will understand, define unfamiliar words and confirm understanding by asking questions.
1.5.7	Use open-ended questions to encourage discussion.
1.5.8	Summarise information at the end of a consultation and check that the patient has understood the most important information.
1.5.11	Give the patient information, and the support they need to make use of the information, in order to promote their active participation in care and self-management.
1.5.14	Explore the patient's preferences about the level and type of information they want. Based on this, give the patient (and their family members and/or carers if appropriate) clear, consistent, evidence-based, tailored information throughout all stages of their care. This should include, but not be limited to, information on: • their condition (or conditions) and any treatment options • where they will be seen • who will undertake their care • expected waiting times for consultations, investigations and treatments.
1.5.17	Give the patient (and/or their family members and carers) information to enable them to use any medicines and equipment correctly. Ensure that the patient and their family members and carers feel adequately informed, prepared and supported to use medicines and equipment and to carry out self-care and self-management.

Empathic Communication Coding System (ECCS) Bylund CL, Makoul G. Examining empathy in medical encounters: an observational study using the empathic communication coding system. Health Commun. 2005;18(2):123-40. doi: 10.1207/s15327027hc1802_2. PMID: 16083407.
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Shared feeling/ experience "I love to cook and eat, as well. I understand how difficult that might be."	Confirmation "I know it can be hard, but we'll try to get to the bottom of this and get you better!"	Acknowledgement with pursuit "We want to do everything we can to get you back to where you can have a good quality of life. Tell me more about this swallowing problem"	Acknowledgement "We're gonna do our best."	Implicit recognition "Do you only have trouble with liquids during mealtimes"	Perfunctory Recognition "Hmm"	Denial "Do you have any other medical problems?"

Audit Cycle Benjamin A. Audit: how to do it in practice. BMJ. 2008;336(7655):1241-1245. doi:10.1136/bmj.39527.628322.AD
Stage 1: Preparing for the audit	Identify problem and local resources for audit Locate relevant information
Stage 2: Selecting audit review criteria	Determine what you are trying to measure Define ideal standards
Stage 3: Measuring levels of performance	Collect data Compare performance with criteria
Stage 4: Making improvements	Implement change
Stage 5: Sustaining improvements	Repeat the audit Develop tools to sustain improvements

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