Influence of treatment expectations on talking with patients

I HAVE experienced chronic pain all of my adult life. As part of my current management plan, I am prescribed pain medication.

There is a lot of stigma attached to medication management of chronic pain, so I often find it difficult to bring it up, even though my regular GP developed the management plan with me and is invariably the one who prescribes it. My concerns about raising it are based on how I feel I will be perceived and on the assumptions that I know could be made about my expectations for treatment.

Doctors use all sorts of heuristics to make decisions and some of these can lead to incorrect assumptions about what patients want and expect. Patients bring their own assumptions too, just like my assumption above that I will be perceived negatively or that there will be resistance, so I design the way I talk to avoid that as much as possible. These assumptions influence, and are influenced by, how doctors and patients communicate with each other.

As these assumptions are evident in consultations, they can be examined through close analysis of recordings. In consultations with surgeons, for example, we can see that patients and surgeons orient to surgery as being the default treatment recommendation. This is not to say that surgery is the preferred option in all or even most cases, but that recommendations for non-surgical management require more interactional work. Recommendations for surgery tend to be presented early and in a straightforward way while recommendations for treatment options other than surgery are delayed and include more justification about why surgery is not the recommended treatment. The assumption is that a patient seeing a surgeon is possibly expecting for surgery to be the recommended treatment option and that surgeons design their recommendations for something other than surgery to counter potential resistance against a non-surgical recommendation.

Similarly, there is an assumption that parents of children sick with upper respiratory symptoms expect antibiotics. While it might feel like that as a clinician, and there would be variation between cultures and medical systems, there is some evidence that tells a different story. Doctors’ perception of parent expectation for antibiotics can be influenced by how a parent presents the child’s illness. If the parent presents a candidate diagnosis, such as “I think my child has tonsilitis”, a doctor is five times more likely to assume that the parent is wanting a prescription. Yet, in this study, this did not match with parent-reported expectations, with other reasons for parents presenting candidate diagnosis, such as legitimacy in seeking care.

Doctors are generally adept at gaining acceptance of treatment recommendations from patients through persuasion, although being responsive to resistance is not the only strategy that can be used. Just as in the surgical consultations described above, there is extra interactional work that doctors do to reduce resistance to treatment recommendations.

By providing a positive action, such as resting and drinking fluids, before telling the patient that antibiotics aren’t suitable, there is higher likelihood of acceptance of the recommendation not to prescribe antibiotics. This can be pre-empted even earlier in the consultation than the treatment recommendation. In response to the problem presentation, doctors can foreshadow the likelihood that the illness is viral to manage patient expectations.

These kinds of strategies to manage interactional resistance may be taught explicitly. During a project where I was observing handovers at an emergency department to develop training material, I watched a senior doctor coach an intern on how to more successfully transfer a patient to a larger hospital.

Many of these strategies would also be developed by the clinician over time through trial and error, with repeated consultations acting as a wind tunnel to find what communication practices result in a smoother consultation.

Using the evidence from the antibiotic prescribing research mentioned above, a training module has been developed as another way to support doctors to more strategically use interactional means to reduce resistance to non-antibiotic treatment recommendations.

Adding in an extra level of expertise through detailed analyses of clinical practice and development of related training can further support doctors to improve consultations in a more systematic and evidence-based way, including how to better understand their own assumptions of patient expectations and how to manage patient resistance to treatment recommendations in a person-centred way.

Dr Sarah J White is a Senior Lecturer in the Faculty of Medicine, Health and Human Sciences at Macquarie University. She is the current Australian National Representative for the International Association for Communication in Healthcare.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.