The doctor±patient relationship: from undergraduateassumptions to pre-registration reality

Clare Williams1, Peter Cantillon2 & Mac Cochrane2

Objectives To describe the ways in which the doctor±

patient relationship experienced by newly quali®ed pre-

registration house of®cers (PRHOs) differed from their

undergraduate expectations.

Design Qualitative study in which in-depth semistruc-

tured interviews were carried out with each PRHO

within 4±6 weeks of the start of their ®rst job.

Setting Three teaching hospitals, three district general

hospitals and four general practices in south-east Eng-

land.

Participants 24 newly quali®ed PRHOs.

Results A number of differences were identi®ed by

PRHOs. These were caused in part by the impact of

factors such as the shortage of time, which could lead to

emotional `blunting'. Some PRHOs were changing

their ideas about what constitutes a `good' doctor, and

were rede®ning the meaning of a `professional' rela-

tionship. The relationships of PRHOs with patients

were also affected by the attitudes of their senior col-

leagues. For example, where PRHOs tried to maintain

a patient-centred relationship, they could be identi®ed

by colleagues as working too slowly. PRHOs working in

general practice were able to utilize and improve their

communication skills with patients, but found it dif®-

cult to transfer these skills back into the hospital setting.

Conclusions Despite receiving substantial undergra-

duate education on how best to communicate with

patients, a variety of factors conspired to prevent

hospital-based PRHOs from utilizing this information.

Building on these ®ndings, a number of recommenda-

tions are made to help improve practice.

Keywords Communication; curriculum; education,

medical, undergraduate; England; interviews; medical

staff, hospital, *education; *physician±patient relations.

Medical Education 2001;35:743±747

Introduction

Patient partnership, with its emphasis on shared deci-

sion making and responsibilities, now has a central place

on the NHS agenda.1 In order to achieve this there is

increasing pressure to change the nature of the doctor±

patient relationship, partly by improving communica-

tion skills.2 Emphasis is now placed on increasing

communication skills training for doctors at all levels.3,4

In particular, medical schools have changed their

curricula to re¯ect these changes, and the teaching and

examining of communication skills is now seen as an

integral element of undergraduate medical education.5

In terms of postgraduate initiatives, the introduction of

pre-registration house of®cer (PRHO) rotations which

include a general practice component is seen as a key

way for junior doctors to learn to communicate more

effectively with patients.6 Despite these changes, many

examples of poor communication continue to be

reported.7 Various reasons are put forward for this,

including the selection procedures of medical schools;

the elitism that characterizes undergraduate medical

education, and continuing medical power.8 More

pragmatically, it has also been suggested that recent

government initiatives, such as limits on waiting times,

have put additional time pressures on senior doctors,

which are then passed on to junior staff.9

This paper focuses on the experiences of a group of

PRHOs who were interviewed within 6 weeks of the

start of their working lives. They had all attended

medical schools where the ongoing teaching and

examining of communication skills was given a high

priority. At this transitional point in their careers, the

PRHOs were forming doctor±patient relationships for

the ®rst time, which they were able to contrast with

their previous student±patient relationships. These

1Social Science Research Unit, University of London, London, UK2Department of Postgraduate Medical Education, Guy's, King's and

St Thomas' School of Medicine, London, UK

Correspondence: C Williams, Social Science Research Unit, University

of London, 18 Woburn Square, London WC1H ONS, UK

Doctor±patient relationship

Ó Blackwell Science Ltd MEDICAL EDUCATION 2001;35:743±747 743

PRHOs were also able to compare with the reality their

previous expectations about what a `good' doctor±

patient relationship should consist of.

Participants and methods

The data were obtained within the context of a qualit-

ative evaluation which explored and compared the

experiences of 24 PRHOs from the South Thames

Region, between August 1998 and August 1999.10 Of

these, 12 were selected because they would be experi-

encing a general practice rotation for 4 months of their

pre-registration year. They were matched with 12

PRHOs who would be experiencing 6 months each in

similar medical and surgical jobs (the only matching

criteria used), but who would not be carrying out a

general practice rotation.

In-depth semistructured interviews lasting approxi-

mately 1 hour were conducted by CW with each

PRHO within 4±6 weeks of the start of their ®rst job. At

that time, the PRHOs were based in three teaching

hospitals, three district general hospitals and four gen-

eral practices within the South Thames Region. The

four PRHOs who started the year in general practice

were interviewed again 1 month after their return to

hospital. The focus of the interviews was on their early

experiences of working and learning as PRHOs, and

included prompts designed to explore whether the

experience was as anticipated, or different. With

permission, the interviews were taped and transcribed.

The transcripts were read several times and coded

using a system of open coding.11 Common categories

were identi®ed, which were re®ned with the inclusion

of data from each new transcript. External validation of

the interpretation and coding was achieved by the

independent reading and coding of transcripts by PC.

The results were compared and discussed, and no

signi®cant differences were identi®ed. Quotes have

been selected as being typical of the perspective being

discussed, and each PRHO has been allocated a num-

ber to protect con®dentiality.

Results

The changing relationship with patients

There were a variety of ways in which the hospital-

based PRHOs described their relationships with

patients as different, when compared with the rela-

tionships they had previously had with patients as

medical students.

Taking control of the patient±doctor relationship

Despite the emphasis on a more equal doctor±patient

relationship, at this early stage in their careers all the

PRHOs felt they were being forced to take control of

their relationships with patients, partly because of the

structures within which they were working:

And now you've got all these timetables and goals

you've got to achieve by the end of the day, you

don't seem to have that much time, and I often

feel like I'm neglecting them [patients] a bit, so I

try and be nice, but you end up being very formal

with them¼you end up having to cut them short

and say, `Look, sorry, can we get back to the

questions', and you say that about ®ve times during

the interview, and it makes me feel quite uncom-

fortable. (PRHO 10)

The implicit consent of patients to procedures

All of the PRHOs also recognized that their new role

brought with it a certain amount of authority which

meant that patients were much more likely to implicitly

accept procedures and treatment being carried out by

them. This was contrasted with the dif®culties that

many had encountered as medical students:

I mean, if you want to just get blood or put a Ven¯on

in, as soon as you say you're a medical student they

get worried, obviously. Well, understandably, they

want to know how many times you've done it before,

can you do it, and if you miss it it's going to be a bad

thing, If you miss it as a houseman it's really not a

major thing, you just keep doing it again until you get

it in. (PRHO 16)

Key learning points

With the aim of promoting a more equal doctor±

patient relationship, the teaching and examination

of communication skills is now recognised as an

important and integral element of undergraduate

education.

Despite extensive undergraduate education in

communication skills, this qualitative evaluation

found that newly quali®ed PRHOs were often

unable to utilize their skills for a variety of reasons,

including structural factors.

Ways in which the doctor±patient relationship

experienced by PRHOs differed from their

undergraduate expectations are discussed.

A number of recommendations are made to help

improve practice.

Ó Blackwell Science Ltd MEDICAL EDUCATION 2001;35:743±747

The doctor±patient relationship: assumptions and reality · C Williams et al.744

I feel like I've got a lot more, not power, but more of

a feasible excuse to go and do things to patients than

I had before. So if I go and put a Ven¯on in now I

know I've got to do it, whether I stab them about

seven times I've still got to get it done, but as a

medical student I would have tried twice and then

gone `Oh, I'm sorry', and given up. (PRHO 15)

Changing ideas about what a `good' doctor is

In a short space of time, the structure in which they

were working had led many of these junior doctors to

fundamentally change their ideas about the care which

patients should receive:

I think to be a good doctor before I thought was to be

very caring and considerate towards the patients, and

then you realise that with time restrictions you can't

always be as caring as you want to be, but you've got

to ensure that they get the right treatment ± if you

can't have a proper conversation with somebody at

least you can make sure that they're treated properly.

(PRHO 10)

In recognizing this change, some of the PRHOs felt

that their relationship with patients was evolving towards

a more `professional' doctor±patient relationship:

I think gradually, day by day, I'm starting to

disconnect with the whole thing a little bit more and

get a little bit less involved, which I think is a good

thing to be honest, and to see the patients as a clinical

problem rather than a person who is ill and needs

help and things, but I think that's just a normal part

of working really¼I'm starting to sound like some-

body I would have hated, but I think in a way I've

got a more professional rapport with them now.

(PRHO 18)

Defensive emotional `blunting'

In contrast to PRHO 18, other PRHOs who recognized

that they were `disconnecting' from patients did not see

this as a positive change in themselves. With their

diverse experiences, the PRHOs who had rotated into

general practice were particularly well placed to

recognize the effects that working within the hospital

structure could bring:

In general practice I had my ®rst death, and because

you know the patients better you feel it more,

whereas in hospital medicine people are dying all the

time and you just become immune to any emotions

at all. It's just another thing and you're just getting

hassle to do a death certi®cate and do this and do

that. It just becomes paperwork. (PRHO 23)

The impact of tiredness

As might be expected, tiredness was also commonly

acknowledged by PRHOs to be a new factor which

could alter their relationships with patients:

Sometimes you do get quite cranky and it's like,

`Does this patient know how long I've been up for?'.

Then you just want to do things as quickly as poss-

ible, but the patient doesn't know and you have to

remind yourself that this patient doesn't know.

(PRHO 24)

Factors within the medical profession

There were also factors from within the medical

profession itself which could potentially affect the

relationships these junior doctors formed with patients.

Perhaps more than at any other time in their working

lives, they were acutely aware of how other more senior

doctors communicated with patients.

Ambition equals `hardness'

There was a recognition by some PRHOs that within

the medical profession a `hard' attitude towards

patients could be seen as synonymous with ambition:

I try and sit and have a chat with my patients at some

point during the day, and I'd like to still be able to do

that¼some doctors become really hard and that's

something I really don't want to happen, is do that

hardening...but I think for you to prove yourself as

ambitious, I think some people take the hard attitude

to things, but I can't treat people as products or what

have you, I just don't like it at all. (PRHO 5)

Incorporating a patient-centred approach

Some PRHOs found that trying to incorporate the

patient-centred approach they had been taught to use

as undergraduates was not always appreciated by more

senior colleagues. PRHO 9 illustrates the commonly

felt perception that talking with patients was not always

seen as the main priority by other doctors:

I think other people don't always see the person

behind the disease, and I like to be aware of how the

process is affecting the patient themselves¼I'm

interested in how they are, I'm not just interested in

whether their toe is better¼but that's something I

®nd a bit annoying, like in Casualty, I feel I clerk

people a lot slower than other doctors, and unfortu-

nately that gets noticed. (PRHO 9)

The doctor±patient relationship: assumptions and reality · C Williams et al. 745

Ó Blackwell Science Ltd MEDICAL EDUCATION 2001;35:743±747

General practice experience

Four of the PRHOs started their year in general prac-

tice, where they were able to utilize and improve their

communication skills. However, all of these PRHOs

found it very dif®cult to bring their improved commu-

nication skills back into the hospital setting. In relation

to his general practice experience, one PRHO stated:

If you compare it with the wards, it is nice to see

patients with their clothes on coming in with all their

dignity, and obviously every patient who comes in,

comes in with their social background and they're

different, and it's a matter of the doctor relating to

each person as an individual and understanding their

social background, and that's a very good experience

I feel. (PRHO 13)

However, once PRHO 13 had been working in his

surgical placement for 1 month he said:

Doing this surgical job there's very little point in

being communicative to the patient. You know,

you've got so many jobs to do you haven't got time to

chat to the patient¼it's very business-like, you have

to be very short and sharp, to the point.

Discussion

One of the main criticisms of qualitative evaluations

relates to their perceived lack of generalizability.

Although many of the PRHOs interviewed mentioned

the issues highlighted, within a short paper it is not

possible to discuss deviant cases, nor is it possible to

fully ground the ®ndings within a broader literature.12

However, these experiences occurred in teaching

hospitals and district general hospitals situated in

different geographical areas. As such, the ®ndings from

this study may well be relevant to PRHOs in other

settings.

All of these PRHOs had received substantial under-

graduate education on how to communicate with

patients. In addition, one of the aims of PRHO place-

ments in general practice is to consolidate and improve

communication skills. However, the structures within

which PRHOs found themselves working in hospital

settings often prevented them from communicating

with patients in the way that they would like. Despite

the reduction in junior doctors' hours, lack of time was

frequently cited as a problem, particularly in relation to

clerking patients. This usually resulted in PRHOs'

taking charge of the interaction in order to obtain the

information that PRHOs, rather than patients, saw as

important. Those PRHOs who did try to maintain a

patient-centred relationship were aware that they could

be identi®ed by other doctors as working too slowly. In

addition, many PRHOs felt that talking to patients was

not perceived as a priority by other, more senior doc-

tors. This supports the work of Baker et al. who draw

attention to the powerful socialization doctors undergo

which teaches them that listening to patients is `¼an

``extra'', to be indulged in only after the real work of

medicine is accomplished'.13

The PRHOs did not speci®cally highlight the impact

of policy-driven factors on their work, but it may be that

these pressures affect senior doctors more directly. The

work of junior doctors cannot be considered in isola-

tion, and previous research has shown how meeting the

requirements of more senior staff can powerfully

in¯uence the time which PRHOs spend on certain

activities.14 Further research is needed to ascertain the

effect on more senior staff of the many additional

pressures, such as the waiting list initiatives and waiting

times in accident and emergency departments, and how

these in turn impact on the work of junior staff.

For most PRHOs, controlling the relationship with

patients also incorporated a realization that their new

role carried a degree of authority with it which meant

that patients were more likely to consent to procedures.

One of the central tasks of their job was carrying out

basic clinical tasks, and many of the PRHOs were

initially concerned about their ability to perform these.

However, whilst it was accepted that patients should be

able to accept or decline the carrying out of procedures

by students, depending on the ability of the student,

this was not seen to be the case once students became

PRHOs.

Previous research has examined the role of medical

schools in socializing students to see both their own and

patients' emotions as detrimental to the study of

medicine,15 and it has been noted that this can result in

doctors displaying an attitude of `detached concern'

towards patients.16 In this study some PRHOs identi-

®ed this as `hardness', which was seen to signify

ambition in more senior doctors. It is recognized that

most medical education still takes place within the

apprenticeship model, with its emphasis on imitation.17

The attitudes and behaviour of more senior doctors can

therefore be very in¯uential on junior staff, who are in

the process of developing professional relationships

with patients.

In addition, some PRHOs spoke of `disconnecting',

of becoming `immune to any emotions', echoing

previous work describing the defensive emotional

`blunting' of sensitivity to human problems, which can

result when PRHOs are inadequately supervised and

guided.18 Although these feelings might be shared with

The doctor±patient relationship: assumptions and reality · C Williams et al.746

Ó Blackwell Science Ltd MEDICAL EDUCATION 2001;35:743±747

peers, they were not seen as issues to be discussed with

senior staff or with educational supervisors. It seems

ironic that during the PRHO year, when one of the

stated aims is for junior doctors to develop `attitudes of

caring and concern for patients and their families',19

the opposite process may be taking place.

The PRHO year is a pivotal time when professional

attitudes are formed. Despite initiatives to improve the

communication skills of undergraduates and PRHOs, it

appears that a number of additional changes need to

occur if a more equal doctor±patient relationship is to

become a reality within the hospital setting. The hours

and workload of junior doctors must be controlled so

that good communication with patients is possible.20

Junior doctors need to feel that they have time to

communicate with patients, which also means that time

spent talking with patients must be seen to be valued by

senior staff. Further research is needed to assess the

effect that recent policy initiatives have on the work of

more senior doctors, and how this in turn affects junior

doctors' working patterns. Communication skills

training for staff at all levels needs to continue, and an

assessment of communication skills needs to be incor-

porated into all staff appraisals. The supervision and

education of PRHOs needs to proactively encourage

critical debate about the ways in which they, as doctors,

are relating to patients in their new role, and how the

transition is affecting them. Unless these junior doc-

tors, the consultants and GPs of the future, are able to

utilize their learned communication skills with patients,

it seems that complaints about doctor±patient

communication will continue.

Acknowledgements

We thank all of the people who participated in this

research.

Contributors

CW was responsible for the day-to-day running of the

project, carried out all of the interviews, and drafted the

paper. PC supervised and helped design the project,

and contributed to the paper. MC helped design the

project, obtained the funding, and contributed to the

paper.

Funding

The evaluation was funded by a grant from The Oak

Foundation.

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Received 31 May 2000; editorial comments to authors 24 October

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Ó Blackwell Science Ltd MEDICAL EDUCATION 2001;35:743±747