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BACKGROUND: While international comparisons of medical practice have noted differences in length of visit, few studies have addressed the dynamics of visit exchange.
OBJECTIVES: To compare the communication of Dutch and U.S. hypertensive patients and their physicians in routine medical visits.
DESIGN: Secondary analysis of visit audio/video tapes contrasting a Dutch sample of 102 visits with 27 general practitioners and a U.S. sample of 98 visits with 52 primary care physicians.
MEASUREMENTS: The Roter Interaction Analysis System applied to visit audiotapes. Total visit length and duration of the physical exam were measured directly.
MAIN RESULTS: U.S. visits were 6 minutes longer than comparable Dutch visits (15.4 vs 9.5 min, respectively), but the proportion of visits devoted to the physical examination was the same (24%). American doctors asked more questions and provided more information of both a biomedical and psychosocial nature, but were less patient-centered in their visit communication than were Dutch physicians. Cluster analysis revealed similar proportions of exam-centered (with especially long physical exam segments) and biopsychosocial visits in the 2 countries; however, 48% of the U.S. visits were biomedically intensive, while only 18% of the Dutch visits were of this type. Fifty percent of the Dutch visits were socioemotional, while this was true for only 10% of the U.S. visits.
CONCLUSIONS: U.S. and Dutch primary care visits showed substantial differences in communication patterns and visit length. These differences may reflect country distinctions in medical training and philosophy, health care system characteristics, and cultural values and expectations relevant to the delivery and receipt of medical services.
Increasing economic pressures toward greater productivity in the delivery of medical care worldwide have focused attention on the impact of visit length on quality of care and patient outcomes.1,2 Within this context, the substantial differences in the length of primary care visits among Western countries has stimulated interest in comparative studies. Estimates of average visit length for general practitioners (GPs) in Europe range between 7 and 16 minutes, with The Netherlands falling in midrange, averaging 10-minute visits.3 In the United States, comparable visits are 17 minutes.4 These numbers suggest that visit length may be a consequence of national health system characteristics as much as national habits and medical care expectations.3
Physicians believe visit duration is an important dimension of quality of care, as do most patients.5 Indeed, some investigators have argued that visit length in itself can be considered a proxy indicator of quality of care.6,7 Short visits are associated with less problem identification,8 fewer preventive actions undertaken,2,8–10 less lifestyle11 or psychosocial discussion,6,10,12–14 and more antibiotics prescribed.12 Many patients report greater ease in discussing problems and more participation in decision making in longer visits.8,15,16 However, it should be noted that the overwhelming majority of patients are satisfied with the time they get for their visit,6,8,15,17,18 and many studies have reported inconsistent or weak associations between length of visit and quality.9,11,12,15,19–21
Many researchers maintain that visit length has less impact on quality of care than do the doctor as a person and his or her working style.1,22 The aspects of physician working style most often linked to quality of care are those encompassed in the broad concept of patient-centeredness.23–25 Definition and measurement of the concept have ranged from surveys of professional and patient attitudes, expectations, and preferences to a variety of approaches and measures reflecting visit behaviors.23–28 There is some consensus in these studies that patient-centeredness involves the grounding of the therapeutic dialog in a biopsychosocial rather than a biomedical paradigm29–32 of active patient engagement in the medical dialog,25 with the doctor being open and responsive to the patient's agenda and perspective, including elicitation of the patient's concerns, expectations, and preferences for treatment26 and establishment of emotional rapport.33
Despite systematic differences in visit length between countries, national debates regarding the length of medical encounters seldom use an international perspective, thus ignoring country-specific influences on visit length that originate in characteristics of health care systems such as primary careness.34 Against this background, a comparative study was designed based on secondary analyses of existing databases to explore this issue in 2 countries that are known for their differences in primary careness, the United States and The Netherlands.34 The aim of the study was to compare Dutch and U.S. medical visits for patients with a common diagnosis of hypertension in terms of visit length, duration of the physical examination, and communication dynamics. The specific research questions are:
What is the difference in visit length between the United States and The Netherlands for a group of patients with a common diagnosis of hypertension?
How are differences in visit length related to (a) conversational contributions of doctor and patient and (b) communication style of the visit?
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First, as anticipated, we found that U.S. visits were longer than comparable Dutch visits for patients with a common diagnosis of hypertension. While prior comparisons of length of visit reflected the general experience of primary care patients, we are unaware of any direct comparisons of visits for a common diagnosis. Further, the U.S. visits had longer physical exam segments than did comparable Dutch visits, although in both countries, the physical exam contributed to about a quarter of the total visit length.
The difference in communication dynamics in the 2 countries also was reflected in the visit's content and focus on instrumental and affective behavior. American doctors asked more questions and provided more information of both a biomedical and psychosocial nature, whereas Dutch physicians were far more likely to engage in affective exchanges, particularly those related to rapport building. In a parallel fashion, differences in patient communication also were evident. Dutch patients were less engaged in content-specific discussions of biomedical or psychosocial topics, but more active in expressing concerns or optimism than were U.S. patients. U.S. patients disclosed more information to their physicians both biomedically and psychosocially, largely in response to the higher number of questions asked of them, and the U.S. patients were given more information in these areas.
The style differences between the 2 countries were especially striking when communication patterns were constructed based on a cluster analysis of physician behaviors. The distribution of visit types was similar for the pattern that marked visits with exceptionally long physical exams, perhaps marking very complex physical health problems. Similarly, the visits characterized by use of the biopsychosocial pattern were equally distributed in the 2 countries. The 2 remaining patterns had distinct Dutch and American distributions. The most common pattern of visit in The Netherlands, accounting for 50% of visits, was characterized by a relatively high amount of socioemotional exchange; this consultation type was found in only 10% of the American consultations. In contrast, the dominant consultation type in the United States, representing 48% of visits, was characterized by biomedically intensive content. This visit type was found in only 18% of the Dutch visits. The U.S. pattern and distribution of visit types produced by the cluster analysis were largely parallel to findings from an earlier U.S. study.28
The nature of the U.S. system is quite different from that of The Netherlands, with relatively few of the study physicians working within a fixed system.34 Indeed, U.S. patients see their primary care physicians less frequently than do Dutch patients; Dutch patients average 4 visits per year to GPs,3 whereas U.S. patients made an estimated 1.5 visits per year to their primary care physicians.42 Helped by the knowledge of having a longitudinal relationship with the patient, GPs in The Netherlands appear more likely to adopt a wait-and-see approach to medical interventions that are not evidence-based in specific situations.43,44 There is some evidence that this approach has consequences for the length of the medical visit. For instance, a large Dutch audiotape study of 75 GPs with 1,048 patients found that physicians with medically intensive interviewing styles conducted longer visits than did physicians with less medically intensive interviewing styles.45 The longer visits were not necessarily of higher quality, because many of the medical interventions undertaken were classified by experts as superfluous. It is reasonable to assume that in The Netherlands, where there is a strong professional awareness about the potential risks of doing too much, less emphasis will be placed on medical interventions. This is likely to result in shorter physical exams, a less medically intense interviewing style, and perhaps greater attention to rapport building and supportive listening. In contrast, U.S. physicians may be seen as guided by a strong professional awareness about the potential risks of doing too little, resulting in a greater emphasis on medical interventions, longer physical exams, and a more medically intense interviewing style. Although no definitive conclusions can be drawn, the speculation is consistent with our data and broad practice trends.
The predominately biomedical focus of the U.S. interviews in relation to the more socioemotional focus of the Dutch visits furthers insight into considerations of the patient-centered continuum. Although the purpose of the current analysis is not to offer a comprehensive definition of patient-centeredness, we would suggest that in the trade-off between biomedically intensive visits and socioemotional visits, it is the latter that are more reflective of physician receptivity and responsiveness to the expression of patients' concerns and needs.
Limitations of the Study
There are several limitations to the study. The data sets used for this analysis are quite old; the American data were collected in 1992, and the Dutch study was conducted in 1986. The most critical consideration regarding the data is not simply how old it is but rather whether changes in practice since the data were collected in the 2 countries are of sufficient magnitude and relevance to invalidate the conclusions drawn. The U.S. study sample average appears in line with recent estimates of U.S. hypertension-related visits of 17.2 minutes in nonprepaid systems and 16.5 minutes in prepaid visits.46 In The Netherlands, the current study visit length was well within more recent estimates.47
A second question, apart from secular changes in length of visit, is the extent to which physicians' communication style may have changed over the years. Although there are few historical data to draw upon, it is not likely that physicians' styles of communication would have changed dramatically over this time period. Physicians' communication style is formed during medical education and in the first years of practice, and is resistant to change once habits are formed.48 Indeed, an earlier cluster analysis of U.S. physicians' communication patterns conducted on data collected in 1984 showed a pattern very similar to that presented in the current study and collected 8 years later.28
In conclusion, our cross-cultural comparison of doctor–patient communication during medical visits suggests that there are distinct national medical cultures that have a profound influence on the nature of exchange during a typical medical visit. We anticipate future systematic international comparison studies to shed light on the microdynamics of the medical encounter and its therapeutic efficacy.