manajemen rumah sakit 5


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

manajemen rumah sakit 5

  1. 1. International Journal for Quality in Health Care 2002; Volume 14, Number 5: 359–367Impact of supervision and self-assessmenton doctor–patient communication in ruralMexicoYOUNG-MI KIM1, MARIA ELENA FIGUEROA1, ANTONIETA MARTIN2, RICARDO SILVA3,SIXTO F. ACOSTA3, MANUEL HURTADO4, PAUL RICHARDSON5 AND ADRIENNE KOLS11Center for Communication Programs, Johns Hopkins University, School of Public Health, Baltimore, 5Quality Assurance Project,Center for Human Services, Bethesda, MD, USA, 2Fronteras, The Population Council, Regional Office, Mexico City, 3InstitutoMexicano del Seguro Social, Programa Solidaridad (IMSS/S), Mexico City, 4Universidad Veracruzana, Veracruz, MexicoAbstractObjective. To determine whether supervision and self-assessment activities can improve doctor–patient communication.Setting and participants. Six supervisors, 60 doctors in their last year of training, and 232 primary health care patients atrural health clinics in Michoacan, Mexico.Design. The main evaluation compared post-intervention measures in control and intervention groups. A small panel studyalso examined changes from baseline to post-intervention rounds in both groups.Intervention. Over a 4-month period, specially trained supervisors added 1 hour of supervision on interpersonal communicationand counseling (IPC/C) to regular site visits. Doctors, who had received prior IPC/C training, periodically audiotaped andassessed their own consultations.Main outcome measures. These comprised frequency of doctors’ facilitative communication, doctors’ biomedical information-giving, and patients’ active communication.Results. The performance of all doctors improved markedly over the study period, but gains in facilitative communicationand information-giving were significantly greater in the intervention than the control group. No single component of theintervention was responsible for the improvement; it resulted from the combination of activities. The doctors appreciatedthe more supportive relationship with supervisors that resulted from the intervention and found listening to themselves onaudiotape a powerful, although initially stressful, experience.Conclusion. Supportive supervision and self-assessment activities can reinforce IPC/C training, prompt reflection andlearning, and help novice doctors improve their interpersonal communication skills.Keywords: communication, quality of care, physician–patient relations, self-assessment, supervisionResearch shows that the quality of communication between cultural differences between indigenous communities anddoctors and their patients contributes to health outcomes as doctors. To provide health care services to rural populations,well as patient satisfaction [1–5]. Doctors make more accurate the Mexican Institute of Social Security/Solidarity (IMSS/S)diagnoses and more effective treatment plans when patients places resident doctors in rural clinics for a 9-month rotationfully disclose their symptoms, concerns, and personal cir- as part of their training. Typically, one of these residentcumstances. Patients feel more committed and better prepared doctors and a nurse staffs a two-room clinic. Most residentto carry out a plan of action when doctors clearly explain doctors come from urban backgrounds, are middle to upperthe diagnosis, treatment options, and instructions. class, and speak Spanish. In contrast, the patients they serve Good communication and counseling skills are especially come from a lower socioeconomic class and mostly speakimportant in rural areas of Mexico, where there are wide indigenous languages. While most resident doctors establishAddress reprint requests to Y.-M. Kim, Senior Research and Evaluation Advisor, Center for Communication Programs,Johns Hopkins University School of Public Health, 111 Market Place, Suite 310, Baltimore, MD 21202-4012, USA.E-mail: 2002 International Society for Quality in Health Care and Oxford University Press 359
  2. 2. Y.-M. Kim et al.a good rapport with patients and take time to ask questions assignment at the rural clinics), a second round of data wasand explain matters, formative research shows that they are collected.less skilled in listening to clients, encouraging them to speak, The data are analyzed in two different ways: a cross-and responding to individual client needs. sectional comparison and a panel study. The cross-sectional IMSS/S has introduced training in interpersonal com- analysis compares post-intervention measures in the inter-munication and counseling (IPC/C) to narrow the com- vention and control groups, and has the advantage of a largermunication gap between young resident doctors and rural sample size. The panel study examines changes over timepatients. While experience elsewhere has demonstrated the from the baseline to post-intervention rounds in both theeffectiveness of IPC/C training [6,7], one-time training has intervention and control groups. It provides a more con-not been sufficient to guarantee that health personnel apply servative measure of the intervention’s impact, since it takesnew communication skills on the job and maintain them into account changes in the control group during the inter-over time [8]. Two opportunities exist for cost-effective vention period. However, the power of the panel study isreinforcement of IPC/C skills among resident doctors at limited by its small sample size.IMSS/S clinics. The first possibility is using the routinesupervision system already in place. Competent and ex- Study sampleperienced physician supervisors make regular 1-day site visitsto IMSS/S clinics to monitor technical standards of care. The study took place in the Zamora region of Michoacan,With training and appropriate tools, they also could assess which is divided into seven supervision zones, each overseenIPC/C performance and provide direct feedback to resident by a single supervisor. One zone was excluded from thedoctors. The second possibility is asking resident doctors study because the high proportion of indigenous peoplesto engage in self-assessment and self-directed learning, an made it atypical. The remaining six zones were randomlyapproach that has maintained and improved health providers’ distributed into control (two zones) and experimental (fourcommunication skills in Indonesia, even in the absence of zones) conditions. This analysis uses data from a larger studyoutside supervision and support [8]. conducted by IMSS/S, which included all 115 rural clinics in In 1998–99, IMSS/S pilot tested both of these approaches the six zones, eliminating the need for random sampling. Aat rural clinics in the state of Michoacan. This study examines team of two research assistants visited each clinic for a day,the impact of a combined intervention of supervision and self- and audiotaped and interviewed the first three patients toassessment on the communication performance of resident come for services. These patients represented a small pro-doctors. Specific objectives are: (1) to determine if supervision portion of the >15–30 patients who might be expected toand self-assessment help doctors to apply newly learned visit a rural clinic in the course of a day. The larger studycommunication skills on the job and to improve those skills involved 631 patients, 82 resident doctors, 33 general prac-over time; and (2) to identify which activities (including titioners, and 115 nurses.supervision visits, audiotaped consultations, self-assessment, The present study includes a subset of patients who werehomework logs, and job aids) are effective and acceptable to attended by resident doctors and for whom complete datadoctors. exists, including audiotapes, observations, and interviews. Technical difficulties, including dead batteries, poor volume control, and excessive background noise, rendered many audiotapes unusable. In addition, some of the resident doctorsMethods had already left the rural clinics when the research assistants arrived to collect the post-intervention data. Post-interventionThis study assessed a cohort of resident doctors who began data for the cross-sectional comparison are available for atheir assignment at an IMSS/S clinic in Michoacan, Mexico total of 157 patients and 60 doctors from 60 clinics scatteredin the summer of 1998. Soon after they arrived, all of the across all six supervision zones. Of these, 95 patients and 36doctors attended a 2-day workshop on IPC/C, followed by doctors were in the intervention group, while 62 patients anda half-day refresher course 5 months later. Baseline data were 24 doctors were in the control group.collected immediately after the refresher course. The doctors The panel study includes every doctor for whom there iswere assigned to intervention and control groups depending matching baseline and post-intervention data. Matching dataon which supervision zone their clinics belonged to; the are available for a subgroup of 28 doctors, who were recordedsupervision zones included in the study were randomly divided with a total of 147 patients. Of these, 21 doctors were in theinto control and experimental conditions as described below. intervention group, and they saw 57 patients in the baselineDuring the following 4 months, doctors in the intervention round and 54 patients in the post-intervention round. Thegroup received visits from supervisors who were specially remaining seven doctors were in the control group, and theytrained in IPC/C and who evaluated doctors’ interactions saw 18 patients in the baseline round and 17 patients in thewith clients; some of these doctors also conducted IPC/C post-intervention round.self-assessment exercises. Doctors in the control group alsoreceived regular supervision visits, but their supervisors were Data collectionnot trained in IPC/C and did not review how well theycommunicated with clients. At the end of the 4-month Audiotaped consultations, which were coded for content, areintervention period (which also marked the end of the doctors’ the primary source of data for this study. Based on an360
  3. 3. Doctor–patient communicationinteraction analysis of 15 consultations recorded earlier at at IMSS/S clinics. Participating supervisors attended a 3-daythe study site, researchers adapted the Roter Interaction training course that covered the importance of interpersonalAnalysis System (RIAS) to code the consultations [9]. RIAS communication, a five-step supervision model for evaluatingwas designed to analyze doctor–patient interactions and has its quality, and key supervision skills. They were trained onbeen extensively tested in medical settings in both developed how to conduct IPC/C supervision using a specially designedand developing countries; studies have reported adequate assessment tool, and they focused on six skill areas deemedinter-coder reliability [7,8,10,11]. The system assigns each essential to the quality of care: listening, being responsive toutterance made by a doctor or patient to one of 48 mutually clients, expressing positive emotions, eliciting information,exclusive coding categories (utterances consist of a phrase or giving information, and encouraging patient participation.sentence that conveys a complete thought). Some examples The 4-month intervention has been called ‘partnershipof coding categories are: gives medical information, asks supervision’ because responsibility for enhancing com-open-ended lifestyle question, shows concern or worry, or munication skills was shared by supervisors and doctors.checks for understanding. Supervisors visited the doctors at 2-month intervals and Two Mexican physicians, both of whom were familiar with engaged in a series of special IPC/C activities: they observedthe services of IMSS/S, performed the RIAS coding. One a consultation, used a checklist to assess the doctors’ com-physician coded all of the baseline data and then trained and munication skills, gave feedback, discussed issues raised bysupervised a second physician to code the post-intervention the doctor, and helped doctors identify specific com-data. As they listened to the audiotapes, the physicians used munication skills that needed work. The doctors recordeda computerized data entry screen to assign codes to each these assignments in a homework log and reviewed theirutterance. The coders were blind to the intervention status progress with the supervisor during the next visit.of the doctors. To test for inter-coder reliability, the first Between supervision visits, the doctors continued to workphysician also coded 22 consultations from the post-inter- on improving their communication skills, especially thosevention round. Agreement between the two coders exceeded listed in the homework log. Doctors were encouraged to90%. The coders also calculated the length of each con- consider every encounter with a patient as an opportunity tosultation, based on the counter numbers on the tape recorder. practice desired behaviors and to improve their com-To ensure the consistency of these measurements, the same munication skills. To prompt self-assessment and self-learn-brand and model of tape recorder was used to audiotape all ing, they were also given a more formal assignment in theconsultations. form of the following: Data on the sociodemographic characteristics and workexperience of the supervisors, doctors, and patients were (1) Each doctor was supposed to audiotape two con-collected in individual interviews. sultations a month, with the permission of the patients. Qualitative data were collected at the end of the study to (2) The doctors listened to the tapes and assessed theirhelp explain the findings. Providers participated in focus communication performance with the help of a jobgroup discussions while supervisors were interviewed in- aid.dividually. Facilitators and interviewers explored their re- (2) Some doctors also completed written self-assessmentactions to the intervention and their perceptions of its impact. forms focusing on specific communication skills. (TheirResearchers also used unstructured observations made during supervisors received additional training to support thisthe implementation process to help explain the findings. activity.)Supervision, self-assessment, and self-learning The job aid consisted of six color-coded sections, eachintervention covering one of the essential IPC/C skill areas listed above.As described above, each doctor attended a 2-day workshop Each section explained the meaning and the importance ofand a half-day refresher course on IPC/C. The curriculum the skill, gave detailed examples of how to perform it withwas designed to help the doctors develop skills in counseling, warmth, and listed behaviors to be avoided.verbal and non-verbal communication, interviewing, listening, In the control group, doctors also received IPC/C training,and helping the client to make a decision. This curriculum but there was no follow up or reinforcement. Althoughwas institutionalized by IMSS/S in a previous project and supervisors made their usual 1-day visits to control clinics,had become a standard part of training by the time this they were not trained in IPC/C supervision nor were theystudy took place. Thus, all of the doctors—whether in the given the special assessment tool. Researchers asked the twointervention or control groups—received the same IPC/C supervisors in the control condition to be on a waiting listtraining. However, doctors in the intervention group were so as not to contaminate the experiment. Therefore, doctorsgiven instructions on the intervention itself during the re- in the control group did not receive IPC/C supervision, norfresher course. did they receive the job aid, a tape recorder, or any other The supervision, self-assessment, and self-learning inter- intervention materials. They continued with their usual routinevention was designed to reinforce this training, to help young of reviewing issues in the technical quality of care and in thedoctors apply communication skills on the job, and to improve adequacy of medical supplies during monthly supervisionthose communication skills over the course of their residency visits. 361
  4. 4. Y.-M. Kim et al.Outcome measures with the purpose of the visit. About half (48%) of the patients came for general medical services, such as colds, stomachThe main outcome measure is doctor facilitative com- pain, and diabetes; their average age was 51 years. One-munication, i.e. communication that promotes an interactive third (34%) came for reproductive health services, includingrelationship between patient and doctor by fostering dialogue, prenatal care, family planning, sexually transmitted infectionsrapport, and patient participation. This concept has been (STIs), and adolescent counseling; their average age was 22developed by some of the authors over the course of previous years. About one-fifth (18%), usually mothers, brought astudies analyzing client–provider interaction in family plan- child who was sick or needed immunization.ning consultations in Kenya and Indonesia [8,12,13]. Fa- The average age of the resident doctors was 25 years, andcilitative communication is operationally defined as a set of 36% of them were male. All of the supervisors were maleRIAS coding categories that past research suggests is related physicians, and their average age was 37 years. All workedto clients playing an active role in the consultation. These full-time as supervisors for IMSS/S, and they had an averageinclude partnership building, showing agreement or under- of 7 years experience in the job.standing, discussion of personal and social issues, expressionof positive emotions, and asking or giving information on Process evaluationlifestyle and psychosocial issues. Four of the intervention’s sixIPC/C content areas were designed to encourage facilitative Supervision. Doctors in both the control and interventioncommunication: active listening, being responsive to patients, groups received an average of 1.7 visits from supervisorsencouraging patient participation, and expressing positive during the 4-month study period, i.e. about one every 2emotions. months. In the control group, none of these visits included Information-giving by doctors is a second outcome meas- supervision on IPC/C. In the intervention group, all of theure. Earlier qualitative studies conducted in Michoacan found visits included >1 hour of supervision on IPC/C. Duringthat giving insufficient information was a common weakness most visits in the intervention group, supervisors and doctorsamong resident doctors and that patients wanted better reviewed the homework log together (1.4 times).explanations. One of the intervention’s IPC/C content areas In focus group discussions, doctors in the interventionencouraged doctors to provide more and better medical and group reported that supervisors offered them more and bettertechnical information to patients. feedback on communication and counseling issues after the In theory, facilitative communication by doctors should intervention began. Doctors also noted changes in super-encourage patients to take a more active part in the con- visors’ interpersonal communication: supervisors began work-sultation. Hence a third outcome measure is patient active ing with the doctors as partners, listening to their ideas, andcommunication, which includes: asking questions, asking for engaging them in discussion, and were more appreciative ofclarification, expressing an opinion, expressing concerns, and their efforts. While doctors praised supervisors for beingdiscussing personal and social issues. kind, accessible, and not scolding, some wanted more time with supervisors and more specific feedback from them.Data analysis Self-assessment and self-learning. Doctors audiotaped an average of 7.2 consultations, a little less than the eight tapes theyThe analysis consistently examines the frequency of each were asked to make, and performed an average of 23.1 self-outcome variable (i.e. the number of utterances per con- assessments, about four in each of the six IPC/C skill areas.sultation) rather than its proportion. In the cross-sectional Thus, doctors listened to each tape several times, assessingstudy, ANOVA was performed to test the significance of a different skill each time. Each self-assessment and self-differences between the control and intervention groups. In learning session included listening to an audiotaped con-the panel study, ANOVA was used to test the significance of sultation, and took 30–60 minutes. Nearly all doctors (97%)changes over time (from the baseline to the post-intervention reported using the job aid regularly and found it useful.rounds) within the intervention and control groups. The Wald Doctors reported using the homework log 8.6 times, ontest was used to test the significance of differences in the average, as part of their self-improvement efforts.rate of change between the intervention and control groups. According to focus group discussions, doctors initiallyMultiple regression analyses were conducted as part of the found the self-assessment process stressful, especially thosecross-sectional and panel studies to control for three potential who did not receive written self-assessment forms and in-confounding factors: the purpose of the visit, the sex of the structions. The doctors worried about asking patients fordoctor, and the length of the session. permission to record the session, they were afraid of hearing their own mistakes on tape, they were anxious about following the steps laid out in the job aid, they felt nervous and self- conscious while the taping was going on, and they wereResults anxious about sharing the tapes with supervisors or nurses. With repetition, however, doctors became proficient at self-Characteristics of study participants evaluation and found that listening to themselves on tapeMost patients were married (84%), women (80%), and had was a powerful and eye-opening experience. The tapes helpeda primary education or less (81%). The age of the patients, them recognize their strengths and weaknesses and providedbut not their marital status, sex or educational level, varied strong motivation to improve.362
  5. 5. Doctor–patient communication a complete thought) per session was significantly greater in the intervention than the control group (196 versus 128, P<0.001) at the end of the study, and both providers and clients contributed to the disparity. In other words, both providers and clients in the intervention group uttered more thoughts per minute than their peers in the control group. According to the panel study, providers’ utterance rate in- creased significantly over the study period in the intervention group (from 6.9 to 9.3 utterances per minute, P<0.001) but not in the control group (from 7.5 to 8.7, not significant). The client utterance rate increased more among the inter- vention (3.6 to 5.7, P<0.001) than the control group (4.0 to 5.0, P<0.05). A qualitative review of the audiotapes identified threeFigure 1 Frequency of the doctors’ use of facilitative and behavioral changes that led to increased utterance rates ininformation-giving communication after the intervention, the intervention group. Firstly, providers spent less time incontrol versus intervention groups. Facilitative, com- silence while writing notes on the patient’s chart. Secondly,munication that promotes an interactive relationship between providers lectured less. Thirdly, providers paused more fre-patient and doctor. quently to allow clients to speak.Impact on length of sessions and utterance rate Impact on doctors’ communicationThere was no significant difference in the length of the Facilitative communication. Doctors in the intervention groupconsultation in the intervention and control groups (13.4 and outperformed the others during the post-intervention round,11.8 minutes, respectively). The panel study found the average with an overall frequency of facilitative communication oflength of the consultation increased significantly over the 4- 48 compared with 30 for the control group (P<0.001) (Figuremonth study period in both the intervention (from 7.0 to 1). Even after controlling for the purpose of the visit, the sex13.3 minutes, P<0.01) and control groups (6.3 to 9.8 minutes, of the doctor, and the length of the session, the interventionP<0.001). showed a significant impact on facilitative communication These numbers mask a significant change in the amount ( =0.28, P<0.001). As Figure 2 shows, doctors in theof conversation exchanged between providers and clients. intervention group performed significantly better than thoseThe number of utterances (phrases or sentences expressing in the control group on three of the six types of facilitativeFigure 2 Doctors’ frequency of use of six types of facilitative communication after the intervention, control versusintervention groups. Partnership, builds a sense of partnership between doctor and patient; Acknowledge, communicatesunderstanding of what patient is saying; Pers/social, includes remarks on personal or social aspects; Positive emotion,gives praise, reassurance; Info-psychosocial, provides counselling on psychosocial aspects; Ques-psychosocial, asks aboutpsychosocial aspects. 363
  6. 6. Y.-M. Kim et al.Figure 3 Doctors’ facilitative communication: panel study. Figure 4 Doctors’ bio-medical information and counseling: panel study.communication: partnership building (12.7 versus 7.3, information and counseling than those in the control groupP<0.001), acknowledgement (12.3 versus 6.2, P<0.001), and (27.5 versus 16.6, P<0.001) (Figure 1), and this differenceexpressing positive emotions (5.9 versus 2.9, P<0.001). remained significant even after controlling for other factors The panel study confirms the intervention’s impact on ( =0.26, P<0.001). The panel study confirms this finding:facilitative communication. While doctors’ communication information-giving increased from 7.8 to 25.1 (P<0.001) inimproved markedly over time in both groups, the gains were the intervention group, compared with a rise from 7.7 tosignificantly greater in the intervention than the control group 16.6 (P<0.001) in the control group (Figure 4). After con-(P=0.004). Levels of facilitative communication rose 238% trolling for other factors, these increases remained significantin the intervention group (from 13.6 to 45.9, P<0.001) and both in the intervention ( =0.44, P<0.001) and control124% in the control group (from 14.6 to 32.7, P<0.001) groups ( =0.42, P<0.05). However, the rate of change was(Figure 3). After controlling for other factors in a multiple significantly greater in the intervention than control groupregression analysis, this rise was significant in the intervention (P=0.0001). RIAS coding does not permit us to measuregroup ( =0.23, P<0.01) but not in the control group ( = the quality of information provided, such as its accuracy and0.20, not significant). In anecdotal reports, doctors and relevance.supervisors said the initial IPC/C training, daily practice with Multiple regression analyses found a somewhat differentpatients, weekly outreach services in the community, and pattern of associations between individual intervention com-supervision had helped doctors become better com- ponents and information-giving than was revealed for fa-municators. Since the control group also attended IPC/C cilitative communication. After controlling for other factors,training, received routine supervision, and learned from their just two components had a significant impact: the numbergrowing experience with patients, it is no wonder that their of times the homework log was used ( =0.18, P<0.01) andlevels of facilitative communication increased as well. the number of audiotapes made ( =0.17, P<0.01), while A series of multiple regression analyses were conducted the number of supervision visits was of borderline significanceto determine which components of the intervention were ( =0.14, P=0.052). Once all of the intervention com-most effective. These analyses controlled for: (1) the purpose ponents were entered in the regression, none of the individualof the visit, which varied between the two data collection components remained significant.rounds, and between control and intervention groups; (2) the Qualitative findings. In focus group discussions, doctorssex of the doctor, which was associated with levels of reported that their new communication skills not only im-facilitative communication; and (3) the length of the session, proved their interactions with patients but also carried overwhich varied widely. When the impact of each component to their relationships with nurses, supervisors, communityon facilitative communication was assessed separately, a sig- members, friends, and family. Doctors also said they foundnificant positive association was found with the number of it more satisfying to view their patient in a larger context, assupervision visits received ( =0.25, P<0.001), the number a person rather than as a diagnosis. Thus they felt theof sessions audiotaped ( =0.20, P<0.01), the number of intervention had contributed to their personal and pro-self-assessments performed ( =0.19, P<0.01), and the num- fessional lives, both for the present and in the future.ber of times the homework log was used ( =0.13, P<0.05).(It was impossible to assess the impact of the job aid, since Impact on patients’ communicationall doctors reported using it frequently.) Only the number ofsupervision visits remained significant, however, when all of The frequency of patient active communication did not differthe intervention components were entered in the regression significantly between the intervention and control groups( =0.20, P<0.05). (13.3 compared with 11.4, respectively, not significant). The Information-giving. Following the intervention, doctors in panel study showed that the frequency of patient activethe intervention group provided 63% more biomedical communication increased dramatically over the study period364
  7. 7. Doctor–patient communicationin both the intervention (from 2.4 to 12.7, =0.07, P<0.001) scope of the analysis also was limited by technical difficultiesand control groups (from 2.6 to 13.0, =0.13, P<0.01), with the audio recording and the departure of some doctorswith no significant difference in the rate of change between prior to the post-intervention round of data collection. Aboutthe two groups. This general increase in active communication one-quarter (27%) of the resident doctors who participatedmay be due to providers’ growing experience and the increased in the study were dropped entirely from the analysis, andlength of the sessions, rather than the indirect impact of the less than half (47%) of those remaining were included in theintervention. These also may explain qualitative reports by panel study. Due to the lack of random sampling, the findingsdoctors in the intervention group: in focus group discussions, must be interpreted with caution. Since the data lost, however,they said patients noticed and responded to the changes in was due to recording problems and scheduling difficulties,their interpersonal communication, appreciated the additional there is no reason to believe it systematically biased thetime spent on talking about their problems, opened up more, results.and were more likely to make return visits. This intervention is rooted in new, supportive approaches to supervision that have broadened the supervisor’s re- sponsibilities in an effort to improve the quality of care [17,Discussion 18]. According to a widely accepted model, clinical supervisors have three primary functions: (1) normative, ensuring that staffSupportive supervision and self-assessment changed pro- adhere to standards; (2) formative, facilitating learning andviders’ communication patterns, increasing the amount of professional development by staff members; and (3) restorative,facilitative communication, shortening their utterances, and providing emotional support to, and ensuring the personalaccelerating the exchange of conversations. These alterations well-being of, staff members [15,19].suggest that doctors adopted a more client-centered, less The supervision intervention implemented in Mexico ac-authoritarian approach to care along with a more participatory knowledged the continuing importance of supervisors’ norm-style of communication—changes that researchers have found ative function in the creation of an observation checklist toproduce better health outcomes [2–5,14]. assess doctors’ IPC/C performance. However, the emphasis In contrast, changes in patient behavior due to the inter- on feedback, two-way discussion, and the homework logvention were neither observed nor expected, since the inter- added a formative, educational dimension that helped doctorsvention could have only an indirect impact upon them. improve their skills. Training in interpersonal communicationHowever, patient active communication in both the inter- also helped supervisors perform the restorative function,vention and control groups increased over time, probably which takes on even more importance when young, in-due to the growing familiarity between patients and doctors. experienced doctors are assigned to live and work in isolatedThe resident doctors were strangers when they first arrived rural clinics where they have no peers or support the IMSS/S clinics. Over the course of their 9-month stint Research also points to the importance of reflection forat the clinic, which included making home visits 1 day a professional decision making and adult learning [20]. Re-week, the doctors gradually met the local people, gained an flective practice requires active observation of events and,appreciation of the local culture, and came to know their later, reflection on them to understand better and learn frompatients. By the end of their stay, they had forged a personal experience. While supervisors can and do prompt reflectionrelationship with many patients, making it easier for patients [19], this study demonstrates that listening to yourself onto speak out. audiotape also stimulates reflection, self-assessment, and self- Studying these young doctors offered both benefits and learning. For doctors, listening to the audiotapes was achallenges. Because they had just finished training and had powerful experience, and self-criticism was a more compellingnot yet established patterns of communication with patients, motivator than outside criticism. While health care providersthese resident doctors may have been more open to the in Indonesia successfully performed IPC/C self-assessmentsinfluence of the intervention than veteran health care pro- without using audiotapes, relying on memory alone wasviders. Indeed, two studies of nurses in the UK found that difficult, and providers were not as deeply moved by theclinical supervision, including its educational component, had process [8].a far greater impact on the least experienced and most junior Partnership supervision may not be suitable for all settings,nurses [15,16]. However, it can be difficult to assess the however. Above all, it requires that a functioning supervisionimpact of an intervention on doctors just entering practice system be in place. Because IMMS/S already had competentbecause their skills rapidly improve with experience. The and experienced supervisors making regular visits to ruralpanel study enabled us to distinguish between the impact of clinics, it was relatively easy to add IPC/C supervision tothe intervention and doctors’ naturally steep learning curve, their responsibilities. In many developing countries, however,since doctors in the control group shared the same IPC/C supervisors are few in number, poorly trained, and lacktraining, routine supervision, and patient experiences as the transportation to visit facilities [20–22]. Even in developedintervention group. countries, the costs of time and training pose a barrier to The study suffers from certain other limitations. Audio supervision of clinical personnel [19,23]. When the super-taping, while less intrusive than having an observer present, vision system is not fully functioning, alternative approachesinevitably affects the behavior both of the doctors, who may become more attractive; for example, self-assessment, re-try harder, and the patients, who may feel inhibited. The flective diaries, and peer review [8,23]. Yet the Mexican 365
  8. 8. Y.-M. Kim et al.experience points to practical limitations here as well. While Referencesaudiotaping consultations proved to be an effective learningtool, IMMS/S found it difficult to supply tape recorders to 1. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N.scattered rural clinics and maintain them in working order Patients’ unvoiced agendas in general practice consultations:once the intervention was scaled up. qualitative study. Br Med J 2000; 320: 1246–1250. Because supervision and self-assessment activities and 2. Greenfield S, Kaplan S, Ware JE, Yano EM, Frank HJ. Patients’materials were designed to complement and build on each participation in medical care: effects on blood sugar controlother, it is difficult to single out the effectiveness of any one and quality of life in diabetes. J Intern Med 1988; 3: 448–457.component of the intervention. Results suggest instead theimportance of multiple, reinforcing interventions for pro- 3. Kaplan SH, Greenfield S, Ware JW. Assessing the effect of the physician–patient interaction on the outcomes of chronicmoting self-learning and behavioral change. Doctors valued disease. Med Care 1989; 27: S110–S127.every element of the intervention, including the supervisionvisits, homework log, job aid, audiotapes, and self-assessment. 4. Stewart M. Effective physician–patient communication andPerhaps because the self-assessment process (including the health outcomes: a review. Can Med Assoc J 1995; 152: 1423–audiotapes) occurred four times more often than supervision 1433.visits and occupied so much more of their time, doctors 5. Roter D, Steward M, Putman SM, Lipkin M, Stiles W, Inui TS.emphasized self-assessment during focus group discussions. The patient–physician relationship: communication patterns ofHowever, they also asked for more time with supervisors primary care physicians. J Am Med Assoc 1997; 277: 350–356.and more feedback from them. 6. De Negri B, Brown L, Hernandez O et al. Improving interpersonal communication between 7 health care providers and clients. Bethesda, MD: Quality Assurance Project, 1997. Available online atConclusion under ‘Products’. Last accessed 29 April 2002.This study demonstrates that a combination of supportive 7. DiPrete Brown LD, de Negri B, Hernandez O, Dominguez L,supervision and self-assessment can reinforce IPC/C training, Sanchak JH, Roter D. An evaluation of the impact of traininghelp doctors apply newly learned skills on the job, and Honduran health care providers in interpersonal communica-contribute to continuing improvement in doctor–patient com- tion. Int J Qual Health Care 2000; 12: 495–501.munication. Because supervision is a standard part of most 8. Kim YM, Putjuk F, Basuki E, Kols A. Self-assessment and peerhealth care systems, it offers a highly effective way of reaching review: improving Indonesian service providers’ communicationdoctors, with training and reinforcement on interpersonal with clients. Int Fam Plann Perspect 2000; 26: 4–20.communication. However, supervisors typically do not give 9. Roter D. The Roter Interaction Analysis System (RIAS) Coding on doctor–patient interaction. Specially designed Baltimore, MD: Johns Hopkins University School of Hygienetraining and assessment tools can direct supervisors’ time and Public Health, 1997.and energy to these important issues. Self-assessment extendsand magnifies the impact of supervision by sharing re- 10. van den Brink-Muinen A, Verhaak PFM, Bensing JM et al. Thesponsibility for performance improvement and enhancing the Euro-Communication Study: an International Comparative Study in Sixpartnership between doctor and supervisor. Further research European Countries on Doctor–Patient Communication in General Practice. Utrecht, The Netherlands: NIVEL, 1999. Availableis needed to test different forms of IPC/C supervision and at Last accessed 29self-assessment, and to refine the balance between them. April 2002. 11. Roter D, Rosenbaum J, de Negri B, Renaud D, DiPrete Brown L, Hernandez O. The effects of a continuing medical educationAcknowledgements programme in interpersonal communication skills on doctor practice and patient satisfaction in Trinidad and Tobago. MedThe study was carried out by the Quality Assurance Project Educ 1998; 32: 181–189.(QAP), Instituto Mexicano del Seguro Social/Solidaridad 12. Kim YM, Odallo D, Thuo M, Kols A. Client participation(IMSS/S), and Johns Hopkins University Center for Com- and provider communication in family planning counseling:munication Programs (JHU/CCP), a sub-contractor of QAP. transcript analysis in Kenya. Health Commun 1999; 11: 1–19.QAP is managed by the Center for Human Services (CHS;Bethesda, MD), and funded by the U.S. Agency for Inter- 13. Kim YM, Kols A, Bonnin C, Richardson P, Roter D. Client communication behaviors with health care providers in In-national Development (USAID) contract number HRN-C- donesia. Patient Educ Couns 2001; 45: 59–68.00-96-900013. The authors thank Javier Cabral, Celia Es-candon, Jesus Castellanos, Maribel Rodriguez (IMSS/S); Phyl- 14. Ong LM, De Haes JCJM, Hoos AM, Lammes FB. Doctor–lis Piotrow, Elizabeth Costenbader, Gary Lewis, (JHU/CCP); patient communication: a review of the literature. Soc Sci MedDebra Roter, Susan Larson (Johns Hopkins School of Public 1995; 40: 903–918.Health); Jim Heiby (USAID); and David Nicholas, Bart 15. Bowles N, Young C. An evaluative study of clinical supervisionBurkhalter, and Paula Tavrow (QAP/CHS) for their as- based on Proctor’s three function interactive model. J Adv Nurssistance. 1999; 30: 958–964.366
  9. 9. Doctor–patient communication16. Teasdale K, Brocklehurst N, Thom N. Clinical supervision and 21. Combary P, Newman C, Glover K et al. Study of the Effects of support for nurses: an evaluation study. J Adv Nurs 2001; 33: Technical Supervision Training on CBD Supervisors’ Performance in Seven 216–224. Regions of Ghana. Chapel Hill, NC: University of North Carolina at Chapel Hill, School of Medicine, Program for International17. Ben Salem B, Beattie KJ. Facilitative supervision: a vital link in Training in Health (INTRAH), 1999. Available at http:// quality reproductive health service delivery. AVSC Working Paper Last accessed 29 April 2002. #10, 1996. Available at workpap/wp10/wp 10.html. Last accessed 29 April 2002. 22. Valadez J, Vargas W, Diprete L. Supervision of primary health care in Costa Rica: time well spent? Health Policy Plann 1990; 5:18. Lammerink M. Ways of working. Health Action 1994; 8: 10. 118–125.19. Kilminster SM, Jolly BC. Effective supervision in clinical practice 23. Teasdale K. Practical approaches to clinical supervision. Prof settings: a literature review. Med Educ 2000; 34: 827–840. Nurse 2000; 15: 579–582.20. Ahmed AM, Gavyole A, Omar HM, Munisi W. The national guidelines for supervision checklist: a tool for monitoring super- vision activities at district level in Tanzania. Ann Ig 1994; 6: 161–166. Accepted for publication 12 June 2002 367